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Objectives/Hypothesis The hypoglossal nerve (XII) has been used as a donor nerve in facial and laryngeal reinnervation. The purpose of this study was to investigate the neuromuscular changes that occur within the tongue following partial or complete transection of XII using a canine model. Study Design Histopathological comparison of tongue denervation following two types of XII resection in a canine model. Methods Ten adult canines underwent complete unilateral resection of XII or resection of only the medial terminal branch of the hypoglossal nerve (mXII). After 6 months of recovery, tongue specimens were analyzed histopathologically using whole cross-sections. Routine histologic sections were assessed by two neuropathologists blinded to the type of denervation. The cross-sectional area was calculated of both sides of the tongue, and the amount of myosin was quantified morphometrically using immunohistochemistry for myosin (antimyosin heavy chain, fast isotype). Statistical comparison between partial and complete denervation was performed using the Student t test. Results Six months following XII transection, quantitative measures of the cross-sectional area of the tongue and content of myosin demonstrated severe muscle atrophy on the operated side of the tongue for both groups, compared to the nonoperated side. For partial transection involving only mXII, the degree of atrophy was less severe (P < .05). Conclusions This study provides new histological information demonstrating that partial resection of the hypoglossal nerve, sacrificing only the proximal medial branch of the hypoglossal nerve (mXII), results in less severe atrophy of the tongue than complete transection of the entire hypoglossal nerve. Level of Evidence NA Laryngoscope, 2016

Background Head and neck cancer constitutes a substantial portion of the burden of disease in South Asia, and there is an undersupply of surgical capacity in this region. The purpose of this study was to estimate the economic welfare losses due to head and neck cancer in India, Pakistan, and Bangladesh in 2010. Methods We used publicly available estimates of head and neck cancer morbidity and mortality along with a concept termed the value of a statistical life to estimate economic welfare losses in the aforementioned countries in 2010. Results. Economic losses because of head and neck cancer in India, Pakistan, and Bangladesh totaled $16.9 billion (2010 US dollars [USD]), equivalent to 0.26% of the region's economic output. Bangladesh, the poorest country, experienced the greatest proportional losses. Conclusion The economic consequences of head and neck cancer in South Asia are significant, and building surgical capacity is essential to begin to address this burden. © 2016 Wiley Periodicals, Inc. Head Neck, 2016

Objective To collect data on skull base surgery training experiences and practice patterns of otolaryngologists that recently completed fellowship training. Design A 24-item survey was disseminated to physicians who completed otolaryngology fellowships in rhinology, head and neck oncology, or neurotology between 2010 and 2014. Results During a typical year, 50% of rhinologists performed more than 20 endoscopic anterior skull base cases, 83% performed fewer than 20 open cases, and were more confident performing advanced transplanum ( p = 0.02) and transclival ( p = 0.03) endoscopic approaches than head and neck surgeons. Head and neck surgeons performed fewer than 20 endoscopic and fewer than 20 open cases in 100% of respondents and were more confident with open approaches than rhinologists ( p = 0.02). Neurotologists performed more than 20 lateral skull base cases in 45% of respondents during a typical year, fewer than 20 endoscopic ear cases in 95%, and were very comfortable performing lateral skull base approaches. Conclusion Many recent otolaryngology fellowship graduates are integrating skull base surgery into their practices. Respondents reported high confidence levels performing a range of cranial base approaches. Exposure to endoscopic ear techniques is minimal in neurotology training, and rhinology training appears to offer increased exposure to skull base surgery compared with head and neck training.

Objectives/Hypothesis To determine the value of a collaborative course for advanced head and neck surgery in East Africa. Study Design Survey of participants. Methods A 3-day course in head and neck surgery was designed for otolaryngologists and trainees from Kenya and surrounding countries through a collaborative effort between Kenyatta National Hospital, the University of Nairobi, and the Head and Neck Divisions from the Vanderbilt Bill Wilkerson Center and the Massachusetts Eye and Ear Infirmary. Topics included neck dissection, parotidectomy, total laryngectomy, parapharyngeal space tumors excision, and pectoralis myocutaneous flaps. A pre- and postcourse self-evaluation survey was administered to measure course impact. Results Eighteen otolaryngologists and trainees participated in the course, with 17 completing course surveys. The majority of participants (72%) were from Kenya. Prior to the start of the course, 41%, 71%, 23%, 12%, and 0% of participants indicated they could complete a neck dissection, parotidectomy, parapharyngeal space mass excision, total laryngectomy, and pectoralis myocutaneous flap, respectively. Following the course, 50%, 94%, 69%, 25%, and 38% of participants indicated they could complete a neck dissection, parotidectomy, total laryngectomy, parapharyngeal space tumors excision, respectively, with a statistically significant increase identified for pectoralis myocutaneous flaps (P

Objectives/Hypothesis To identify histopathologic features associated with poor correlation of frozen and permanent pathology margins following wide local excision for advanced cutaneous squamous cell carcinomas of the head and neck. Study Design Retrospective review. Methods A retrospective review of patients undergoing excision of advanced head and neck squamous cell carcinomas between the years 2010 AND 2013 was performed. Demographic, operative, and pathology data were collected. Overall correlation between frozen section margins and final margins on permanent section results was calculated. Positive and negative predictive values of several histopathologic features were determined. Results Forty-one cases were identified from the database. Perineural invasion, lymphovascular invasion, and a component of poorly differentiated carcinoma were identified in 61.3%, 34.5%, and 17.1% of cases, respectively. Discrepancy between frozen section margins and permanent margins was identified in eight cases (19.5%). The false-negative rate for poorly differentiated carcinoma, lymphovascular invasion, and perineural invasion was 14%, 36%, 26%, respectively. The positive and negative predictive value of poorly differentiated carcinoma, lymphovascular invasion, and perineural invasion in predicting discrepancy between frozen and permanent margins was 14% and 80%, 36% and 84%, and 26% and 92%, respectively. Conclusions This study demonstrated a moderate rate of discrepancy between frozen and permanent section analysis of operative margins from high-risk cutaneous squamous cell carcinomas of the head and neck. The presence or absence of certain histopathologic features appears to be associated with a higher rate of frozen section discrepancy. Evaluation of these features in a preoperative biopsy or staging excision may be useful in planning definitive excision and reconstruction. Level of Evidence 4 Laryngoscope, 125:636–639, 2015

Complications arising from acute suppurative parotitis (ASP) are rare but can be morbid. We report the case of a young female who presented with facial swelling, trismus and diplopia. She was found to have ASP complicated by orbital abscess, cavernous sinus thrombosis, carotid arteritis, and cerebral infarction. Cultures from parotid abscess needle aspiration, orbitotomy and blood sampling returned fusobacterium necrophorum. After a lengthy course of antibiotics and anticoagulation, the patient recovered to near-baseline status. To the best of our knowledge, this is the first case of ASP with such extensive orbital and vascular complications, and highlights the importance of awareness for such events.

Objectives/Hypothesis Determine trends in global health-related publication in otolaryngology. Study Design A review of research databases. Methods A search of publications available on PubMed and nine additional databases was undertaken reviewing two time periods 10 years apart for the timeframes 1998 to 2002 (early time period) and 2008 to 2012 (recent time period) using specific search terms to identify global health-related publications in otolaryngology. Publications were examined for region of origin, subspecialty, type of publication, and evidence of international collaboration. χ[2] and t test analyses were used to identify trends. Results In the 1998 to 2002 time period, a total of 26 publications met inclusion criteria for the study, with a mean of 5.2 ± 2.8 publications per year. In the 2008 to 2012 time period, a total of 61 publications met inclusion criteria, with a mean of 12.3 ± 5.6 publications per year. The 235% increase in global health-related publications identified between the two study periods was statistically significant (P = .02). The absolute number of publications in which collaboration occurred between countries increased from three in the early time period to nine the recent time period. Conclusions There has been a significant increase in the volume of global health-related publications in English language otolaryngology journals over the past decade, providing strong evidence of the increasing trend of global health as an academic pursuit within the field of otolaryngology. Level of Evidence NA Laryngoscope, 125:848–851, 2015

To highlight an unusual cause of chronic cough, we present two cases of chronic cough in older children referred to a pediatric otolaryngology outpatient clinic with persistent symptoms despite extensive previous workup and treatment. Cranial neuropathy was identified in each case. As a result, magnetic resonance imaging was performed revealing Chiari type I malformation. In each case, surgical decompression provided symptom improvement. Chronic cough is a rare presenting symptom in children with Chiari type I malformation. We emphasize the significance of awareness for unusual cases of cough to aid in the correct identification and treatment in children.

Objectives/Hypothesis To determine trends in office visits and medical specialty seen for surgical diagnoses of the thyroid gland. Study Design A cross-sectional analysis of a national healthcare database. Methods From the National Ambulatory Medical Care Survey (NAMCS), all cases of surgical thyroid disorders (e.g., benign neoplasm of thyroid gland, malignant neoplasm of thyroid gland, multinodular goiter) were extracted for 2 calendar year cohorts: 1995 to 1999 and 2005 to 2009. In addition to demographic information, the medical specialty of the health care provider seen was extracted. Comparisons were conducted for the proportion of surgical thyroid cases seen between general surgeons and otolaryngologists for the respective cohorts. Results In the 1995 to 1999 cohort, there were a total of 107 ± 13 thousand outpatient visits annually to either general surgery or otolaryngology for surgical thyroid conditions. Among these, 62.7 ± 8.4 thousand visits (58.3 ± 5.6%) were seen by general surgery versus 44.8 ± 9.1 thousand (41.7 ± 5.6%) seen by otolaryngology. In comparison, in the 2005 to 2009 cohort, there were 218 ± 29 thousand visits annually for surgical thyroid conditions. Among these, 88.4 ± 17 thousand (40.5 ± 5.4%) were seen by general surgery versus 130 ± 21 thousand (59.5 ± 5.4%) seen by otolaryngology. The increase in proportion of surgical thyroid patients seen by otolaryngology in the second 5 year cohort was statistically significant (P = 0.032, chi-square). Conclusions There is a national trend in the United States toward otolaryngologists seeing an increasing majority proportion of increasingly prevalent surgical thyroid conditions. These data objectively confirm the perceived increasing role of otolaryngologists in the management of surgical thyroid disorders on a national level. Level of Evidence 2a. Laryngoscope, 123:3239–3242, 2013

Background Allergic rhinitis (AR) and chronic rhinosinusitis (CRS) are a major burden to the healthcare system. Although no causal relationship has been established, previous work has demonstrated a strong association of AR with CRS. In this study, we sought to identify risk factors that may influence speed of development of CRS in patients with AR. Methods Retrospective review of all patients diagnosed with AR without CRS presenting to an otolaryngology clinic at a tertiary medical center as part of a multidisciplinary allergy evaluation between March 2004 and November 2011. Medical records were evaluated for clinicodemographic factors including age, gender, smoking history, medical comorbidities, categories of AR based on formal allergy testing, the presence of sinonasal anatomic variants on computed tomography as well as subsequent development of CRS. Results Faster progression to CRS in patients with AR was associated with comorbid asthma (hazard ratio [HR] = 3.97) as well as sinonasal anatomic variants, such as infraorbital cells (HR = 7.39), and frontal intersinus cells (HR = 68.03), on multivariate survival analysis. A statistically significant but negative interaction between infraorbital cells and frontal intersinus cells suggests that concomitant presence of both leads to a less than additive increase in the rate of CRS progression. Conclusion Sinonasal anatomical variants, infraorbital cells, and frontal intersinus cells, as well as comorbid asthma are associated with faster development of CRS in patients with AR. The presence of these clinical risk factors identifies patients who should be counseled on compliance with medical therapy for AR.

The hypoglossal nerve (XII) has been used as a donor nerve in facial and laryngeal reinnervation. The purpose of this study was to investigate the neuromuscular changes that occur within the tongue following partial or complete transection of XII using a canine model.Histopathological comparison of tongue denervation following two types of XII resection in a canine model.Ten adult canines underwent complete unilateral resection of XII or resection of only the medial terminal branch of the hypoglossal nerve (mXII). After 6 months of recovery, tongue specimens were analyzed histopathologically using whole cross-sections. Routine histologic sections were assessed by two neuropathologists blinded to the type of denervation. The cross-sectional area was calculated of both sides of the tongue, and the amount of myosin was quantified morphometrically using immunohistochemistry for myosin (antimyosin heavy chain, fast isotype). Statistical comparison between partial and complete denervation was performed using the Student t test.Six months following XII transection, quantitative measures of the cross-sectional area of the tongue and content of myosin demonstrated severe muscle atrophy on the operated side of the tongue for both groups, compared to the nonoperated side. For partial transection involving only mXII, the degree of atrophy was less severe (P.05).This study provides new histological information demonstrating that partial resection of the hypoglossal nerve, sacrificing only the proximal medial branch of the hypoglossal nerve (mXII), results in less severe atrophy of the tongue than complete transection of the entire hypoglossal nerve.NA Laryngoscope, 126:2689-2693, 2016.

Objective To characterize our experience with the surgical management of anterior skull base malignancy, and to propose an algorithm for surgical approach to anterior skull base malignancies. Design Retrospective review. Setting Academic cranial base center. Participants Sixty-seven patients who underwent resection of paranasal sinus or anterior skull base malignancy with an endoscopic, cranioendoscopic, or traditional anterior craniofacial approach. Outcome Measures Complications, recurrence, and survival. Results There were 48 males and 19 females, ranging from 6 to 88 years old. There were three groups: endonasal endoscopic resection (n = 10), cranioendoscopic resection (n = 12), and traditional craniofacial resection (n = 45). The most common tumor pathologies included esthesioneuroblastoma, squamous cell carcinoma, and sinonasal undifferentiated carcinoma. Patients with T3/T4 disease were less likely to undergo endoscopic resection (p = 0.007). The 5-year disease-free survival was 82.1% overall, with no statistically significant differences among approaches. There were no differences in orbital complications, meningitis, or cerebrospinal fluid leak. Use of a transfacial incisions predisposed patients to surgical site infection and sinocutaneous fistulae. An algorithm for surgical approach was developed based on these results. Conclusion Sinonasal and skull base malignancies can be safely surgically addressed via several approaches. Surgical approach should be selected algorithmically based on preoperative clinical assessment of the tumor and known postoperative complication rates.

Background Head and neck cancer, for which the diagnosis and treatment are often surgical, comprises a substantial proportion of the burden of disease in South Asia. Further, estimates of surgical volume suggest this region faces a critical shortage of surgical capacity. We aimed to estimate the total economic welfare losses due to the morbidity and mortality of head and neck cancer in India, Pakistan, and Bangladesh for 1 year (2010). Methods We used publicly available estimates from the Institute for Health Metrics and Evaluation regarding the morbidity and mortality of head and neck cancer in India, Pakistan, and Bangladesh, along with an economic concept termed the value of a statistical life, to estimate total economic welfare losses due to head and neck cancer in the aforementioned countries in the year 2010. The counterfactual scenario is absence of disease. Sensitivity analyses were done with regard to how the value of a statistical life changes with income. Findings In 2010, the most conservative estimate of economic welfare losses due to head and neck cancer in the three studied countries is US$16·9 billion (2010 USD, PPP), equivalent to 0·26% of their combined gross domestic product (GDP). The welfare losses experienced by the population younger than 70 years of age accounted for US$15·2 billion (90% of the total losses). When adjusted for the size of their respective economies, Bangladesh, the poorest of the three countries, incurred the greatest loss (US$930 million), equivalent to 0·29% of its GDP. India and Pakistan experienced welfare losses of US$14·1 billion and US$1·9 billion, respectively. These figures are equivalent to 0·26% of the GDP for both countries. Oropharyngeal and hypopharyngeal cancer made up the largest share of the total burden at 39% (US$6·6 billion), followed closely by oral cavity cancer at 34% (US$5·7 billion). Interpretation The burden of non-communicable diseases, to which cancer contributes greatly, is growing at a rapid pace in South Asia. Head and neck cancer is a leading cause of cancer-related mortality in this region, and this study suggests that the associated economic welfare losses, estimated to be US$16·9 billion in 2010 alone, are substantial. A number of strategies are available to address this burden. Surgery, as part of a multidisciplinary approach that includes radiation therapy and chemotherapy, plays a central part in the diagnosis and treatment of head and neck cancer, and building surgical capacity, which offers large economies of scope and scale, can not only address the burden of head and neck cancer, but also create a platform for beginning to confront the rising tide of non-communicable diseases. Funding None.

Patients with a septal deviation and concerns about nasal obstruction often undergo septoplasty to improve nasal airflow. Following primary septoplasty, however, some patients have persistent symptoms due to nasal valve dysfunction and may require nasal valve surgery.To evaluate the change in disease-specific quality of life for patients who undergo nasal valve correction after failed septoplasty using the Nasal Obstruction Symptom Evaluation (NOSE) survey and to determine whether identifiable anatomical risk factors are more common in patients with a history of failed septoplasty.Prospective observational outcomes study conducted at a tertiary care medical center. Forty patients who underwent nasal valve correction through an open approach from January 1, 2012, through December 31, 2014, with a history of septoplasty for nasal obstruction were included. Data analysis was conducted from January 1, 2013, through May 1, 2015. [corrected].Demographic information, a standardized nasal examination, and preoperative and postoperative NOSE scores were collected and reviewed.Comparison between preoperative and postoperative NOSE scores at 2, 4, and more than 6 months after surgery.Forty patients were included in the study; 23 (57%) were male and 17 (43%) were female. The mean age was 39.3 years. Findings from preoperative nasal examination demonstrated moderate or severe internal nasal valve narrowing in 38 (95%) patients, internal nasal valve collapse in 19 (48%), external nasal valve narrowing in 18 (45%), or external nasal valve collapse in 16 (40%). The most common anatomical cause of obstruction was internal nasal valve narrowing in 38 (95%) patients, dorsal septum deflection in 26 (65%), and narrowed middle vault in 16 (40%). The mean (SD) preoperative NOSE score was 75.7 (20.1). Mean (SD) postoperative NOSE scores at 2, 4, and greater than 6 months were 31.4 (27.2), 34.0 (19.8), and 22.1 (18.8), respectively, with significantly improved NOSE scores at each time point compared with before surgery (P .001).Nasal valve dysfunction remains an underdiagnosed entity and should be considered in all patients with septal deviation before septoplasty, especially in patients with a severe dorsal deflection and a narrow middle vault. In this study, surgical nasal valve correction demonstrated a significant reduction in nasal obstruction, as measured by a validated outcome measure, in patients for whom a previous septoplasty had failed.4.

To characterize patterns of utilization and outcomes following transfusion in head and neck patients undergoing free flap reconstruction.Case series with chart review.Tertiary academic medical center.Two hundred eighty-two head and neck patients undergoing free flap reconstruction from 2011 to 2013. Outcome parameters included post-transfusion hematocrit increase, length of stay (LOS), flap survival, and perioperative complications.Of all head and neck free flap patients, 48.9% received blood transfusions. Average pretransfusion hametocrit (Hct) was 24.7%±0.2% with 2.5±0.1 units of blood transfused. Transfused patients were more likely to have been taken back to the operating room. Rates of transfusion were similar between flap types, although anterolateral thigh (ALT) and fibular free flap (FFF) patients had higher transfusion requirements compared to radial forearm free flap (RFFF) patients. Further, FFF patients trended toward receiving transfusions earlier. Transfusion did not influence flap survival but was associated with wound dehiscence, myocardial infarction, congestive heart failure, respiratory distress, and pneumonia. Subset analyses by flap type revealed that differences were significant among the RFFF and FFF cohorts but not ALT patients. When comparing patients who were transfused for Hct21 to those transfused for Hct27, there were no differences in LOS, flap survival, or postsurgical complications.Among the different types of flaps, FFF and ALT are associated with higher transfusion requirements. Transfusion in patients undergoing free flap reconstruction does not significantly affect flap survival but was associated with perioperative complications. Our data support consideration of a restrictive transfusion policy in free flap patients.

To determine the value of a collaborative course for advanced head and neck surgery in East Africa.Survey of participants.A 3-day course in head and neck surgery was designed for otolaryngologists and trainees from Kenya and surrounding countries through a collaborative effort between Kenyatta National Hospital, the University of Nairobi, and the Head and Neck Divisions from the Vanderbilt Bill Wilkerson Center and the Massachusetts Eye and Ear Infirmary. Topics included neck dissection, parotidectomy, total laryngectomy, parapharyngeal space tumors excision, and pectoralis myocutaneous flaps. A pre- and postcourse self-evaluation survey was administered to measure course impact.Eighteen otolaryngologists and trainees participated in the course, with 17 completing course surveys. The majority of participants (72%) were from Kenya. Prior to the start of the course, 41%, 71%, 23%, 12%, and 0% of participants indicated they could complete a neck dissection, parotidectomy, parapharyngeal space mass excision, total laryngectomy, and pectoralis myocutaneous flap, respectively. Following the course, 50%, 94%, 69%, 25%, and 38% of participants indicated they could complete a neck dissection, parotidectomy, total laryngectomy, parapharyngeal space tumors excision, respectively, with a statistically significant increase identified for pectoralis myocutaneous flaps (P .001) and total laryngectomy (P = .009). There was also a trend toward an increase in the number of participants indicating an ability to complete parotidectomy following the course (P = .085).This survey demonstrates the potential value of a collaborative course in advanced head and neck surgery as one useful model for increasing the number of well-trained head and neck surgeons in East Africa.

Intra-operative nerve monitoring (IONM) of the recurrent laryngeal nerve (RLN) during thyroid and parathyroid surgery is thought to aid in identification and dissection of the RLN. While utilization of IONM is increasing, one area of variability in its application is the assessment of adequate endotracheal tube electrode placement for IONM during the case. The main objective of this study is to assess the overall success of utilizing respiratory variation to confirm proper endotracheal tube placement for RLN monitoring.A prospective study of RLN monitoring during thyroid and parathyroid surgery at an academic referral center.Fifty-five cases were included. Fifty (91 %) achieved optimal respiratory variation during endotracheal tube position. Five (9 %) required repeat laryngoscopy to confirm correct endotracheal tube placement following patient positioning. For the respiratory variation group, average amplitude achieved during initial vagus, maximum vagus, initial RLN, and maximal RLN was 700 (± 474) mA, 921 (± 616) mA, 887 (± 584) mA, and 1330 (± 843) mA during evoked stimulation, respectively. For the repeat laryngoscopy group, average amplitude achieved during initial vagus, maximum vagus, initial RLN, and maximal RLN evoked stimulation was 591 (± 364) mA, 959 (± 306) mA, 771 (± 424) mA, and 1462 (± 855) mA during evoked stimulation, respectively. There was no statistical difference between the two groups for average initial vagus amplitude (p = 0.62), average maximum vagus amplitude (p = 0.89), average initial RLN amplitude (p = 0.67), or average maximum RLN amplitude (p = 0.74).The findings of this study support the International Neural Monitoring Study Group recommendation that confirmation of endotracheal tube electrode placement be performed either by confirmation of adequate respiratory variation or by repeat direct laryngoscopy.

Objective To determine trends in sinonasal undifferentiated carcinoma (SNUC) survival patterns in the United States. Design Retrospective review of national database. Participants All cases of SNUC in the National Cancer Institute's Surveillance Epidemiology and End Results program from 1973 to 2010 were examined. Main Outcome Measures Age-adjusted incidence and survival rates were calculated and stratified by demographic information and treatment modality. Cohort analysis was performed to analyze survival patterns over time. Results A total of 318 SNUC cases were identified. Age-adjusted incidence rate (IR) was 0.02 per 100,000. Incidence was greater in males (IR: 0.03) than females (IR: 0.01; p = 0.03). Overall 5- and 10-year relative survival rate was 34.9% and 31.3%, respectively. Overall median survival was 22.1 months. Median survival following surgery combined with radiation was 41.9 months. Five-year relative survival rate following surgery, radiation, or surgery combined with radiation was 38.7%, 36.0%, and 39.1%, respectively. Median survival from 1973–1986 and 1987–2010 was 14.5 and 23.5 months, respectively. Conclusions This study provides new data regarding survival patterns of SNUC in the United States, confirming survival benefit with surgery and radiation as well as identifying a trend toward improved survival in recent decades.

To identify histopathologic features associated with poor correlation of frozen and permanent pathology margins following wide local excision for advanced cutaneous squamous cell carcinomas of the head and neck.Retrospective review.A retrospective review of patients undergoing excision of advanced head and neck squamous cell carcinomas between the years 2010 AND 2013 was performed. Demographic, operative, and pathology data were collected. Overall correlation between frozen section margins and final margins on permanent section results was calculated. Positive and negative predictive values of several histopathologic features were determined.Forty-one cases were identified from the database. Perineural invasion, lymphovascular invasion, and a component of poorly differentiated carcinoma were identified in 61.3%, 34.5%, and 17.1% of cases, respectively. Discrepancy between frozen section margins and permanent margins was identified in eight cases (19.5%). The false-negative rate for poorly differentiated carcinoma, lymphovascular invasion, and perineural invasion was 14%, 36%, 26%, respectively. The positive and negative predictive value of poorly differentiated carcinoma, lymphovascular invasion, and perineural invasion in predicting discrepancy between frozen and permanent margins was 14% and 80%, 36% and 84%, and 26% and 92%, respectively.This study demonstrated a moderate rate of discrepancy between frozen and permanent section analysis of operative margins from high-risk cutaneous squamous cell carcinomas of the head and neck. The presence or absence of certain histopathologic features appears to be associated with a higher rate of frozen section discrepancy. Evaluation of these features in a preoperative biopsy or staging excision may be useful in planning definitive excision and reconstruction.

Objectives:Determine trends in global health-related otolaryngology publications.Methods:A systematic search of publications available on PubMed was undertaken reviewing two time periods ten years apart for the timeframes 1998 to 2002 (early time period) and 2008 to 2012 (recent time period) using the search word “otolaryngology” in combination with “developing countries,” “global health,” or “low income countries”; specifying human studies with abstracts in the English language. Publications related only to specific populations within the United States or Europe were excluded. The region of origin and type of publication were assigned as well as the author origin. Chi-squared and t-test analysis was used to identify trends.Results:In the 1998-2002 time period, a total of 11 publications met inclusion criteria for the study with a mean of 2.2+/-1.3 publications per year. In the 2008-2012 time period, a total of 39 publications met inclusion criteria with a mean of 7.6+/-3.1 publications per year. The 354%...

A56-year-oldwomanpresentedwitha several-yearhistoryofnasal obstructive symptoms and anosmia. Despite previous courses of fluticasonepropionate,sheexperiencedno improvement.Shehad noassociatedpain, rhinorrhea,headaches, changes invision,or epistaxis, and her medical history was negative for either allergic rhinitis or chronic rhinosinusitis. Findings from the physical examinationwerenotable forbilateral, obstructingnasalmassesarising from the superior nasal cavity (Figure, A). She was placed on a 14-day course of oral prednisone, 60 mg perday,witha5-day taper, inaddition to fluticasonenasal spray.The patient reported some initial improvement of her symptomswhile taking prednisone, albeit without complete resolution, with return of her symptoms after cessation of systemic steroids. A computed tomographic (CT) scan was obtained and demonstrated polypoid masses within the olfactory clefts bilaterally with marked demineralization of the cribriform plates (Figure, B). Magnetic resonance imaging (MRI) demonstrated soft-tissue changes at the crista galli extending to the margin of the cribriform plate without dural enhancement or intracranial involvement. The patient was subsequently taken to the operating room for abiopsyandbilateral subtotal resectionof themasses.Hematoxylineosin stain of the specimen at low (Figure, C) and high (Figure, D) magnifications revealedproliferationofglandular structureswithciliatedepitheliumandabundant goblet cells. Glandswere in continuity with the surface epithelium, invaginating into the submucosa without evidence of epithelial dysplasia or atypia. Without further treatment, the patient reported complete resolution of her symptoms 1 year postoperatively. What is your diagnosis? A B

Objectives/Hypothesis To determine trends in survival patterns for cranial chordoma in the United States. Study Design A cross-sectional analysis of a national healthcare database. Methods All cases of microscopically confirmed cranial chordoma between 1973 and 2009 from the Surveillance, Epidemiology, and End Results (SEER) program of the National Cancer Institute were examined. Age-adjusted incidence and survival rates were calculated and stratified by treatment. Additionally, in order to assess trends over time, comparisons in survival were conducted for 3 calendar year cohorts: 1975 to 1984, 1985 to 1994, and 1995 to 2004. Results A total of 594 cases of microscopically confirmed chordoma involving cranial sites were identified, which accounted for 42% of all chordomas. Age-adjusted incidence rate (IR) of all chordomas was 0.089 per 100,000. Overall median survival time with surgery plus radiation was 9.2 years. Age and treatment modality were found to influence patient survival. Specifically, age > 50 years was associated with a significant increase in mortality rate (P

Allergic rhinitis (AR) and chronic rhinosinusitis (CRS) are a major burden to the healthcare system. Although no causal relationship has been established, previous work has demonstrated a strong association of AR with CRS. In this study, we sought to identify risk factors that may influence speed of development of CRS in patients with AR.Retrospective review of all patients diagnosed with AR without CRS presenting to an otolaryngology clinic at a tertiary medical center as part of a multidisciplinary allergy evaluation between March 2004 and November 2011. Medical records were evaluated for clinicodemographic factors including age, gender, smoking history, medical comorbidities, categories of AR based on formal allergy testing, the presence of sinonasal anatomic variants on computed tomography as well as subsequent development of CRS.Faster progression to CRS in patients with AR was associated with comorbid asthma (hazard ratio [HR] = 3.97) as well as sinonasal anatomic variants, such as infraorbital cells (HR = 7.39), and frontal intersinus cells (HR = 68.03), on multivariate survival analysis. A statistically significant but negative interaction between infraorbital cells and frontal intersinus cells suggests that concomitant presence of both leads to a less than additive increase in the rate of CRS progression.Sinonasal anatomical variants, infraorbital cells, and frontal intersinus cells, as well as comorbid asthma are associated with faster development of CRS in patients with AR. The presence of these clinical risk factors identifies patients who should be counseled on compliance with medical therapy for AR.

Background Sphenoid sinus fungal balls (SSFB) are rare entities that can result in serious orbital and intracranial complications. There are few published reports of complications that result from SSFB. Objective To review the incidence of skull base erosion and orbital or intracranial complications in patients who present with SSFB. Methods A retrospective review was performed of all the patients with SSFB who were treated at the Massachusetts Eye and Ear Infirmary from 2006 to 2014. Presenting clinical data, radiology, operative reports, pathology, and postoperative course were reviewed. Results Forty-three patients with SSFB were identified. Demographic data were compared between patients with (39.5%) and those without (61.5%) skull base erosion. Two patients underwent emergent surgery for acute complications of SSFB (one patient with blindness, one patient who had a seizure). Both patients with acute complications had evidence of skull base erosion, whereas no patients with an intact skull base developed an orbital or intracranial complication (p = 0.15). All the patients were surgically managed via an endoscopic approach. Conclusion SSFBs are rare but may cause significant skull base erosion and potentially severe orbital and intracranial complications if not treated appropriately. Endoscopic sphenoidotomy is effective in treating SSFB and should be performed emergently in patients who presented with associated complications.

Importance Vocal fold immobility following injury to the recurrent laryngeal nerve (RLN) may lead to substantial morbidity. A reinnervation treatment strategy offers several theoretical benefits over static treatment options. This study evaluates the robustness of reinnervation of the larynx using a split-hypoglossal nerve graft in an animal model, with outcomes assessed by independent blinded review. Objectives To assess whether a full-hypoglossal nerve graft to the RLN after RLN section can provide return of dynamic vocal fold motion in a canine model, and to validate that a split-hypoglossal nerve graft to the RLN may also provide dynamic vocal fold motion to rehabilitate laryngeal function in a canine model. Design, Setting, and Subjects A pilot animal study to assess the feasibility and morbidity of laryngeal reinnervation following RLN injury with an end-to-end full-hypoglossal or split-hypoglossal nerve graft was performed at an animal care and research facility in 10 adult female dogs. The study dates were January to July 2013. Interventions We performed full-hypoglossal (full XII group [n = 5]) and split-hypoglossal (split XII group [n = 5]) nerve grafts to the RLN in a canine model following RLN section. Main Outcomes and Measures Morbidity was evaluated through scored feeding observation. Laryngeal function was assessed by video laryngoscopy and evoked laryngeal electromyography was performed at baseline and 6 months after surgery. Video laryngoscopy was graded by independent reviewers blinded to study intervention. Results No clinically significant morbidity was identified after surgery. On review of video laryngoscopy, all 5 animals in the full XII group and all 5 animals in the split XII group demonstrated vocal fold motion by at least 1 independent reviewer. All 3 reviewers agreed on motion in 1 of 5 animals in the full XII group and in 1 of 5 animals in the split XII group. Stimulation of the hypoglossal nerve demonstrated neural connection on evoked laryngeal electromyography in all animals at 6 months. Conclusions and Relevance This study confirms that a full-hypoglossal or split-hypoglossal nerve graft may restore vocal fold motion, without significant functional morbidity, following RLN section in a canine model.

Awomaninher70spresentedwithanenlargingrightneckmassover the previous 6months. Prior neck ultrasonography and a computed tomography(CT)scanshowedaheterogeneousechogenic right thyroidmass with tracheal displacement and a noncalcified pulmonary noduleonthe left side.Aradioactive iodinescanrevealeda largecold nodule. A positron emission tomographic (PET) scan showed increased fludeoxyglucose F 18 avidity of both the right thyroid mass and the lung nodules. Results from the initial fine-needle aspiration (FNA) from the outside institutionwere nondiagnostic. Laboratory assessment showed a calcium level of 10.8mg/dL, a thyroid-stimulating hormone (TSH) level lower than 0.01 mIU/L, and a calcitonin level lower than 5 pg/mL. A repeated CT scan revealed an 8.8-cm thyroid mass on the right side infiltrating the tracheoesophageal groove and invading the internal and anterior jugularveins, alongwithasuspicious level II/III lymphnodesandmultiple lung nodules (Figure, A). Repeated FNA revealed amalignant neoplasmcomposedofepithelioid cells, low-to-intermediategrade of probable thyroid origin, and positive results from a immunohistochemical test for thyroid transcription factor 1 (TTF-1) (Figure, B). (To convert calcium to millimoles per liter, multiply by 0.25; to covert calcitonin to picomoles per liter, multiply by 0.292.) Open biopsy showed the anterior jugular vein entirely replaced by necrotic tumor. Microscopically, the specimen was invasive, with insular and solid growth pattern, frequent mitoses, and abundant necrosis (Figure, C and D). Immunoperoxidase studies werepositive for thyroglobulin andTTF-1,with anelevatedKi-67 index (30%); cells were negative for p53, calcitonin, and chromogranin. Computed tomography–guidedFNAof the lungnodules revealed tumor cells cytologically similar to those from the thyroid biopsyandpositive forTTF-1.Despite local resection, radiation, and chemotherapy, thepatientdevelopedweaknessandataxia secondary to brain metastasis found on magnetic resonance imaging 4 months later. What is your diagnosis? A