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IMPORTANCE: Fear is commonly experienced by individuals newly diagnosed with papillary thyroid cancer (PTC). OBJECTIVE: To explore the association between gender and fears of low-risk PTC disease progression, as well as its potential surgical treatment. DESIGN, SETTING, AND PARTICIPANTS: This single-center prospective cohort study was conducted at a tertiary care referral hospital in Toronto, Canada, and enrolled patients with untreated small low risk PTC (<2 cm in maximal diameter) that was confined to the thyroid. All patients had a surgical consultation. Study participants were enrolled between May 2016 and February 2021. Data analysis was performed from December 16, 2022, to May 8, 2023. EXPOSURES: Gender was self-reported by patients with low-risk PTC who were offered the choice of thyroidectomy or active surveillance. Baseline data were collected prior to the patient deciding on disease management. MAIN OUTCOMES AND MEASURES: Baseline patient questionnaires included the Fear of Progression–Short Form and Surgical Fear (referring to thyroidectomy) questionnaires. The fears of women and men were compared after adjustment for age. Decision-related variables, including Decision Self-Efficacy, and the ultimate treatment decisions were also compared between genders. RESULTS: The study included 153 women (mean [SD] age, 50.7 [15.0] years) and 47 men (mean [SD] age, 56.3 [13.8] years). There were no significant differences in primary tumor size, marital status, education, parental status, or employment status between the women and men. After adjustment for age, there was no significant difference observed in the level of fear of disease progression between men and women. However, women reported greater surgical fear compared with men. There was no meaningful difference observed between women and men with respect to decision self-efficacy or the ultimate treatment choice. CONCLUSIONS AND RELEVANCE: In this cohort study of patients with low-risk PTC, women reported a higher level of surgical fear but not fear of the disease compared with men (after adjustment for age). Women and men were similarly confident and satisfied with their disease management choice. Furthermore, the decisions of women and men were generally not significantly different. The context of gender may contribute to the emotional experience of being diagnosed with thyroid cancer and its treatment perception.

IMPORTANCE: Pharyngocutaneous fistula (PCF) results in an inflammatory reaction, but its association with the rate of locoregional and distant control, disease-free survival, and overall survival in laryngeal cancer remains uncertain. OBJECTIVE: To determine if pharyngocutaneous fistula after salvage laryngectomy is associated with locoregional and distant control, disease-free survival, and/or overall survival. DESIGN, SETTING, AND PARTICIPANTS: A multicenter collaborative retrospective cohort study conducted at 5 centers in Canada and the US of 550 patients who underwent salvage laryngectomy for recurrent laryngeal cancer from January 1, 2000, to December 31, 2014. The median follow-up time was 5.7 years (range, 0-18 years). MAIN OUTCOMES AND MEASURES: Outcomes examined included locoregional and distant control, disease-free survival, and overall survival. Fine and Gray competing risk regression and Cox-proportional hazard regression models were used for outcomes. Competing risks and the Kaplan-Meier methods were used to estimate outcomes at 3 years and 5 years. RESULTS: In all, 550 patients (mean [SD] age, 64 [10.4] years; men, 465 [85%]) met inclusion criteria. Pharyngocutaneous fistula occurred in 127 patients (23%). The difference in locoregional control between the group of patients with PCF (75%) and the non–PCF (72%) group was 3% (95% CI, −6% to 12%). The difference in overall survival between the group with PCF (44%) and the non–PCF group (52%) was 8% (95% CI, −2% to 20%). The difference in disease-free survival between PCF and non–PCF groups was 6% (95% CI, −4% to 16%). In the multivariable model, patients with PCF were at a 2-fold higher rate of distant metastases (hazard ratio, 2.00; 95% CI, 1.22 to 3.27). Distant control was reduced in those with PCF, a 13% (95% CI, 3% to 21%) difference in 5-year distant control. CONCLUSIONS AND RELEVANCE: This multicenter retrospective cohort study found that development of PCF after salvage laryngectomy is associated with an increased risk for the development of distant metastases.

IMPORTANCE: Accurate measurement of health state utilities (HU) is the cornerstone for cost-utility analyses and the valuation of quality of life for given health states. Current indirect methods of HU derivation lack face validity for patients with head and neck cancer. The appropriateness of these measures compared with direct methods, such as the standard gamble (SG), time trade-off (TTO), and visual analog scale (VAS), have not been assessed in this patient population. OBJECTIVE: To assess the convergent and construct validities of 5 different HU derivation methods in patients with head and neck cancer. DESIGN, SETTING, AND PARTICIPANTS: In a cross-sectional study, we recruited 100 consecutive patients with squamous cell carcinoma of the upper aerodigestive tract treated in the outpatient surgical oncology clinics of the Princess Margaret Cancer Centre from August 1 through October 31, 2014. We enrolled patients with a minimum of 3 months of follow-up after completion of treatment and no evidence of recurrent or metastatic disease. Participants completed SG, TTO, and VAS exercises, the EuroQoL instrument (EQ-5D), and the Health Utilities Index Mark 3 (HUI3) questionnaire. Data analysis was performed November 1 through December 15, 2014. EXPOSURES: Head and neck cancer and HU measures. MAIN OUTCOMES AND MEASURES: We assessed convergent validity of the 5 HU instruments through Spearman rank order correlation assessment. We determined construct validity through a priori hypotheses relating HU scores with clinical indexes of disease severity. RESULTS: The SG and TTO measures generated higher mean (SD) utility scores (0.91 [0.17] and 0.94 [0.14], respectively) than the VAS, EQ-5D, and HUI3 (0.76 [0.19], 0.82 [0.18], and 0.75 [025], respectively) (P < .001). The maximum score of 1.0 was reported in 60 of 99 cases (61%) for the SG and 75 of 99 cases (76%) for the TTO (a significant ceiling effect), in contrast to 5 of 99 cases (5%) for the VAS, 29 of 99 cases (29%) for the EQ-5D, and 6 of 99 cases (6%) for the HUI3. The VAS showed strong correlations with the EQ-5D (ρ = 0.63 [P < .001]) and HUI3 (ρ = 0.50 [P < .001]), and the HUI3 strongly correlated with the EQ-5D (ρ = 0.67 [P < .001]), whereas the SG and TTO generally correlated poorly with other HU measures (ρ range, 0.19-0.29) and with one another (ρ = 0.21 [P < .001]). The VAS, EQ-5D, and HUI3 were able to discriminate between participants who underwent salvage surgery compared with those who underwent primary surgery (mean [SD] utility scores, 0.48 [0.13] vs 0.76 [0.20] [P = .006], 0.62 [0.17] vs 0.83 [0.19] [P = .004], and 0.37 [0.29] vs 0.78 [0.22] [P = .004], respectively). Mean EQ-5D utility scores monotonically increased over time since completion of treatment (0.26 [P = .01]). The HUI3 yielded lower utility values for participants with laryngeal cancer (mean [SD], 0.59 [0.29]). The SG and TTO measures frequently generated utility scores that contradicted our hypothesized expectations. CONCLUSIONS AND RELEVANCE: Indirect HU measures may be more reflective of the health status of patients with head and neck cancer than direct measures. Current instruments lack face validity for attributes germane to this population.

Many patients require tracheal reconstruction either for tracheal stenosismalacia or following tumor extirpation. However, such patients can be debilitated following failed conventional treatments. Recent advances in tissue engineering and vascularized composite grafts are accelerating the field of tracheal reconstruction. This article reviews new clinical concepts for tracheal reconstruction.

OBJECTIVE To develop a clinically useful perioperative blood transfusion prediction model for patients undergoing a major head and neck surgical procedure requiring free-flap reconstruction. DESIGN Retrospective observational study. SETTING Tertiary care university-affiliated teaching hospital (University Health Network, Toronto, Ontario, Canada). PATIENTS All patients with a head and neck malignant neoplasm undergoing major head and neck surgery requiring free-flap reconstruction. MAIN OUTCOME MEASURE Perioperative single-unit red blood cell transfusion. RESULTS All the preoperative variables were tested for an association with perioperative blood transfusion using univariable and multivariable analyses. After multivariable regression analysis, the following preoperative variables were found to be significantly associated with perioperative transfusion: sex, body mass index, T stage, preoperative hemoglobin level, and type of free-flap reconstruction used (ie, osseous vs nonosseous). The regression model was used to develop a transfusion risk score. Receiver operating characteristic curve analysis confirmed adequate discrimination of risk using the transfusion risk score. CONCLUSIONS We have developed a reliable model for predicting perioperative blood transfusion requirements in patients undergoing major head and neck surgery requiring free-flap reconstruction. This model can be used for accurate preoperative risk stratification.Arch Otolaryngol Head Neck Surg. 2010;136(12):1199-1204--

The purpose of this article is to review current microvascular mandibular reconstruction techniques and recent literature on the advances of tissue engineering as they relate to mandibular reconstruction.

Limited follow-up data on aesthetic outcome and survival after microsurgical reconstruction of complex scalp and forehead defects are available. These data are important to improve reconstruction quality and patient counseling. The purpose of this study was to evaluate surgical, aesthetic, and oncologic outcome of free flap scalp and forehead reconstructions in the patient population of two academic centers.

OBJECTIVE To evaluate the survival impact of postoperative radiation therapy (RT) in patients with early T stage (T1-2) oral cavity squamous cell carcinoma (OCSCC) and a single positive lymph node. PATIENTS Between 1983 and 2004, a total of 1539 patients were treated with surgery for T1-2N1 OCSCC. MAIN OUTCOME MEASURES The Surveillance, Epidemiology, and End Results database was used to determine whether postoperative RT improves survival in patients with T1-2N1 OCSCC. RESULTS Postoperative RT improved the 5-year overall survival rate (41.4% for surgery alone vs 54.2% for surgery plus RT [P < .001]). Improvement in overall survival in patients with T1N1 disease did not achieve statistical significance with the addition of RT in contradistinction to that in patients with T2N1 disease. Adjuvant RT improved survival in patients with T2 tongue and floor of mouth disease (52.3% vs 37.9% [P = .002] and 39.9% vs 17.7% [P = .003], respectively). CONCLUSION In cases involving T1-2N1 OCSCC in the Surveillance, Epidemiology, and End Results database, the use of RT is associated with statistically significant improved overall survival and cause-specific survival in patients with T2 disease, most strongly in the oral tongue and the floor of the mouth.Arch Otolaryngol Head Neck Surg. 2010;136(3):225-228--

While 7 face transplants have been performed around the world, to date, there remains debate regarding the validity of this procedure. We submit that performing a facial transplant—in the appropriately selected patient—is technically defensible and ethically sound. By outlining the technical and ethical boundaries of the debate, responding to the key arguments against the procedure, and describing its motivations and potential benefits, we state our justification of facial transplantation.Arch Facial Plast Surg. 2010;12(1):60-63--

OBJECTIVE To compare the 20-year cost-effectiveness of initial hemithyroidectomy vs total thyroidectomy in the management of small papillary thyroid cancer in the low-risk patient. DESIGN Pooled data from the published literature were used to determine key statistics for decision analysis such as rates of recurrence, rates of complications for all interventions undertaken, and rates of death. The 2005 costs were obtained from the US Department of Health and Human Services, as well as from Medicare reimbursement schedules. Future costs were discounted at 6%. SETTING Decision analysis study. PATIENTS Data from the published literature. MAIN OUTCOME MEASURES A state-transition (Markov) decision model was constructed based on the most recent American Thyroid Association recommendations. A cost-effectiveness analysis was performed using fixed probability estimates and Monte Carlo microsimulation, with effectiveness defined as cause-specific mortality or recurrence-free survival. After identifying initial results, sensitivity and threshold analyses were performed to assess the strength of the recommendations. RESULTS Initial probability estimates were determined from a review of 940 abstracts and 31 relevant studies examining outcomes in patients with low-risk thyroid cancer undergoing thyroidectomy or neck dissection. During 20 years, cost estimates (including initial surgery, follow-up, and treatment of recurrence) were between $13 896.81 and $14 241.24 for total thyroidectomy and between $15 037.58 and $15 063.75 for hemithyroidectomy. Cause-specific mortality was similar for both treatment strategies, but recurrence-free survival was higher in the total thyroidectomy group. Sensitivity and threshold analyses demonstrated that these results were sensitive to rates of recurrence and cost of follow-up but remained robust when compared with willingness to pay. CONCLUSIONS Total thyroidectomy dominates over hemithyroidectomy as initial treatment for low-risk papillary thyroid cancer. However, in sensitivity analyses, these results varied by institution because of heterogeneity in long-term treatment outcomes. With changing protocols of management, it is possible that hemithyroidectomy will emerge as being more cost-effective. Long-term prospective trials are necessary to validate our findings.Arch Otolaryngol Head Neck Surg. 2007;133(12):1245-1253 --

ObjectivesLittle evidence exists to guide surgeons in the management of the sublingual glands (SLG) not macroscopically involved by squamous cell carcinoma of the floor of mouth and oral tongue. This study aims to determine the frequency with which the SLG is invaded, to identify variables predicting for SLG invasion and the morbidity associated with it's resection in entirety.

Objectives:Laryngopharyngeal reconstruction continues to challenge in terms of operative morbidity and optimal functional results. The primary aim of this study is to determine whether complications can be predicted on the basis of reconstruction in patients undergoing pharyngectomy for tumors involving the hypopharynx. In addition, we detail a reconstructive algorithm for management of partial and total laryngopharyngectomy defects.

The occurrence of pharyngocutaneous fistula after oncologic head and neck surgery is a serious complication. It is the most common complication after major hypopharyngeal and laryngeal ablative surgery. The cause and management guidelines are still controversial. Contributing risk factors of impaired wound healing should be recognized in preoperative planning. Perioperative technical issues and preventive postoperative care play a major role in the prevention of fistulae, limiting the severity of the fistula and minimizing secondary complications. Surgical salvage of cancers treated with organ preservation approaches is associated with higher rates of postoperative complications, particularly in cases in which mucosal membranes are transgressed and surgically closed. Patients who require surgical repair are best treated by the use of regional myocutaneous flaps or free tissue transfers. This subset of patients is likely best treated in regional centers of excellence with well developed multidisciplinary programs for ablative and reconstructive head and neck surgery.