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Abstract Background Traumatic brain injury (TBI) induces activation of microglia. Activated microglia can in turn increase secondary injury and impair recovery. This innate immune response requires hours to days to become fully manifest, thus providing a clinically relevant window of opportunity for therapeutic intervention. Microglial activation is regulated in part by poly(ADP-ribose) polymerase-1 (PARP-1). Inhibition of PARP-1 activity suppresses NF-kB-dependent gene transcription and thereby blocks several aspects of microglial activation. Here we evaluated the efficacy of a PARP inhibitor, INO-1001, in suppressing microglial activation after cortical impact in the rat. Methods Rats were subjected to controlled cortical impact and subsequently treated with 10 mg/kg of INO-1001 (or vehicle alone) beginning 20 - 24 hours after the TBI. Brains were harvested at several time points for histological evaluation of inflammation and neuronal survival, using markers for microglial activation (morphology and CD11b expression), astrocyte activation (GFAP), and neuronal survival (NeuN). Rats were also evaluated at 8 weeks after TBI using measures of forelimb dexterity: the sticky tape test, cylinder test, and vermicelli test. Results Peak microglial and astrocyte activation was observed 5 to 7 days after this injury. INO-1001 significantly reduced microglial activation in the peri-lesion cortex and ipsilateral hippocampus. No rebound inflammation was observed in rats that were treated with INO-1001 or vehicle for 12 days followed by 4 days without drug. The reduced inflammation was associated with increased neuronal survival in the peri-lesion cortex and improved performance on tests of forelimb dexterity conducted 8 weeks after TBI. Conclusions Treatment with a PARP inhibitor for 12 days after TBI, with the first dose given as long as 20 hours after injury, can reduce inflammation and improve histological and functional outcomes.

Objective: (1) Describe short and long-term opioid prescribing patterns and variation after common otolaryngologic procedures and (2) assess risk factors for chronic opioid use in this cohort., Study Design: Retrospective cohort., Setting: Optum's deidentified Integrated Claims-Clinical data set., Methods: An adult cohort of patients undergoing common otolaryngology procedures from 2010 to 2017 was identified. Associations between procedure and other covariates with any initial opioid prescription and continuous opioid prescriptions were assessed with multivariable modeling. Opioid use was defined as continuous if a new prescription was filled within 30 days of the previous prescription. A time-to-event analysis assessed continuous prescriptions from the index procedure to end of the last continuous opioid prescription., Results: Among a cohort of 19,819 patients undergoing predominately laryngoscopy procedures (12,721, 64.2%), 2585 (13.0%) received an opioid prescription with variation in receiving a prescription, daily dose, and total initially prescribed dose varying by procedure, patient demographics, provider characteristics, and facility type. Opioids were prescribed most frequently after tonsillectomy (45.4%) and least frequently after laryngoscopy with interventions (3.9%), which persisted in the multivariable models. Overall rates of continuous use at 180 and 360 days were 0.48% and 0.27%, respectively. Among patients receiving an initial opioid prescription, maintaining continuous prescriptions was associated with tonsillectomy procedures, age (adjusted hazard ratio [aHR]: 0.997 per year, 95% confidence interval [CI]: 0.993-0.999), opioid prescriptions 6 months preprocedure (aHR: 0.42, 95% CI: 0.37-0.47), and nonotolaryngology initial prescribers (aHRs: <1, P < .05)., Conclusion: There is substantial variation in initial prescribing practices and continuous opioid prescriptions after common Otolaryngology procedures, but the overall rate of maintaining a continuous prescription starting after these procedures is very low., Level of Evidence: Level 3., (© 2024 American Academy of Otolaryngology–Head and Neck Surgery Foundation.)

Background: Postoperative radiotherapy radiation therapy (PORT) for early-stage human papillomavirus (HPV)-positive oropharyngeal squamous cell carcinoma (OPSCC) with positive lymphovascular invasion (LVI) has an unclear association with overall survival (OS)., Methods: This retrospective cohort study queried the National Cancer Database for surgically treated, T1-2, N0-1 HPV+ OPSCC from 2010 to 2019. Primary exposures were LVI and PORT, and the main outcome was 5-year OS. Odds ratios and hazard ratios (HR) with 95% confidence intervals (CIs) were generated using multivariable models and Cox proportional hazard models, respectively., Results: Of 2768 patients, average age was 59.3 years, 2207 (79.7%) were male, and 386 (13.9%) had LVI. Of patients with LVI as their sole adverse pathologic feature, 220 (57.0%) received PORT, which was not associated with 5-year OS (HR, 1.13; CI, 0.65-1.19)., Conclusions: Patients with surgically treated, early-stage HPV+ OPSCC and positive LVI as their only pathologic adverse feature may not require PORT., (© 2024 Wiley Periodicals LLC.)

Objective: Survival of laryngeal cancer is decreasing; thus, optimal treatment selection is paramount. Specifically, T3 disease survival appears similar with surgical or non-surgical management; however, the implications of vocal cord fixation on treatment selection and survival are unknown. This study seeks to determine if surgical treatment of patients with T3M0 laryngeal cancer with vocal cord fixation is associated with superior survival compared to non-surgical treatment., Methods: The National Cancer Database (NCDB) was queried for all T3M0 laryngeal carcinoma cases from 2004 to 2015, whose treatment included surgery or radiation therapy. Cases were stratified by cord fixation status and overall survival was compared using multivariable methods based on surgical versus non-surgical management., Results: Non-surgical management was more common, regardless of cord fixation status (84% in fixed and 79% in mobile). Cord fixation itself did not influence survival; however, surgical management had a significant survival benefit in the fixed cohort (HR = 0.843; 95% CI: 0.738, 0.962)., Conclusion: In this large observational cohort study of T3M0 laryngeal cancer, those with fixed cords had superior survival when managed surgically., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Importance: Diagnostic delay can negatively affect patient outcomes in head and neck cancer (HNC). Neck mass and other symptoms of undiagnosed HNC may be treated with antibiotics, delaying diagnosis and treatment, despite current clinical practice guidelines., Objective: To investigate temporal trends, associated factors, and time from symptom onset to antibiotic prescribing before an HNC diagnosis., Design, Setting, and Participants: A retrospective cohort study was conducted using data obtained from a deidentified electronic health records data set from January 1, 2011, to December 31, 2018. Patients with HNC enrolled in the data set for at least 1 year before diagnosis date determined by either 1 inpatient encounter or first of 2 outpatient encounters within 6 months were included. Data analysis was conducted from May 1 to November 9, 2022., Exposure: Antibiotic prescription within 3 months before HNC diagnosis date., Main Outcomes and Measures: The primary outcome was days from the first documented symptom to HNC diagnosis., Results: The cohort included 7811 patients with HNC (4151 [53.1%] men, mean [SD] age, 60.2 [15.8] years). At least 1 antibiotic was prescribed for 1219 patients (15.6%) within 3 months before HNC diagnosis. This represented an increase over the 8.9% prescribing rate during the baseline period 12 to 9 months before diagnosis. The rate of antibiotic prescribing within 3 months before diagnosis did not change significantly over time (quarterly percent change, 0.49%; 95% CI, -3.06% to 4.16%). Patients receiving an antibiotic prescription within 3 months of an HNC diagnosis had a 21.1% longer time between symptom onset and HNC diagnoses (adjusted rate ratio [ARR], 1.21; 95% CI, 1.14-1.29). Compared with diagnosis by otolaryngologists, primary care/internal medicine physicians were most likely to prescribe antibiotics for patients who were diagnosed with a presenting symptom (adjusted prevalence ratio, 1.60; 95% CI, 1.27-2.02). In patients presenting with neck mass/swelling, those presenting with other symptoms were more likely to have longer intervals from symptom onset to diagnosis (ARR, 1.31; 95% CI, 1.08-1.59)., Conclusions and Relevance: The findings of this cohort study suggest there is an increased rate of antibiotic prescription in the 3 months before HNC diagnosis, which is associated with an increased time to diagnosis. These findings identify an area for improvement in HNC care and guidelines.

Objective: Determine trends and survival implications of adjuvant systemic therapy use for lower risk head and neck cancer., Study Design: Retrospective cohort study., Setting: US National Cancer Database, 2010 to 2019., Methods: Patients with mucosal head and neck squamous cell carcinoma treated with surgery and postoperative radiation therapy were identified. Adjuvant systemic therapy trends in those with and without extranodal extension or positive margins were assessed as annual percent change by JoinPoint analysis. Factors associated with adjuvant systemic therapy and overall survival were assessed with multivariable models and cox proportional hazard models, respectively., Results: From 2010 to 2019, approximately one-third of head and neck cancer patients without extranodal extension or positive margins received adjuvant systemic therapy. This rate decreased throughout the study period, with the highest annual percent change from 2016 to 2019 (12.21%; 95% confidence interval: 3.73%-19.95%). Younger age, male sex, Hispanic ethnicity, community program setting, advanced stage, and lymphovascular invasion increased the odds a patient would receive adjuvant systemic therapy. Adjuvant systemic therapy was associated with inferior overall survival when used in those without extranodal extension or positive margins after controlling for covariates., Conclusion: Though decreasing, adjuvant systemic therapy use is still common in the absence of extranodal extension and positive margins, and a variety of patient, provider, and oncologic factors may influence its use. The inferior overall survival after adjuvant systemic therapy in the absence of high-risk features suggests any oncologic benefit may not outweigh the costs and morbidity of the therapy., (© 2023 American Academy of Otolaryngology-Head and Neck Surgery Foundation.)

Importance: The assessment and management of surgical margins in stage I and II oral cavity squamous cell carcinoma is one of the most important perioperative aspects of oncologic care, with profound implications for patient outcomes and adjuvant therapy. Understanding and critically reviewing the existing data surrounding margins in this context is necessary to rigorously care for this challenging group of patients and minimize patient morbidity and mortality., Observations: This review discusses the data related to the definitions related to surgical margins, methods for assessment, specimen vs tumor bed margin evaluation, and re-resection of positive margins. The observations presented emphasize notable controversy within the field about margin assessment, with early data coalescing around several key aspects of management, although studies are limited by their design., Conclusions and Relevance: Stage I and II oral cavity cancer requires surgical resection with negative margins to obtain optimal oncologic outcomes, but controversy persists over margin assessment. Future studies with improved, well-controlled study designs are required to more definitively guide margin assessment and management.

Background: Uninsured individuals age 55-64 experience disproportionately poor outcomes compared to their insured counterparts. Adequate coverage may prevent these delays. This study investigates a "Medicare-effect" on head and neck squamous cell carcinoma (HNSCC) diagnosis and treatment., Methods: The Surveillance, Epidemiology, and End Results (SEER) database was queried for persons ages 60-70 years in the United States from 2000 to 2016 with HNSCC. A "Medicare effect" was defined as an increase in incidence, reduction in advanced stage presentation, and/or decrease in cancer-specific mortality (CSM)., Results: Compared to their Medicaid or uninsured counterparts, patients age 65 have an increased incidence of HNSCC diagnosis, reduction in advanced stage presentation, decrease in cancer-specific mortality, and higher likelihood of receiving cancer-specific surgery., Conclusions: Patients age 65 with Medicare have decreased incidence of HNSCC, less hazard of late-stage diagnosis, and lower cancer-specific mortality than their Medicaid or uninsured counterparts, supporting the idea of a "Medicare effect" in HNSCC., (© 2023 Wiley Periodicals LLC.)

Background: There has been conflicting evidence on the independent prognostic role of human papillomavirus (HPV) status in sinonasal cancer. The objective of this study was to assess whether the survival of patients with sinonasal cancer differs based on various HPV statuses, including HPV-negative, positive for the high-risk HPV-16 and HPV-18 (HPV16/18) subtypes, and positive for other high-risk and low-risk HPV subtypes., Methods: In this retrospective cohort study, data from the National Cancer Database were extracted from the years 2010-2017 for patients who had primary sinonasal cancer (N = 12,009). The outcome of interest was overall survival based on HPV tumor status., Results: Study included an analytic cohort of 1070 patients with sinonasal cancer who had confirmed HPV tumor status (732 [68.4%] HPV-negative; 280 [26.2%] HPV16/18-positive; 40 [3.7%] positive for other high-risk HPV; and 18 [1.7%] positive for low-risk HPV). HPV-negative patients had the lowest all-cause survival probability at 5 years postdiagnosis (0.50). After controlling for covariates, HPV16/18-positive patients had a 37% lower mortality hazard than HPV-negative patients (adjusted hazard ratio, 0.63; 95% confidence interval [CI], 0.48-0.82). Patients aged 64-72 years (crude prevalence ratio, 0.66; 95% CI, 0.51-0.86) and 73 years and older (crude prevalence ratio, 0.43; 95% CI, 0.31-0.59) presented with lower rates of HPV16/18-positive sinonasal cancer than those aged 40-54 years. In addition, Hispanic patients had a 2.36 times higher prevalence of non-HPV16/18 sinonasal cancer than non-Hispanic White patients., Conclusions: These data suggest that, for patients with sinonasal cancer, HPV16/18-positive disease may confer a significant survival advantage compared with HPV-negative disease. Other high-risk and low-risk HPV subtypes have survival rates similar to the rates for HPV-negative disease. HPV status might be an important independent prognostic factor in sinonasal cancer that could be used in patient selection and clinical decisions., (© 2023 American Cancer Society.)

Background: HPV-related oropharyngeal squamous cell carcinoma (OPSCC) is associated with a favorable prognosis, yet patients of color and low socioeconomic status (SES) continue to experience inferior outcomes. We aim to understand how the emergence of HPV has impacted race and SES survival disparities in OPSCC., Methods: A retrospective cohort of 18,362 OPSCC cases from 2010 to 2017 was assembled using the SEER (Surveillance, Epidemiology, and End Results) database. Cox proportional regression and Fine and Gray regression models were used to calculate hazard ratios (HRs) adjusting for race, SES, age, subsite, stage, and treatment., Results: Black patients had lower overall survival than patients of other races in HPV-positive and HPV-negative OPSCC (HR 1.31, 95% CI 1.13-1.53 and HR 1.23, 95% CI 1.09-1.39, respectively). Higher SES was associated with improved survival in all patients. Race had a diminished association with survival among high SES patients. Low SES Black patients had considerably worse survival than low SES patients of other races., Conclusion: Race and SES interact variably across cohorts. High SES was protective of the negative effects of race, although there remains a disparity in outcomes among Black and non-Black patients, even in high SES populations. The persistence of survival disparities suggests that the HPV epidemic has not improved outcomes equally across all demographic groups., (© 2023 The Authors. Cancer Medicine published by John Wiley & Sons Ltd.)

Background: The epidemiology of head and neck cancer (HNC) sites differ substantially. This study compares HNC incidence trends by site and demographic subgroups., Methods: We used the U.S. Cancer Statistics Public Use Database to calculate HNC incidence rates per 100 000. We assessed trends with annual percent change (APC) longitudinally from 2001 to 2017., Results: The oropharyngeal cancer incidence APC decreased from 4.38% (95% CI: 3.6, 5.1) to 2.93% (2.5, 3.3) in 2008 among White males. Oral cavity cancer incidence rose in Other race males (APC 2.5% [1.6, 3.36]) and White females (APC: 0.96% [0.7, 1.2]). Although decreasing (APC: -1.15% [-1.48, -0.83]), laryngeal cancer incidence remained disproportionately high among Black males., Conclusions: Notable incidence trends occurred in non-White groups at non-oropharyngeal sites. With parity of smoking rates by race, differing sexual behaviors, and shifting demographics by race and sex, future studies of HNC trends should consider stratifying analyses to understand health disparities., (© 2022 Wiley Periodicals LLC.)

Importance: Oncologic treatment is costly to the health care system and to individuals, but patients with head and neck cancer (HNC) also have long-term care needs after treatment. Survivors of HNC require specific consideration given their rapidly growing numbers. This subpopulation of cancer survivors often experiences long-term treatment-associated morbidity., Objective: To describe the total and out-of-pocket (OOP) costs associated with HNC survivorship and the risk factors for financial toxicity among this population., Design, Setting, and Participants: This was a retrospective review and economic evaluation of a cohort of US adults with a diagnosis of HNC from 2006 to 2018. The study used data the from IBM MarketScan Commercial Claims Database. Data were analyzed from November 2020 to June 2022., Exposures: Treatment for HNC., Main Outcomes and Measures: Total and OOP medical costs were assessed monthly and reported relative to the date of HNC diagnosis. The primary outcome was the difference between a patient's mean monthly survivorship costs (13-60 months after diagnosis) and mean monthly baseline costs (7-12 months before diagnosis). Univariate and multivariable linear regression models were created for total and OOP costs to generate coefficient estimates with 95% CIs., Results: The study cohort of this economic evaluation included 19 098 patients with HNC (median [range] age, 56 [18-64] years; 14 144 [74.1%] men and 4954 [25.9%] women; race and ethnicity were not considered). Throughout the survivorship period, median total and OOP costs were $372 per month and $31 per month higher than baseline costs, respectively, with variation in expenses by demographic information, health plan type, and oncologic variables. In the multivariable model, greater total and OOP excess survivorship costs were associated with female sex ($343/mo; 95% CI, $126 to $560 and $9/mo; 95% CI, $4 to $14). Highest and lowest total excess survivorship costs associated with cancer site were seen for hypopharyngeal ($1908/mo; 95% CI, $1102 to $2714) and oropharyngeal cancers (-$703/mo; 95% CI, -$967 to -$439) vs oral cavity cancers. Compared with surgery or radiation therapy alone, multimodal treatment was generally associated with excess OOP survivorship costs., Conclusions and Relevance: The findings of this retrospective economic evaluation review suggest that the costs of HNC survivorship remain persistently elevated above baseline costs for at least 5 years after diagnosis. High survivorship costs were associated with female sex, hypopharyngeal tumors, and treatment with multimodal therapy. Practitioners should seek to minimize costs for these patients at higher-risk of financial toxicity after treatment and work to provide directed supportive services.

Objective: This study assesses longitudinal epidemiologic trends in the oldest head and neck cancer (HNC) patients, comparing the oropharynx to other mucosal HNC sites., Materials and Methods: Using data from the Surveillance, Epidemiology, and End Results database, trends in incidence, two-year cancer specific mortality, and percent of cases recommended for and which received surgery from 2000 to 2018 in patients ages ≥85 years were assessed using Joinpoint analysis by HNC site. Trends were quantified as annual percentage change (APC) with 95% confidence intervals (CI)., Results: Among older adults, oropharyngeal cancer (OPC) incidence increased (APC = 1.80% [95% CI: 0.94-2.67]), while mortality decreased (APC = -2.01% [95% CI: -3.26--0.74]) from 2000 to 2018. At other mucosal HNC sites, incidence and mortality remained stable. Percentage of patients who received surgery significantly changed for oropharyngeal (APC = -15.34% from 2000 to 2005 [95% CI: -24.37 to -4.79]) and laryngeal (APC = -4.61% from 2000 to 2008 [95% CI -8.28 to -0.80]) cancers. Trends in recommendation for surgery varied by site with significant decreases at the larynx, oral cavity, and oropharynx., Conclusion: OPC incidence is increasing among the oldest HNC patients. An increasing proportion of HPV-associated tumors could account for associated mortality improvement. There has been a shift towards non-surgical therapy possibly due to known favorable response of HPV-associated OPC to radiation therapy and/or poor surgical candidacy in this age group. The evolving treatment approach has not been detrimental to population-level survival outcomes, but optimal treatment has yet to be established. Future studies with pathologically confirmed HPV status are needed to better understand older adult OPC burden., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Objective: Examine the characteristics of recent head and neck (H&N) oncology fellowship graduates and assess their current perceptions of career alignment and satisfaction., Methods: H&N fellowship graduates from American Head and Neck Society-accredited programs between 2015 to 2020 were surveyed. Two-sample t tests and analysis of variance tests were used to determine the effect of respondents' demographics, fellowship characteristics, career preferences, and current practice on their degree of career alignment with expectations and overall job satisfaction., Results: Fifty-eight fellowship graduates completed the cross-sectional survey. Of all respondents, 52 (89.7%) primarily preferred an academic job, of whom 5 (9.6%) went into private practice. Respondents in private practice, those treating general otolaryngology patients, and those who do not work with residents demonstrated significantly poorer job alignment and career satisfaction as compared with those in academic medicine, those treating only H&N patients, and those working with residents, respectively., Discussion: The majority of graduating H&N fellows prefer a job in academic medicine; however, there may be an insufficient number of desirable academic positions available each year to meet such demand., Implications for Practice: By setting realistic career expectations, preparing for a mixed scope of practice, and integrating resident involvement into private practice groups, H&N providers may ultimately find more fulfillment in their work. These findings could also be valuable to the American Head and Neck Society and fellowship programs in designing training and in planning for the number of available fellowship positions each year., (© The Authors 2022.)

Purpose: Head and neck cancer (HNC) patients frequently require care through emergency departments (ED) due to lack of access or symptom acuity, however, the frequency and implications of this occurrence have not been delineated., Objective: To determine the association between emergency department admission of HNC surgery with length of stay (LOS) and total costs (TC)., Methods: A cohort of 12,920 adult HNC patients admitted to acute care hospitals receiving ablative surgery during index admission was identified using the New York State Inpatient Database from 2006 to 2016. Outcomes included LOS, TC, 90-day complications, and inpatient mortality., Results: Eight percent of the cohort was admitted through the ED, which increased over the study period from 6.52% (95% CI: 5.05-7.99) to 17.0% (95% CI: 14.9-19.1). ED admission was associated with a longer LOS (11 days longer, 95% CI 10.3-11.7) and higher mean TC ($43,197) versus non-ED admission ($19,010), with a mean difference of $24,191 (95% CI 20,713-27,669). After controlling for covariates, ED admission was associated with an 81.6% (95% CI 76.8-86.5) and 80.4% (95% CI 70.5-90.8) increase in LOS and TC, respectively, and decreased survival with a hazard ratio of 1.97 (95% CI 1.60-2.42)., Conclusions: Rates of ED admission for HNC diagnoses requiring surgical intervention during index admission are rising and associated with longer LOS higher TC, more postoperative complications, and increased inpatient mortality after accounting for patient and facility differences. Striving for high-quality HNC cancer care demands addressing barriers to care that contribute to patients relying on the ED for access., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Objectives/hypothesis: Radiation-associated sarcomas of the head and neck (RASHN) are known but rare sequelae after radiation for squamous cell carcinoma. The purpose of this study was to characterize RASHN, estimate the risk of RASHN in head and neck squamous cell patients after therapeutic radiation, and compare their survival to that of patients with de novo sarcomas of the head and neck (dnSHN)., Study Design: Retrospective database analysis., Methods: RASHN and dnSHN cases were collected from the Surveillance, Epidemiology, and End Results Database to identify risk factors and calculate incidence and latency. Survival was compared between RASHN and dnSHN., Results: The risk of RASHN was 20.0 per 100,000 person-years. The average latency period was 124.2 months (range 38-329). The cumulative incidence of RASHN at 20 years was 0.13%. Oral cavity and oropharynx primaries demonstrate increased risk. Five-year overall survival of RASHN was 22.4% compared to 64.5% for dnSHN., Conclusions: RASHN are confirmed to be rare. RASHN have poor overall survival and worse survival compared to dnSHN. The impact of intensity-modulated radiation therapy protocols on this risk is unknown. Modifiable risk factors of smoking and alcohol consumption continue to dwarf radiation therapy as risk factors of second primary head and neck cancers., Level of Evidence: 3 Laryngoscope, 132:1034-1041, 2022., (© 2021 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: To determine the frequency and management of short- and long-term complications related to oromandibular free flap reconstruction and identify potentially predictive factors of hardware complications., Study Design: Retrospective chart review., Methods: A retrospective database from chart review was formed consisting of 266 oromandibular free flap reconstructions performed at a single institution over a 15-year period. Data were collected on demographics, surgical treatment, complications, and management of complications. Subgroup univariate and multivariate analyses were performed to compare patients with hardware complications and those without., Results: Eighty-one of 266 patients (30.5%) that underwent oromandibular reconstruction had an early complication (<4 weeks after surgery), and the most common complications were cervical wound dehiscence (11.3%) and fistulas (9.40%). Eighty of 266 patients (30.1%) had a long-term complication (>4 weeks after surgery) and the most common complication was plate exposure (26.7%). Univariate and multivariate analyses showed no association between whether there was hardware extrusion and fibula versus scapula, smoking history, virtual surgical planning (VSP), and dental implantation (P > .05). Only early complications (OR, 3.59, 95% CI, 1.83-7.05, P < .01) and patients undergoing oromandibular reconstruction for osteoradionecrosis (OR, 2.26, 95% CI, 1.10-4.64, P = .03) were strongly and independently associated with subsequent hardware extrusion on univariate analysis., Conclusions: Both short- and long-term complications are common after oromandibular reconstruction. The most important predictive factor for a late complication is an early complication and prior radiation. There was no difference of plate complications among the various free flap types. Dental implantation and use of VSP were not associated with hardware complications., Level of Evidence: 4 Laryngoscope, 131:1997-2005, 2021., (© 2021 The American Laryngological, Rhinological and Otological Society, Inc.)

Purpose: Privately insured patients with head and neck cancer (HNC) typically have better outcomes; however, differential outcome among Medicaid versus the uninsured is unclear. We aimed to describe outcome disparities among HNC patients uninsured versus on Medicaid., Methods: A cohort of 18-64-year-old adults (n = 57 920) with index HNC from the Surveillance, Epidemiology, and End Results 18 database (2007-2015) was analyzed using Fine and Gray multivariable competing risks proportional hazards models for HNC-specific mortality., Results: Medicaid (sdHR = 1.65, 95% CI 1.58, 1.72) and uninsured patients (sdHR = 1.55, 95% CI 1.46, 1.65) had significantly greater mortality hazard than non-Medicaid patients. Medicaid patients had increased HNC mortality hazard than those uninsured., Conclusion: Compared with those uninsured, HNC patients on Medicaid did not have superior survival, suggesting that there may be underlying mechanisms/factors inherent in this patient population that could undermine access to care benefits from being on Medicaid., (© 2021 Wiley Periodicals LLC.)

Importance: Guidelines for many head and neck cancers, especially laryngeal cancers, allow for multiple treatment options. Currently, inequitable provision of surgery may contribute to outcome disparities. However, the role of geospatial factors remains understudied., Objective: To assess the association between US geospatial factors and treatment selection for patients with laryngeal cancer., Design, Setting, and Participants: In this retrospective cohort study, patients diagnosed with laryngeal squamous cell carcinoma between January 1, 2004, and December 31, 2014, were identified from the Surveillance, Epidemiology, and End Results database. Adjusted odds ratios (aORs) for surgical treatment were generated from multivariable, hierarchical models to assess associations with oncologic, demographic, and county variables. Outlier US counties with the highest and lowest aORs were described. Data analysis was performed from April 29 to September 11, 2020., Exposures: County of residence., Main Outcomes and Measures: The aORs for surgical treatment were generated from multivariable, hierarchical models. Outlier counties with the highest and lowest aORs are described., Results: The cohort includes 21 289 patients (mean [SD] age, 63.6 [11.2] years; 17 214 [80.9%] male) in 598 counties. Most counties had no otolaryngologist (365 [61.0%]) or radiation oncologist (434 [72.6%]). Surgery rates varied from 7.1% to 85.7% among counties with at least 10 cases. After oncologic variables were controlled for, factors independently associated with surgical treatment included patient age (aOR [95% CI], 0.94; 0.91-0.98 per 10 years), marital status (single versus married: aOR [95% CI], 0.87 [0.79-0.97]), and county social deprivation index (aOR [95% CI], 0.98 [0.97-1.00 per 5 points]) but not physician number (≥2 otolaryngologists: aOR [95% CI], 0.91 [0.75-1.11] vs ≥1 radiation oncologist: aOR [95% CI], 0.91; 0.75-1.11). The 5% of counties most likely to provide surgery (aOR, >1.23) were nearly all large metropolitan areas (2593 patients [93.3%]) and treated a disproportionately large number of patients (2778 [13.1%]). The 5% of counties least likely to provide surgery (aOR, <0.79) were also mostly large metropolitan areas (1676 patients [91.2%]) and treated a disproportionately large number of patients (1838 [8.6%]). Patients in counties least likely to provide surgery had inferior survival compared with those most likely to provide surgery (adjusted hazard ratio, 1.16; 95% CI, 1.00-1.35)., Conclusions and Relevance: These findings suggest that sociodemographic factors contribute to the wide variety in surgical treatment practices by county. The largest metropolitan counties were often outliers regarding their adjusted odds of surgical treatment. This finding is concerning for the counties least likely to provide surgery where survival is inferior.

Objective: To systematically review the literature to determine the prevalence and clinical outcomes of second primary oropharyngeal squamous cell carcinoma (OPSCC)., Data Sources: Search strategies created with a medical librarian were implemented using multiple databases in October 2019., Review Methods: The population of interest included adults age >18 years with a p16+ or human papillomavirus-positive OPSCC. The outcome was a synchronous or metachronous second primary OPSCC. Inclusion and exclusion criteria were designed to capture all study designs. In total, 685 records were identified by the search strategy. Two reviewers independently performed the review, extracted data, and performed a quality assessment. Primary Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. A random-effects model was used for the meta-analysis., Results: A total of 2470 patients with 35 second primary OPSCCs from 15 studies were identified. The pooled prevalence of second primary OPSCC was 1.4% (range, 0%-14.3%). In the random-effects model, the prevalence was estimated at 1.3% (95% CI, 0.7%-2.3%; P = .51, I 2 = 52%). Of the 30 patients with treatment information, 26 (86.7%) received surgical treatment, while 4 (13.3%) underwent nonsurgical therapy. Of the 29 patients with available survival information, 22 (75.9%) had no evidence of disease at last follow-up, 5 (17.2%) ultimately died of disease, and 2 (6.9%) were alive with disease., Conclusion: Overall, the rate of second primary OPSCC in patients with an index p16+ OPSCC is low, and most patients are successfully treated. Insufficient evidence currently exists to recommend routine elective tonsillectomy during surgical treatment of p16+ OPSCC.

Background: This study aims to provide modern estimates of survival for untreated head and neck cancer (HNC) and to identify patient- and tumor-specific factors associated with not receiving definitive treatment., Methods: Adults with mucosal HNC were identified from the Surveillance, Epidemiology, and End Results (SEER) database. Median overall survival of untreated patients was calculated and stratified by site and stage. Cause-specific survival and factors associated with no treatment were investigated with advanced statistics., Results: The study cohort included 6477 patients who received no treatment. Overall, untreated patients had a median survival of 12 months, with significant variability by site and stage. Multivariable analysis identified advanced age, black race, unmarried status, and lack of private insurance as associated with no treatment., Conclusions: Survival of HNC without treatment is dismal, yet substantial variation exists by tumor site and stage. Higher rates of no treatment among the poor and racial minorities are potentially driven by disparities in care availability and provision., (© 2020 Wiley Periodicals LLC.)

Background: Oropharyngeal squamous cell carcinoma (OPSCC) epidemiology has not been examined previously in the nationwide Veterans Affairs (VA) population., Methods: Joinpoint regression analysis was applied to OPSCC cases identified from VA administrative data from 2000 to 2012., Results: We identified 12 125 OPSCC cases (incidence: 12.2 of 100 000 persons). OPSCC incidence declined between 2000 and 2006 (annual percent change [APC] = -4.27, P < .05), then increased between 2006 and 2012 (APC = 7.02, P < .05). Significant incidence increases occurred among white (APC = 7.19, P < .05) and African American (APC = 4.87, P < .05) Veterans and across all age cohorts. The percentage of never-smokers increased from 8% in 2000 to 15.7% in 2012 (P < .001), and 2-year overall survival improved from 31.2% (95% confidence interval (CI) [30-33.4]) to 55.7% (95% CI [54.4-57.1])., Conclusions: OPSCC incidence is increasing across all racial and age cohorts in the VA population. Smoking rates remain high among Veterans with OPSCC and gains in survival lag those reported in the general population., (© 2020 Wiley Periodicals LLC.)

Objectives: Human papillomavirus (HPV)-associated cancers account for about 9% of the cancer mortality burden in the United States; however, survival differs among sociodemographic factors. We determine sociodemographic and clinical variables associated with HPV-associated cancer survival., Methods: Data derived from the Surveillance, Epidemiology, and End Results 18 cancer registry were analyzed for a cohort of adult patients diagnosed with a first primary HPV-associated cancer (anal, cervical, oropharyngeal, penile, vaginal, and vulvar cancers), between 2007 and 2015. Multivariable Fine and Gray proportional hazards regression models stratified by anatomic site estimated the association of sociodemographic and clinical variables and cancer-specific survival., Results: A total of 77 774 adults were included (11 216 anal, 27 098 cervical, 30 451 oropharyngeal, 2221 penile, 1176 vaginal, 5612 vulvar; average age = 57.2 years). The most common HPV-associated cancer was cervical carcinoma (58%) for females and oropharyngeal (81%) for male. Among patients diagnosed with anal/rectal squamous cell carcinoma (SCC), males had a higher risk of death than females. NonHispanic (NH) blacks had a higher risk of death from anal/rectal SCC, oropharyngeal SCC, and cervical carcinoma; and Hispanics had a higher risk of death from oropharyngeal SCC than NH whites. Marital status was associated with risk of death for all anatomic sites except vulvar. Compared to nonMedicaid insurance, patients with Medicaid and uninsured had higher risk of death from anal/rectal SCC, oropharyngeal SCC, and cervical carcinoma., Conclusions: There exists gender (anal) and racial and insurance (anal, cervical, and oropharyngeal) disparities in relative survival. Concerted efforts are needed to increase and sustain progress made in HPV vaccine uptake among these specific patient subgroups, to reduce cancer incidence.

Background: Patients with head and neck cancer (HNC) are at risk for limited healthcare access., Methods: Individuals reporting a history of cancer were identified from the Medical Expenditure Panel Survey, an annual assessment of the nation's health. Access to care variables were compared between "HNC" and "other cancer" using multivariable methods and stratified by age 65., Results: From 1998 to 2015, 420 patients with HNC and 14 468 with other cancers completed the survey. Among patients with HNC, 10.4% (95% confidence interval [CI] 5.0-15.9) lacked a regular provider, compared to 6.1% (95% CI 5.5-6.6) of other cancer survivors. Ten percent of HNC survivors lacked a regular provider and 14.6% report barriers to needed care. For those 65 years and older, HNC was associated with lacking a regular provider (adjusted odds ratio 2.58, 95% CI 1.15-5.80)., Conclusion: HNC was associated with lack of a regular care provider after age 65, which may result in substandard survivorship care., (© 2020 Wiley Periodicals, Inc.)

Objective: Improved head and neck cancer survival has been associated with traveling farther distances for treatment, potentially due to patients seeking higher-quality facilities. This study investigates the role of both facility and confounding patient factors on this relationship., Study Design: Review of national registry data., Setting: National Cancer Database., Subjects and Methods: Adults with head and neck cancer diagnosed from 2004 to 2014 were identified. Overall survival was compared among distance-to-facility quartiles via univariate and multivariate survival models. Then, the analysis was stratified by facility and patient factors, and the association between distance and survival was compared among strata., Results: Overall survival was worst in the shortest-distance quartile (<5 miles; median survival, 80.7 months; 95% CI, 79.2-82.3), while other distance groups showed similar survival (range, 96.4-104 months). This finding remained in the multivariate model (adjusted hazard ratio vs first distance quartile: 0.88; 95% CI, 0.87-0.89). The association between survival and distance persisted in all subgroups when stratified by facility volume and type (adjusted hazard ratio range, 0.82-0.91), suggesting that facility quality does not fully account for this association. When stratified by income, distance remained statistically associated with survival but with a smaller effect size than that of income., Conclusion: The association between distance to treating facility and head and neck cancer survival is limited to patients with worse survival outcomes living within 5 miles of the facility and is not fully explained by measures of facility quality.

Objective: To perform the first systematic review evaluating all established treatment modalities of head and neck lymphedema resulting from head and neck cancer therapy. Since craniofacial lymphedema treatment represents unique challenges not addressed by extremity lymphedema therapies, a systematic review and evaluation of treatment modalities specific to this area is needed to guide clinical management and further research., Data Sources: Four electronic databases were searches from inception to September 2018. These included Scopus (Embase), PubMed (Medline), Clinicaltrials.gov, and Cochrane Databases., Review Methods: A search string was developed, and all databases queried for keywords on three subjects: head and neck cancer, lymphedema, and therapy. Results were uploaded to an EndNote database where relevant items were identified by hand-searching all titles and abstracts. Subsequently results were combined, duplicates removed, and full papers screened according to eligibility criteria., Results: Of a total 492 search results, twenty-six items met eligibility criteria for this review. These included fourteen cohort studies, seven case reports, two randomized controlled trials, two systematic reviews, and one narrative review totaling 1018 study subjects. The manual lymph drainage group had the largest number of studies and participants, with fewer studies investigating selenium, liposuction, and lymphaticovenular anastomosis., Conclusion: Evidence for the efficacy of all types of lymphedema therapy is limited by paucity of large randomized controlled trials. While manual lymph drainage is best studied, liposuction and surgical treatments have also been effective in a small number of patients., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: To determine whether marital status independently predicts survival in a head and neck cancer (HNC) survivor population., Methods: In this retrospective cohort study, we analysed data from 460 adult patients (59.31 ± 11.42) years diagnosed with HNC at an academic tertiary referral centre between 1997 and 2012. Cox proportional hazards model estimated the effect of marital status on survival., Results: Our study had 73% men, and 82.2% were Whites. We found an association between marital status and HNC survival. Unmarried HNC patients had a 66% increase in hazard of death compared to married patients (aHR = 1.66, 95% CI = 1.23-2.23). This was after controlling for sociodemographic variables (age, race, sex and health insurance status), social habits (tobacco and alcohol), primary anatomical subsite (oral cavity, oropharyngeal, laryngeal and others), stage at presentation (early vs. late stage) and treatment modality (surgery, surgery with adjuvant therapies, other single modality therapy and palliative care)., Conclusions: Being married confers survival advantage for HNC survivors. Our finding underscores the need to recognise this aspect of survivorship. Social support should be considered part of standard care for managing HNC. There may also be need to develop other support mechanisms, especially for unmarried HNC survivors., (© 2019 John Wiley & Sons Ltd.)

Importance: Head and neck cancer (HNC) is more common among socioeconomically disenfranchised individuals, making financial burden particularly relevant., Objective: To assess the financial burdens of HNC compared with other cancers., Design, Setting, and Participants: In this retrospective review of nationally representative, publicly available survey, data from the Medical Expenditure Panel Survey were extracted from January 1, 1998, to December 31, 2015. A total of 444 867 adults were surveyed, which extrapolates to a population of 221 503 108 based on the weighted survey design. Data analysis was performed from April 18, 2018, to August 20, 2018., Exposures: Of 16 771 patients with cancer surveyed (weighted count of 10 083 586 patients), 489 reported HNC (weighted count of 261 631)., Main Outcomes and Measures: Patients with HNC were compared with patients with other cancers on demographics, income, employment, and health. Within the HNC group, risk factors for total medical expenses and relative out-of-pocket expenses were assessed with regression modeling. Complex sampling methods were accounted for with weighting using balanced repeated replication., Results: A total of 16 771 patients (mean [SD] age, 62.3 [18.9] years; 9006 [53.7%] female) with cancer were studied. Compared with patients with other cancers, patients with HNC were more often members of a minority race/ethnicity, male, poor, publicly insured, and less educated, with lower general and mental health status. Median annual medical expenses ($8384 vs $5978; difference, $2406; 95% CI, $795-$4017) and relative out-of-pocket expenses (3.93% vs 3.07%; difference, 0.86%; 95% CI, 0.06%-1.66%) were higher for patients with HNC than for patients with other cancers. Among patients with HNC, median expenses were lower for Asian individuals compared with white individuals ($5359 vs $10 078; difference, $4719; 95% CI, $1481-$7956]), Westerners ($8094) and Midwesterners ($5656) compared with Northwesterners ($10 549), and those with better health status ($16 990 for those with poor health vs $6714 for those with excellent health). Higher relative out-of-pocket expenses were associated with unemployment (5.13% for employed patients vs 2.35% for unemployed patients; difference, 2.78%; 95% CI, 0.6%-4.95%), public insurance (5.35% for those with public insurance vs 2.87% for those with private insurance; difference, 2.48%; 95% CI, -0.6% to 5.55%), poverty (13.07% for poor patients vs 2.06% for high-income patients), and lower health status (10.2% for those with poor health vs 1.58% for those with excellent health)., Conclusions and Relevance: According to this study, HNC adds a substantial, additional burden to an already financially strained population in the form of higher total and relative expenses. The financial strain on individuals, assessed as relative out-of-pocket expenses, appears to be driven more by income than by health factors, and health insurance does not appear to be protective.

Objectives: The aim of the study was to estimate hospitalization cost, and factors associated with hospitalization costs and length of stay (LOS) of patients treated for head and neck cancer in the United States., Methods: Data on 71,440 weighted hospital admissions from the 2014 National Inpatient Sample with a diagnosis of head and neck cancer were examined. Multivariable linear regression models estimated factors associated with hospitalization costs, and negative binomial regression models were used to identify factors associated with hospital LOS. Factor variables included characteristics of the patient, clinical, and hospital characteristics., Results: The average hospitalization cost was US $18,371 and the average LOS was 6.6 days. LOS was significantly associated with admissions involving bacterial infection, major operating procedures, chemo procedure, and radiation procedure as well as admissions at medium or small bed size hospitals, and rural hospitals. Admissions among black patients, elective admissions, admissions involving bacterial infection, major operating procedures, chemo procedure, radiation procedure, and advance comorbidities were associated with increased hospitalization costs. In contrast, admissions at urban nonteaching or rural had increased hospitalization costs., Conclusions: Admissions that involve higher number of comorbidities, metastasis, bacterial infection, radiation, and chemo procedures had longer hospital stay and higher cost whereas admissions are rural hospitals had shorter hospital stay and lower cost. Understanding these factors associated with increased LOS and hospitalization cost will help efforts to decrease health care cost and improve quality of care.

Objectives: To determine whether the impact of marital status on head and neck cancer (HNC) outcomes vary by gender., Methods: The Surveillance, Epidemiology, and End Results 18 database from 2007 to 2014 was queried for eligible cases of HNC (n = 71,799). An interaction term (gender*marital status) was tested for each outcome of interest (cancer-specific survival, stage of presentation, adequate treatment), and when significant (p < 0.05), the model was stratified by gender. A competing risks proportional hazards (subdistribution [sd]) model estimated the interaction effect on cancer-specific survival. Logistic regression estimated effect on stage of presentation and treatment type., Results: There was significant gender*marital status interaction for cancer-specific survival and stage of presentation. While married/partnered patients had the highest survival among both genders, males benefitted more: widowed (male sdHR = 1.41, 95% CI 1.31, 1.52; female sdHR = 1.15, 95% CI 1.06, 1.26), divorced/separated (males: sdHR = 1.39, 95% CI 1.32, 1.46; females: sdHR = 1.17, 95% CI 1.06, 1.28), or never married (males: sdHR = 1.42, 95% CI 1.36, 1.49; females: sdHR = 1.15, 95% CI 1.05, 1.26). When stratified by oropharyngeal cancer vs. non-oropharyngeal HNC, unmarried males had 50-60% increased hazard of death, while no difference was found for females. Unmarried males also had greater odds of presenting with late-stage disease compared with females. No gender*marital status interaction was observed for adequate treatment, although married/partnered survivors had greater odds of receiving adequate treatment., Conclusions: While there are survival benefits for married patients with HNC, married/partnered males, especially those with oropharyngeal cancer, may benefit more than females., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Objectives/hypothesis: Head and neck squamous cell carcinoma (HNSCC) prognosis strongly correlates with demographic factors. This study aimed to determine whether demographic predictors of HNSCC survival differ between age cohorts, with an emphasis on the growing elderly demographic., Study Design: Outcomes research., Methods: Adults with squamous cell carcinoma of the upper aerodigestive tract were identified from the Surveillance, Epidemiology and End Results 18 database. Demographic and oncologic factors were compared between three age groups: 18 to 49, 50 to 74, and >75 years. Factors associated with cancer-specific survival were assessed in each cohort using subdistribution hazard ratio (sHR) and 95% confidence interval (CI) produced by multivariate competing risk models., Results: A cohort of 69,098 patients included 10,588 (15.3%) 75 years or older and 9,882 (14.3%) less than 50 years old. Older patients were more often female (35.4% vs. 25.1% aged 18-49 years and 20.4% aged 50-74 years), white (78.7% vs. 69.4% and 75.9%), insured (63.5% vs. 46.5% and 56.8%), and married (56.6% vs. 53% and 51.1%), but received adequate treatment less often (72.0% vs. 86.3% and 82.7%). In the older cohort, male sex was associated with lower mortality (sHR: 0.92, 95% CI: 0.85-1.00), and unlike the younger cohorts, black race was no longer associated with mortality (sHR: 1.07, 95% CI: 0.94-1.22). Marriage was associated with lower mortality in all age groups but with diminishing effects (single sHR: young 1.52, middle 1.31, older 1.14)., Conclusions: Elderly HNSCC patients have distinct effects from demographic prognostic factors and should be considered a separate subgroup with unique epidemiology, risks, and preferences., Level of Evidence: 2c Laryngoscope, , 129:146-153, 2018., (© 2018 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives: To assess head and neck cancer (HNC) patients' perspectives on the value and burdens of routine cancer follow-up care., Materials and Methods: Data was obtained from HNC patients (n = 100) at an urban, tertiary head and neck cancer clinic. A novel 15-question survey tool evaluated the logistic, financial, and psychosocial burdens associated with clinic visits. The clinical characteristics and survey responses of demographic groups were analyzed with comparative statistics. Linear regression modeling was utilized to identify predictors of overall stress., Results: A majority of study participants were male (74%), white (83%), and had histories of tobacco (77%) and alcohol (77%) use. Most participants were satisfied with the frequency of their office visits (75%). Patients with laryngeal cancer, advanced stage disease, or who underwent multimodality therapy more often desired increased appointment frequency. These patients also rated the burdens of travel cost and overall stress higher, compared to patients desiring visits less often (41.5% vs 28.4%, p = 0.047 and 46.6% vs 38.3%, p = 0.003, respectively). Travel stress was associated with highest overall stress (beta 0.6, CI: 0.4, 0.7)., Conclusion: The HNC survivor population is uniquely disenfranchised in several social and economic ways. While most patients are satisfied with their follow-up care, a significant subset of patients - those with limited social support, high financial stress, functional deficits, and those with transportation burdens - desire more frequent care. Survivorship care plans should incorporate the perspectives of current survivors., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Objectives: To determine differences in oropharyngeal squamous cell carcinoma (OPSCC) incidence between 1975 and 2014 stratified by race, sex, and age., Materials and Methods: We obtained age-adjusted OPSCC incidence rates for race and sex groups from 1975 to 2014 using the Surveillance, Epidemiology, and End Results 9 database. We defined OPSCC as cancers of the base of tongue, lingual/palatine tonsil, oropharynx, soft palate, uvula, and Waldeyer's ring. We used Joinpoint analyses to determine incidence trends for race/sex/age groupings., Results: There were 38,624 oropharyngeal primary tumors in the analyses. Males accounted for 74% of sample population, and whites accounted for 84% of tumors. Overall, there was a 57.3% increase in incidence of oropharyngeal between 1975 and 2014. For blacks and whites, average incidence was lower for females than males. Rates for black males aged ≥50years was highest for most of the follow-up time but decreased sharply around 1988 and were surpassed by the significant increase in incidence in white males aged 50-59 (1995-2014 APC=4.07, p<0.001) and ≥60years (2002-2014 APC=4.25, p<0.001). For males aged ≥60, whites had higher rates than blacks starting in 2010. OPSCC incidence in White males (10.99 per 100,000 person-years) surpassed rates in Blacks (10.14 per 100,000 person-years) beginning in 2008., Conclusion: OPSCC has significantly increased in the United States in the last 40 years. This overall increase in OPSCC can primarily be attributed to white males. OPSCC prevention and early detection efforts could target these demographic factors to decrease rising OPSCC incidence., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Background: Aside from cancer mortality, patients with head and neck cancer have increased mortality risk. Identifying patients with the greatest loss of cancer-independent life expectancy can guide comprehensive survivorship programs., Methods: Age-based survival data from the Surveillance, Epidemiology, and End Result (SEER) database for patients with head and neck cancer were censored for mortality from the index cancer. Life expectancy and years of life lost (YLL) referenced to the general population were calculated. Cox proportional regression models produced hazard ratios (HRs)., Results: Cancer-independent life expectancy for patients with head and neck cancer is 6.5 years shorter than expected. The greatest hazard and impact of other-cause mortality was associated with black race (HR 1.23; YLL 8.55), stage IV (HR 1.60; YLL 7.92), Medicaid (HR 1.55; YLL 12.9), and previous marriage (HR 1.49; YLL 11.4)., Conclusion: Patients with head and neck cancer lives are foreshortened independent of their cancer diagnosis necessitating management of noncancer mortality to maximize overall survival., (© 2017 Wiley Periodicals, Inc.)

Objective: Survival of advanced laryngeal cancer is declining while the popularity of organ preservation protocols grows. This study assesses the survival impact of refusing surgical treatment for locally advanced, resectable laryngeal cancer., Methods: Adult patients with T3 and T4a non-metastatic laryngeal squamous cell carcinoma were identified from the Surveillance, Epidemiology and End Results 18 database from 2004 to 2013. Patients were stratified based on a recommendation for extirpative surgery and the refusal of surgery. Multivariate logistic regression modeling identified variables associated with refusal. A multivariate cox proportional hazard model produced adjusted Kaplan-Meier survival curves. Survival was compared using adjusted hazard ratios (aHR) with 95% confidence intervals (CI)., Results: Of 5786 patients in the study, 2877 were recommended for surgical treatment and 138 (4.8%) refused. Refusal of surgery was associated with unmarried status (Single, odds ratio (OR) 1.79, CI 1.10-2.92), black race (OR 1.50, CI 1.00-2.22), T3 tumors (OR 1.80, CI 1.26-2.61) and N3 nodal disease (OR 3.50, CI 1.24-8.48). Compared to patients undergoing surgery, those who refused had lower 5-year cancer specific survival and increased hazard of cancer-specific mortality (aHR 1.60, CI 1.24-2.07) which resulted in decreased 5-year survival (50.0vs 60.1%), after controlling for other factors., Conclusion: Refusal of surgery for locally advanced laryngeal cancer is more common in patients without marital support and with T3 tumors. This decision results in a 10% survival decrease at 5-year. Future study is needed to understand patients' reasoning behind this decision and to investigate additional factors not available in this dataset., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Purpose/objectives: The increasing survivorship of head and neck squamous cell carcinoma (HNSCC) comes with a risk of death from other causes, known as competing causes. The demographics of HNSCC are also evolving with increasing incidence of Human Papillomavirus (HPV) associated tumors. This study describes competing causes of death for the HNSCC population compared to the general population and identifies associated risk factors., Methods: Adult patients with first mucosal HNSCC (2004-2011) were identified from the Surveillance, Epidemiology and End Result database. Competing causes of death were compared to reference populations using proportion of deaths and Standardized Mortality Ratios (SMR). A multivariable competing risk survival analysis yielded subdistribution hazard ratios (HR) for competing mortality., Results: Of 64,598 HNSCC patients, 24,602 (38.1%) were deceased including 7142 deaths (29.0%) from competing causes. The most common were cardiovascular disease, lung cancer, and other cancers. All relative mortality rates were elevated, especially liver disease (SMR 38.7; 95% CI: 29.4-49.3), suicide (SMR 37.1; 95% CI: 26.1-48.6), and subsequent primary cancers (SMR 7.5; 95% CI: 6.78-8.32). Demographic and tumor factors independently increased risk of competing mortality, including age (HR per 5years 1.24; 95% CI: 1.22-1.25), sex (male HR 1.23; 95% CI: 1.16-1.32), race (Black HR 1.17; 95% CI: 1.09-1.26), insurance (uninsured HR 1.28; 95% CI: 1.09-1.50), and marital status (single HR 1.29; 95% CI: 1.21-1.37)., Conclusion: Nearly one in three HNSCC patients died from competing causes. When developing long term survivorship regimens for HNSCC patients, clinicians should be familiar with this population's specific risks., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Skin grafts offer a dynamic repair option for nasal defects of appropriate size, depth, and location. Granulation and grafting can successfully be used as stand-alone reconstructive options or in conjunction with flap repair. This article reviews suitable indications for graft and granulation use in nasal repair to achieve optimum functional and esthetic outcomes., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Purpose: To investigate the effect of race and sex on long-term survival of oral and oropharyngeal cancer., Methods: The Surveillance, Epidemiology and End Results database was queried for adult oral and oropharyngeal cancer patients with at least 25-year follow-up. Kaplan-Meier survival curves and cox proportional hazards model were used to identify differences., Results: Of the 22,162 patients identified, 70.3% were males. Only 8.9% were alive at 25 years post-diagnosis. Black males show the poorest overall and disease-specific survival rates (p < 0.001). After controlling for covariates, Blacks had a 40% higher hazard of mortality compared with Whites (HR 1.40, 95% CI 1.35-1.46), while females had a 9% reduction in mortality risk (HR 0.91, 95% CI 0.88-0.94)., Conclusions: Overall and disease-specific survival is poor for oral and oropharyngeal cancer patients, and Black men fare worst. This illustrates the need for long-term cancer survival plans incorporating disparity effects in overall cancer outcomes.

Background: Many studies have demonstrated the advantage of postoperative concurrent chemoradiotherapy (CRT) over radiotherapy (RT) alone in locoregional control, but few have examined overall survival with respect to national databases., Methods: The literature was searched for eligible randomized controlled trials. The Surveillance, Epidemiology, and End Results (SEER) Database and National Cancer Data Base (NCDB) were searched for 5-year overall survival data., Results: Twenty-eight studies were examined and demonstrated 44% greater locoregional control (relative risk [RR] = 0.56; 95% confidence interval [CI] = 0.46-0.68) and 12% overall survival benefit (RR = 0.88; 95% CI = 0.81-0.98) with postoperative adjuvant CRT compared to adjuvant RT. Overall SEER survival was 45.0% in 1973, rising to 53.2% in 2005. The NCDB documents a similar increase in overall survival from 45.5% in 1994 to 53.4% in 2005., Conclusion: The literature shows mortality benefit of adjuvant CRT in patients with advanced head and neck cancer, reflected in SEER and NCDB., (© 2015 Wiley Periodicals, Inc.)

Objective: To determine the safety, efficacy, and potential for hearing preservation of an electroacoustic hearing system in patients with severe high-frequency and moderate low-frequency hearing loss., Patients: Five patients were included in this study with steeply down-sloping sensorineural hearing loss. All patients had a history of hearing aid use and similar hearing in the contralateral ear. Ages ranged from 48 to 69 years., Intervention: All participants were implanted with an electro-acoustic stimulation (EAS) device using a hearing preservation technique. This device integrates electric and acoustic stimulation into a single processor for simultaneous ipsilateral bimodal stimulation., Main Outcome Measure(s): Pure-tone audiograms (PTA) and speech reception thresholds (SRTs) during preoperative evaluation; initial cochlear implant (CI) stimulation; initial EAS stimulation; and at 3, 6, and 12 months poststimulation. Consonant-Nucleus-Consonant (CNC) monosyllables preoperatively and at 3, 6, and 12 months poststimulation., Results: All participants showed preserved hearing in the surgical ear after implantation as measured by PTA and SRT. Significant improvement in speech recognition testing over hearing aid was observed at 3 months with EAS versus 6 months with CI-only stimulation. Facial stimulation occurred in 1 patient and resolved after reprogramming., Conclusion: There were no significant complications in this cohort of patients. Adequate hearing preservation was achieved. EAS and CI aided conditions both showed significant improvement over hearing aid with EAS condition achieving significance sooner.

Objective: This study aims to characterize the performance plateau in adult cochlear implant recipients after the initial postimplantation increase by using word recognition testing and an explicit definition of performance plateau., Study Design: Retrospective review., Setting: Urban, tertiary referral center., Patients: One hundred twenty-five patients with 138 devices tested with AzBio were matched to 130 patients with 138 devices tested with HINT based on performed on CNC monosyllable tests., Intervention: Patient's performance was measured overtime using AzBio and HINT tests to determine when and at what score their performance reached a plateau., Main Outcome Measure(s): Time from implantation to reach a performance plateau and plateau score with each test., Results: Thirty-four devices reached a HINT plateau and 30 devices reached an AzBio plateau. Patients reached plateaus at similar times postoperatively using HINT and AzBio, 18.8 and 16.5 weeks, respectively (p = 0.476). Five patients tested with HINT plateaued at scores of 99% to 100%, whereas no patients plateaued above 92% with AzBio., Conclusion: Patients reached a plateau in performance at similar median times using AzBio and HINT, despite the ceiling effect of HINT in some patients. Most patients who reach a plateau did so within 4 months, but exactly when and if a patient's performance plateaus varies significantly among individuals. Further study is required to determine which test best reflects when a patient reaches his or her maximal performance in natural listening conditions.

Tumours arising in the small bowel are rare, accounting for less then 2% of all gastrointestinal neoplasms. Adenocarcinoma accounts for 40% of small bowel malignancies. They are rarely considered as a differential diagnosis, and their discovery is usually greeted with surprise. We present a case in which aspecific symptoms of this neoplasm, non-informative instrumental examinations and a coexisting hiatal hernia led to the misdiagnosis of reflux disease until a complication such as abdominal occlusion occurred. To the best of our knowledge this is the second case in the literature in which a jejunal adenocarcinoma mimicked a gastro-oesophageal reflux disease and delayed the correct diagnosis.

Background: The aims of this study were to compare peritumoral injection of (99m)Tc-labeled albumin and subdermal injection of blue dye with subareolar (SA) injection of blue dye alone in terms of success of the sentinel lymph node identification rate, false negative (FN) rate, overall accuracy, and sensitivity of the two procedures., Methods: From January 1999 to October 2002, 155 patients with localized breast cancer were treated. Patients were subdivided into two groups. In patients in group 1 (n = 115; January 1999 to December 2001), lymphoscintigraphy together with injection of vital dye was performed. In patients in group 2 (n = 40; January 2002 to October 2002), SA injection of blue dye alone was performed., Results: In patients in group 1, the overall successful identification rate was 94.8%. The success rate of identifying a sentinel lymph node by a combination of the two techniques was 95%. With blue dye alone, the successful identification rate was 94.6% in patients in group 1 (subdermal) and 97.5% in group 2 (SA). The FN rate was 9% in group 1 and 0% in group 2. The overall accuracy of lymphatic mapping was 97% in group 1 and 100% in group 2. Sensitivity was 91% in group 1 and 100% in group 2., Conclusions: This study of dye-only injection into the SA plexus demonstrates a high sentinel node identification rate, absent FN rate, and rapid learning curve. On the basis of these findings, we propose that injections into the SA lymphatic plexus are the optimal way to perform dye-only lymphatic mapping of the breast.

From January 1976 to December 2000, in the Surgical and Specialistic Sciences Department, Ist Chair of Surgical Physiopathology, University of Bari, we observed 13 cases of ano-rectal trauma. Except in wartime, these traumas are unusual. The aetiology is variable. In our experience we found 3 lesions due to firearms (24%), 2 patients with polytrauma after car accidents (15%), 3 iatrogenic lesions (24%), 1 lesion due to compressed air (7%), and 4 lesions due to objects used for autoeroticism (30%). Timely diagnosis and treatment were essential for a good outcome. The surgical choice was based on the patient's condition, the aetiology of the lesion and its anatomical site. We constructed 7 temporary colostomies and performed 2 Hartmann's operations. In 4 patients we extracted objects from the rectum. Four patients died.