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To assess whether preoperative tracheostomy (PreOT) increases risk of complications after total laryngectomy (TL) and to determine if timing of tracheostomy creation is associated with an increased risk.Retrospective cohort study.Tertiary care hospital between 2007 and 2020.Inclusion criteria were patients who underwent primary or salvage TL for oncologic treatment. Dependent variables of interest included surgical complications, such as wound dehiscence, infection, hematoma, complete flap failure, fistula formation, and stoma stenosis, as well as medical complications. Categorical variables were compared with chi-square test or Fisher exact test, and continuous variables were compared with an independentA total of 306 patients were included. Primary TL was performed in 161 (53%) patients and salvage in 145 (47%) patients. Of the patients undergoing primary laryngectomy, 105 (65%) received a PreOT. Of the patients undergoing salvage laryngectomy, 86 (59%) received a PreOT. In both primary and salvage cases, there was no association between PreOT and surgical or medical complications. Additionally, there was no significant association between timing of tracheostomy and surgical complications. On multivariable analysis, the presence of a PreOT was not associated with surgical complications. In salvage cases, those with a PreOT had a significantly longer average length of stay than those without a PreOT (12 vs 9 days,PreOT in patients undergoing primary and salvage laryngectomies was not associated with surgical or medical complications postlaryngectomy. Timing of tracheostomy in relation to laryngectomy was not found to adversely affect clinical outcomes.

Determine which variables impact postoperative discharge destination following head and neck microvascular free flap reconstruction.Retrospective review of prospectively collected databases.Consecutive patients undergoing head and neck microvascular free flap reconstruction between January 2010 and December 2019 (n = 1972) were included. Preoperative, operative and postoperative variables were correlated with discharge destination (home, skilled nursing facility [SNF], rehabilitation facility, death).The mean age of patients discharged home was lower (60 SD ± 13, n = 1450) compared to those discharged to an SNF (68 SD ± 14, n = 168) or a rehabilitation facility (71 SD ± 14, n = 200; p 0.0001). Operative duration greater than 10 h correlated with a higher percentage of patients being discharged to a rehabilitation or SNF (25% vs. 15%; p 0.001). Patients were less likely to be discharged home if they had a known history of cardiac disease (71% vs. 82%; p 0.0001). Patients were less likely to be discharged home if they experienced alcohol withdrawal (67% vs. 80%; p = 0.006), thromboembolism (59% vs. 80%; p = 0.001), a pulmonary complication (46% vs. 81%; p 0.0001), a cardiac complication (46% vs. 80%; p 0.0001), or a cerebral vascular event (25% vs. 80%; p 0.0001). There was no correlation between discharge destination and occurrence of postoperative wound infection, salivary fistula, partial tissue necrosis or free flap failure. Thirty-day readmission rates were similar when stratified by discharge destination.There was no correlation with the anatomic site, free flap donor selection, or free flap survival and discharge destination. Patient age, operative duration and occurrence of a medical complication postoperatively did correlate with discharge destination.4 Laryngoscope, 133:95-104, 2023.

OBJECTIVES/HYPOTHESIS We aim to 1) evaluate trends in adjuvant treatment of human papilloma virus (HPV)-related oropharyngeal cancer; 2) assess change in complications and functional outcomes over time; and 3) assess change in overall and disease-free survival (DFS) over time. STUDY DESIGN Retrospective analysis. METHODS Charts of patients who underwent transoral robotic surgery for HPV-related oropharyngeal cancer between 2011 and 2019 were reviewed. Trend analysis was used to compare rate of adjuvant treatment over time. The Kaplan-Meier method was conducted to analyze overall survival (OS) and DFS. RESULTS Three hundred and forty-two patients met inclusion criteria. One hundred and sixty-three (47.7%) patients underwent adjuvant radiation, and 90 (26.3%) patients underwent adjuvant chemoradiation. Rate of extranodular extension decreased significantly from 38.9% to 24.0% (P = .004). Rate of adjuvant therapy decreased significantly from 90.9% to 62.5% between 2011 and 2019 (P = .001). In patients who received adjuvant treatment, rate of adjuvant chemoradiation therapy decreased significantly from 40.0% to 20.0% (P

Patients with recurrent oropharyngeal cancer can achieve survival benefits from surgical salvage, and often require simultaneous free-flap reconstruction. Resection and reconstruction can impact function, leading to tube dependence.describe rates of tracheostomy and gastrostomy tube dependence after oropharyngeal resection and free flap after prior radiation.evaluate patient, tumor, and treatment factors associated with tube dependence.Retrospective, multi-institutional cohort study. Patients treated from 2003 to 2020. Average follow-up 21.4 months.Five tertiary care centers.Consecutive cohort of patients undergoing resection and simultaneous free-flap reconstruction for oropharyngeal squamous cell carcinoma after head and neck radiation.gastrostomy tube dependence and tracheostomy or tracheostoma 1 year after surgery. Univariable and multivariable logistic regression were performed to identify factors associated with dependence.89 patients underwent oropharyngectomy and free-flap reconstruction; 18 (20%) underwent total laryngectomy as part of tumor extirpation. After surgery, 51 patients (57%) lived 12 months. Among patients alive at 12 months, 22 (43%) were at least partially-dependent on gastrostomy tube, and 15 (29%) had either tracheostomy or tracheostoma. On multivariable analysis, extensive glossectomy (OR 16.6, 95% CI 1.83-389, p = 0.026) and total laryngectomy (OR 11.2, 95% CI 1.71-105, p = 0.018) were associated with long-term gastrostomy tube. No factors were associated with long-term tracheostomy on multivariable analysis.Even among long-term survivors after salvage resection and free-flap reconstruction, rates of tube dependence are significant. This multi-institutional review is the largest such study to the date and may help inform shared decision-making.IV Laryngoscope, 2022.

Objective: Evaluate the effect of p16 status on disease-free survival (DFS) and overall survival (OS) in patients with sinonasal squamous cell carcinoma (SCC) undergoing treatment with curative intent; and to assess how p16 status may affect patterns of recurrence. Study Design: Retrospective cohort study. Setting: Tertiary medical center. Methods: Patients with sinonasal SCC treated with curative intent from 2012 to 2018 were identified. Independent variable of interest was p16 status, which was assessed using immunohistochemistry (IHC) with a 70% staining cutoff for positivity. Kaplan Meier survival curve was plotted to assess correlation between p16 status and DFS and OS. Association between recurrence patterns and p16 status was conducted using chi square and fisher’s exact tests. Multivariable Cox proportional hazard analysis was conducted to assess association between independent variables and DFS. Results: Fifty patients with sinonasal SCC met inclusion criteria. Patients were p16 positive in 28/50 (56%) of cases. Kaplan Meier survival curve revealed no statistically significant association between p16 status and DFS or OS survival ( P = .780, P = .474). There was no difference in recurrence patterns in patients with p16 positive versus negative tumors. Conclusion: p16 status did not have prognostic value on DFS and OS in our cohort of patients with sinonasal SCC undergoing treatment with curative intent. There was no difference in recurrence patterns between the 2 populations. Based on the results of this study, p16 status should not impact counseling of patients as it relates to their prognosis from SNM.

To analyze CD8+ and FoxP3+ T-cell cellular density (CD) and intercellular distances (ID) in head and neck squamous cell carcinoma (HNSCC) samples from a neoadjuvant trial of durvalumab +/- metformin.Paired pre- and post-treatment primary HNSCC tumor samples were stained for CD8+ and FoxP3+. Digital image analysis was used to determine estimated mean CD8+ and FoxP3+ CDs and CD8+-FoxP3+ IDs in the leading tumor edge (LTE) and tumor adjacent stroma (TAS) stratified by treatment arm, human papillomavirus (HPV) status, and pathologic treatment response. A subset of samples was characterized for T-cell related signatures using digital spatial genomic profiling.Post-treatment analysis revealed a significant decrease in FoxP3+ CD and an increase in CD8+ CDs in the TAS between patients receiving durvalumab and metformin versus durvlaumab alone. Both treatment arms demonstrated significant post-treatment increases in ID. Although HPV+ and HPV- had similar immune cell CDs in the tumor microenvironment, HPV+ pre-treatment samples had 1.60 times greater ID compared with HPV- samples, trending toward significance (p = 0.05). At baseline, pathologic responders demonstrated a 1.16-fold greater CD8+ CDs in the LTE (p = 0.045) and 2.28-fold greater ID (p = 0.001) than non-responders. Digital spatial profiling revealed upregulation of FoxP3+ and cytotoxic T-lymphocyte-associated antigen 4 (CTLA-4) in the TAS (p = 0.006, p = 0.026) in samples from pathologic responders.Analysis of CD8+ and FoxP3+ detected population differences according to HPV status, pathologic response, and treatment. Greater CD8+-FoxP3+ ID was associated with pathologic response. CD8+ and FoxP3+ T-cell distributions may be predictive of response to immune checkpoint inhibition.gov (Identifier NCT03618654).Level 3 Laryngoscope, 2022.

Background The oncologic outcomes of surgery alone for patients with American Joint Committee on Cancer 7th edition (AJCC 7th) pN2a and pN2b human papillomavirus-associated oropharynx squamous cell carcinoma (HPV+OPSCC) are not clear. Methods The authors performed a 12-institution retrospective study of 344 consecutive patients with HPV+OPSCC (AJCC 7th pT0-3 N3 M0) treated with surgery alone with 6 months or more of follow-up using univariate and multivariate analyses. Results The 2-year outcomes for the entire cohort were 91% (182 of 200) disease-free survival (DFS), 100% (200 of 200) disease-specific survival (DSS), and 98% (200 of 204) overall survival (OS). The 18 recurrences within 2 years were 88.9% (16 of 18) local and/or regional recurrences and 11.1% (2 of 18) distant metastases. Recurrences were not significantly associated with smoking, pT stage, or pN stage. The 16 patients with locoregional recurrences within 2 years all underwent successful salvage treatments (median follow-up after salvage: 13.1 months), 43.8% (7 of 16) of whom underwent salvage surgery alone for a 2-year overall salvage radiation need of 4.5% (9 of 200). The 2-year outcomes for the 59 evaluable patients among the 109 AJCC 7th pT0-2 N2a-N2b patients with 1 to 3 pathologic lymph nodes (LNs) were as follows: local recurrence, 3.4% (2 of 59); regional recurrence, 8.4% (5 of 59); distant metastases, 0%; DFS, 88.1% (52 of 59); DSS, 100% (59 of 59); OS, 96.7% (59 of 61); and salvage radiation, 5.1% (3 of 59). Conclusions With careful selection, surgery alone for AJCC 7th pT0-2N0-N2b HPV+OPSCC with zero to 3 pathologic LNs without perineural invasion, extranodal extension, or positive margins results in high DFS, DSS, OS, and salvage treatment success. Because of the short-term follow-up, these data support further investigation of treatment de-escalation in this population.

Importance: Mandibular condyle reconstruction with vascularized free flaps can re-establish form and function after resection. However, no reports have been published regarding the postoperative an...

BACKGROUND Locoregional recurrence rates following parotidectomy for cancer remain as high as 20-30%. The auriculotemporal nerve (ATN) may allow parotid cancers to spread from the facial nerve (FN) toward the skull base, causing local recurrence. METHODS Retrospective review of 173 parotidectomies for malignancy. Preoperative and post-recurrence imaging were reviewed by a neuroradiologist for signs of tumor adjacent to the ATN. RESULTS Clinical and imaging signs of possible ATN involvement correlated with FN weakness and sacrifice. Eight patients had pathologically confirmed tumor from the ATN or V3. Forty-four percent of local recurrences had post-recurrence imaging showing tumor along the course of the ATN. Locoregional failure along the ATN was also associated with preoperative FN weakness, intraoperative FN sacrifice, and failure to complete recommended adjuvant therapy. CONCLUSIONS Parotid cancers may invade the FN and spread to the skull base via the ATN. If not appropriately managed, this may lead to local recurrence.

Despite advances in multimodal treatment for oral cavity squamous cell carcinoma, recurrence rates remain high, providing an opportunity for new therapeutic modalities that may improve oncologic outcomes. Much recent attention has been paid to the molecular interactions between the tumor cells with the adjacent peritumoral microenvironment, in which immunosuppressive molecular changes create a landscape that promotes tumor progression. The rationale for the introduction of immunotherapy is to reverse the balance of these immune interactions in a way that utilizes the host immune system to attack tumor cells. In the preoperative setting, immunotherapy has the advantage of priming the unresected tumor and the associated native immune infiltration, supercharging the adaptive anti-tumor immune response. It also provides the basis for scientific discovery where the molecular profile of responders can be interrogated to elucidate prognostic markers to aid in future patient selection. Preoperative immunotherapy is not without limitations. The risk of surgical delay due to immune adverse events must be carefully discussed by members of a multidisciplinary treatment team and patient selection will be critical. One day, the discovery of predictive biomarkers may allow for algorithms where pre-surgical immunotherapy decreases the size of surgical defect and impacts the intensity of adjuvant therapy leading to improved patient survival and decreased morbidity. With further study, immunotherapy could become a key component of future treatment algorithm.

Objective To identify functional outcome and orbital complication rate of the preserved orbit and to identify predictors of orbital impairment in periorbital free flap reconstruction. Materials and methods A retrospective review was conducted on patients undergoing orbit-sparing surgery with periorbital free flap reconstruction at a tertiary institution from 2006 to 2017. Orbital complication rate and orbital functional outcomes were analyzed. A univariable and multivariable logistic regression analysis was used to assess predictors of functional outcome. Results Forty-nine patients met inclusion criteria. Ninety-eight percent of patients maintained a functional eye post-operatively. Most periorbital free flaps, 37 (75.5%), were performed following oncologic resection. Overall orbital function was graded as functional without impairment in 29 (59.2%) patients, functional with impairment in 19 (38.8%) patients, and nonfunctional in 1 (2.0%) patient. Postoperative orbital sequelae occurred in 32 (65.3%) patients. Twenty-one (42.9%) patients underwent 35 revision operations for late orbital sequelae. Extent of resection (OR, 5.93; CI 95%, 1.05–33.4; p = 0.044) and adjuvant RT (OR, 4.69; CI 95% 1.18–18.6; p = 0.028) significantly correlated with impairment in a functional orbit on multivariable analysis. Conclusion Orbit-sparing surgery with periorbital free flap reconstruction carries a significant risk of a variety of orbital sequelae, most commonly ectropion, requiring surgical intervention. However, most patients maintain a functional eye. The need for delayed exenteration/enucleation is low and is primarily limited to cancer recurrence. Significant predictors of complications include extent of resection and adjuvant radiation therapy.

To investigate variables that predict medical and surgical complications in patients undergoing salvage surgery after primary organ-preserving therapy for head and neck cancer and to investigate the effect of complications on 5-year overall survival.A retrospective study was conducted on patients undergoing salvage surgery after primary organ-preserving therapy for head and neck cancer at a tertiary institution from 2006 to 2011. Multivariable regression analysis was used to assess association between independent variables and medical and surgical complications. A Kaplan-Meier survival curve was plotted to assess effect of surgical and medical complications on 5-year overall survival.One hundred thirty-six patients undergoing salvage surgery after primary organ-preservation surgery met inclusion criteria. Surgical complications occurred in 68/136 (50.0%) of patients. After adjusting for confounders, young age and history of hypothyroidism were significant predictors of surgical complications (p 0.05). Medical complications occurred in 37/136 (27.2%) of patients. After adjusting for confounders, older age and history of hepatic disease were significant predictors of having a medical complication (p 0.05). Patients with no complications had better overall survival than patients with medical complications (p = 0.009). There was no difference in overall survival between patients without complications and patients with surgical complications only (p = 0.259).Risk factors for medical and surgical complications include history of hypothyroidism, liver disease, and age. Survival outcomes are not affected by surgical complications but are significantly affected by medical complications highlighting the importance of personalized patient care and medical co-management.

Objective To test the null hypothesis that there is no difference in patient cost savings between the telemedicine and traditional face-to-face approach. The second objective was to assess the financial impact on the peripheral healthcare system, as compared with staffing a conventional clinic with "on-site" otolaryngologist. Methods Twenty-one patients were enrolled. To assess "patient-benefit" cost savings, a model was formulated that would utilize a certified nurse practitioner (CNP) to conduct a general otolaryngology clinic at the peripheral site, as compared with having to travel to the tertiary referral center. A "peripheral site-benefit" cost analysis was performed to assess costs of initiating and operating a telemedicine clinic at the peripheral site, compared with having an on-site otolaryngologist. Results The total patient-benefit cost savings would be $182.09 per patient per encounter and $333.22 per patient annually. The fixed cost to the peripheral site to initiate the telemedicine system was $9,895. Two hundred sixty telemedicine encounters would be needed to offset the initial cost, and 537 encounters would be needed to surpass revenue of the conventional clinic. Conclusion A real-time telemedicine otolaryngology clinic provides significant cost savings for both patients and the peripheral healthcare system. This pilot study supports telemedicine as a cost-effective approach to providing general otolaryngology care to rural patients. Level of Evidence 4.

Objectives To determine the rate of gastrostomy tube dependence after transoral robotic surgery (TORS), and to determine which patient or surgical factors increase the likelihood of gastrostomy tube dependence. Methods Retrospective chart review of all patients who underwent TORS for oropharyngeal squamous cell carcinoma (OPSCC) at a single institution from January 2011 through July 2016. Patients who underwent TORS for recurrent OPSCC were excluded. Primary outcome was gastrostomy tube (g-tube) dependence. Univariable and multivariable logistic regression were performed to identify risk factors for g-tube dependence at 3-months and 1-year. Results A total of 231 patients underwent TORS during the study period. At 3-month follow-up, 58/226 patients (25.7%) required g-tube. At 1-year and 2-year follow-up, 8/203 (3.9%) and 5/176 (2.8%), remained dependent on g-tube, respectively. Advanced T stage (T3) (OR = 6.07; 95% CI, 1.28–28.9) and discharge from the hospital with enteral access (OR = 7.50; 95% CI, 1.37–41.1) were independently associated with increased risk of postoperative gastrostomy tube dependence at 1 year on multivariable analysis. Conclusions Long-term gastrostomy tube dependence following TORS is rare, particularly in patients that receive surgery alone. Patients with advanced T stage tumors have poorer functional outcomes. Early functional outcomes, as early as discharge from the hospital, are a strong predictor for long-term functional outcomes.

Objectives: To determine the impact of lymph node yield (LNY) in patients undergoing neck dissection at the time of total laryngectomy (TL). To determine the impact of radiation therapy (RT) on LNY. Methods: Retrospective review of LNY and clinical outcomes in 232 patients undergoing primary or salvage total laryngectomy (TL) with ND. Results: Preoperative RT significantly decreased mean LNY from 31.7 to 23.9 nodes ( P Conclusions: Radiotherapy significantly reduces LNY in patients undergoing TL and ND. Within a single institution cohort, positive margins, but not LNY, is associated with survival in both primary and salvage TL patients. Level of Evidence: 4

2594 Background: Delineating clinical factors that predict immune checkpoint inhibitor (ICI) cancer therapy response is a pressing need and smoking is a known factor. In this study we leveraged a large international (heavily US) database to perform the largest study to date for all cancers and major cancer sub-sites/types. Methods: Utilizing the TriNetX electronic health records database with 84.3M patients we tested the hypotheses that ICI response stratifies based on smoking, and continued smoking after ICI. Queries were constructed using billing codes for all cancer types treated with an ICI with and without smoking. The smoking cohort was subsequently sub-stratified for continuing vs cessation of smoking after ICI. Next, using ICI therapy as the index event, odds ratios (OR) with 95% confidence intervals for death, and treatment related secondary outcomes were calculated between 0.5-5 years after ICI treatment. Statistics were calculated using TriNetX's integrated statistical platform before and after 1:1 propensity score matching (PSM) for smoking related co-morbidities. Results: The OR for death after ICI therapy for smokers ( n 13336) vs non-smokers ( n 38973) for any cancer type was 1.27(1.21-1.34) and decreased to 1.11(1.04-1.19) after PSM. Further sub-stratifying the smoking cohort for continued vs cessation of smoking yielded ORs of 1.13(1.03-1.24) and 1.12(1.01-1.24) before and after PSM respectively. Secondary outcomes included ablative surgery, chemotherapy, radiation, and secondary neoplasm. ORs for receiving chemotherapy, and developing secondary neoplasm were most consistently statistically significant across comparisons. Conclusions: Smoking adversely potentiates cancer outcomes after ICI therapy. PSM for smoking related comorbid conditions decreased the magnitude of this association although the findings remained clinically and statistically significant. This highlights the key role in smoking related co-morbid conditions as prognostic clinical characteristics. Furthermore, this suggests that smoking affects ICI on a mechanistic/biological level beyond increasing burden of medical comorbidities. Lastly, as smoking cessation also improved outcomes after PSM this further suggests that washout of smoke toxins has a mechanistic/biological effect on ICI activity. [Table: see text]

OBJECTIVES/HYPOTHESIS To describe multidimensional quality of life (QOL) outcomes in patients with sinonasal malignancies (SNM). To elucidate factors predicting worse QOL in this population. STUDY DESIGN Retrospective chart review at tertiary institution. METHODS A retrospective chart review on patients treated for SNM from 2006 to 2019 at a tertiary medical center was conducted. QOL outcomes were measured using the Hospital Anxiety and Depression Scale (HADS) and the Functional Assessment Cancer Therapy - Nasopharynx (FACT-NP) score. A stepwise multiple linear regression analysis was conducted to assess factors predicting worse QOL. RESULTS Eighty-one patients met inclusion criteria. Twelve (14.8%) patients had a subscale score >11 for anxiety (HADS-A) or depression (HADS-D) indicating significant anxiety or depression, at a median of 24 (8-68.5) months post treatment. The median FACT-NP total score was 136 (110-152). On multivariable analysis, advanced T classification, single status, and worse social support survey score were significant predictors of worse HADS score. Worse social support survey score was a significant predictor of worse total FACT-NP score. CONCLUSION After adjusting for confounders, at a median of 24 months after completion of definitive therapy for SNM, advanced T classification and single relationship status were found to be significant predictors of anxiety and depression (based on HADS). A worse social support survey score was associated with worse anxiety, depression, and QOL (based on HADS and FACT-NP). Identifying these factors early may help to guide treatment and psychiatric referral to at-risk individuals after the treatment of SNM. LEVEL OF EVIDENCE 3 Laryngoscope, 131:E2212-E2221, 2021.

OBJECTIVES: to examine the impact of radiotherapy center volume on overall survival in patients with oral cavity and oropharyngeal squamous cell carcinoma getting adjuvant radiation therapy after receiving surgery at a high-volume center. MATERIALS AND METHODS: a retrospective study was conducted on patients with oral cavity squamous cell carcinoma or oropharyngeal squamous cell carcinoma treated surgically at a tertiary institution from 2000 to 2012 who received adjuvant radiotherapy. The outcome variable was overall survival and the independent variable was location of adjuvant radiation therapy: high-volume center (HVC) versus low-volume center (LVC). Cox proportional hazards models were used to assess associations between predictors of death. Variables that were found to be significant at the α = 0.10 were included in a multivariable model. RESULTS: 336 patients met inclusion criteria. One-hundred thirty-nine patients received adjuvant radiation therapy at HVC and 197 patients received adjuvant radiation therapy at LVC. A univariate Cox proportional hazards model identified the variables location, age, marital status, subsite, T stage, extracapsular extension, and smoking status to include in a multivariable model. Age, subsite, T stage, and extracapsular extension were independent predictors of overall survival (p < .05). Location (p=.55), marital status (p=.29), and smoking status (p=.22) were not statistically significant predictors of survival. CONCLUSION: After surgery at a HVC, the volume of adjuvant radiation therapy center was not significantly associated with overall survival. Significant predictors of survival included age, subsite, T stage, and extracapsular extension.

Objectives/hypothesis To assess the feasibility of jet ventilation in obese patients and to compare complications of jet ventilation in obese and nonobese patients. Study design Retrospective review of medical records. Methods We reviewed 46 patient charts (70 procedures) with the diagnosis of tracheal or subglottic stenosis who underwent endoscopic surgery with jet ventilation between March 2014 and January 2017. Adequacy of jet ventilation was assessed by chest rise, avoidance of endotracheal intubation, and length of case and ventilation. Records were reviewed for demographic details, anesthesia records, and complications. Results In 29/70 (41.4%) of cases, patients were obese; in 9/29 (31.0%) of these cases, patients were morbidly obese. Jet ventilation was successful in 28/29 (97%) of obese cases. In 1/29 (3.4%) of cases, the patient required alternative airway management. There were no significant differences between obese and nonobese patients in chest rise, need for endotracheal intubation, and length of surgery or ventilation (P > .05). There were 2/29 (6.9%) cases of intra- and postoperative complications including laryngospasm (1/29, 3.4%) and tachycardia (1/29, 3.4%). Rate of complications did not differ between obese and nonobese patients (P = .178). Conclusions Jet ventilation in obese patients can be done successfully, and complications are similar between obese patients and nonobese patients. Level of evidence 4. Laryngoscope, 1887-1892, 2018.

Objective To evaluate diagnostic concordance of a synchronous telemedicine otolaryngology clinic with use of currently available technology. Study design Prospective. Methods Patients in a rural otolaryngology clinic were enrolled in a pilot telemedicine clinic. To assess system fidelity, an on-site and remote (consulting) otolaryngologist conducted simultaneous patient evaluations using streaming telecommunication technology for all aspects of the clinical encounter, including high-definition examination and endoscopic images. Both physicians and patients were blinded and diagnoses recorded. Post-encounter physician surveys and an original patient-centered TeleENT Satisfaction Questionnaire (TESQ) were used to assess overall satisfaction. Results Twenty-one patients were enrolled consecutively. Visual technology was found acceptable in all cases, and audio technology was acceptable in 20 of 21 encounters. Patient satisfaction was 96%, and patients felt comfortable using a telemedicine system in the future. Encounters were not significantly longer than traditional encounters. Physician diagnostic agreement was found in 95% of cases, and the consulting physician indicated that all encounters provided sufficient history, examination, and high-quality images to generate an accurate diagnosis, order additional workup, and/or make an appropriate referral. Conclusion A synchronous otolaryngology telemedicine clinic is comparable to a standard clinic in terms of diagnostic concordance and patient satisfaction when using streaming technology and high-definition images. Using telemedical technology may be a viable way to increase otolaryngology access in remote or underserved areas. With system validity now established, future studies will assess the feasibility of using trained on-site physician extenders (nurse practitioners or physician assistants) to conduct in-person patient encounters with remote otolaryngologist support. Level of evidence 2c. Laryngoscope, 128:1068-1074, 2018.

NUT midline carcinoma (NMC) is a rare and aggressive disease encountered in the midline of the head and neck or mediastinum. Due to its sparse incidence and subtle pathologic features, we aim to increase knowledge and awareness for this pathologic entity. We present an exemplary case of a young, healthy male presenting with oral cavity pain and cervical lymphadenopathy. This patient was initially diagnosed with an unspecified, highly aggressive sublingual gland malignancy and underwent locoregional resection with free flap reconstruction however suffered a rapid local recurrence and widely extensive metastasis within just 1 month. After rigorous analysis, final pathologic diagnosis revealed a poorly differentiated carcinoma with evidence of squamous differentiation that eventually, post-mortem tested positive for NMC. Only one prior case of sublingual gland NMC has been previously reported as we discuss the literature regarding all sublingual gland malignancies as well as the pathologic features and treatment options for NMC. We recommend consideration of testing for the NUT proto-oncogene at the time of biopsy in the clinical setting of a poorly differentiated midline carcinoma, especially with squamous differentiation, of the head or neck in order to identify patients for clinical trial enrollment and appropriately counsel on the poor clinical prognosis. Improving clinician awareness is critical to increase diagnostic accuracy and need to study prospective treatment outcomes as the first step toward improving management of this difficult disease.

OBJECTIVE: To assess the utility of rapid parathyroid hormone (PTH) values in predicting transient post-operative hypocalcemia in patients with unplanned parathyroidectomy during total or completion thyroidectomy. METHODS: All patients who underwent total or completion thyroidectomy between January 2010 and January 2015 were reviewed. Incidences of post-operative hypocalcemia were compared in patients with and without unplanned parathyroidectomy. Unplanned parathyroidectomy was defined as intra-operative incidental or intentional parathyroidectomy. Logistic regression assessed for predictors of hypocalcemia and optimum amount of calcium supplementation. RESULTS: Thirty-eight (13.6%) patients had evidence of incidental parathyroidectomy and 39/280 (13.9%) patients had parathyroid autotransplantation intra-operatively. Central neck dissection and malignancy were identified as risk factors for unplanned parathyroidectomy (p = 0.001, p = 0.060). Patients with unplanned parathyroidectomy were more likely to have hypocalcemia (p = 0.002) and hypoparathyroidism (p < 0.0005). PTH value was the only significant predictor of hypocalcemia in these patients. In patients with a post-operative PTH of ≤15, initial calcium supplementation ≥ 1000 mg decreased the risk of hypocalcemia (p < 0.05). CONCLUSION: Post-operative PTH value predicts hypocalcemia in patients undergoing total and completion thyroidectomy with unplanned parathyroidectomy. In patients with a post-operative PTH

To determine if elderly patients (≥70 years) have differences in functional and survival outcomes compared to non-elderly patients (70 years) following transoral robotic surgery.A retrospective cohort study was conducted on patients undergoing robotic surgery for head and neck cancer at a tertiary institution from 2011 to 2016. Functional status was evaluated with diet, enteric feeding status, Functional Oral Intake Scale (FOIS), tracheostomy tube placement, and unplanned readmission. Kaplan Meier method and Cox proportional hazard model were used to assess overall survival (OS) and disease-free survival (DFS) between elderly and non-elderly patients.Two hundred and forty-six patients met inclusion criteria. The mean age of the cohort was 63.5 ± 9.74 years. There were 64 patients (26.0%) that were ≥70 years. Elderly patients were more likely to be discharged with enteric access (p 0.002). As early as 3 months, there was no significant difference in need for enteric feeds, diet, or FOIS score. There was no difference in tracheostomy tube rates and unplanned readmission between both cohorts. There was no significant difference in OS and DFS between age groups when stratified by p16 status.Elderly patients are more likely to require perioperative enteric feeding, but 3-month, 1-year, and 2-year functional outcomes are comparable to younger patients. Survival outcomes are similar in both populations.

To evaluate voice outcomes of medialization laryngoplasty in the elderly population (65 years and older) and to identify swallow outcomes, complication rates, and predictors of voice outcomes.Case series with chart review.Two tertiary academic medical centers.We retrospectively reviewed charts of 136 patients age 65 years and older undergoing medialization laryngoplasty between January 2008 and May 2016 at 2 tertiary academic institutions. Primary outcome was assessed using Voice Handicap Index 10 (VHI-10) score and Grade, Roughness, Breathiness, Asthenia, and Strain (GRBAS) score. Secondary outcomes were assessed using the Eating Assessment Tool 10 (EAT-10) when dysphagia was present, stroboscopic analysis of glottic closure, and complication rates. A logistic regression analysis assessed predictors of voice improvement after medialization laryngoplasty.Total GRBAS and VHI-10 scores showed a significant improvement postoperatively ( P.05). A ≥20% improvement was seen in 81.6% of patients, and a ≥50% improvement was seen in 53.7%. No patient had major complications. Minor complications occurred in 5.9% of patients. Multivariable logistic regression identified preoperative injection augmentation as an independent predictor of less improvement in VHI-10 score ( P = .015). Voice therapy prior to medialization did not affect voice outcomes ( P = .640).Patient- and provider-perceived voice quality are significantly improved after medialization laryngoplasty in the elderly, and the procedure is associated with a low complication rate even in an elderly cohort. Improvement in patient-perceived voice outcomes after medialization laryngoplasty was diminished in patients with preoperative injection augmentation.

Head and neck squamous cell carcinoma (HNSCC) is the 6th most common cancer worldwide and has a mortality rate of 50% despite surgery. The major risk factors associated with HNSCC are smoking, alcohol, and human papillomavirus (HPV). p53, a transcriptional factor, is the most commonly mutated protein in HNSCC and plays an important and early role in tumorigenesis. The chapter highlights the story of p53 in the progression and management of HNSCC. In particular, we address p53’s mutational landscape and its resultant phenotypic outcomes. In addition, p53 as a prognostic biomarker and predictive biomarker for clinical outcome is addressed. Finally, we discuss p53 as a druggable target in HNSCC patients. This chapter aims to expand the understanding of the role of p53 in HNSCC in order to improve management of HNSCC patients by providing them with a personalized and customizable treatment plan.