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Introduction Endoscopic endonasal surgery (EES) has become the preferred approach for pituitary tumor resection. Nevertheless, research on quality of life related to pituitary adenoma surgery is scarce. Objective The aim of the study is to evaluate short-term quality of life in patients after endoscopic endonasal resection of pituitary tumors and to find predictors for poor quality of life (QOL) outcome. Materials and Methods A prospective cohort study was conducted, including all patients who underwent EES for pituitary tumors in a tertiary medical referral center. Recruited patients completed the Anterior Skull Base Disease-Specific QOL (ASBS-Q) questionnaire and the Sinonasal Outcome Test 22 (SNOT-22) questionnaire before surgery, 2 and 4 to 6 months after surgery. Demographic and clinical data was collected. Results Our study included 49 patients. The overall ASBS-Q scores significantly improved 4 to 6 months after surgery (4.46 vs. 4.2, p Conclusion We found that patients after EES reported improved QOL 4 to 6 months post surgery. Specific improvement was noted in the QOL related to pain and vitality.

Objectives: Advanced cutaneous squamous cell carcinoma of the head and neck (CSCCHN) is associated with poor outcome despite multimodality therapy. Comprehensive risk stratification may pinpoint the most suitable adjuvant treatment. This study aimed to evaluate the outcomes of surgically treated locoregional CSCCHN and to identify prognostic indicators of treatment outcomes. Methods: We retrospectively analyzed disease variables, pathologic characteristics, and management in association with treatment outcomes of all consecutive advanced CSCCHN patients who underwent surgical resection at Tel Aviv Sourasky Medical Center. Results: From 2008 to 2018, 74 patients met the inclusion criteria. Only perineural invasion (PNI) was significantly associated with worse overall survival (OS) ( P = .001). Location within the facial “mask areas” was significantly associated with pathologically negative cervical disease ( P = .001). Forty-seven patients underwent adjuvant radiation therapy (RT) which significantly improved OS and disease-free survival versus surgery alone ( P = .025 and P = 0.035, respectively). Conclusion: PNI was associated with worse OS in surgically treated advanced CSCCHN. Adjuvant RT conferred better outcomes despite high risk features.

Accuracy of the number and location of pathological lymph nodes (LNs) in the pathology report of a neck dissection (ND) is of vital importance.To quantify the error rate in reporting the location and number of pathologic LNs in ND specimens.All patients who had undergone a formal ND that included at least neck level 1 for a clinical N1 disease between January 2010 and December 2017 were included in the study. The error rate of the pathology reports was determined by various means: comparing preoperative imaging and pathological report, reporting a disproportionate LN distribution between the different neck levels, and determining an erroneous location of the submandibular gland (SMG) in the pathology report. Since the SMG must be anatomically located in neck level 1, any mistake in reporting it was considered a categorical error.A total of 227 NDs met the inclusion criteria and were included in the study. The study included 128 patients who had undergone a dissection at levels 1-3, 68 at levels 1-4, and 31 at levels 1-5. The best Kappa score for correlation between preoperative imaging and final pathology was 0.50. There were nine cases (3.9%) of a disproportionate LN distribution in the various levels. The SMG was inaccurately reported outside neck level 1 in 17 cases (7.5%).At least 7.5% of ND reports were inaccurate in this investigation. The treating physician should be alert to red flags in the pathological report.

Introduction Isolated nasal obstruction (INO) is a common complaint of multiple etiology. The preoperative evaluation of patients presenting with nasal obstruction and deviated nasal septum (DNS) does not typically include imaging. The benefits of performing computed tomography (CT) in the preoperative setting are inconclusive. Objective Assessing the contribution of preoperative CT to the surgical treatment of non-sinusitis patients presenting with INO and DNS. Methods A retrospective cohort study on patients referred to surgery for nasal obstruction due to DNS or turbinate hypertrophy between 2006 and 2015. Data was retrieved from patients' medical charts. The CT scans and clinical data were reassessed by a second surgeon blinded to the patients' clinical course. Results Seventy of the 843 patients (8.06%) who underwent endoscopic sinonasal procedures during the study period had presented with INO and met the inclusion criteria. Thirty-eight (55.88%) of them underwent CT scans during their preoperative assessment. Modification of the initial preoperative planning based on the radiological findings was required in 32 cases (84.2%). When reassessed by a second blinded surgeon, 58% of cases required surgical modification rather than classical submucosal resection of nasal septum and turbinate reduction (P = 0.048). Conclusion Computed tomography was found beneficial in the preoperative planning for patients with INO. The original surgical plan based upon physical examination findings was modified based on radiological findings in 84.2% of the patients.

Background Masticator space involvement in oral cavity squamous cell carcinoma (OCSCC) is considered an unresectable disease. Nevertheless, achieving negative resection margins is feasible in limited masticatory space involvement. Materials and methods A multi-institutional study on OCSCC patients with masticator space invasion who underwent surgical resection. Margin status was assessed according to anatomic tumor involvement of the inframandibular and supra-mandibular notch. Results One-hundred and thirty-two patients met the inclusion criteria. Then, 67 patients (50.8%) were diagnosed with a supra-notch tumor and 65 (49.2%) with an infra-notch disease. Negative margins were more common in the infra-notch group (43.3 vs. 23.1%, p = 0.014), and positive margins were more common in the supra-notch group (41.5 vs. 23.9%, p = 0.041). Multivariable analysis demonstrated that supra-notch tumors had an increased likelihood for involved resection margins (odds ratio = 2.46, p = 0.036). Conclusion OCSCC patients with masticator space involvement are prone for positive surgical margins in tumors extending above the supra-mandibular notch.

Tracheal invasion in thyroid cancer is a well-known form of advanced disease. There is an ongoing controversy over outcomes of tracheal shaving in this situation. The aim of this study was to compare the results of tracheal shaving to radical resections in patients with low-volume tracheal involvement. An institutional case series and a meta-analysis was conducted. All studies that included patients diagnosed with well-differentiated thyroid cancer (WDTC) and tracheal invasion were analyzed. Patients with low-volume tracheal invasion (according to the Shin classification) were extracted from the various studies and subsequently included in this study. The outcomes of tracheal shaving and radical resection were consolidated and compared. All recurrences and mortality over 10 years of follow-up were calculated using the Kaplan–Meier method. Institutional case series included 22 patients diagnosed with WDTC and tracheal invasion that underwent resection. There was one case of recurrence (4.5%) during the follow-up period and no mortality. The meta-analysis yielded a total of 284 patients from six studies who met the inclusion criteria. The 10-year overall survival was 82.4% for the shave group and 80.8% for the resection group. The combined Kaplan–Meier curves revealed no statistically significant difference between the two techniques (hazard ratio [HR] = 0.86, P = .768). The combined 10-year local control rate of the shave group was 90.2%. The outcomes of tracheal shaving in low-volume invasion are similar to more aggressive forms of tracheal resections. Shave resection is oncologically safe in carefully selected WDTC patients demonstrating minimal tracheal invasion.

To study optimal head position after intratympanic steroid injections to enhance drug bioavailability.Application of virtual and in vitro models of the intratympanic anatomy.The surgical 3-dimensional printing laboratory of a tertiary academic medical center.A high-resolution computerized tomographic scan of healthy temporal bone and surrounding soft tissue was segmented and reconstructed to a 3-dimensional model. The tympanic membrane was perforated in the posterior-inferior quadrant. Methylene blue-stained 10-mg/mL dexamethasone was administered to the middle ear cleft, after which a 3-dimensional rotation in space was performed to hypothesize the optimal position in relation to gravity. The same stereolithography file used for the actual model was used for a digital virtual liquid flow simulation. The optimal head position was defined as the one with the maximum vertical distance between the round window membrane and the plane of the aditus ad antrum and eustachian tube orifice.The virtual model yielded the following position of the head as optimal: 53º rotation away from the injected ear in the vertical axis (yaw), 27º rotation toward the noninjected ear in the longitudinal axis (roll), and 10º neck extension in the transverse axis (pitch).Virtual imaging determined that 53º and 27º yaw and roll, respectively, away and 10º pitch were the optimal position for drug delivery after intratympanic injection to the middle ear and that an erect head position provided optimal passage of steroids from the middle ear to the inner ear.

BACKGROUND The aims of this study were to report our center's experience with infratemporal fossa (ITF) tumors, to review the treatment modalities and outcomes. METHODS Data of patients that underwent resection of ITF tumors in a single tertiary referral medical center were collected and analyzed. RESULTS Sixty-three patients were included. Sarcoma was the most common pathology (18; 29%). The most common surgical approach was the preauricular-orbitozygomatic approach (24; 38%), followed by endoscopic, craniofacial resection, and combined approaches. Forty-seven patients (75%) required reconstruction, 23 (49%) involving free tissue transfer. Thirty-five patients (76%) with malignant lesions required adjuvant therapy consisting of radiotherapy, chemotherapy, or both. Thirty-three patients suffered from complications related to surgery or adjuvant therapy. The three- and five-years survival rates for malignancy were 82% and 66%, respectively. CONCLUSION Complete surgical resection of ITF involving tumors is feasible, providing good long-term survival. Multidisciplinary approach is the key for success.

Objective Myxedema coma is a serious complication of hypothyroidism that can be precipitated by major surgery. It is extremely rare, with only a few reports in the literature. This study aims to present a relatively large case series of post-surgical myxedema coma and to analyze medical and surgical risk factors. Methods Analysis of the patients’ surgical records and medical charts. Results Four patients developed postoperative myxedema coma and were evaluated for risk factors. Three had known hypothyroidism. Two had undergone large head and neck composite resections necessitating a free flap repair for malignant disease. One had undergone coronary artery bypass graft for ischemic heart disease, and another had undergone endoscopic cholecystectomy for complicated cholecystitis. All four patients required prolonged hospitalization, including treatment in the intensive care unit. One patient had undergone full cardiopulmonary resuscitation directly related to the myxedema coma state. Conclusion We present a series of four patients who developed myxedema coma following major surgery. We recommend that patients with known hypothyroidism who are scheduled for major surgery should be tested for thyroid function status and assessed for postoperative risk of hypothyroidism. Those who develop complications following major surgery, should be immediately tested for thyroid function to rule out myxedema coma.

To report a simple and novel method for intra-operative planning of fibula free flap reconstruction by means of a balsa wood (BW) model. Retrospective chart review. Between 2010 and 2015, 29 patients underwent mandibular reconstruction by a BW osteotomy design in which a single BW beam (US$4) is cut into segments to match the plate. The segments are then assembled together in a three-dimensional (3D) fashion to conform to the contour of the defect and the angles of attachment. Osteotomies are then performed according to the BW segment lengths and angles. Outcomes were retrospectively analyzed for number of procedures, operative times, and complications between the balsa wood method and more standard techniques, e.g., conventional 3D models. The length of the average mandibular defect was 9.62 cm (4–19), and the mean number of fibula segments was 2.03 ± 0.92 (range 1–4). Only one case (3.4%) necessitated revision surgery. Three patients (10.3%) had minor complications. Comparison of the results of the 13 patients reconstructed solely by BW to the 16 reconstructed by both BW and a 3D-printed model revealed that the use of BW alone did not significantly alter the average number of segments [2.31 (BW) vs 1.69 (combined); P = 0.07] or ischemia time (173 min vs 171 min, respectively, P = 0.938). The use of balsa wood as a model for intra-operative planning of fibula free flap osteotomies is an effective, inexpensive, and safe technique.

Acute supraglottic laryngitis (ASL) is manifested by supraglottic inflammation that has the potential for rapid and fatal airway obstruction. Complete/incomplete vocal fold immobility (VFIm) in the setting of ASL may contribute to airway obstruction. The rate of VFIm complicating ASL is not known, and it is not clear whether its occurrence alters the course and the management of ASL, particularly the need to secure the airway (by endotracheal intubation/tracheostomy). This study seeks to describe the natural history of VFIm associated with ASL (ASLIm) and to determine the added effect of VFIm on ASL severity, management, and the need for intervention to secure the airway. This is a retrospective cohort study in a tertiary referral center. The medical records of all patients hospitalized due to ASL between January 2007 and December 2016 were reviewed. Of the 214 patients admitted due to ASL, VFIm was identified in 9 (4.2%). The VFIms resolved within 1–90 days in all 8 patients with available follow-up of 1–3 months. One patient required endotracheal intubation. The 9 ASLIm patients had significantly higher rates of hoarseness and a history of diabetes mellitus. There was no group difference in the need to secure the airway. VFIm is an apparently uncommon finding among patients with ASL. It appears to be usually transient, short-lasting, and full recovery can be expected. VFIm did not alter the ASL course, nor did it put our patients at increased risk for the need for intervention to secure the airway. 4.

To compare short- and long-term quality of life (QOL) scores in patients undergoing mandibular resection and reconstruction.All the patients who underwent resection and reconstruction of the mandible between 2000 and 2015 at a large tertiary center were retrospectively reviewed. Their QOL was measured by the University of Washington QOL questionnaire. Between 12 and 189 months (median 83.5 months) had elapsed since the end of treatment. The QOL of the short-term ( 5 years) and long-term ( 5 years) follow-up groups was compared and analyzed.Fifty-eight patients completed the questionnaire. The scores for physical function, emotional function, activity, recreation, and taste domains were significantly higher for the long-term follow-up group. The activity and pain domains posed a significant problem for significantly more patients in the short-term follow-up group.Comparison of the short- and long-term QOL scores of patients undergoing mandibular resection and reconstruction revealed that the scores for the latter were significantly higher in several domains. This finding might be indicative of a cumulative effect of time on patients' QOL, even many years post-treatment.

Background Marfan syndrome (MFS) is a genetic disorder affecting connective tissue. The composition of the dura can change. Consequently, lumbo-sacral dural herniations and cerebrospinal fluid (CSF) leaks are encountered, however, they have yet to been described in the temporal bone. Aims/objectives To define the prevalence of temporal bone meningocele or encephalocele among patients with MFS. Materials and methods Reviewed medical records of all adult patients, diagnosed with MFS, who were treated between 1993 and 2018 at a single academic referral institute. Head targeted CT scans were analyzed. The presence of an anterior or lateral skull base defect was recorded. Results One-hundred and one patients diagnosed with MFS were identified. Twelve of which had suitable CT scans and were enrolled in the study. The median age of patients with defects was 65 years (range 41-71). Five of the twelve patients (41.6%) had tegmen defect. Of the seven defects found, the median size of the defects was 3 mm (range 2-5 mm). All defects were in the temporal bone, none in the anterior skull base. Conclusions and significance The prevalence of radiological evidence of a temporal bone defect among patients with MFS is high. This is a new, important, and potentially life-threatening association with the syndrome.

Pediatric skull base and craniofacial surgery presents a unique challenge since the potential benefits of therapy must be balanced against the cumulative impact of multimodality treatment on craniofacial growth, donor-site morbidity, and the potential for serious psychosocial issues. Skull base reconstruction using locoregional flaps or free flaps may be safely performed in pediatrics. Although the general principles of skull base reconstruction are applicable to nearly all patients, the unique demands of skull base surgery in pediatrics merit special attention. Multidisciplinary care in experienced centers is of utmost importance.

BACKGROUND We aimed to investigate whether depth of invasion (DOI) should be an independent indication for postoperative radiotherapy (PORT) in small oral squamous cell carcinomas (SCC). METHODS Retrospective analysis of DOI (

Objective: The presence of clinically detectable papillary thyroid carcinoma (PTC) metastases in the lateral neck is an indication for neck dissection (ND) and thyroidectomy. Although there is a consensus regarding the importance of therapeutic selective ND of involved levels II to IV in patients with clinically evident locoregional metastatic disease, the prognostic benefit of level V prophylactic ND remains debatable. Methods: All patients who underwent thyroidectomy with ND for metastatic PTC between 2006 and 2019 were included in a single-institution retrospective study. Preoperative characteristics at initial presentation, imaging workup, intraoperative findings, and the final histopathological reports were retrieved from the institutional database. Results: A total of 189 patients with locally advanced PTC were identified, of whom 22 (11.6%) patients underwent therapeutic selective ND at levels II to IV together with level V dissection due to clinical involvement. Comparison of the patients who were operated on level V to those who were not revealed no significant difference. The disease recurrence rate was 20.1% throughout an average follow-up of 5.1±3.1 years. No significant differences in recurrence rate were found between patients who underwent and those who did not undergo level V ND (22.7% vs 19.8%, P = .648). No recurrence at resected level V was detected during follow-up, while recurrence at level V was found in 4 (2.1%) patients who did not undergo level V dissection. Evidence of macroscopic and microscopic extrathyroidal extension was significant predictors of disease recurrence risk. Conclusion: There were no significant associations between level V dissection and risk for recurrence. Recurrence at level V was rare (4/189 patients, 2.1%). Our study’s findings suggest a low prophylactic benefit of an elective level V ND. Elective level V ND should not be done routinely when lateral ND is indicated but should rather be considered after careful evaluation in high-risk patients.

BACKGROUND: After diagnosing well-differentiated thyroid cancer (WDTC), assessment of the risk for disease-specific recurrence is essential for deciding between hemi-thyroidectomy (HT) and total thyroidectomy (TT). The American Thyroid Association (ATA) 2015 guidelines suggest that patients with 1–4 cm WDTC without suspicious features may be suitable for HT. Patients’ preoperatively determined risk levels are re-stratified according to surgical and final histopathological findings. The incidence and clinical implications of high-risk features discovered postoperatively in patients with preoperatively determined low-risk WDTC are yet to be better defined. METHODS: Thyroidectomies performed in the Tel-Aviv Sourasky Medical Center (TASMC) [2006–2018] were included. Patients with 1–4 cm WDTC without evidence of positive cervical lymph nodes, invasion to adjacent structures, or high-risk cytology were considered at low risk for disease-specific recurrence—suitable for lobectomy. Patients were stratified according to their risk for disease-specific recurrence, pre- and postoperatively, and the rate of completion thyroidectomy was determined. RESULTS: In total, 301 (21%) patients were preoperatively stratified as low risk. Forty-six of them (15%) were re-stratified postoperatively as intermediate-to-high-risk. There were no significant differences in the characteristics of the patients who maintained their original stratification to patients who were upscaled to a higher risk level postoperatively. CONCLUSIONS: We report a 15% rate of postoperative risk escalation of patients who required completion thyroidectomy according to current ATA guidelines. In our opinion, this rate of postoperative WDTC upscaling of risk requiring more radical surgery than originally planned, is acceptable. Meticulous preoperative personalized evaluation by an experienced multidisciplinary dedicated team is essential.

Background Papillary thyroid cancer (PTC) usually metastasizes via lymphatic channels in a sequential fashion, first to the central compartment, followed by the lateral neck. PTC patients diagnosed with lateral neck disease (N1b) without proof for central involvement traditionally undergo prophylactic central neck dissection (pCND). However, substantial evidence on outcomes to support this approach is lacking. Materials and methods We conducted a dual center retrospective study to compare the rate of central neck recurrence between N1b PTC patients undergoing pCND and those spared pCND. All patients diagnosed with N1b PTC who underwent total thyroidectomy and lateral neck dissections with or without pCND between January 1998 and December 2015 were included in this study. The rates of central neck recurrences were compared between the groups. Results The 111 patients who met the inclusion criteria were 44 females (39.6%) and 67 males (60.4%), with a mean age of 50.2 ± 17.7 years, and a mean follow-up of 10.2 ± 5.3 years. Sixty patients (54.1%) underwent a pCND and 51 patients (45.9%) did not (non-pCND). During follow-up, 18 patients (16.2%) had level VI recurrences, 13 in the pCND group and 5 in the non-pCND group. Cox-regression models with propensity scoring did not reveal any inclination or an advantage for performing pCND. Conclusion The present study demonstrated no advantage in performing pCND to prevent central neck recurrence among PTC patients with lateral neck involvement only. These findings question the need for pCND in patients without clinical evidence of central neck disease.

Background The free fibula flap is commonly referred to as a “workhorse” for head and neck reconstruction. During our 21-year experience with this flap, we have performed several changes in preoperative planning, operative technique, and postoperative follow-up. Patients and Methods A retrospective cohort study designed to analyze the cohort of patients who underwent free fibula transfer for head and neck reconstruction. Demographics, medical background, operative data, and postoperative outcome were collected. The changes we performed in preoperative planning, operative technique, and postoperative follow-up were assessed and their impact on outcome discussed. Results During 1998 to 2019 a total of 128 free fibula flaps were transferred for head and neck reconstruction. When comparing the patients treated in the early years to those who were treated in recent years we found no statistically significant difference in minor or major nonmicrosurgical complications in the recipient and donor site and in the rate of take backs due to microsurgical reasons. However total flap failure rate improved from 28% in early years to 8% in recent years (p = 0.012). Conclusion During this 21-year period, we performed several changes in our practice. This included the use of a three-dimensional (3D) prefabricated model of the mandible, a shift toward side-table osteotomies, increasing the rate of osteofascial flaps in contrast to osteocutaneous flaps and the use of an implantable Doppler. These changes, together with a learning curve of the surgical team, significantly improved our overall success rates.

OBJECTIVES/HYPOTHESIS The effects of different electrocautery power settings on mucosal contraction and margin status in the oral cavity have not been well established. The aim of this study was to examine how different levels of electrocautery energy outputs affect oral mucosal tissue margins. STUDY DESIGN Animal model. METHODS A model of 23 adult rats was used (two specimens per rat). After anesthetizing the animals, a 6-mm biopsy punch marked the resection margin on the buccal mucosa (one per cheek). The specimens were excised by means of three energy levels, a cold knife, and monopolar diathermy that was set on either 20 W or 30 W cut modes. The specimens were evaluated for extent of contraction. RESULTS A total of 45 samples were obtained and measured, including 15 specimens in the cold-knife group, 15 specimens in the 20 W group, and 15 specimens in the 30 W group. The median diameters of the specimens after resection were 4.5 mm for the cold-knife group (interquartile range [IQR] = 4.0-5.0), 3.5 mm for the 20 W group (IQR = 3.5-4.0), and 2.8 mm for the 30 W group (IQR = 2.5-3.0). Specimen contraction was 25.0%, 41.7%, and 53.3%, respectively. The difference in shrinkage between each pair was statistically significant: cold knife versus 20 W, P = .001; cold knife versus 30 W, P

The 2019 novel coronavirus (SARS-CoV-2) and the disease it causes - coronavirus disease 2019 (COVID-19) have rapidly swept across the world since the first known human manifestation on December 8, 2019 in Wuhan (Hubei Province, China)1,2. The epidemic of the COVID-19 has presented as a grim and complex situation, causing great impact on economy and society, and seriously interfering with ordinary medical practice, threatening to exceed healthcare capacity in many countries over the globe. With no doubt, dealing with the COVID-19 has caused great social and medical crisis that presented great challenges to the medical and healthcare society, forcing it to face unprecedented times, and to reconceptualize how to provide quality health care while enforcing public health measures necessary for pandemic containment and optimal allocation of healthcare resources. However, along with this unparalleled time challenges, came great opportunities for changes and improvements, for innovations and creative solutions, some of which should be adopted and incorporated to the daily medical practices and social routine, even in the post-COVID-19 pandemic era., Highlights • The 2019 novel coronavirus (SARS-CoV-2) has rapidly swept across the world. • The epidemic of the COVID-19 has presented as a grim and complex situation, causing great impact on economy and society, and seriously interfering with ordinary medical practice. • COVID-19 pandemic has created many challenges, but also forced us to re-examine how to provide more patient-centered high-quality care. • The pandemic has changed how we deliver care, which also allows for re-evaluation and improvment of common practices. • We should adopt some of the crisis' guidelines and habits to our new routine.

OBJECTIVES The aim of this study was to assess the extent of thyroid function control among pregnant women who had previously undergone a therapeutic thyroidectomy. DESIGN Retrospective cohort study. SETTING The largest health maintenance organization in Israel. PARTICIPANTS All female patients who were pregnant between May, 2001 and September, 2012 and had a medical history of thyroid surgery. MAIN OUTCOME MEASURE The thyroid-stimulating hormone (TSH) levels throughout the pregnancy were compared to recommended trimestral values. A multivariate analysis was performed to determine risk factors for not attaining TSH recommended range. RESULTS A total of 477 females with a history of thyroid surgery had given 701 births during the study period. Forty-three percent (n = 203), had thyroidal malignancy. Nearly half of the women underwent total thyroidectomy (43.4%, n = 207). The women's TSH values were within the recommended range in only 60% (n = 350) of the pregnancies during the first trimester (0.1-2.5 mIU/L), in 61% (n = 335) during the second trimester (0.2-3 mIU/L), and in 70% (n = 338) during the third trimester (0.3-3 mIU/L). In multivariate analysis, women that underwent a total thyroidectomy due to a benign thyroid disease, were at the highest risk for not attaining target TSH levels. CONCLUSIONS This very large cohort of pregnant women with a past history of thyroid surgery demonstrated a significant percentage of pregnancies with TSH values above the recommended range. Women that underwent a total thyroidectomy due to benign thyroid disease were at the highest risk for gestational hypothyroidism.

Treating malignant tumors of the anterior skull base (ASB) is a challenging task, given their late presentation, diverse histology, and involvement of an intricate anatomical space requiring complex surgery. Advances in imaging, gradual refinement of surgical and reconstruction techniques, and improvement of perioperative care during recent decades have resulted in improved clinical outcomes for patients. In addition, assessing functional outcomes and quality-of-life issues have become a fundamental part in the holistic care of patients with ASB tumors. Once dominated by open procedures, the modern field of skull base surgery is rapidly incorporating endoscopic techniques. These techniques have been previously reserved for sinonasal inflammatory diseases, but in recent years they have sequentially and increasingly been applied to more complex disorders. The list of indications includes intracranial pathologies and malignant sinonasal neoplasms with skull base involvement. Open ASB surgery in this new era is reserved for selected cases, yet it is still considered the "gold standard" for treating ASB malignancy. The paucity of evidence-based data regarding the management of ASB tumors is still a major limit of the discipline of ASB surgery, resulting from the rarity and high degree of heterogeneity of these tumors. Therefore, no guidelines exist and prospective large cohort collaborative studies are required in order to consolidate our knowledge of the behavior of each histology encountered, and to assess the clinical and quality-of-life outcomes of the different treatment modalities currently used.

To provide an overview of the feasibility and safety of current minimally invasive remote-access approaches for thyroid surgery, in view of the amounting new challenges and paradigm shifts in the management of thyroid pathologies. Over the past two decades, several remote-access approaches for thyroid surgery have been developed to improve cosmesis; however, none has been widely adopted extensively in the Western world. The recently emerged transoral endoscopic thyroidectomy via vestibular approach (TOETVA) is the only true minimally invasive approach, completely avoiding skin incisions. It has a relatively short learning curve, midline surgical view, accessible surgical equipment, and relatively broad inclusion criteria with promising surgical outcomes as reported to date. TOETVA has proven to be safe and feasible for carefully selected patients. Further experience and long-term follow-up are needed to define the added value of TOETVA except for improved cosmetic outcome.

Background: The global incidence of thyroid cancer (TC) has risen considerably during the last three decades, while prognosis is generally favorable. We assessed long-term all-cause mortality and its association with cardiovascular risk factors in Israeli TC survivors compared to the general population. Methods: The computerized database of Clalit Health Services, the largest healthcare fund in Israel, was used to identify individuals who were diagnosed with TC during 2001-2014 (exposed group) and age- and sex-matched individuals from the same healthcare system without thyroid disease or a cancer history (non-exposed group). Cox regression hazard ratios (HRs) and 95% confidence intervals (95% CIs) for all-cause mortality were calculated by exposure status. Findings: During a 15-year follow-up (median 8 years), 577 TC survivors out of 5,677 (10·2%) exposed patients and 1,235 individuals out of 23,962 (5·2%) non-exposed patients died. The TC survivors had an increased risk of all-cause mortality (HR=1·89, 95% CI 1·71-2·10), after adjusting for cardiovascular risk factors already present at the beginning of the follow-up. This increased risk was most pronounced in the 55- to 64-year old age group (HR=1·49, 95% CI 1·33-1·67). At the end of the follow-up, the TC survivors who died had a higher prevalence of hypertension (14·6% vs. 10·3%, P=0·002), more dyslipidemia (11·4% vs. 7·2%, P

The risk for occult neck nodal metastasis in carcinoma of the parotid gland is inconclusive. Therefore, addressing a negative neck prophylactically and the extent to do so remain controversial. This systematic review aimed to determine the rate of occult nodal metastasis for each neck level, and consequently, to elucidate the proper extent of elective neck dissection (END). A meta-analysis of all studies that included patients with a diagnosis of parotid malignancies who underwent an END was performed. The risk for occult nodal metastasis was calculated for each neck level separately. The search strategy identified 124 papers from January 1980 to December 2019 in the various databases. Nine retrospective studies (n =548) met the inclusion criteria. The risk for occult neck nodal metastasis ranged from 0.0 to 9.43% with a random-effect model of 2.2% for level 1 (n =459), from 3.4 to 28.38% with a random-effect model of 16.51% for level 2 (n =548), from 0.0 to 21.63% with a random-effect model of 4.23% for level 3 (n =518), from 0.0 to 17.02% with a fixed-effect model of 0.39% for level 4 (n =310), and from 0.0 to 11.63% with a fixed-effect model of 1.7% for level 5 (n =417). The rate of occult neck nodal metastasis in parotid malignancies is low, with neck level 2 the most commonly involved. The results of this meta-analysis prevented the authors from substantiating the appropriate extent of an END in parotid cancer.

Reconstruction of surgical defects by free tissue transfer following resection of head and neck tumors in children are sparse. This study aims to assess the feasibility and safety of free flap reconstruction following surgical ablation of head and neck and skull base tumors in children based on our experience and the recent literature.Data from medical files of all children and adolescents18 years of age who underwent free flap reconstruction following resection of head and neck and skull base tumors at our tertiary center between 2000 and 2018 were retrospectively reviewed. Data on early and late complications at the primary and donor sites, functional and aesthetic outcome, and tumor control were analyzed.Twenty-four children (mean age 11.3 ± 5.1 years) were enrolled. Early complications occurred in 14 (56%) and late complications occurred in 8 (32%) of the procedures, with surgical intervention required in 4 (16%). Prior chemoradiation, sarcoma, non-reanimation procedures, and the use of rectus abdominis free flaps were associated with higher complication rates. The final functional and cosmetic outcomes, including mastication, deglutition, and speech, were satisfactory in all patients with one exception.Free flap transfer is a safe and feasible technique for reconstructing head and neck and skull base defects following surgical excision of tumors in children. Early identification and precautionary measures against the effects of potential causes of complications may improve outcome. Larger international cohort studies are warranted.

Importance Peristomal pathologies in tracheostomized children are common and often difficult to treat. They may preclude decannulation even after the initial pathology that required tracheostomy had been resolved. Objective We evaluated the safety and effectiveness of combined direct laryngoscopy and trans-stomal endotracheal surgery in the treatment of pediatric peristomal pathologies. Methods The medical records of all children and adolescents with tracheostomies who were surgically treated for peristomal pathologies by a combined endotracheal and trans-stomal approach between January 2006 and August 2018 were retrospectively reviewed. Pathologies included stenosis, tracheomalacia, granulation tissue, and a combination of pathologies. Patient demographics and clinical details were retrieved. The primary outcome measure was successful decannulation. Secondary outcome measures were intra- and postoperative complications and number of procedures performed. Results In total, 105 subjects aged 6 months to 17 years who underwent combined direct laryngoscopy and trans-stomal surgery were included. Fifty-two (49.5%) of them were successfully decannulated. The specific decannulation rates were 30.3%, 56%, and 59.6% for tracheal stenosis (TS), suprastomal granulation tissue (SSGT), and both, respectively. Trans-stomal microdebrider resection resulted in decannulation rates of 66.7% for TS and 88.8% for SSGT. Intra- and postoperative complications occurred in 4 (12.1%), 1 (4%), and 9 (20.45%) patients with TS, SSGT, and both, respectively. Older age at the time of first operation (p = .03) and tracheal stenosis (p = .02) were significantly associated with decannulation failure. Conclusion Combined direct laryngoscopy and trans-stomal endotracheal surgery can enable decannulation in almost 50% of children with peristomal pathologies, thus obviating open surgery. Multiple procedures may be required, depending upon the type and severity of the pathology. Complications are more common with multiple pathologies.

Background The diagnostic yield of core needle biopsies (CNB) in cervical lymphadenopathy for lymphoma diagnosis is controversial. The aim of this study was to calculate the accuracy of cervical CNB in diagnosing lymphoma. Methods We conducted a meta-analysis of all studies on patients presenting with cervical lymphadenopathy and referred to CNB. Patients with a diagnosis other than lymphoma were excluded. All cases diagnosed with lymphoma sufficient to guide treatment based on CNB outcome were considered accurate (actionable) results. A separate meta-analysis was performed for various lymphoma subtypes. Results Three prospective and 19 retrospective studies, comprising 1120 patients, met the inclusion criteria. The rate of actionable lymphoma diagnoses following CNB ranged from 30% to 96.3%, with a random-effects model of 82.45% (95% confidence interval [CI] =0.76-0.88) and a fixed-effects model of 78.3% (95% CI =0.75-0.80). Conclusion CNB for cervical lymphadenopathy in lymphoma cases is relatively accurate in guiding treatment.

Objectives/hypothesis To describe the histopathology of the invasion patterns of advanced-stage external auditory canal (EAC) squamous cell carcinoma (SCC). Study Design Retrospective cohort study. Methods Retrospective analysis of medical records of patients diagnosed with EAC SCC available at the Massachusetts Eye and Ear temporal bone (TB) collection. TBs underwent processing for histologic examination. Hematoxylin and eosin-stained slides were examined. Histologic findings were compared to premortem clinical data. Results Nine TBs were identified. Male:female ratio was 6:3. The average age of diagnosis and duration of survival was 64 (46-80 years) and 2.3 years (1-50 months), respectively. All presented with T4 disease, most commonly due to petrous apex (PA) invasion and facial nerve (FN) weakness. The mastoid air cells system served as a tumor conduit to the tegmen mastoideum and overlying dura in four patients, posterior fossa dura in one patient, vertical segment of FN in four patients, and middle ear (ME) and lateral semicircular canal in five patients. The tumor did not penetrate the tympanic membrane, oval window membrane (fenestra vestibule), or round window (RW) membrane. Supra- and infralabyrinthine pneumatization patterns allowed direct routes to the PA. Translabyrinthine PA invasion was seen in two patients. The most common locus of otic capsule invasion was the cochlea. One patient had FN paralysis due to compression rather than invasion. Conclusions SCC does not tend to extend from the ME to the inner ear through the RW and vestibule-stapedial ligament. Tumors tend to spread along the preexisting TB air-tract routes. Well-aerated TB, may facilitate extension to the PA. Level of evidence 4 Laryngoscope, 131:E590-E597, 2021.

Objectives Despite its technical feasibility, anterior skull base surgery still carries the risk of severe postoperative complications, morbidity, and mortality. The reported rate of complications has diminished over the past two decades, but they continue to pose various challenges. This study aims to report late complications in a relatively large series of patients who underwent open anterior skull base surgery, and to propose methods for averting such complications. Methods Retrospective chart review of all patients who underwent anterior open skull base surgery between 2000 and 2016 in a university-affiliated tertiary referral cancer center. Results There were 301 operations, of which 198 (65.8%) were for benign disease and 103 (34.2%) were for malignant tumors. The male-to-female ratio was 1.4:1, and the mean age was 44.8 years. Delayed complications occurred in 85 patients (28.2%): 31 (10.3%) involved wounds, 18 (13.9%) involved the central nervous system, and 14 (4.6%) involved the orbit. Multivariate analysis found malignant pathology, intracranial extension, and previous radiochemotherapy as predictors for the development of a delayed complication. The patients who were operated in the later study period (after 2007) had lower rates of all three types of complications compared with the earlier study period. Conclusion Delayed complications following skull base surgery are in decline. This is mainly due to the advancement in imaging studies, surgical techniques, development of sophisticated reconstructive procedures, and the cooperation of multidisciplinary teams. We attribute the reduction in our department to our revised treatment protocol which is presented herein, with emphasis on averting the occurrence of these complications. Level of Evidence The level of evidence is 4.

Introduction Direct laryngoscopy in children is usually performed with spontaneous ventilation and monitored by pulse oximetry. It is currently unknown if spontaneous ventilation has an effect on cerebral oxygenation. We hypothesized that cerebral oxygenation may be impeded during direct laryngoscopy with spontaneous ventilation in children. Objective Our objective was to determine if children who undergo direct laryngoscopy under general anesthesia with spontaneous breathing experience significant reductions in cerebral oxygen saturation levels, and whether or not these reductions are accompanied by decreases in peripheral oxygen saturation levels. Methods This pilot study included 16 consecutive children who underwent direct laryngoscopy under general anesthesia and spontaneous ventilation. The INVOS™ system, which is currently used to monitor cerebral oxygen saturation levels during neurosurgery and cardiothoracic surgery, consists of a processing unit and 2 sensors that are applied to the patient's forehead. We used it to record cerebral oxygenation levels throughout the procedure. Peripheral pulse oximetry was recorded simultaneously, and the results were compared to the levels recorded by the INVOS™ system. Results Cerebral oxygen saturation levels decreased by more than 20% from baseline in 7/10 children with tracheostomy and in 2/6 children without tracheostomy, while peripheral oxygen saturation levels remained intact in all the children. The mean time from induction of anesthesia to significant decrease in the cerebral oxygenation level (rSO2) was 14 ± 6 min for the tracheostomy group and 14.5 ± 1.5 min for the no tracheostomy group. Conclusions Children who undergo direct laryngoscopy under general anesthesia with spontaneous ventilation may display reductions in brain oxygenation levels that are not detected by standard pulse oximetry, which reflects only peripheral oxygenation levels. Further study is required to explore the possible effect of this phenomenon in children who undergo direct laryngoscopy.

The treatment of patients with advanced head and neck cancers requires an extensive oromandibular and craniomaxillofacial resection in many cases. The reconstruction after these extensive resections presents many challenges to the reconstructive surgical team. The purpose of the reconstruction is not only to rehabilitate the physical facial appearance, but also to rehabilitate function, in order to improve future quality of life. To achieve this goal, the use of free tissue reconstruction is often required. The main challenge with osseous free flap reconstruction of the facial bones is the need of perfect alignment at the defect site. The use of different 3D technologies including computerized models and printed 3D stereolithographic models in the preoperative setting improves the accuracy and the outcome of the reconstruction.

Treating malignant tumors of the anterior skull base (ASB) is a challenging task, given their late presentation, diverse histology, and involvement of an intricate anatomical space requiring complex surgery. Advances in imaging, gradual refinement of surgical and reconstruction techniques, and improvement of perioperative care during recent decades have resulted in improved clinical outcomes for patients. In addition, assessing functional outcomes and quality-of-life issues have become a fundamental part in the holistic care of patients with ASB tumors. Once dominated by open procedures, the modern field of skull base surgery is rapidly incorporating endoscopic techniques. These techniques have been previously reserved for sinonasal inflammatory diseases, but in recent years they have sequentially and increasingly been applied to more complex disorders. The list of indications includes intracranial pathologies and malignant sinonasal neoplasms with skull base involvement. Open ASB surgery in this new era is reserved for selected cases, yet it is still considered the "gold standard" for treating ASB malignancy. The paucity of evidence-based data regarding the management of ASB tumors is still a major limit of the discipline of ASB surgery, resulting from the rarity and high degree of heterogeneity of these tumors. Therefore, no guidelines exist and prospective large cohort collaborative studies are required in order to consolidate our knowledge of the behavior of each histology encountered, and to assess the clinical and quality-of-life outcomes of the different treatment modalities currently used.

OBJECTIVES/HYPOTHESIS Investigate the feasibility of soldering a free cartilage graft into a tracheal defect by laser heating and assessing the resulting burst pressure and thermal damage to the cartilage. STUDY DESIGN Animal study. METHODS A 20 × 8 mm defect was created in fresh cadaveric pig tracheas, a cartilage graft of the same size was harvested from the thyroid ala cartilage, and the graft was fitted into the defect. The soldering process involved covering the edges with liquid albumin and using a fiber-laser system for heating the edges to temperature T under temperature control. This was done for groups of grafts at various temperatures T = 60°C to 90°C. The tracheas were sealed, for each group the burst pressure was measured, and a histologic examination of the soldered incisions was performed. RESULTS The burst pressures were in the range of 66 to 409 mm Hg. The median burst pressure was 78, 157, 231, and 146 mm Hg, respectively, for T = 60°C, 70°C, 80°C, and 90°C. Statistical analysis revealed significant differences in burst pressures between the T = 60°C group and the T = 80°C and T = 90°C groups (P < .05). The highest burst pressure was measured in the T = 80°C group. Histologic examination revealed no thermal damage to the cartilage at this temperature. CONCLUSIONS Performing a sutureless laser soldering of a free cartilage graft to a tracheal defect, achieving an immediate watertight bond, is feasible. At T = 80°C the highest burst pressures were achieved. No histologic damage was observed. In vivo studies are needed before implementation of this technique in laryngotracheopasty. LEVEL OF EVIDENCE NA Laryngoscope, 129:58-62, 2019.

Objectives/hypothesis Anterior skull base operations pose the risk for postoperative cerebrospinal fluid (CSF) leak. Routine lumbar continuous drainage catheter (LD) placement is intended to decrease CSF leaks and central nervous system (CNS) complications, but there are no sound evidence-based data on its efficacy. The primary goal of this study was to review CNS complications following anterior open skull base surgery and their association with LD placement. The secondary goal was to define predictors for the development of early CNS complications. Study design Retrospective case series. Methods We conducted a retrospective analysis of all patients who underwent anterior skull base surgery between 2000 and 2016 at the Tel Aviv Sourasky Medical Center, an Israeli tertiary referral center. Results A total of 226 patients underwent open skull base surgery, of whom 118 had elective perioperative continuous LD insertion and 108 did not. Delayed complications were defined as those occurring more than 30 days after the index operation. Thirty-one (26%) patients in the LD group had early CNS complications compared with only two (1.6%) in the non-LD group, whereas 13 (11%) of the former patients had late CNS complications compared with four (3%) of the latter patients. Early systemic and late wound complications were also significantly more numerous in the LD group. On multivariate analysis, elective LD insertion and intracranial tumor extension were found to be predictors for developing early CNS complications. Conclusions The placement of continuous LDs might increase the risk of developing early and late CNS complications after open anterior skull base surgery. Level of evidence 4 Laryngoscope, 128:2702-2706, 2018.

Background Sorafenib improves progression-free survival in patients with progressive radioactive iodine-refractory differentiated thyroid carcinoma, but causes severe side effects. Estrogens may accelerate thyroid carcinoma cell growth. Our group recently reported that isoflavone derivative 7-(O)-carboxymethyl daidzein conjugated to N-t-boc-hexylenediamine (cD-tboc), a novel anti-estrogenic compound, retards the growth of both thyroid carcinoma cell lines and cultured human carcinoma cells. Vitamin D receptor (VDR) is expressed in malignant cells and responds to 1,25 dihydroxyvitamin D3 (1.25D) by decreased proliferative activity in vitro. The purpose of this study was to examine the effects of vitamin D metabolites (VDM) on the expression of estrogen receptors (ERs), VDR, and 1OHase mRNA, and to evaluate the inhibitory effect of low doses of sorafenib in combination with cDtboc and VDM on cell proliferation in cultured human papillary thyroid carcinoma (PTC). Methods In 19 cultured PTC specimens and 19 normal thyroid specimens, harvested during thyroidectomies from the same patients, expression levels of ERα, ERβ, VDR, and 1 alpha-hydroxylase (1OHase) mRNA (by quantitative real-time PCR) were determined at baseline and after treatment with VMD. Cell proliferation was determined by measurement of 3[H] thymidine incorporation after treatment with sorafenib alone, sorafenib with added 1.25D or cD-tboc, and sorafenib with both 1.25D and cD-tboc added. Results 1,25D increased mRNA expression of all tested genes in the malignant and normal thyroid cells, while the ERα mRNA of the normal cells was unaffected. 1.25D dose-dependently inhibited cell proliferation in the malignant cells. The inhibitory effect of sorafenib on cell proliferation in the malignant cells was amplified after the addition of cDtboc and 1.25D, such that the maximal inhibition was not only greater, but also had been attained at a 10-fold lower concentration of sorafenib (20 μg/ml). This inhibition was similar to that of the generally used concentration of sorafenib (200 μg/ml) alone. Conclusions The demonstration that low concentrations of cDtboc and 1.25D markedly amplify the inhibitory effect of sorafenib on the growth of human PTC supports the use of a 10-fold lower concentration of sorafenib. The findings may promote a new combination treatment for progressive radioactive iodine-refractory PTC.

INTRODUCTION: The impact of the dimensional parameters of the pharyngeal bony frame by its length, width and the position of the hyoid upon the severity of obstructive sleep apnea syndrome (OSAS) has not been investigated in depth. Interactions of those parameters with body mass index (BMI) and their overall reciprocal effect on OSAS severity have also not been established. MATERIALS AND METHODS: This retrospective cross-sectional study was conducted on 108 male OSAS patients followed in OSAS outpatient clinics between November 2014 and October 2015. They all underwent a polysomnography test, and an apnea–hypopnea index (AHI) was calculated. They also underwent an upper airway computerized tomographic scan in which three craniofacial parameters were evaluated: inter-pterygoid distance (IPD), hard palate-to-hyoid (HP-H) distance, and gnathion plane-to-hyoid (GP-H) distance. RESULTS: A longer pharynx and an inferiorly placed hyoid bone correlated with the AHI (r = 0.33, p = 0.001 and r = 0.226, p = 0.03, respectively). GP-H correlated with body mass index (BMI) (r = 0.3243, p

BACKGROUND Up to half of patients with oral cavity squamous cell carcinoma (OCSCC) have stage I to II disease. When adequate resection is attained, no further treatment is needed; however, re-resection or radiotherapy may be indicated for patients with positive or close margins. This multicenter study evaluated the outcomes and role of adjuvant treatment in patients with stage I to II OCSCC. METHODS Overall survival (OS), disease-specific survival, local-free survival, and disease-free survival rates were calculated with Kaplan-Meier analysis. RESULTS Of 1257 patients with T1-2N0M0 disease, 33 (2.6%) had positive margins, and 205 (16.3%) had close margins. The 5-year OS rate was 80% for patients with clear margins, 52% for patients with close margins, and 63% for patients with positive margins (P 2-fold increase in the risk of recurrence (P

Introduction The steady increase in average life expectancy has led to a rise in the number of referrals of elderly patients for major operations. It is not clear whether age itself is a risk factor for morbidity and mortality after skull base operations. We investigated a possible link among a cohort of patients older than 80 years of age who underwent those surgeries in our department. Methods We conducted a retrospective analysis of all patients who underwent skull base surgery at the TASMC (Tel Aviv Sourasky Medical Center) between 2000 and 2016. Results A total of 369 patients underwent open skull base surgeries in our institution, and 13 were patients older than 80 years. The median age of the octogenarians was 83.4 (range 80–89), and the male-to-female ratio was 7:6. Twelve patients had major systemic comorbidities. Four patients had major complications associated with surgery: three had early wound complications, and one each had early central nervous system complications, early and late systemic complications, and late orbital complications. This complication rate is comparable to that of our younger group of 356 patients. The overall survival rate was measured for 30 days, 1 year, and 3 years, and it was not significantly different between the octogenarians and that of the younger patients. Further comparison of the elderly group with 13 matched younger patients revealed no difference of morbidity and mortality between the two groups. Conclusions Despite their systemic comorbidities, the morbidity and mortality rates associated with skull base surgery in octogenarians appear to be comparable to that of younger patients undergoing the same procedures.

Introduction Pediatric skull base and craniofacial reconstruction presents a unique challenge since the potential benefits of therapy must be balanced against the cumulative impact of multimodality treatment on craniofacial growth, donor-site morbidity, and the potential for serious psychosocial issues. Objectives To suggest an algorithm for skull base reconstruction in children and adolescents after tumor resection. Materials and Methods Comprehensive literature review and summary of our experience. Results We advocate soft-tissue reconstruction as the primary technique, reserving bony flaps for definitive procedures in survivors who have reached skeletal maturity. Free soft-tissue transfer in microvascular technique is the mainstay for reconstruction of large, three-dimensional defects, involving more than one anatomic region of the skull base, as well as defects involving an irradiated field. However, to reduce total operative time, intraoperative blood loss, postoperative hospital stay, and donor-site morbidity, locoregional flaps are better be considered the flap of first choice for skull base reconstruction in children and adolescents, as long as the flap is large enough to cover the defect. Our “workhorse” for dural reconstruction is the double-layer fascia lata. Advances in endoscopic surgery, image guidance, alloplastic grafts, and biomaterials have increased the armamentarium for reconstruction of small and mid-sized defects. Conclusions Skull base reconstruction using locoregional flaps or free flaps may be safely performed in pediatrics. Although the general principles of skull base reconstruction are applicable to nearly all patients, the unique demands of skull base surgery in pediatrics merit special attention. Multidisciplinary care in experienced centers is of utmost importance.

Solitary cystic masses of the lateral neck in an adult patient can pose a diagnostic dilemma. Malignancy must be ruled out since metastases arising from H&N cancers may mimic the presentation of benign cystic masses. Only a small number of studies have investigated the diagnostic management and malignancy rate of clinically benign solitary cervical cystic lesions. There are no established guidelines for the diagnostic evaluation. Retrospective review of the clinical, cytological, radiological, and pathological records of all adult patients (> 18 years) operated on for second branchial cleft cysts (BrCC) between 1/2008–2010/2016. Patients with apparent primary H&N malignancy, history of H&N cancer or irradiation, preoperative fine needle aspiration (FNA) of highly suggestive or confirmed malignancy, missing pertinent data, or age less than 18 years were excluded from analysis. 28 patients were diagnosed as having BrCC. The diagnosis was based on clinical findings, FNA cytology, and typical sonographic features. The histologic analysis determined an overall rate of malignancy of 10.7% (3/28): two patients had metastatic papillary thyroid carcinoma, and one patient had metastatic tonsillar squamous cell carcinoma. Purely cystic features on pre-operative ultrasound was the only significant predictor for true BrCC on final histology (p = .02). Occult malignancy is not rare among adult patients presenting with a solitary cystic mass of the lateral neck. A diagnostic algorithm is proposed. Further studies are needed to establish the appropriate workup and management of an adult patient presenting with a solitary cystic mass of the lateral neck.

The purpose of this retrospective chart review study was to review the nature and clinical course of benign and malignant submandibular gland tumors at 2 major university-affiliated tertiary medical centers. All patients who underwent submandibular salivary gland excision between 1990 and 2010 were included. Clinical and disease-related data were collected from the medical charts. One hundred ninety-three patients were identified, of whom 108 (56%) had non-neoplastic disorders (sialolithiasis and sialadenitis). The remaining 85 patients (44%) had a submandibular salivary gland tumor. The most common benign neoplasm was pleomorphic adenoma (53 patients). Twenty tumors (24%) were malignant: adenoid cystic carcinoma in 11 patients, mucoepidermoid carcinoma in 6 patients, and adenocarcinoma in 3 patients. Recurrence was noted in 7 patients with submandibular gland malignancy and in 2 patients with pleomorphic adenoma. The 5-year disease-free survival rate was 63%. Tumors of the submandibular gland are infrequently malignant. Recurrent submandibular salivary gland pleomorphic adenoma is rare compared with recurrences in the parotid gland.