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Conductive flexible hydrogels have attracted immense attentions recently due to their wide applications in wearable sensors. However, the poor mechanical properties of most conductive polymer limit their utilizations. Herein, a double network hydrogel is fabricated via a self-sorting process with cationic polyacrylamide as the first flexible network and the lantern[3 3 ]arene-based hydrogen organic framework nanofibers as the second rigid network. This hydrogel is endowed with good conductivity (0.25 S m -1 ) and mechanical properties, such as large Young's modulus (31.9 MPa), fracture elongation (487%) and toughness (6.97 MJ m -3 ). The stretchability of this hydrogel is greatly improved after the kirigami cutting, which makes it can be used as flexible strain sensor for monitoring human motions, such as bending of fingers, wrist and elbows. This study not only provides a valuable strategy for the construction of double network hydrogels by lanternarene, but also expands the application of the macrocycle hydrogels to flexible electronics., (© 2024 Wiley‐VCH GmbH.)

Importance: The most frequent presenting symptom for patients with human papillomavirus (HPV)-associated oropharyngeal squamous cell carcinoma (OPSCC) is a lateral neck mass. Circulating tumor tissue-modified viral (TTMV)-HPV DNA is a unique biomarker produced by the fragmentation of HPV DNA during the degradation of HPV-associated tumors, and its detection and quantitation are currently being used as an adjunct to imaging in monitoring for disease recurrence and may have utility for diagnosis., Objective: To measure the diagnostic characteristics of TTMV-HPV DNA compared with gold standard tissue biopsy for diagnosing HPV-OPSCC in patients presenting with an indeterminate lateral neck mass., Design, Setting, and Participants: This prospective diagnostic test study enrolled patients 18 years or older who presented with a lateral neck mass to a large urban tertiary health care system from December 2021 to June 2023. Participants underwent standard-of-care testing to obtain a tissue diagnosis and a single TTMV-HPV DNA measurement., Main Outcomes and Measures: The primary outcome of interest was sensitivity, while specificity, positive predictive value, and negative predictive value were secondary end points. A subset analysis was performed comparing test performance metrics between TTMV-HPV DNA testing and fine-needle aspiration., Results: A total of 138 patients were included, of whom 80 (58.0%) were men, with median age of 57.5 years (IQR, 43.3-67.0 years). Of 138 patients, 87 (63.0%) had neck masses in level 2 and 47 (34.1%) had HPV-OPSCC. TTMV-HPV DNA testing exhibited a sensitivity of 95.7% (95% CI, 85.5%-99.5% [45 of 47 patients]), specificity of 97.8% (95% CI, 92.3%-99.7% [89 of 91 patients]), positive predictive value of 95.7% (95% CI, 85.5%-99.5% [45 of 47 patients]), and negative predictive value of 97.8% (95% CI, 92.3%-99.7% [89 of 91 patients])., Conclusions and Relevance: In this diagnostic study of patients presenting with a lateral neck mass, circulating TTMV-HPV DNA demonstrated excellent diagnostic test characteristics for the detection of HPV-OPSCC. Such testing may have particular utility for patients in whom obtaining adequate tissue is problematic, as is often the case with cystic neck masses and unknown primary tumors.

Objectives: Clinical and imaging examinations frequently have indeterminate results during cancer surveillance, which can lead to overtreatment and cause psychological and financial harm to the patient. This study addresses the critical need to enhance diagnostic precision and decision-making in the management of HPV-associated oropharyngeal cancer. This study evaluated the utility of tumor tissue-modified viral (TTMV)-HPV DNA to resolve indeterminate disease status following definitive treatment for HPV-associated oropharyngeal cancer., Materials and Methods: In this retrospective cohort, patients treated for HPV-associated oropharyngeal cancer at eight U.S. institutions and who received one or more TTMV-HPV DNA tests during post-treatment surveillance between February 2020 and January 2022 were included., Results: Among 543 patients, 210 patients (38.7%; 210/543) experienced one or more clinically indeterminate findings (CIFs) during surveillance, with 503 CIFs recorded. Of those patients with an "indeterminate" disease status at a point during surveillance, 79 were associated with contemporaneous TTMV-HPV DNA testing. TTMV-HPV DNA testing demonstrated high accuracy (97.5%; 77/79) in correctly determining recurrence status. Patients whose disease status was "indeterminate" at the time of a positive TTMV-HPV DNA test were clinically confirmed to recur faster than those whose disease status was "no evidence of disease." Only 3% of patients (17/543) experienced indeterminate TTMV-HPV DNA tests during surveillance. Discordance between TTMV-HPV DNA tests and clinical results was minimal, with only 0.6% (3/543) of patients showing positive tests without recurrence., Conclusion: Our findings support the utility of circulating TTMV-HPV DNA in resolving indeterminate disease status and informing the subsequent clinical course., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Objective: The primary objective of this study was to evaluate oncologic outcomes of all published cases of supracricoid partial laryngectomy (SCPL) performed in the United States. The secondary objective was to assess the functional outcomes associated with this procedure., Review Methods: A systematic review of PubMed, SCOPUS, and Embase for all English-language studies pertaining to SCPL performed in the United States was conducted until August 2021. Primary outcomes included disease-specific survival (DSS), overall survival, and local recurrence rate. Secondary outcomes included larynx preservation rate, gastrostromy tube dependency, days to gastrostomy tube removal, decannulation rate, and days to decannulation., Results: A total of six studies were included in the analysis. A total of 113 patients (58.5%) underwent SCPL surgery as a primary treatment method whereas 80 patients (41.5%) underwent SCPL as salvage surgery. The 5-year DSS rates were 87.8% and 100% for primary and salvage procedures, respectively. Approximately 10.3% of patients undergoing a salvage SCPL procedure experienced a local recurrence whereas only 1.85% of primary SCPL procedures resulted in local recurrence. The rates of decannulation following primary and salvage SCPL were 92.7% and 88.1%, respectively. With regard to swallowing, primary and salvage SCPL procedures demonstrated comparably low postoperative gastrostomy tube dependency rates of 3.66% and 4.76%, respectively., Conclusions: SCPL performed in the United States is an effective surgical technique that produces excellent outcomes in qualifying patients, thus validating its viability as an organ-preserving surgical alternative. Laryngoscope, 134:3003-3011, 2024., (© 2024 The American Laryngological, Rhinological and Otological Society, Inc.)

Purpose: This study compared treatment and outcomes for patients with HPV-positive oropharyngeal squamous cell carcinoma (OPSCC) based on their travel distance to treatment facility., Materials and Methods: Patients with cT1-4, N0-3, M0 HPV-positive OPSCC in the National Cancer Database from 2010 to 2019 were identified and split into four quartiles based on distance to facility, with quartile 4 representing patients with furthest travel distances. Multivariable-adjusted logistic regression and Cox proportional hazards modeling were used to analyze the primary outcome of treatment received, and secondary outcomes of clinical stage, overall survival, surgical approach (i.e., TORS versus other), and 30-day surgical readmissions., Results: 17,207 patients with HPV-positive OPSCC were evenly distributed into four quartiles. Compared to patients in quartile 1, patients in quartile 4 were 40 % less likely to receive radiation versus surgery (OR = 0.60; 95 % CI = 0.54-0.66). Among the patients who received surgery, quartile 4 had a higher odds of receiving TORS treatment compared to quartile 1 (4v1: OR = 2.38; 95 % CI = 2.05-2.77), quartile 2 (4v2: OR = 2.31, 95 % CI = 2.00-2.66), and quartile 3 (4v3: OR = 1.75; 95 % CI = 1.54-1.99). Quartile 4 had a decreased odds of mortality compared to Quartile 1 (4v1: OR = 0.87; 95 % CI = 0.79-0.97). There were no differences among the quartiles in presenting stage and 30-day readmissions., Conclusions: This study found that patients with furthest travel distance to facility were more often treated surgically over non-surgical management, with TORS over open surgery, and had better overall survival. These findings highlight potential disparities in access to care for patients with HPV-positive OPSCC., Competing Interests: Declaration of competing interest The authors have no financial disclosures or conflicts of interests to report., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: Evaluate utility of postoperative phosphate and calcium/phosphate ratio (Ca/P) as surrogates for parathyroid hormone (PTH) following total thyroidectomy., Study Design: Retrospective cohort study., Setting: Tertiary care hospital., Methods: We retrospectively reviewed patients 18 years or older who underwent total thyroidectomy in a tertiary care hospital by a single surgeon from 2015 through 2021. Patients with incomplete data, pre-existing hypoparathyroidism, vitamin D deficiency, or renal failure were excluded. All patients had PTH drawn within 4 hours of surgery and serum calcium, albumin, and phosphate levels on postoperative Day 1. Corrected calcium was used to calculate a Ca/P. Receiver operating characteristic (ROC) curves were generated to compare phosphate level or Ca/P with PTH. Each possible surrogate was assessed relative to PTH cutoffs of less than 5, 10, 15, and 20 pg/mL. A good screening test was defined as having an area under the curve (AUC) greater than 0.8., Results: A total of 185 patients underwent total thyroidectomy with 1 fellowship-trained otolaryngologist. Most patients were female (62%), median age 48 years. Most surgeries were performed for cancer (68%). Six (3.2%) patients required IV calcium supplementation and 2 (1.1%) required readmission for symptomatic hypocalcemia. ROC curves comparing phosphate and Ca/P to PTH at the listed cutoffs demonstrated AUC ranging from 0.55 to 0.66 and 0.61 to 0.79, respectively. None met the threshold for a good screening test., Conclusion: Postoperative phosphate and Ca/P ratio are not surrogates for PTH levels following total thyroidectomy. More research is needed to identify cost-effective strategies for postoperative calcium monitoring in patients undergoing total thyroidectomy., Level of Evidence: Retrospective cohort study., (© 2024 American Academy of Otolaryngology–Head and Neck Surgery Foundation.)

Objective(s): Despite advancements in imaging techniques and cytological analysis, plunging ranula remains a challenging surgical, radiologic, and pathologic phenomenon. Of the 18 patients we evaluated at our institution, we highlight three cases that illustrate the high rate of misleading imaging and cytological results when assessing plunging ranula., Methods: Imaging results, biopsy findings, operative techniques, and pathological reports were reviewed from patients who had either a preoperative or postoperative diagnosis of ranula and underwent surgery by a single head and neck surgeon at a tertiary care center., Results: Of the 18 identified patients, computed tomography was correct on preoperative imaging 73% of the time and magnetic resonance imaging was correct on preoperative imaging 71% of the time. Two patients underwent preoperative ultrasound and their ultrasound reports did not accurately diagnose the presence of a ranula. Two patients underwent preoperative fine needle aspiration biopsy due to inconclusive preoperative imaging, in which results suggested either a ranula or epidermal cyst. Both ultimately did not match the final pathology. Three of eighteen patients (17%) underwent an inappropriate initial surgery due to incorrect imaging diagnoses and/or biopsy findings., Conclusion: Despite use of preoperative modalities to distinguish plunging ranula from other cystic floor of mouth lesions, surgeons must be aware that no workup modality is fully precise. The potential for revision surgery must be included in all preoperative discussions for presumed plunging ranula., Level of Evidence: 4 Laryngoscope, 134:2689-2696, 2024., (© 2024 The American Laryngological, Rhinological and Otological Society, Inc.)

We present a novel, efficient approach to demonstrating supplemental margins during oncologic resection. Surgeons and pathologists annotated 10 virtual models of surgical defects and resection specimens in 3D using an iPad-based application, Procreate®. Incorporating this method into the surgical workflow can improve interdepartmental communication and provide visual documentation of surgical steps taken to address at-risk margins. Laryngoscope, 134:2783-2786, 2024., (© 2023 The American Laryngological, Rhinological and Otological Society, Inc.)

Purpose: To compare human papillomavirus (HPV) testing, prevalence, and association with prognosis between head and neck squamous cell carcinoma (HNSCC) subsites., Materials and Methods: This study utilized the National Cancer Database (NCDB) to identify patients diagnosed with HNSCC between 2010 and 2017. Rates of HPV testing, HPV-positivity, and changes in these rates over time were measured by subsite. The impact of HPV-positivity on overall survival across six head and neck subsites was assessed using multivariable-adjusted Cox proportional hazards analysis., Results: A total of 121,550 patients were included. Of this cohort, 87,575 (72.1%) were tested for HPV, with the oropharynx (55,049/64,158; 85.8%) displaying the highest rates of testing and the sinonasal tract (1519/2853; 53.2%) displaying the lowest testing rates. Of the 86,136 with a definitive result, 46,878 (54.4%) were HPV-positive, with the oropharynx (40,313/54,205; 74.4%) displaying the highest rates of HPV-positivity and the oral cavity (1818/11,505; 15.8%) displaying the lowest. HPV-positive malignancy was associated with significantly improved adjusted overall survival in the oropharynx (HR = 0.42 [95% CI: 0.43-0.47]), oral cavity (HR = 0.86 [95% CI: 0.79-0.95]), sinonasal tract (HR = 0.63 [95% CI: 0.48-0.83]), larynx (HR = 0.78 [95% CI: 0.71-0.87]), and hypopharynx (HR = 0.56 [95% CI: 0.48-0.66]), but not the nasopharynx (HR = 0.93 [95% CI: 0.77-1.14])., Conclusion: HPV testing rates were significantly lower in non-oropharyngeal subsites. This is relevant as HPV-associated disease displayed significantly improved overall survival in both the oropharynx and four of five non-oropharyngeal subsites. While validation with prospective studies is necessary, these findings may warrant HPV testing in all HNSCC subsites., Competing Interests: Declaration of competing interest No conflicts of interest to report., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: Opportunities exist to improve intraoperative communication and documentation of resection margin details. We instituted a "frozen section timeout" that centers around visualization of the paired resection specimen and surgical defect-facilitating effective, bidirectional exchange of information., Methods: We designed an interactive form for use during the "frozen section timeout" including annotated 3D virtual models of the resected specimen and surgical defect, plus a "line-item" table for primary and supplemental margin results. The "timeout" was conducted over a Zoom call between the operating room and frozen section laboratory. The form was simultaneously projected and discussed while all members of the surgical care team stopped activities. Nurses, co-surgeons, and all other members of the surgical team were encouraged to take part in this process., Results: Twenty-six frozen section timeouts were conducted during head and neck surgeries in the Department of Otolaryngology at Mount Sinai West Hospital. These timeouts were facilitated by the lead surgeon, and all other activities were halted to ensure that critical information was shared, documented, and agreed upon. During the timeout, the annotated specimen and defect scans were displayed, clearly demonstrating the at-risk margins and the corresponding location and breadth of supplemental margins harvested., Conclusion: Incorporating a frozen section timeout can improve intraoperative communication, increase transparency, and potentially eliminate uncertainty regarding margin status and tumor clearance. Visualization of at-risk margins and the corresponding location and breadth of supplemental margins promises an unprecedented level of documentation and understanding. This novel technique can establish a new and improved standard of care., Level of Evidence: NA Laryngoscope, 134:725-731, 2024., (© 2023 The American Laryngological, Rhinological and Otological Society, Inc.)

Introduction: The multiple treatment options available to patients with thyroid nodules can generate uncertainty and confusion. Radiofrequency ablation (RFA) and ethanol ablation (EA) are two alternative modalities to manage thyroid nodules. As patients more frequently utilize online resources to guide their decision-making, the quality of such resources must be evaluated. The goal of this study was to assess the quality of online patient materials relating to RFA and EA compared to standard thyroidectomy., Methods: The terms "thyroidectomy," "thyroid radiofrequency ablation," and "thyroid ethanol ablation" were searched on Google. Flesch Reading Ease (FRE), Flesch-Kincaid Grade Level (FKGL), Simple Measure of Gobbledygook (SMOG), and Patient Education Materials Assessment Tool (PEMAT) understandability and actionability were calculated for each website. Statistical analysis was conducted on SPSS Statistics. Google trends were used to determine search interest for each term (May 2016 - May 2021)., Results: Of the 77 websites that met our inclusion criteria (30 thyroidectomy sites, 30 RFA sites, and 17 EA sites), the average FRE, FKGL, and SMOG scores of the RFA websites were significantly worse than those of the thyroidectomy websites (p < 0.05). The FKGL and SMOG scores of the EA websites were significantly worse than those of the thyroidectomy websites (p < 0.05). The average understandability and actionability scores for thyroidectomy websites were significantly higher than those of RFA and EA websites (p < 0.05)., Conclusion: Ablation websites have lower search interest, readability, validity, understandability, and actionability scores in comparison to traditional thyroidectomy websites. Our findings emphasize the need to consider readability and PEMAT scores when developing online educational resources for ablative alternatives to thyroidectomy to allow for greater patient accessibility., (© 2024 S. Karger AG, Basel.)

Objective: Division of the sternothyroid muscle during thyroidectomy is a widely accepted surgical technique to provide improved exposure of the thyroid gland, thus facilitating the ligation of superior pole vessels and identification of the laryngeal nerves. However, few have examined the impact on voice outcomes. We evaluate the impact of sternothyroid muscle division on patient-perceived voice outcomes after thyroidectomy., Study Design: Prospective cohort study., Setting: Tertiary academic institution., Methods: A prospective cohort study was conducted comparing pre- and postoperative voice outcome data after thyroidectomy, measured using Voice Handicap Index-10. The cohort of 109 patients underwent lobectomy or total thyroidectomy by a single surgeon at 1 institution. The sternothyroid muscle was fully divided in all surgeries. The integrity of the recurrent laryngeal and external branches of the superior laryngeal nerve was assessed using intraoperative nerve monitoring and postoperative laryngoscopy. Pre- and postoperative Voice Handicap Index-10 scores were compared., Results: No statistically significant difference was found between total pre- and postoperative Voice Handicap Index-10 scores (μ preop  = 1.92, μ postop  = 1.83, p = .87). There were no questions yielding statistically significant responses between pre- and postoperative groups. This was consistent regardless of whether the sternothyroid muscle was cut unilaterally or bilaterally. Men showed a statistically significant improvement in score after surgery., Conclusion: These findings support no difference in postoperative voice outcomes after the intraoperative division of the sternothyroid muscle. This supports the usage of this technique as a safe means to facilitate exposure during thyroid surgery and will serve as important information to guide intraoperative surgical decision-making., (© 2023 American Academy of Otolaryngology-Head and Neck Surgery Foundation.)

Importance: There is growing interest in the use of circulating plasma tumor human papillomavirus (HPV) DNA for diagnosis and surveillance of patients with HPV-associated oropharyngeal squamous cell carcinoma (OPSCC). Recent advances in the assays, combining the identification of circulating HPV tumor DNA and tumor DNA fragment analysis (tumor tissue-modified viral [TTMV]-HPV DNA), have been shown to be highly accurate. However, use of these newer techniques has been limited to small cohort studies and clinical trials., Objective: To establish the clinical efficacy of plasma TTMV-HPV DNA testing in the diagnosis and surveillance of HPV-associated OPSCC in a contemporary clinical setting., Design, Setting, and Participants: This retrospective observational cohort study included patients with OPSCC who underwent TTMV-HPV DNA testing between April 2020 and September 2022 during the course of routine clinical care. For the diagnosis cohort, patients with at least 1 TTMV-HPV DNA measurement prior to initiation of primary therapy were included. Patients were included in the surveillance cohort if they had at least 1 TTMV-HPV DNA test performed after completion of definitive or salvage therapy., Main Outcomes and Measures: Per-test performance metrics, including sensitivity, specificity, positive predictive value, and negative predictive value, for TTMV-HPV DNA testing., Results: Of 399 patients included in the analysis, 163 were in the diagnostic cohort (median [IQR] age, 63 [56-68.5] years; 142 [87.1%] male), and 290 were in the surveillance cohort (median [IQR] age, 63 [57-70] years; 237 [81.7%] male). Of the 163 patients in the diagnostic cohort, 152 (93.3%) had HPV-associated OPSCC while 11 (6.7%) had HPV-negative OPSCC. The TTMV-HPV DNA sensitivity in pretreatment diagnosis was 91.5% (95% CI, 85.8%-95.4% [139 of 152 tests]), and the specificity was 100% (95% CI, 71.5%-100% [11 of 11 tests]). In the surveillance cohort, 591 tests conducted in 290 patients were evaluated. A total of 23 patients had molecularly confirmed pathologic recurrences. The TTMV-HPV DNA test demonstrated sensitivity of 88.4% (95% CI, 74.9%-96.1% [38 of 43 tests]) and specificity of 100% (95% CI, 99.3%-100% [548 of 548 tests]) in detecting the recurrences. Positive predictive value was 100% (95% CI, 90.7%-100% [38 of 38 tests]), and negative predictive value was 99.1% (95% CI, 97.9%-99.7% [548 of 553 tests]). The median (range) lead time from positive TTMV-HPV DNA test to pathologic confirmation was 47 (0-507) days., Conclusions and Relevance: This cohort study demonstrated that when evaluated in a clinical setting, the TTMV-HPV DNA assay demonstrated 100% specificity in both diagnosis and surveillance. However, the sensitivity was 91.5% for the diagnosis cohort and 88.4% for the surveillance cohort, signifying that nearly 1 in 10 negative tests among patients with HPV-associated OPSCC was a false negative. Additional research is required to validate the assay's performance and, if validated, then further research into the implementation of this assay into standard clinical practice guidelines will be required.

Purpose: Human papillomavirus (HPV) is causally linked to oropharyngeal squamous cell carcinoma (OPSCC). Consensus guidelines recommend clinical exams and imaging in decreasing frequency as part of posttreatment surveillance for recurrence. Plasma tumor tissue modified viral (TTMV)-HPV DNA testing has emerged as a biomarker which can inform disease status during surveillance., Experimental Design: This retrospective observational cohort study involved 543 patients who completed curative-intent therapy for HPV-associated OPSCC between February 2020 and January 2022 at eight U.S. cancer care institutions. We determined the negative predictive value (NPV) of TTMV-HPV DNA for recurrence when matched to physician-reported clinical outcome data (median follow-up time: 27.9 months; range: 4.5-154)., Results: The cohort included mostly men with a median age of 61 who had locoregionally advanced disease. HPV status was determined by p16 positivity in 87% of patients, with a positive HPV PCR/ISH among 55%; while pretreatment TTMV-HPV DNA status was unknown for most (79%) patients. Patients had a mean of 2.6 tests and almost half had three or more TTMV-HPV DNA results during surveillance. The per-test and per-patient sensitivity of the assay was 92.5% [95% confidence interval (CI): 87.5-97.5] and 87.3% (95% CI: 79.1-95.5), respectively. The NPV for the assay was 99.4% (95% CI: 98.9-99.8) and 98.4% (95% CI: 97.3-99.5), respectively., Conclusions: TTMV-HPV DNA surveillance testing yields few false negative results and few missed recurrences. These data could inform decisions on when to pursue reimaging following first disease restaging and could inform future surveillance practice. Additional study of how pretreatment TTMV-HPV DNA status impacts sensitivity for recurrence is needed., (©2023 The Authors; Published by the American Association for Cancer Research.)

Supramolecular hydrogels involved macrocycles have been explored widely in recent years, but it remains challenging to develop hydrogel based on solitary macrocycle with super gelation capability. Here, the construction of lantern[3 3 ]arene-based hydrogel with low critical gelation concentration (0.05 wt%), which can be used for efficient oil-water separation, is reported. The lantern[3 3 ]arenes self-assemble into hydrogen-bonded organic nanoribbons, which intertwine into entangled fibers to form hydrogel. This hydrogel which exhibits reversible pH-responsiveness characteristics can be coated on stainless-steel mesh by in situ sol-gel transformation. The resultant mesh exhibits excellent oil-water separation efficiency (>99%) and flux (>6 × 10 4 L m -2 h -1 ). This lantern[3 3 ]arene-based hydrogel not only sheds additional light on the gelation mechanisms for supramolecular hydrogels, but also extends the application of macrocycle-based hydrogels as functional interfacial materials., (© 2023 Wiley-VCH GmbH.)

Frozen section has remained the diagnostic gold standard for intraoperative pathological evaluation of surgical margins for head and neck specimens. While achieving tumor-free margins is of utmost importance to all head and neck surgeons, in practice, there are numerous debates and a lack of standardization for the role and method of intraoperative pathologic consultation. This review serves as a summary guide to the historical and contemporary practice of frozen section analysis and margin mapping in head and neck cancer. In addition, this review discusses current challenges in head and neck surgical pathology, and introduces 3D scanning as a groundbreaking technology to bypass many of the pitfalls in the current frozen section workflow. The ultimate goal for all head and neck pathologists and surgeons should be to modernize practices and take advantage of new technology, such as virtual 3D specimen mapping techniques, that improves the workflow for intraoperative frozen section analysis., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Background: Neutrophil-to-lymphocyte ratio (NLR) is a biomarker of systemic inflammation that is associated with adverse oncologic and surgical outcomes. We investigated the use of NLR as a prognostic indicator of complications of head and neck cancer (HNC) surgeries., Methods: We conducted a retrospective study of 11 187 Veterans who underwent HNC surgery between 2000 and 2020. We calculated preoperative NLR values and fit logistic regression models adjusting for potential confounding factors, comparing high-NLR patients to low-NLR patients., Results: The cohort had a median age of 63 and was 98% men. High-NLR patients had increased odds of 30-day mortality (p < 0.001), having 1+ perioperative complications (p < 0.001), sepsis (p = 0.03), failure to wean from mechanical ventilation (p = 0.04), pneumonia (p < 0.001), and pulmonary embolism (p = 0.02) compared with low-NLR patients., Conclusion: NLR was a robust, independent predictor of 30-day mortality, having 1+ surgical complications, sepsis, failure to wean from mechanical ventilation, pneumonia, and pulmonary embolism., (© 2023 Wiley Periodicals LLC.)

Background: Frozen section analysis of oral cancer specimens is ideal for assessing margin distances and depth of invasion (DOI); the latter impacts intraoperative decisions regarding elective neck dissection (END). Here, we show that intraoperative determination of worst pattern of invasion (WPOI), specifically WPOI-5, has a high level of accuracy. This relates to our demonstration herein that WPOI-5 predicts occult cervical metastases (OCM) for pT1 oral squamous carcinoma (OSC)., Methods: The presence of OCM was correlated with WPOI in 228 patients with primary T1/T2/cN0 OSC undergoing resection and END. Concordance between intraoperative and final pathology WPOI determination was assessed on 51 cases of OSC., Results: WPOI-5 predicts OCM in pT1 patients, compared with WPOI-4/WPOI-3 (p < 0.0001). Most pT1 WPOI-5 tumors had DOI of 4-5 mm (24/59 or 40.7%). Only two pT1 WPOI-5 tumors had DOI < 4 mm (3.0 and 3.5 mm). If END were performed in this pT1 cohort for all WPOI-5 OSC patients regardless of DOI, OR all OSC patients with DOI ≥ 4 mm regardless of WPOI, then no OCM would be missed (p = 0.017, 100% sensitivity, 29% specificity, 77% positive predictive value, 23% negative predictive value). With respect to intraoperative WPOI-5 determination, the accuracy, sensitivity, and specificity was 92.16, 73.33, and 100.0%, respectively., Conclusions: DOI ≥ 4 mm is the dominant predictor of OCM. For the rare WPOI-5 OSC with DOI < 4 mm, it is reasonable to suggest that surgeons perform END. WPOI-5 may be accurately determined intraoperatively. As microscopic instruction is needed to accurately assess WPOI-5, a teaching link is included in this manuscript., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Oropharyngeal squamous carcinomas cause significant morbidity and mortality. Poor prognosticators include lymphovascular and perineural invasion. Extratumoral phenotypes of these histologic findings confer worse prognoses., Methods: We report eight cases of recurrent oropharyngeal cancer with diffuse extratumoral lymphovascular invasion (ELVI) or extratumoral perineural invasion (EPNI) and review the existing literature., Results: On salvage resection for recurrence following primary radiation or chemoradiation, six patients manifested ELVI and two showed EPNI. These patterns conferred difficulty with complete surgical clearance; final pathologic analysis demonstrated positive margins for all eight patients. The six patients with ELVI were p16+ and the two with EPNI were p16-. Currently, two patients are deceased and six patients are alive at an average follow-up of 17.4 months. Of the six living patients, 2 have a new recurrence and are in hospice while 4 have no evidence of disease., Conclusions: ELVI and EPNI have received little consideration in the literature as unique histopathologic features of oropharyngeal squamous carcinoma. We present the first series on these adverse extratumoral features in recurrent disease. We call attention to these unique histologic features in the setting of recurrent oropharyngeal cancer to encourage others to track the results of therapeutic intervention and to identify successful strategies for treatment., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Vivian Su is currently employed by the Thyroid Head and Neck Cancer Foundation. Gabriella T. Seo, Monica H. Xing, and Lily Greenberg were previously employed by the Thyroid Head and Neck Cancer Foundation., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Salivary duct carcinoma (SDC) is an uncommon and aggressive salivary malignancy. The oncocytoid variant of salivary duct carcinoma (OSDC) has only been reported in the English literature once before. Here we detail two new patients. A 71-year-old female presented with a painless enlarging left parotid mass. Imaging and fine-needle aspiration were nondiagnostic. The second patient, a 79-year-old male, presented with painless swelling in the right cheek. Imaging was nondiagnostic. Both patients underwent surgical resection. Histopathology revealed bland yet infiltrative OSDC in both cases. These tumors were AR+ (androgen receptor) by immunohistochemistry. Potential difficulty exists in distinguishing the oncocytoid variant of SDC, a rare and relatively bland tumor, from oncocytoma, a more commonly encountered entity. AR expression can aid in the correct diagnosis., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Human papillomavirus associated oropharyngeal squamous cell carcinoma (HPVOPSCC) usually affects a younger patient population. As such, the risk for long term toxicity associated with therapy is an important consideration. Multiple trials focused on de-escalation of therapy to preserve survival outcomes while minimizing treatment toxicity are currently in progress, however the question of which patients are ideal candidates for de-escalation remains unanswered. Circulating tumor DNA (cfHPVDNA) has emerged as a means of monitoring disease in patients with HPVOPSCC. Undetectable postoperative cfHPVDNA levels portend a better prognosis and by extension, may identify ideal candidates for de-escalation therapy. We propose an overview and rationale for a new institutional clinical trial protocol focusing on the use of cfHPVDNA to risk stratify patients for adjuvant therapy. We hypothesize that many surgical patients currently receiving radiation therapy may be clinically observed without adjuvant therapy., Methods: Patients with measurable cfHPVDNA and clinically resectable HPVOPSCC will undergo TORS resection of tumors and neck dissection. Patients with undetectable cfHPVDNA at 3 weeks post-op will be allocated to low or high-risk treatment protocol groups. The low risk group consists of patients with <4 positive lymph nodes, ≤2 mm extranodal extension (ENE), and perineural invasion (PNI) or lymphovascular invasion (LVI) alone. The high-risk group is made up of patients with ≥4 positive lymph nodes, gross ENE, positive margins, N2c disease and/or the combination of both PNI and LVI. The low-risk group will be allocated to an observation arm, while the high-risk group will receive 46 Gy of adjuvant radiotherapy and weekly cisplatin therapy. The primary outcome of interest is 2-year disease recurrence with secondary outcomes of 2-year disease free survival, locoregional control, overall survival, and quality of life measures. A sample of 126 patients in the low-risk group and 73 patients in the high-risk group will be required to evaluate non-inferiority to the standard of care., Discussion: This study will provide much needed recurrence and survival data for patients that undergo primary TORS followed by observation or de-escalated adjuvant therapy. Additionally, it will help delineate the role of cfHPVDNA in the risk stratification of patients that undergo treatment de-intensification., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Chai, Ferrandino, Barron, Donboli, Roof, Khan, Teng, Posner, Bakst and Genden.)

Objective: To measure the effect of thyroidectomy difficulty on intraoperative neuromonitoring false loss of signal (LOS) and to compare intraoperative endotracheal tube-based neuromonitoring (ETNM) and Checkpoint palpation-based direct stimulation (pDS) signals with postoperative laryngoscopy. We hypothesized that pDS has higher a positive predictive value for postdissection confirmation of recurrent laryngeal nerve function than ETNM and that this difference is accentuated with increasing thyroidectomy difficulty., Study Design: Prospective single-arm cross-sectional study comparing ETNM and pDS for patients undergoing hemi-, total, or completion thyroidectomy from July 2018 to March 2020., Setting: Single-surgeon series at a tertiary care hospital., Methods: Percentage concordance and positive and negative predictive values were measured. Each thyroidectomy was assigned a validated thyroidectomy difficulty score, and recorded recurrent laryngeal nerve signals were compared with postoperative vocal fold mobility., Results: Percentage concordance was 90.09%. Positive and negative predictive values were 0.19 (95% CI, 0.09-0.31) and 1.0 for ETNM and 0.59 (95% CI, 0.35-0.82) and 1.0 for pDS. The difference in positive predictive value was significant (0.40 [95% CI, 0.33-0.47], P < .001). False LOS rates for ETNM and pDS were 13.19% versus 3.30% (9.89% [95% CI, 1.80%-18.62%], P = .0155), 44.11% versus 0% (44.11% [95% CI, 25.80%-60.54%], P < .001), and 73.33% versus 13.33% (60% [95% CI, 24.76%-78.46%], P = .001) for the second through fourth thyroidectomy difficulty score quartiles, respectively. False LOS with ETNM was linearly correlated with increasing difficulty ( R 2 = 0.97)., Conclusion: ETNM was subject to high rates of postdissection false LOS that increased with thyroidectomy difficulty score. pDS is a reliable alternative that has higher positive predictive value than ETNM, particularly in more challenging cases such as those with posteriorly fixed thyroid cancers and fibrotic glands., Evidence Level: 2.

Background: Devascularization of the parathyroid glands is generally accepted as the most common mechanism for iatrogenic hypocalcemia, a frequently seen complication of both total and completion thyroidectomy procedures. Much has been written about iatrogenic hypoparathyroidism, but few papers have precisely delineated the arterial supply of the parathyroid glands and the common anatomical variations that may impact parathyroid preservation during thyroid surgery., Methods: We offer an illustrated review and discussion of the only two anatomic studies published in the medical literature focusing on parathyroid vasculature. In addition, we examine current techniques of parathyroid identification, preservation, and classification., Findings: A surgical technique that preserves the parathyroid arteries is vital to preserving the viability of the parathyroid gland(s) during thyroid surgery. In 1907, Halsted and Evans described a technique of ligating the distal branches of the thyroid arteries beyond the origin of the parathyroid arteries, a technique termed ultra-ligation. In 1982, Flament et al.. reported three distinct anatomical variations of the parathyroid arteries which place the parathyroid blood supply at risk for devascularization during thyroid surgery. Our review also highlights novel techniques that aid surgeons in identification and assessment of the parathyroid glands., Conclusions: Recognition of the variations of parathyroid anatomy and their potential to lead to devascularization aids thyroid surgeons in their pursuit of parathyroid preservation. An awareness of the variety of novel parathyroid identification and preservation techniques can assist surgeons to achieve this goal., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Purpose: The varied treatment options available to patients with HPV-positive oropharyngeal squamous cell carcinoma (OPSCC) can cause significant patient confusion. In particular, transoral robotic surgery (TORS) has become widely used for treatment of HPV-positive OPSCC. As patients commonly refer to the internet for additional information, we aim to evaluate the quality of online patient educational materials for TORS in comparison to other otolaryngology surgical procedures., Methods: The terms "transoral robotic surgery," "glossectomy," "thyroidectomy," and "neck dissection" were searched on Google. Flesch reading ease, Flesh-Kincaid Grade Level, MD review rates, and PEMAT understandability and actionability were assessed for each search term. Google trends was used to determine search interest for each term between May 2015 and May 2020., Results: Of the 30 TORS websites that met inclusion criteria, the average FRE and FKGL scores were 40.74 and 11.60 (that of an average high school senior). The FRE and FKGL scores for TORS were all statistically significantly lower than those of all comparator search terms ( P  < .05). Only 1 out of 30 TORS sites were MD reviewed, representing the lowest MD review rate across all search terms. Understandability and actionability scores for TORS were also the lowest across all search terms at 77.71% and 2.66%, respectively. TORS had the lowest search interest., Conclusions: In comparison to other common otolaryngology procedures, TORS websites are the least patient friendly. As TORS becomes a more widely used procedure, it is critical that TORS websites become higher quality resources that patients can reliably reference.

Objectives/hypothesis: The primary objective of this study was to assess the safety of parathyroidectomy during pregnancy as treatment for hyperparathyroidism (HPTH) in comparison to nonsurgical management plans. Secondary outcomes involved analyzing the safety of surgery in the third trimester and the benefit of operating on asymptomatic pregnant patients., Study Design: Systematic review., Methods: PRISMA-guided systematic review of all cases of primary hyperparathyroidism during pregnancy published in peer-reviewed English journals on PubMed/MEDLINE, EMBASE, and SCOPUS from 1980 to 2020., Results: A total of 75 manuscripts were included in this review describing 382 cases of gestational hyperparathyroidism. The median maternal age was 31 years. Overall, 108 cases (28.3%) underwent parathyroidectomy during pregnancy while 274 cases (71.7%) were treated nonsurgically. The majority of surgeries took place during the second trimester (67.6%). Complications and/or deaths were less likely to occur after surgery in the second trimester (4.48%) as compared to surgery in the third trimester (21.1%). Nine surgically treated cases resulted in infant complications and/or death; however, none of these nine cases had any surgical complications. Despite these complications, the overall infant complication rate for patients who underwent surgical treatment remained lower than that of patients treated with conservative therapy (9.1% vs. 38.9%)., Conclusions: This review suggests that for all pregnant patients with diagnosed HPTH, parathyroidectomy should be considered regardless of symptomatology. Our data suggest that parathyroidectomy is associated with fewer risks than more conservative treatments and results in better fetal outcomes. Surgery during the third trimester is feasible and surgery should be considered in both symptomatic and asymptomatic patients. Laryngoscope, 131:1915-1921, 2021., (© 2021 The American Laryngological, Rhinological and Otological Society, Inc..)

Background: Treatment of human papillomavirus-related oropharyngeal squamous cell carcinoma (HPVOPC) results in unprecedented high survival rates but possibly unnecessary toxicity. We hypothesized that upfront surgery and neck dissection followed by reduced-dose adjuvant therapy for early and intermediate HPVOPC would ultimately result in equivalent progression-free survival (PFS) and overall survival while reducing toxicity., Methods: This study was a nonrandomized phase II trial for early-stage HPVOPC treated with transoral robotic surgery (TORS) followed by reduced-dose radiotherapy. Patients with previously untreated p16-positive HPVOPC and <20 pack years' smoking history were enrolled. After robotic surgery, patients were assigned to group 1 (no poor risk features; surveillance), group 2 (intermediate pathologic risk factors [perineural invasion, lymphovascular invasion]; 50-Gy radiotherapy), or group 3 (poor prognostic pathologic factors [extranodal extension [ENE], more than three positive lymph nodes and positive margin]; concurrent 56-Gy chemoradiotherapy with weekly cisplatin)., Results: Fifty-four patients were evaluable; there were 25 in group 1, 15 in group 2, and 14 in group 3. Median follow-up was 43.9 months (9.6-75.8). Disease-specific survival was 98.1%, and PFS was 90.7%. PFS probability via Kaplan-Meier was 91.3% for group 1, 86.7% for group 2, and 93.3% for group 3. There were five locoregional failures (LRFs), including one distant metastasis and one contralateral second primary. Average time to LRF was 18.9 months (9.6-59.0); four LRFs were successfully salvaged, and the patients remain disease free (11.0-42.7 months); one subject remains alive with disease., Conclusion: The results indicate that upfront surgery with neck dissection with reduced-dose radiation for T1-2, N1 stage (by the eighth edition American Joint Committee on Cancer staging manual) HPVOPC results in favorable survival with excellent function in this population. These results support radiation dose reduction after TORS as a de-escalation strategy in HPVOPC., Implications for Practice: Transoral robotic surgery can provide a safe platform for de-escalation in carefully selected patients with early-stage human papillomavirus-related oropharyngeal cancer. In this clinical trial, disease-specific survival was 100%, over 90% of the cohort had a reduction of therapy from standard of care with excellent functional results, and the five patients with observed locoregional failures were successfully salvaged., (© 2021 AlphaMed Press.)

Background: Metastatic thyroid carcinoma to retropharyngeal and parapharyngeal (RP/PP) lymph nodes is rare. Literature suggests previous lateral neck dissection (LND) may alter patterns of lymphatic drainage in the neck, predisposing to these less common sites of spread., Methods: PRISMA-guided systematic search for all published cases detailing RP/PP metastases of well-differentiated thyroid carcinoma from 1970 to 2019., Results: Seventy articles were identified and 44 were included, along with seven cases treated at our institution, totaling 239 cases. Cases represented both retropharyngeal (60.7%) and parapharyngeal (39.3%) metastases identified in the initial (27.6%) and recurrent (72.4%) setting., Conclusion: RP/PP metastases generally present in the recurrent setting. RP/PP metastases often represent high-risk disease, and surgical treatment is recommended., (© 2020 Wiley Periodicals LLC.)

Objective: To evaluate the utility of lymph node ratio (LNR) as a prognostic factor for survival and recurrence in surgically treated patients with human papillomavirus (HPV)-related oropharyngeal squamous cell carcinoma (OPSCC)., Study Design: Retrospective cohort study., Methods: In this retrospective cohort study of a tertiary healthcare system in a major metropolitan area, we reviewed 169 consecutive patients with HPV-related OPSCC treated using transoral robotic surgery. Univariable and multivariable Cox proportional hazards regression analysis with stratified models were used to compare LNR with other traditional clinicopathologic risk factors forrecurrence and survival. An LNR cutoff was found using the minimal P approach., Results: Multivariable Cox regression models showed that each additional percentage increase in LNR corresponded to an adjusted hazard ratio (HR) of 1.04 (confidence interval [CI] 1.02-1.07). LNR was more significant when adjusted for adequate lymph node yield of ≥ 18 nodes (HR 5.05, 95% confidence interval [CI] 1.38-18.47). The minimal P generated cutoff point at LNR ≥ 17% demonstrated a HR 4.34 (95% CI 1.24-15.2) for disease-free survival., Conclusion: For HPV-related OPSCC, continuous LNR and an LNR threshold of 17% could be helpful in identifying recurrent disease in addition to measures such as lymph node number alone., Level of Evidence: 4., (© 2020 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: A subset of patients who undergo major palatomaxillary reconstruction do not initially achieve their intended oncologic and/or reconstructive goals and require additional surgery. We aim to detail the unique management considerations in this patient population., Methods: We performed a retrospective review of patients who underwent palatomaxillary reconstruction by the senior author (m.l.u.) between 1998 and 2016., Results: Twenty-one patients required multiple reconstructions. The median time to second reconstruction was 17 months. The most common reason for a second reconstruction was for recurrent disease (10 of 21), followed by functional/aesthetic reasons (7 of 21) and osteoradionecrosis (4 of 21). Four patients went on to have a third reconstruction, and two underwent a fourth. A total of 27 reconstructions were performed, consisting of 20 soft tissue free flaps, four vascularized bone free flaps, and three locoregional flaps., Conclusion: This patient cohort represents unique oncologic and reconstructive challenges. With long-term follow-up, multiple reconstructions may be required to optimize oncologic and functional/aesthetic outcomes. This is the first series of its kind that details the reasons for, as well as the outcomes of, patients who required multiple reconstructive procedures following initial palatomaxillary reconstruction., Level of Evidence: 2B Laryngoscope, 130:2349-2353, 2020., (© 2019 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: To compare rates of unexpected high-risk pathologic features between Chinese and non-Asian patients who underwent thyroidectomy for papillary thyroid cancer., Methods: This was a retrospective cohort study at a tertiary academic urban medical center. Patients who underwent thyroidectomy for papillary carcinoma from 2015 to 2017 were included. Patient demographics, tumor characteristics, and tumor histopathology were analyzed. Primary outcome was the presence of adverse histopathologic features such as lymphovascular invasion (LVI) or microscopic/minimal extrathyroidal extension (mETE). Differences between the groups were analyzed using multivariate logistical regression analysis and propensity score-weighted analysis., Results: One hundred seventy-nine patients were included: 58 Chinese-born and 121 non-Asian. The median age of the cohort was 47 years old (36-58). Twenty-nine percent of patients were male, and 71% were female. There was no statistically significant difference between the two cohorts in rates of LVI, multifocality, extent of surgery, or presence of thyroiditis. Patients with mETE were more likely to have larger tumors (P = 0.00247). Both the multivariate and propensity-weighted models demonstrated that Chinese ancestry was independently associated with an increased rate of unexpected mETE (adjusted prevalence ratio, 2.52; 95% confidence interval, 1.82-3.48)., Conclusion: mETE is significantly higher in the immigrant Chinese compared to the non-Asian population. Given the high prevalence of unexpected mETE in the Chinese population, the added risk of this finding should be brought into the discussion during initial surgical planning., Level of Evidence: 3 Laryngoscope, 130:1844-1849, 2020., (© 2019 The American Laryngological, Rhinological and Otological Society, Inc.)

The six previously reported civilian cases of mucosal leishmaniasis (ML) diagnosed in the United States have all represented imported New World ML. We describe two new patients with ML diagnosed in New York City-a Syrian immigrant with a nasal mass ( Leishmania tropica ), the first report of Old World ML in the United States, and an American ecologist who worked in Bolivia and had been treated for cutaneous infection 23 years before developing lesions ( L . ( Viannia ) braziliensis ) initially of the uvula, soft palate, and posterior pharynx and subsequently the larynx.

Importance: Incorporation of patient perspectives, or patient-reported outcomes, in functional outcome measures has been gaining prominence in the literature on reconstructive surgery., Objective: To create and validate an instrument for measuring the main functional areas of concern for patients with head and neck cancer., Design, Setting, and Participants: This 4-phase mixed-methods qualitative study was conducted from July 1, 2013, to June 30, 2016, in a quaternary head and neck oncology center in Edmonton, Alberta, Canada. Patients were recruited from 3 Head and Neck Research Network sites: University of Alberta (Edmonton, Canada), Mount Sinai Health Network (New York, New York), and University of Turku Hospital (Turku, Finland). The inclusion criteria included 18 years of age or older, diagnosis of squamous cell carcinoma involving the subsites of the head and neck (ie, oral cavity, oropharynx, hypopharynx, and larynx), and at least 1 year since treatment completion. Those patients who were undergoing additional active treatment or with evidence of disease recurrence were excluded. Data were analyzed from July 1, 2013, to June 30, 2016., Main Outcomes and Measures: The primary outcome measures were the clinical correlation of the Edmonton-33 instrument scores with swallowing, speech, dry mouth, and chewing assessment outcomes., Results: In total, 10 patients with head and neck cancer (mean age, 59.6 years; 6 men [60%]) were included in phase 1 of the study, 5 patients (mean age, 55.2 years) were included in phase 2, 10 patients were included in phase 3, and 25 patients with head and neck cancer (mean age, 62.6 years; 14 men [56%]) participated in the phase 4 validation. The Edmonton-33 instrument scores correlated strongly with the swallowing scores of the MD Anderson Dysphagia Inventory (r = 0.77; 95% CI, 0.49-1.0), the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-Head and Neck 35 (EORTC QLQ-H&N35) (r = -0.73; 95% CI, -1.0 to -0.44), and the modified barium swallow test (r = -0.60; 95% CI, -0.94 to -0.25). The instrument scores were also strongly correlated with the Speech Handicap Index scores (r = -0.64; 95% CI, -0.97 to -0.31), word intelligibility scores (r = 0.61; 95% CI, 0.27-0.95), and sentence intelligibility scores (r = 0.55; 95% CI, 0.19-0.91). A moderate to strong correlation was observed between the Edmonton-33 instrument and the EORTC QLQ-H&N35 scores in the dry mouth (r = -0.54; 95% CI, -0.91 to -0.18) and chewing (r = -0.45; 95% CI, -0.84 to -0.06) domains. The factor loading values for the domains of swallowing, speech, dry mouth, and chewing were all greater than 0.3. The mean factor loading values for the items related to swallowing were 0.71 (95% CI, 0.62-0.80) and for the items related to speech were 0.76 (95% CI, 0.72-0.80). The mean factor loading values for the items related to dry mouth were 0.71 (95% CI, 0.59-0.83) and for those related to chewing were 0.77 (95% CI, 0.69-0.85)., Conclusions and Relevance: The Edmonton-33 appears to be a validated instrument that will allow patients with head and neck cancer to assess and report their own functional outcomes. It could serve as a single comprehensive measure for functional outcomes.

Two dimensional conductive metal-organic frameworks (2D cMOFs) have been widely applied as electrocatalysts, electronic devices, and sensors. In addition, their intrinsic electronic properties could be efficiently tuned via varying the conjugated linkers. Herein, we report a novel 2D cMOF based on complexation of 2,3,7,8,12,13-hexahydroxyl truxene and copper ions via the energy economical interfacial reaction. This 2D cMOF was obtained as a brilliant black powder and showed a bulk electrical conductivity of 3.5 × 10 -3 S cm -1 at 30 °C. Additionally, the cMOF-modified glassy carbon electrode could act as an electrochemical sensor for sensing paraquat with a limit of detection at 4.1 × 10 -8 M (S/N = 3). The accession of truxene-Cu to the cMOF family would shed new light on the impact of the organic conjugated linker and broaden the scope of cMOFs' applications.

Background: Medullary thyroid carcinoma (MTC) is a somewhat rare, particularly aggressive form of thyroid cancer. The authors present what we believe to be the first case of MTC diagnosed solely on the basis of molecular testing, as well as a review of the literature concerning this topic and oncocytic variants of MTC., Case Description: A 30-year-old female patient with a 1.1 cm thyroid nodule underwent a fine-needle aspiration biopsy showing a Bethesda IV Hurthle cell neoplasm. Molecular testing of the specimen identified a RET M918 T mutation. The patient underwent a total thyroidectomy and bilateral central neck dissection. Initial pathologic analysis yielded a diagnosis of Hurthle cell adenoma. Based on the patient's known RET mutation, immunohistochemistry for calcitonin was performed and yielded a positive result. The final diagnosis was amended to an oncocytic variant of medullary thyroid carcinoma., Discussion: Had this patient undergone fine-needle aspiration (FNA) biopsy without molecular testing or serum calcitonin measurement, the patient's disease would have been diagnosed as a Hurthle cell adenoma. Despite the lack of characteristic features of malignancy and the rarity of oncocytic MTC, the diagnostic pitfall in this oncocytic lesion was avoided due to molecular testing at the time of FNA biopsy., Conclusion: This case draws attention to the unique clinical value of molecular testing in the diagnosis of MTC. The authors believe this case supports the consideration for molecular testing to prevent missed diagnoses in cases of rare benign-appearing disease., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Common in head and neck cancer patients, trismus can make speech and swallowing difficult and can compromise quality of life (QOL). Jaw range of motion exercise therapy may prevent or treat trismus in surgical patients. While the importance of these exercises is well-documented, there is little literature regarding the optimal timing of exercise initiation., Methods: A prospective pilot study investigated the effects of early vs late jaw exercise intervention on postoperative jaw opening and QOL measures, which were examined descriptively., Results: Timing of exercise intervention was not found to significantly impact the measured outcomes. However, provisional, descriptive findings showed that jaw opening was significantly associated with multiple QOL measures, with greater jaw opening associated with improved QOL. For certain QOL measures, this positive association was stronger at earlier time points than at later time points., Conclusions: The exploratory findings of this pilot study support further research into possible benefits of early jaw exercise intervention., (© 2019 Wiley Periodicals, Inc.)

Objective: Human papillomavirus (HPV) has been identified as a risk factor for oropharyngeal squamous cell carcinoma (OPSCC) and a cause of the recent dramatic rise in the incidence of this disease. HPV-positive OPSCC typically affects a younger population and has no validated screening test. This study aims to outline the common presenting signs of HPV-positive OPSCC., Methods: We conducted a retrospective single-institution review on 370 patients who were treated at the Icahn School of Medicine at Mount Sinai, New York City, between April 2007 and November 2015 for OPSCC. We included patients with newly diagnosed OPSCC and sufficient history and physical data in the final analysis. Univariate analysis was used to compare HPV-positive and HPV-negative cohorts for demographics, tumor location, tumor staging, initial presentation and symptoms, and physical exam findings., Results: Two hundred and seven patients met the inclusion criteria. The most common initial symptoms for OPSCC were neck mass (51.7%) and sore throat (13.0%). The HPV-positive cohort was more likely to present with a chief complaint of neck mass compared to the HPV-negative cohort (56.1% vs. 22.2%; P = 0.0015). A positive neck exam was associated with HPV-positive status (73.9% vs. 40.7%; P = 0.0012)., Conclusion: HPV-positive OPSCC is an incipient epidemic, poised to surpass cervical cancer as the most common HPV-related cancer by 2020. Initial presenting signs may often be mistaken for benign processes. This study provides physicians with a better understanding of initial presentation of patients with HPV-positive OPSCC, leading to earlier diagnosis and improved outcomes., Level of Evidence: 4 Laryngoscope, 129:877-882, 2019., (© 2018 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: Syphilis is a sexually transmitted infection with various presentations. Although, oropharyngeal manifestations are known to occur, the purpose of this study is to present the first case series in which the lesions were initially mistaken for human-papillomavirus (HPV)-related oropharyngeal squamous cell carcinoma (OPSCC)., Methods: A multi-institutional retrospective review., Results: Six cases of oropharyngeal syphilis were initially thought to be secondary to OPSCC due to presentation. Symptoms were vague and exam findings consisted of either a tonsillar or base of tongue mass, or lymphadenopathy. Biopsies were negative for OPSCC. Further workup diagnosed syphilis, with resolution of symptoms and lesions after antibiotic treatment., Conclusions: Head and neck manifestations of syphilis have been reported in the literature. However, this is the first series reporting on oropharyngeal syphilis masquerading as HPV-related OPSCC. Ultimately, otolaryngologists must maintain a high suspicion for syphilis in order to ensure prompt diagnosis and treatment., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Transoral robotic surgery (TORS) has been utilized to deintensify treatment. No studies have measured swallow safety and efficiency, nor assessed the functional impact of TORS alone., Methods: This prospective cohort underwent baseline and 1-month postsurgery assessments including modified barium swallow evaluation, using the Dynamic Imaging Grade of Swallowing Toxicity (DIGEST) rating system, tongue range of motion assessment, the Performance Status Scale (PSS), and quality of life with the MD Anderson Dysphagia Inventory (MDADI)., Results: All DIGEST safety scores were 0 (normal) at both time points. DIGEST efficiency scores were mildly impaired in 2 of 10 patients postsurgery. PSS scores revealed all patients were on regular diets, were 100% understandable, and were eating in public at both time points. Tongue Range of Motion scores were 100 of 100 at both time points. MDADI scores were not significantly different across time points., Conclusions: Careful identification of patients can result in excellent outcomes following TORS. Future studies will examine longer follow-up of speech, swallowing, and tongue function in patients undergoing TORS surgery., (© 2018 Wiley Periodicals, Inc.)

Background: There is little population-level data evaluating risk factors for postoperative complications after total laryngectomy., Methods: We conducted a retrospective review of the American College of Surgeons National Quality Improvement Program identifying patients who underwent total laryngectomy as a primary procedure from 2005 to 2014. Multivariate analysis was performed to identify variables that were independently associated with overall and major complications., Results: Eight hundred seventy-one cases met inclusion criteria. Three hundred twenty-eight patients (37.7%) had complications, with operative time (hours; P < .0001), class III (P < .001) wound status, and patient age (decade; P = .003) associated with overall complications. Two hundred one patients had major complications that were associated with steroid use (P = .01) and class III (P = .0083) wound classification. Preoperative hematocrit was correlated with a reduction of all and major complications on multivariate analysis (P < .0001 and P = .036)., Conclusion: Identifying and optimizing risk factors may improve outcomes in total laryngectomy., (© 2018 Wiley Periodicals, Inc.)

Objective: Analyze patients treated with transoral robotic surgery (TORS) in the context of the eighth edition of the American Joint Committee on Cancer (AJCC) staging system., Methods: Retrospective cohort study including 110 human papillomavirus-related oropharyngeal cancer (HPV+OPC) patients with a minimum 1-year follow-up treated with TORS between 2007 to 2016. Kaplan-Meier methods were used to estimate 3-year disease-free survival and assess differences in recurrence., Results: One hundred and ten patients with a median follow-up of 54 months were analyzed. Of those, 85% of patients were male, with a median age of 60. Twenty-two percent of patients received no adjuvant therapy; 43% received adjuvant radiation; and 35% underwent adjuvant chemoradiation. Extracapsular spread was identified in 24% of patients. Overall survival was 100%, with estimated 3-year disease-free survival (DFS) (95% confidence interval) of 87% (77, 93). Under the seventh edition of the AJCC, 5% of patients were stage I; 11% were stage II; 26% were stage III; and 57% were stage IVa. Twenty-seven patients (25%) were upstaged on final pathology, whereas 15 patients (14%) were downstaged. Under the eighth edition of the AJCC, 94% of patients were stage I for both clinical and pathologic staging systems. Six patients (6%) were upstaged on final pathology, whereas six patients (6%) were downstaged. No factors demonstrated statistical significance for DFS. Within pathologic stage I, Kaplan-Meier estimates for DFS did not reach statistical significance., Conclusion: The majority of patients undergoing TORS for HPV + OPC are stage I under the eighth edition of the AJCC staging system, with limited pathologic re-staging compared with the prior system. Oncologic outcomes are favorable for this group. No clinicopathologic features are significant for DFS within pathologic stage I., Level of Evidence: 2b. Laryngoscope, 128:1133-1139, 2018., (© 2017 The American Laryngological, Rhinological and Otological Society, Inc.)

Importance: Transoral robotic surgery has revolutionized the practice of head and neck surgery over the past decade, with indications now expanding to include laryngeal pathology. Although laryngeal chondrosarcoma is a rare entity, trends in otolaryngology literature suggest that it can frequently be managed with conservative approaches. We hope to inspire other head and neck surgeons to consider transoral robotic surgery for the treatment of such tumors so that outcomes data can be collected and studied., Observation: An 87-year-old male presented with a left-sided supraglottic mass that was found incidentally on imaging performed for an unrelated reason. Flexible fiberoptic laryngoscopy revealed a cystic-appearing supraglottic mass with near complete obstruction of the glottis airway. Internal review of the imaging demonstrated a 3.5 by 2.3 by 2.8 cm centrally hypodense lesion with a rim of calcification in the left paraglottic space, with resultant narrowing of the laryngeal airway., Intervention: The patient underwent awake tracheostomy and transoral robotic subtotal resection of the mass using the Da Vinci surgical system (Intuitive Surgical Inc., Sunnyvale, CA, USA). The vocal folds, ventricular mucosa, and arytenoid cartilage were grossly preserved. Final pathology revealed a low-grade cartilaginous neoplasm consistent with low-grade chondrosarcoma., Conclusions and Relevance: Chondrosarcoma of the larynx is a rare entity that accounts for roughly 1% of laryngeal neoplasms. Recent trends in otolaryngology literature and practice suggest that low-grade chondrosarcomas can be effectively treated with organ-preserving, conservative surgery. Transoral robotic surgery offers numerous advantages over both open and endoscopic approaches. To our knowledge, this is the first report in the literature describing the successful use of transoral robotic surgery for the resection of a laryngeal chondrosarcoma., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective Identify risk factors for 30-day reoperation and readmission after parathyroidectomy for primary hyperparathyroidism. Study Design Retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database from 2012 through 2014. Subjects and Methods Patients undergoing parathyroidectomy and parathyroid reexploration for primary hyperparathyroidism. Univariate and multivariate analyses were conducted to determine risk factors for reoperation and readmission. Results Of the 9439 patients who underwent parathyroidectomy, 72 patients underwent 1 reoperation in the first 30 days after surgery, and 8 patients underwent 2 reoperations. The most common reasons were hematoma (25%) and persistent hyperparathyroidism (15.9%). Risk factors included smoking (odds ratio [OR], 1.86; 95% confidence interval [CI], 0.97-3.31), insulin-dependent diabetes (OR, 2.38; 95% CI, 1.02-4.86), and history of bleeding disorder (OR, 3.95; 95% CI, 1.48-8.79). In total, 182 (1.9%) patients were readmitted within 30 days of surgery; the most common cause was hypocalcemia (17.0%). Risk factors included operative time (hours) (OR, 1.3; 95% CI, 1.1-1.5), insulin-dependent diabetes mellitus (OR, 2.01; 95% CI, 1.2-3.3), dyspnea with moderate exertion (OR, 5.77; 95% CI, 0.86-14.67), and age (decade) (OR, 1.16; 95% CI, 1.02-1.32). Patients undergoing outpatient surgery were less likely to be readmitted (OR, 0.49; 95% CI, 0.35-0.69) or undergo reoperation (OR, 0.44; 95% CI, 0.27-0.73). Conclusions Thirty-day reoperation rate after parathyroidectomy was low and most commonly occurred due to hematoma. Risk factors for readmission were multifactorial and associated with perioperative factors, patient factors, and medical comorbidities. Preoperative counseling for patients at increased risk of readmission and reoperation may decrease these rates.

Objectives/hypothesis: Fiberoptic laryngoscopy is dependent on accurate descriptions of examination findings. Traditional recording methods can be impractical for inpatient consults. Therefore, we aim to determine the utility of a smartphone-coupled portable recording system with flexible laryngoscopy for transmitting information between resident and attending physicians in a real-time setting., Study Design: Pilot prospective study in a tertiary academic hospital., Methods: This is a prospective study of inpatient consultations in a tertiary referral hospital over a 3-month period from April 2015 to June 2015. Flexible laryngoscopy was performed by a resident physician, and mobile recordings were relayed to an attending physician. Concordance of laryngoscopy interpretations between resident and attending physicians as well as changes in management were documented., Results: Seventy-nine fiberoptic examinations were recorded and compared. Each consult was categorized as follows: airway evaluation (AE) (43%, 34/79), voice evaluation (VE) (3.7%, 3/79), dysphagia (D) (24%, 19/79), and aerodigestive tract mass/pathology (ADM) (29.1%, 23/79). Nine examinations showed discordance between resident and attending interpretations. Inter-rater agreement was good, with a kappa value of 0.747 (95% confidence interval: 0.643-0.851). The frequency of discordant exams within each group was as follows: AE (15%, 5/34), VE (33%, 1/3), D (11%, 2/19), and ADM (4.3%, 1/23). In five patients, changes in laryngoscopy interpretation changed clinical management. Seven nondiscordant exams had a change in management after attending review. Of the 79 exams, only one required repeat flexible laryngoscopy by the attending physician., Conclusions: Portable recording of flexible laryngoscopy is an effective tool for timely management of inpatient consultations., Level of Evidence: 4. Laryngoscope, 128:818-822, 2018., (© 2017 The American Laryngological, Rhinological and Otological Society, Inc.)

Importance: Mucinous eccrine carcinoma is a rare entity that most commonly affects the head and neck. Due to its low frequency of occurrence, review of its etiology, histopathology, and treatment strategies is beneficial to all clinicians who may encounter similar appearing masses., Observation: An 84-year-old male presented with a blue mass on the left cheek. This mass started as a small bump and grew significantly over one year. His primary care physician monitored its growth and ultimately referred to an otolaryngologist. Imaging findings revealed a multi-lobular solid and cystic left buccal lesion. FNA was suggestive of low grade mucoepidermoid carcinoma., Intervention: Patient underwent surgical excision with primary closure of the defect. Frozen section was consistent with low grade salivary malignancy. Final pathology revealed primary mucinous eccrine carcinoma of the skin., Conclusions and Relevance: Mucinous eccrine carcinoma is a rare entity commonly seen in the head and neck region. Mucinous deposits to the skin from primaries elsewhere in the body are much more common than primary lesions of the skin. Histology is a key component of the diagnosis but full oncologic workup is required. Treatment typically includes wide local excision with possible adjuvant chemotherapy or radiation for high risk features., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Eagle Syndrome can present with a variety of symptoms and be caused by an elongated styloid process or calcified stylohyoid ligament. Patients failing medical management of this disorder may be treated with surgical excision of the styloid process. In the literature, transoral and transcervical approach have both been described. Although transoral approaches typically begin with a tonsillectomy, tonsil-sparing approaches have also been utilized. With the advent of robotic surgery, the potential for a tonsillectomy sparing approach has become a feasible alternative, preventing the pain and morbidity associated with adult tonsillectomy while continuing to provide superior exposure and instrumentation. We report three successful cases of patients treated with tonsillectomy sparing transoral robot assisted styloidectomy. This represents the first application of this technique in the literature and suggests the potential for a paradigm shift in the surgical management of this disease., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: While aggressive treatment for oral cancer may optimize survival, decrements in speech and swallowing function and quality of life often result. This exploratory study investigated how patients recover their communicative function, swallowing ability, and quality of life after primary surgery [with or without adjuvant (chemo)radiation therapy] for tongue cancer over the course of the first year post-operation., Methods: Patients treated for oral cancer at three institutions (University of Alberta Hospital, Mount Sinai Beth Israel Medical Center, and Turku University Hospital) were administered patient-reported outcomes assessing speech [Speech Handicap Index (SHI)], swallowing [(M.D. Anderson Dysphagia Inventory (MDADI)] and quality of life [European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Head and Neck Module (EORTC-H&N35)]. Outcome measures were completed pre-operatively and at 1-, 6-, and 12-months post-operatively., Results: One hundred and seventeen patients undergoing partial glossectomy with reconstruction participated in this study. Results indicated no significant differences in swallowing function (MDADI and EORTC-H&N35 subscales) between baseline and 6 months post-surgery and no significant differences in speech function (SHI subscales) between baseline and 1 year post-surgery. Most quality of life domains (EORTC-H&N35 subscales) returned to baseline levels by 1 year post-operation, while difficulties with dry mouth and sticky saliva persisted. A clear time trend of adjuvant (chemo)radiation therapy negatively affecting dry mouth scores over time was identified in this study, while negative independent effects of chemoradiation on MDADI swallowing, and EORTC-H&N35 swallowing, eating, and opening mouth subscales were found., Conclusions: Assessment time influenced patient-reported speech, swallowing, and quality of life outcomes, while treatment (by time) effects were found for only swallowing and quality of life outcomes. Results of the present study will help guide clinical care and will be useful for patient counseling on expected short and long-term functional and quality of life outcomes of surgical and adjuvant treatment for oral cavity cancer.