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Objective Data pertaining to the outcomes of retrosternal goiter surgeries performed at secondary care centers, where thoracic surgery expertise is not readily available, is infrequently reported. Careful patient selection is crucial to avoid an unexpected need for a sternotomy during surgery. We sought to evaluate the surgical management of patients with retrosternal goiters treated at two secondary care centers. Methods Retrospective review of clinical records and computed tomographic (CT) scans of 557 patients who underwent thyroid surgery at the Departments of Otolaryngology, Head and Neck Surgery of Manukau Surgery Center and Whangarei Base Hospital. Inclusion criterion was extension of goiter below the plane of the thoracic inlet on CT scan. Clinicopathologic features and surgical outcomes were recorded. Results The prevalence of retrosternal goiter was 72 of 557 patients (12.9%). All patients in this series underwent thyroidectomy transcervically. Dyspnea was present in 48 patients (66.7%). On preoperative CT scans, the goiter was noted to extend beyond the aortic arch in seven patients (9.7%), tracheal bifurcation in five patients (6.9%) and posterior mediastinum in 15 patients (20.8%). Malignancy was diagnosed in eight patients (11.1%) histologically. Postoperatively, vocal cord paralysis was temporary in 5 patients (6.9%) and permanent in 1 patient (1.4%). Hypocalcaemia was transient in 10 patients (13.9%). No permanent hypocalcemia, tracheomalacia, postoperative hematoma or patient death was reported. During the study period, 4 patients were encountered in the outpatients setting whereby the evaluation of their CT imaging demonstrated features deemed to be at high risk of requiring a sternotomy: primary mediastinal goiter (n = 2) and inferior extent of goiter to the level of right atrium (n = 2). These patients were pre-emptively referred to a tertiary center where thoracic surgery service was available and their data was reported separately. Conclusion With careful patient selection, the majority of retrosternal goiter can be resected transcervically with minimal morbidities. Preoperative CT scan yielded useful surgical information; in the presence of primary mediastinal goiter or inferior extent of goiter to the level of the right atrium, surgery should be planned in a tertiary center where thoracic surgeon is available.

Evofosfamide (TH-302) is a clinical-stage hypoxia-activated prodrug of a DNA-crosslinking nitrogen mustard that has potential utility for human papillomavirus (HPV) negative head and neck squamous cell carcinoma (HNSCC), in which tumor hypoxia limits treatment outcome. We report the preclinical efficacy, target engagement, preliminary predictive biomarkers and initial clinical activity of evofosfamide for HPV-negative HNSCC. Evofosfamide was assessed in 22 genomically characterized cell lines and 7 cell line–derived xenograft (CDX), patient-derived xenograft (PDX), orthotopic, and syngeneic tumor models. Biomarker analysis used RNA sequencing, whole-exome sequencing, and whole-genome CRISPR knockout screens. Five advanced/metastatic HNSCC patients received evofosfamide monotherapy (480 mg/m2 qw × 3 each month) in a phase 2 study. Evofosfamide was potent and highly selective for hypoxic HNSCC cells. Proliferative rate was a predominant evofosfamide sensitivity determinant and a proliferation metagene correlated with activity in CDX models. Evofosfamide showed efficacy as monotherapy and with radiotherapy in PDX models, augmented CTLA-4 blockade in syngeneic tumors, and reduced hypoxia in nodes disseminated from an orthotopic model. Of 5 advanced HNSCC patients treated with evofosfamide, 2 showed partial responses while 3 had stable disease. In conclusion, evofosfamide shows promising efficacy in aggressive HPV-negative HNSCC, with predictive biomarkers in development to support further clinical evaluation in this indication.

Background Recognized prognostic indicators for metastatic cutaneous squamous cell carcinoma (SCC) of the head and neck include facial nerve involvement, immune status, and “parotid” staging system (P-stage). We sought to examine the impact of lateral temporal bone resection (LTBR) on prognosis. Methods We conducted a retrospective analysis of 160 patients with metastatic cutaneous SCC to the parotid. All patients had parotidectomy and neck dissection; 27% had additional LTBR when the tumor was adherent to the temporal bone. Results Overall 5-year survival was 48%, disease-specific survival 77%, and locoregional control 83%. Corresponding results for immunocompetent versus immunocompromised were 55%, 86%, and 87% versus 12%, 48%, and 64%. On Cox regression analysis, only immunocompromised status (ie, lymphoproliferative disorder, organ-transplant patient) was prognostically significant (p < .001). Conclusion More radical resection that may include LTBR mitigates the poorer prognosis with advanced disease in our series. Treatment must be individualized in immunocompromised patients who have shortened overall survival. © 2013 Wiley Periodicals, Inc. Head Neck 36: 545–550, 2014

Objectives/Hyphothesis: Surgical volumes have been shown in many fields to reflect expertise and to be associated with improved clinical outcomes. We sought to test similar hypotheses that neck dissection is a volume-sensitive procedure wherein the number of lymph nodes harvested and clinical outcomes are correlated with the number of neck dissections performed. Methods: We conducted a retrospective analysis of 375 neck dissections. The number of nodes harvested was examined by multiple linear regression before and after mathematical correction for pathologists' variation over time. The prior experiences of the surgeons were also averaged, depending on whether there was regional recurrence after at least 9 months of follow-up. Results: More nodes were found by the pathologists over time, with 2.1 more nodes being found on average for each successive year (P < .001). After correcting for this effect of time, there remained a significant relationship between surgeons' experience and number of nodes harvested (P < .003). Additionally, cases that recurred were operated by less-experienced surgeons (P = .02). Conclusions: We have demonstrated that there is a “learning curve” for neck dissection. Our most experienced surgeon harvested on average 11 more nodes than similar specimens submitted by the group of inexperienced surgeons. The effect of experience remains significant even without adjusting for time (P < .001). Surgical experience also affects clinical outcome months after the dissection. This retrospective review supports surgical volume as an indicator of expertise in neck dissection that could be used to assess trainees' progress and for quality assurance in large head and neck units. Laryngoscope, 2009

Acinic cell carcinoma is an uncommon malignancy of the salivary glands and as such it has been difficult to accurately delineate its natural history. The aim of this study is to assess the behaviour of acinic cell salivary cancer of the parotid gland presenting to a single head and neck surgical unit in Auckland. The study is a structured review of cases of acinic cell carcinoma of the parotid gland presenting from 2000 to 2006 to the Head and Neck Unit at Auckland Hospital, those identified from the pathology database and the Otobase head and neck database. Case records and pathology reports were reviewed. Fifteen patients were identified, 9 men and 6 women. The mean age was 67.2 years, with range 50-85 years. The mean follow up was 4.4 years and range 1.1-7 years. There was one case of local recurrence during study period and no deaths. Five of 15 patients received postoperative radiotherapy. Postoperative complications consisted of one wound haematoma and two cases of marginal mandibular weakness (one transient and one permanent). Current management strategies are obtaining appropriate rates of recurrence and postoperative complications within the Auckland population.

Background. Our aim was to examine the effect of a compromised immune state on the outcomes in patients treated for metastatic cutaneous squamous cell carcinoma (SCC). Methods. A retrospective analysis of patients with metastatic cutaneous SCC to the parotid and neck treated at Greenlane Hospital between 1992 and 2002 was conducted. Outcomes were compared between immune-competent and immunocom- promised patients. A logistic regression analysis of likely risk factors for poor outcome was done. Results. Forty-nine patients were identified, nine of whom were immunocompromised. All patients were treated by paroti- dectomy and/or neck dissection. The facial nerve was sacrificed in 42% of the patients. Thirty-seven patients underwent post- operative radiotherapy (76%). Recurrence was significantly more common in the immunocompromised group (56% vs 28%), with higher rates of local and distant recurrence. Survival at 1 and 2 years was reduced. Conclusion. Immunocompromise has a significant impact on the outcome of metastatic cutaneous SCC to the parotid and neck, affecting recurrence and survival. A 2006 Wiley Period- icals, Inc. Head Neck 28: 244 - 248, 2006

Background: Vocal dysfunction in patients with thyroid pathology has been poorly documented, and dysfunction after thyroid surgery is generally reported in terms of recurrent laryngeal nerve or external laryngeal nerve palsy. But voice dysfunction is more complex than simply nerve integrity. The present study reports the incidence of dysphonia in patients presenting for thyroid surgery, and relates postoperative changes in vocal function to recurrent and external laryngeal nerve function, and the surgical handling of the strap muscles. Methods: Fifty patients were assessed by Visipitch before and after thyroidectomy. Following surgery the patients filled out a questionnaire. Results: Overall 26 of 44 patients had no subjective postoperative voice change, while 10 reported subjective deterioration and eight reported subjective improvement in voicing. Postoperative objective assessment of these patients found that 17 were the same, eight refused to come for testing because they felt their voice had not changed, 13 were better and six were worse. Following surgery two patients (4.5%) had temporary recurrent laryngeal nerve palsies (2.5% of nerves at risk), and four patients (10%) suffered external laryngeal nerve palsies. Division of strap muscles was not detrimental to voicing. Six patients were lost to follow-up. Fifteen patients (34%) presented with vocal abnormalities, six (40%) of whom improved postoperatively. Conclusions: Patients may have voicing abnormalities before thyroid surgery is performed. Surgery may improve or worsen the voice irrespective of the pre-operative voice status.

Background The plunging ranula is a relatively uncommon phenomenon which represents a mucus escape reaction occurring from disruption of the sublingual salivary gland. We present a series of 20 patients managed at Green Lane Hospital (Auckland, New Zealand) over a 9-year period. Methods A retrospective review of 13 patients with this condition was undertaken, and a prospective study was conducted on 7 patients. Information was collected on age, sex, ethnic origin, history of onset, predisposing factors, treatment, and outcome of treatment. Results The patients were all young adults with a median age of 31 years. The sex distribution was relatively equal, with 11 men and 9 women. All patients were Maori or Pacific Island Polynesians. Six patients gave a clear history of preceding trauma to the neck or oral cavity. Two recurrences were seen, both in patients who had had the sublingual gland excised via a cervical approach. Five patients sustained lingual nerve damage during surgery. Full function recovered in four patients, but the complication was still present in the fifth patient at 2 years, after which he was lost to follow-up. Conclusions Plunging ranulas appear to occur with greater incidence in the Maori and Pacific Island Polynesian populations. The precise etiology of their predisposition is unknown, although local trauma or inherent mylohyoid dehiscences may play important roles. Removal of the sublingual gland via either a cervical or intraoral approach is important in the management of this condition. Excision of the pseudocyst is probably unnecessary and places surrounding structures at risk of damage, but a biopsy of the pseudocyst wall is important to confirm the diagnosis. © 1998 John Wiley & Sons, Inc. Head Neck20: 63–68, 1998.

Recognized prognostic indicators for metastatic cutaneous squamous cell carcinoma (SCC) of the head and neck include facial nerve involvement, immune status, and "parotid" staging system (P-stage). We sought to examine the impact of lateral temporal bone resection (LTBR) on prognosis.We conducted a retrospective analysis of 160 patients with metastatic cutaneous SCC to the parotid. All patients had parotidectomy and neck dissection; 27% had additional LTBR when the tumor was adherent to the temporal bone.Overall 5-year survival was 48%, disease-specific survival 77%, and locoregional control 83%. Corresponding results for immunocompetent versus immunocompromised were 55%, 86%, and 87% versus 12%, 48%, and 64%. On Cox regression analysis, only immunocompromised status (ie, lymphoproliferative disorder, organ-transplant patient) was prognostically significant (p.001).More radical resection that may include LTBR mitigates the poorer prognosis with advanced disease in our series. Treatment must be individualized in immunocompromised patients who have shortened overall survival.

Aim: Embolization of external carotid vessels in the treatment of intractable epistaxis is not well documented in Australasia. The aim of the present retrospective study was to audit our experience with the technique, and to compare it with other centres. Methods: Retrospective review. Results: Twenty-nine embolizations were performed in 28 patients. Embolization was successful in 24 out of 28 patients (86%). Three patients required ligation of the anterior ethmoidal arteries, one of whom subsequently underwent successful repeat embolization. There were minor complications in 6/29 procedures (21%), and no major complications. Conclusion: Our outcomes compare favourably with those of larger centres. Embolization is an effective tool in the management of patients with intractable epistaxis.

Background. The patient with nasopharyngeal carcinoma (NPC) frequently is initially seen with regional node dissemination. Preliminary investigations suggest that the presence of Epstein-Barr virus (EBV) genomes in neck metastases from an occult primary may be diagnostic and predictive of NPC. The goal of this study was to test this proposition. Methods. The polymerase chain reaction (PCR) was used to detect the presence of EBV DNA in fine-needle aspirate (FNA) samples obtained from malignant neck nodes. Control samples were obtained from other locations in the head and neck. Patients. The patients in this study were evaluated at the Toronto Princess Margaret Hospital, a province-wide tertiary care cancer treatment center. Of the 23 patients evaluated with malignant neck masses, 6 had NPC, 5 patients had metastatic squamous cell carcinoma of an unknown primary, and 12 patients served as controls with other known head and neck carcinomas. One of the patients initially diagnosed as an unknown primary later demonstrated NPC. FNA specimens were also obtained from 24 normal parotid, submandibular, or thyroid glands for comparison. Results. In the samples with sufficient DNA for analysis, EBV was detected in 5 of 5 neck nodes from patients with known NPC. EBV was also detected in the neck node of a patient who went on to develop NPC and in a cervical node from 1 of 2 patients in whom the primary tumor remained unknown. None of the evaluable control neck nodes or FNA controls from other sites demonstrated EBV. Conclusions. These results demonstrate the utility of NPC-diagnostic EBV gene amplification in FNA samples of neck metastases and suggest that the presence of the EBV genome in FNA samples of neck nodes is predictive of the presence of NPC. © 1995 Jons Wiley & Sons, Inc.

The cytologic and histologic slides on all patients with a diagnosis of Hürthle cell tumor at Mount Sinai Hospital during the last 12 years were reviewed. There were 67 Hürthle cell tumors of which 15 (22%) were malignant. Four carcinomas (27%) occurred in a background of thyroiditis. Forty-three patients with Hürthle cell tumors had undergone preoperative fine-needle aspiration, of which 31 had satisfactory aspirates. For Hürthle cell neoplasia, fine-needle aspiration cytology had a sensitivity of 83.8% (26 of 31) and positive predictive value of 93% (26 of 28), provided that the aspirate was of adequate cellularity. All 3 cases predicted as Hürthle cell carcinoma on the basis of cellular and nuclear atypia were correctly predicted, but 3 carcinomas composed of bland cells were incorrectly predicted as adenomas. We conclude that aspiration cytology can differentiate nonneoplastic from neoplastic Hürthle cell lesions with high accuracy, but that the differentiation between benign and malignant lesions is less reliable.

High-frequency ultrasonography is ideally suited to imaging of the thyroid and parathyroid glands by virtue of their superficial location in the neck. Ultrasonography of the thyroid is most commonly used in the evaluation of the solitary nodule. Ultrasonography of the parathyroid glands is usually performed to evaluate and localise parathyroid abnormalities in patients with hypercalcemia. The increased diagnostic acumen offered by this modality allows a realistic working diagnosis and leads to a rational management strategy.

OBJECTIVES/HYPHOTHESIS: Surgical volumes have been shown in many fields to reflect expertise and to be associated with improved clinical outcomes. We sought to test similar hypotheses that neck dissection is a volume-sensitive procedure wherein the number of lymph nodes harvested and clinical outcomes are correlated with the number of neck dissections performed.We conducted a retrospective analysis of 375 neck dissections. The number of nodes harvested was examined by multiple linear regression before and after mathematical correction for pathologists' variation over time. The prior experiences of the surgeons were also averaged, depending on whether there was regional recurrence after at least 9 months of follow-up.More nodes were found by the pathologists over time, with 2.1 more nodes being found on average for each successive year (P.001). After correcting for this effect of time, there remained a significant relationship between surgeons' experience and number of nodes harvested (P.003). Additionally, cases that recurred were operated by less-experienced surgeons (P = .02).We have demonstrated that there is a "learning curve" for neck dissection. Our most experienced surgeon harvested on average 11 more nodes than similar specimens submitted by the group of inexperienced surgeons. The effect of experience remains significant even without adjusting for time (P.001). Surgical experience also affects clinical outcome months after the dissection. This retrospective review supports surgical volume as an indicator of expertise in neck dissection that could be used to assess trainees' progress and for quality assurance in large head and neck units. Laryngoscope, 2009.

Objective To assess the predictive value of wound amylase as an indicator for pharyngocutaneous fistula development following laryngectomy for cancer. Design and Setting We conducted a prospective observational study at a tertiary referral center of 102 consecutive laryngeal or hypopharyngeal cancer patients undergoing laryngectomy with or without pharyngectomy. Intervention Data were collated on potential predictors of fistula formation compared with rate of development of clinical fistulas, all confirmed radiologically. Main Outcome Measures Rate of fistula formation was determined for the following potential predictors: extent of resection (extended laryngectomy), postoperative wound (drain) amylase, previous radiotherapy, neck dissection, preoperative and postoperative hemoglobin and albumin levels, and postoperative transfusion. Sensitivity, specificity, and positive and negative predictive values of significant predictors were ascertained. Results The only significant predictors of fistula formation were extent of resection (extended laryngectomy) and drain amylase >4000 IU/L. If both factors are combined, the sensitivity, specificity, and positive and negative predictive values for fistula development are 83, 94, 63, and 98 percent, respectively. Conclusion We advocate that patients be managed postoperatively according to the presence or absence of these given predictors to reduce occurrence of fistula formation in the high-risk group.

Head and neck cancer patients frequently require gastrostomy feeding. Different insertion techniques have been described. The aim of the present study was to compare clinical results of percutaneous endoscopic and radiological gastrostomies in patients treated in a regional head and neck cancer unit.The records of patients who received either percutaneous endoscopic gastrostomy (PEG) or percutaneous radiological gastrostomy (PRG) between August 1997 and February 2001 were reviewed retrospectively. Documented complications (leak, infection, nausea and vomiting, ileus, bleeding, peritonitis) were recorded, compared and evaluated.There were 74 patients (56 PEG, 18 PRG), most with stage III and IV head and neck malignancy. There was a significantly lower incidence of complications in PEG than PRG (11% vs 44%, P = 0.004). There was a delay of feeding due to tube placement in 4% of PEG and 22% of PRG (P0.025). Major complications occurred in 3.6% and 5.6% of PEG and PRG, respectively. Generally the complication rate for either form of gastrostomy was comparable with other studies. No procedure-related deaths occurred.Selection bias, technique and tube type appeared to influence the complication rate in the present review. Percutaneous endoscopic gastrostomy will remain the authors' preferred method while PRG will be reserved for those cases for whom endoscopic placement is deemed to be impractical.

Objectives The purposes of this study were to examine the quality of life (QL) of patients who received treatment for cancer of the parotid or temporal region, and to identify factors contributing to it. The relationships between clinician-based measures of treatment outcome and the patient-based counterparts were also evaluated. Methods A retrospective, cross-sectional study was conducted on 23 patients who had received either a temporal bone resection or a combination of parotidectomy and radiotherapy. The QL survey involved both global QL and measures of the appearance, communication, hearing, physical, psychological, and social domains. Patients were assessed clinically for their performance status, facial nerve function, disfigurement, and hearing and the results were compared with patient-rated QL. Correlation between the QL variables and global QL was identified using Spearman correlation tests. Results Ongoing physical symptoms, communication difficulties, and social disturbances were associated with poorer global QL (P

Purpose: To determine results of various treatments for T3 fixed-cord lesions and the subset T3 glottic cancer in Auckland from 1979 to 1995. Patients and Methods: Data were collected retrospectively from a departmental database, and the notes were reviewed. Because of the difficulty in determining the subsite of some fixed-cord lesions, the entire group of T3 fixed-cord lesions was examined, and those tumors that were considered to be definitely arising from the glottis were then analyzed as a specific subset. Results: Fixed-cord lesions were diagnosed in 75 patients (21 supraglottic, 54 glottic). Primary surgery (total laryngectomy) was performed on 46 patients, primary radical dose radiotherapy was undertaken on 25 patients, and four patients were treated palliatively. For T3 fixed-cord lesions, disease-specific survival for radiotherapy and surgery was 36% and 66%, respectively, and 32% and 67%, respectively, for T3 glottic lesions. For both T3 fixed-cord and T3 glottic lesions, surgery produced significantly better survival than did radiotherapy ( P = .0157). With radiotherapy greater than 60 Gy, cancer of the larynx has been controlled in seven of 13 patients, although only five patients are alive, with a median follow-up of 24 months (range, 12–49 months). Conclusion: Radiotherapy less than 60 Gy produced markedly inferior results to surgery for T3 fixed-cord lesions and T3 glottis in Auckland. Radiotherapy at more than 60 Gy shows promise, but an ongoing audit is essential to ensure that survival is similar to surgery and to that reported by those promoting organ-preservation protocols.

A head and neck ultrasound-guided fine-needle aspiration clinic was set up to determine the role of ultrasound and ultrasound-guided fine-needle aspiration in the evaluation of patients with lesions in this region. One hundred ninety-five lesions were biopsied by ultrasound-guided fine-needle aspiration in 203 patients. Ultrasound detected 2 or more lesions in 14 (48%) of 29 patients with a clinically solitary thyroid nodule. Three (8.8%) of 34 lesions thought to be within the parotid gland were determined to be external. A pronounced learning curve was evident in the technique of ultrasound-guided fine-needle aspiration, particularly for nonpalpable disease. Adequacy of sampling for each 3-month period was 71%, 89%, and 94%, respectively. Seventy-four percent of central aspirations were satisfactory compared to 54% of peripheral aspirations. Ultrasound-guided fine-needle aspiration did not alter the clinical staging of metastatic neck disease in 8 patients having 10 neck dissections but proved useful in detecting nodal recurrence in 3 irradiated necks that did not proceed to surgery. The smallest node to harbor malignancy had 4-mm maximal axial diameter. We conclude that ultrasound and ultrasound-guided fine-needle aspiration are valuable adjuncts to the clinical examination.

Twenty-nine patients with lesions of the neck, skull base, and cavernous sinus had test balloon occlusions of the internal carotid artery (ICA) to determine the feasibility of sacrifice of the artery. Only one patient (3.4%) showed evidence of cerebrovascular compromise. Sixteen patients who tolerated test occlusions went on to ICA sacrifice. Ten patients had permanent balloon occlusion (PBO) of the ICA for cavernous aneurysms or to "trap" carotid-cavernous fistulae (CCF). Complications occurred in three patients (30%) with permanent morbidity in one patient (10%). One patient with CCF had PBO of the proximal ICA only, resulting in an unstable neurologic state and ultimately in death. Two patients had resection of skull base tumors 2 and 6 days after PBO of the ICA. Both suffered strokes and one died. Three patients had surgical sacrifice of the ICA without PBO. Two of these patients suffered cerebral ischemia without permanent sequelae. We conclude that test occlusion of the ICA with clinical monitoring will miss a significant number of patients with inadequate cerebrovascular reserve. Sensitivity is improved by controlled reduction of systemic blood pressure during the test occlusion. Resection of a skull base tumor soon after PBO of the ICA should be done in a delayed fashion or preceded by extracranial-intracranial arterial bypass. Patients who have had the artery sacrificed should be monitored in an intensive care setting for 48 hours to avoid hypotension, which could cause cerebrovascular ischemia.

Objective To test the hypothesis that extended postoperative antibiotic cover would reduce the incidence of pulmonary complications in patients undergoing major head and neck surgery with tracheostomy. Design A prospective, randomized, controlled trial was carried out to determine the efficacy of an extended course (5 days) of intravenous amoxicillin–clavulanic acid in reducing the rate of atelectasis and pulmonary infections postoperatively. Other possible risk factors that might predispose to pulmonary complications were also evaluated. Setting Tertiary referral center for head and neck surgery. Patients Consecutive patients younger than 80 years with planned surgery for carcinoma of the oral cavity, pharynx, or larynx were enrolled. Patients with diabetes, those who had received antibiotics within 1 week before surgery, and those with preexisting pulmonary disease were excluded. Intervention Patients were randomly assigned no antibiotics or a 5-day course of intravenous amoxicillin–clavulanic acid postoperatively. Main Outcome Measures The development of pulmonary complications (pulmonary infection or atelectasis). Results Eighty-six patients were enrolled; 73 patients met the criteria for analysis. Thirty-four (47%) developed pulmonary complications; 29 (40%) had a pulmonary infection. An extended course of antibiotics did not reduce the rate of pulmonary infections ( P = .57). Positive risk factors for a pulmonary infection were presence of preoperative obstructive lung function and postoperative atelectasis. Conclusions An extended course of antibiotics did not prevent the development of postoperative pulmonary infections in patients undergoing major head and neck surgery with tracheostomy. Poor pulmonary function and postoperative atelectasis emerged as significant risk factors for pulmonary infection.