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Acute oropharyngeal hemorrhage is a serious complication for patients with oropharyngeal squamous cell carcinoma (OPSCC), particularly in patients with a history of radiation therapy (RT).Retrospective case series from at a tertiary care center for treated patients with HPV-positive OPSCC presenting with oropharyngeal hemorrhage.Median time from completion of chemoradiation to first hemorrhagic event was 186 days (range 66-1466 days). Seven patients (58%) required intervention to secure their airway. All patients were evaluated for endovascular intervention, six (50%) were embolized. Eight patients (67%) had a second hemorrhagic event; median time to second bleed was 22 days (range 3-90 days).Acute oropharyngeal hemorrhage is a sequelae following treatment for HPV-positive OPSCC. The majority of bleeds occurred within a year of completion of treatment. While more research is needed to determine optimal treatment paradigms, endovascular intervention should be considered, even if noninvasive imaging does not demonstrate active bleeding.

Objective: To compare the utility of positron emission tomography-computed tomography (PET-CT) versus contrasted CT neck combined with routine chest imaging for disease staging and treatment planning in human papillomavirus (HPV) associated oropharyngeal squamous cell carcinoma (OPSCC) with clinically evident sites of primary disease. Methods: All adult patients with primary HPV-associated OPSCC at a single quaternary care cancer center from 2018 to 2019 were reviewed, and those with images available for re-review were included. Primary outcomes included concordance in clinical staging between the 2 imaging modalities of interest (PET-CT vs CT), as well as independent agreement of each with pathologic staging. Analysis was performed via ordinal logistic regression. A secondary outcome was treatment selection after diagnostic imaging, analyzed via chi-squared testing. Results: In total, 100 patients were included for evaluation, of which 89% were male, 91% Caucasian, and mean age was 61.2 years (SD 9.6). Clinical disease staging agreed between imaging modalities in 95% of cases (54 of 57 patients). Pathologic staging agreed with clinical staging from CT neck in 93% of cases (25 of 27 patients; P = .004), and with PET-CT in 82% (14 of 17 patients; P =.003). No differences were observed between the 2 imaging modalities for subsequent treatment selection ( P = .39). Conclusion: In uncomplicated HPV-associated OPSCC, CT offers equivalent diagnostic accuracy to that of combined whole-body PET-CT for clinical staging, and has no appreciable impact on treatment selection. A reduced reliance on routine PET-CT during initial workup of HPV-associated OPSCC may be favorable for otherwise healthy patients with clinically evident sites of primary disease.

Delayed upper aerodigestive tract (UADT) perforation is a rare complication of anterior cervical spinal hardware. The purpose of this study was to investigate swallowing outcomes between treatment approaches for delayed UADT perforation. A retrospective chart review was performed on patients with anterior cervical hardware and delayed UADT perforation who were treated at a single tertiary care center between 2000 and 2020. Of the twelve patients identified, most patients presented with dysphagia (n = 9, 75%) and/or neck pain (n = 7, 58%). Perforations generally occurred at the level of C6 (n = 6, 50%) and C7 (n = 4, 33%) and spanned only one spinal level (n = 8, 67%). The majority (n = 8, 67%) of patients were past or current cigarette users. Operative approaches included primary repair (n = 5, 42%) and rotational flap (n = 4, 33%); the rotational flap harvest sites included supraclavicular fasciocutaneous (n = 2), infrahyoid muscle (n = 1), and sternocleidomastoid muscle (n = 1). While most patients demonstrated penetration and/or aspiration on first post-operative swallow study (n = 6), this resolved completely within a median time of 31 days. There were no differences in swallowing outcomes between repair approaches. Patient smoking history appears to be a clear risk factor for the development of delayed UADT perforation from anterior cervical spine hardware. A variety of techniques can be used to repair these perforations, and there were no differences in swallowing outcomes between repair approaches.

To determine the preoperative risk factors most predictive of prolonged length of stay (LOS) or admission to a skilled nursing facility (SNF) or inpatient rehabilitation center (IPR) after free flap reconstruction of the head and neck.Retrospective cohort study.Tertiary academic medical center.Retrospective review of 1008 patients who underwent tumor resection and free flap reconstruction of the head and neck at a tertiary referral center from 2002 to 2019.Of 1008 patients (65.7% male; mean age of 61.4 years, SD 14.0 years), 161 (15.6%) were discharged to SNF/IPR, and the median LOS was 7 days. In multiple linear regression analysis, Charlson Comorbidity Index (CCI;Common tools for assessing frailty and need for additional care may be inadequate in a head and neck reconstructive population. CCI appears to be the best of the aggregate metrics assessed, with significant relationships to both LOS and placement in SNF/IPR.

(1) Evaluate the association of flap type with late complications in patients undergoing osseous head and neck reconstruction with the fibula free flap (FFF), osteocutaneous radial forearm free flap (OCRFFF), and scapula free flap (SFF). (2) Compare the prevalence of late complications based on minimum duration of follow-up.Retrospective cohort study.Multiple academic medical centers.Patients undergoing FFF, OCRFFF, or SFF with ≥6-month follow-up were stratified by type of flap performed. The association of flap type with late complications was analyzed via univariable and multivariable logistic regression, controlling for relevant clinical risk factors. Additionally, the frequency of late complications by minimum duration of follow-up was assessed.A total of 617 patients were analyzed: 312 (50.6%) FFF, 230 (37.3%) OCRFFFF, and 75 (12.2%) SFF. As compared with the SFF, the FFF (adjusted odds ratio [aOR], 3.05; 95% CI, 1.61-5.80) and OCRFFF (aOR, 2.17; 95% CI, 1.12-4.22) were independently associated with greater odds of overall late recipient site wound complications. The SFF was independently associated with the lowest odds of hardware exposure when compared with the FFF (aOR, 2.61; 95% CI, 1.27-5.41) and OCRFFF (aOR, 2.38; 95% CI, 1.11-5.12). The frequency of late complications rose as minimum duration of follow-up increased until plateauing at 36 months.This multi-institutional study suggests that the long-term complication profile of the SFF and OCRFFF compares favorably to the FFF. The SFF may be associated with the fewest overall late recipient site complications and hardware exposure, while the FFF may be associated with the most of these 3 options.

To evaluate the associations between median household income (MHI) and area deprivation index (ADI) on postoperative outcomes in oral cavity cancer.Retrospective review (2000-2019).Single-institution tertiary medical center.MHI and ADI were matched from home zip codes. Main postoperative outcomes of interest were length of tracheostomy use, length of hospital stay, return to oral intake, discharge disposition, and 60-day readmissions. Linear and logistic regression controlled for age, sex, race, body mass index, tobacco and alcohol use history, primary tumor location, disease staging at presentation, and length of surgery. A secondary outcome was clinical disease staging (I-IV) at time of presentation.The cohort (N = 681) was 91.3% White and 38.0% female, and 51.7% presented with stage IV disease. The median age at the time of surgery was 62 years (interquartile range [IQR], 53-71). The median MHI was $47,659 (IQR, $39,324-$58,917), and the median ADI was 67 (IQR, 48-79). ADI and MHI were independently associated with time to return of oral intake (β = 0.130, P = .022; β = -0.092, P = .045, respectively). Neither was associated with length of tracheostomy, hospital stay, discharge disposition, or readmissions. MHI quartiles were associated with a lower risk of presenting with more advanced disease (Q3 vs Q1: adjusted odds ratio, 0.56 [95% CI, 0.32-0.97]).MHI is associated with oral cavity cancer staging at the time of presentation. MHI and ADI are independently associated with postoperative return to oral intake following intraoral tumor resection and free flap reconstruction.

Background Commonly used predictive models for postoperative pulmonary complications (PPCs) do not perform when applied to head and neck cases. A head and neck-specific risk prediction tool is needed. Methods Data on 794 free flap head and neck surgery cases at a single center were abstracted from the electronic medical record. Each case was reviewed for the development of PPCs. A predictive model was developed and was then compared to existing predictive models for PPCs. Results The least absolute shrinkage and selection operator procedure identified age, alcohol use, history of congestive heart failure, preoperative packed cell volume, preoperative oxygen saturation, and preoperative metabolic equivalents as predictors of PPCs in the head and neck population. The model demonstrated an area under the receiving operating characteristic curve of 0.75 (0.69-0.80) with moderately good calibration. Comparisons to the performance of existing models demonstrate superior performance. Conclusions The model for the development of PPCs developed in this article displays superior performance to existing models.

Objectives: To examine whether social determinants of health (SDH) factors are associated with time to diagnosis, treatment selection, and time to recurrent surgical intervention in idiopathic subglottic stenosis (iSGS) patients. Methods: Adult patients with diagnosed iSGS were recruited prospectively (2015-2017) via clinical providers as part of the North American Airway Collaborative (NoAAC) and via an online iSGS support community on Facebook. Patient-specific SDH factors included highest educational attainment (self-reported), median household income (matched from home zip code via U.S. Census data), and number of close friends (self-reported) as a measure of social support. Main outcomes of interest were time to disease diagnosis (years from symptom onset), treatment selection (endoscopic dilation [ED] vs cricotracheal resection [CTR] vs endoscopic resection with adjuvant medical therapy [ERMT]), and time to recurrent surgical intervention (number of days from initial surgical procedure) as a surrogate for disease recurrence. Results: The total 810 participants were 98.5% female, 97.2% Caucasian, and had a median age of 50 years (IQR, 43-58). The cohort had a median household income of $62 307 (IQR, $50 345-$79 773), a median of 7 close friends (IQR, 4-10), and 64.7% of patients completed college or graduate school. Education, income, and number of friends were not associated with time to diagnosis via multivariable linear regression modeling. Univariable multinominal logistic regression demonstrated an association between education and income for selecting ED versus ERMT, but no associations were noted for CTR. No associations were noted for time to recurrent surgical procedure via Kaplan Meier modeling and Cox proportional hazards regression. Conclusions: Patient education, income, and social support were not associated with time to diagnosis or time to disease recurrence. This suggests additional patient, procedure, or disease-specific factors contribute to the observed variations in iSGS surgical outcomes.

ImportanceDefinitive diagnosis of a thyroid nodule in a child is obtained through diagnostic surgery. This is problematic because pediatric thyroid surgery is associated with higher rates of complications. In adults, preoperative molecular testing improves the management of thyroid nodules, but this has not been validated in children.ObjectiveTo determine whether the molecular landscape of pediatric thyroid nodules is amenable to detection by a multigene genomic classifier (GC) test (ThyroSeq v3; Sonic Healthcare USA).Design, Setting, and ParticipantsThis was a retrospective consecutive case series and GC testing of fine-needle aspiration (FNA) and formalin-fixed paraffin-embedded (FFPE) tissues from sequential pediatric thyroidectomies performed between January 2003 and December 2019 at a single tertiary academic medical center. The study included 95 patients (median [range] age, 16.3 [4.8 to 21.1] years; 75 [79%] female) who underwent surgery for a thyroid nodule.InterventionsA total of 118 thyroid nodule samples (95 FFPE, 23 companion FNAs) yielded informative next-generation sequencing data and multigene GC.Main Outcomes and MeasuresThe primary outcome was the determination of the pediatric thyroid molecular landscape. The secondary outcome was the diagnostic accuracy of the GC test for pediatric thyroid nodules.ResultsOf the 95 patients, 75 (79%) were female, and the median (IQR) age was 16.3 (14.0-17.3) years. Next-generation sequencing confirmed the unique molecular landscape of malignant pediatric thyroid nodules (compared with adults), which is dominated by gene fusions (most commonly RET and NTRK), rare BRAF/RAS alterations, and no TP53 or TERT promoter pathogenic variants. Several poorly differentiated thyroid cancers harbored DICER1 variants. Benign nodules appeared to be almost exclusively associated with TSHR and DICER1 alterations. The test demonstrated a 96% sensitivity (95% CI, 87%-99%) and 78% specificity (95% CI, 64%-88%). The negative predictive value was 95% (95% CI, 88%-98%) and the positive predictive value was 83% (95% CI, 74–89%). The concordance of GC between 23 pairs of matched FFPE and FNA tissues was 96%.Conclusions and RelevanceThe study results of this retrospective consecutive case series suggest that the molecular landscape of pediatric nodules is unique but remains amenable to molecular classification. The multigene GC test, with high sensitivity and reasonably high specificity, represents a potential addition to the diagnostic workup of children with thyroid nodules and may decrease the use of diagnostic surgery.

Microvascular free tissue transfer is an important reconstructive option for defects of the head and neck. The present study aims to identify preoperative patient- and tumor-specific characteristics, laboratory values, and other risk factors associated with early free flap failure.Retrospective cohort study of 1070 patients.Head and neck surgical oncology service at a tertiary care center from 2005 to 2019.Demographics, comorbidities, preoperative laboratory values, treatment history, and cancer stage were collected for consecutive patients who underwent free flap reconstruction of the head and neck and experienced early free flap failure (8 days from surgery).In 1070 patients, the prevalence of early free flap failure was 3.8% (n = 41). Female sex (odds ratio [OR], 2.58; 95% CI, 1.36-4.99), presence of peripheral vascular disease (OR, 2.78; 95% CI, 1.05-6.57), and elevated preoperative platelet count (OR, 2.67; 95% CI, 1.20-5.47) were independently associated with risk of early free flap failure.Female sex, peripheral vascular disease, and preoperative thrombocytosis are all strong predictors of early free flap failure. This suggests that hypercoagulability and poor vessel quality may predispose patients to flap loss. Patients with elevated platelets or peripheral vascular disease warrant careful reconstructive decision making and close monitoring in the perioperative period.

Identify risk factors and outcomes of recurrent well-differentiated thyroid cancer.Retrospective case-control analysis.Tertiary care academic center in Nashville, Tennessee.This single-center analysis reviews 478 patients who underwent initial surgical management of well-differentiated thyroid carcinoma between 2002 and 2017. Patients were dichotomized with or without recurrent well-differentiated thyroid cancer. Demographic and clinicopathologic risk factors were carefully reviewed. Univariate, multiple regression, and survival analyses were used to evaluate predictors of recurrence.Thirty-eight patients (7.9%) who received initial surgical intervention for well-differentiated thyroid carcinoma at our institution recurred, with an average time to recurrence of 24 months. Male sex, tumor size, multifocality, extrathyroidal extension, lymphovascular invasion, number of positive lymph nodes, and low lymph node yield were all significantly associated with locoregional recurrence (Extrathyroidal extension, number of positive lymph nodes, and low lymph node yield are independent clinicopathologic risk factors for postoperative recurrence of well-differentiated thyroid cancer. Metastatic lymph node ratio is uncommonly used but can be an important prognosticator of recurrence. Patients with metastatic lymph node ratio ≥0.3 should be counseled on their increased risk of recurrence and should undergo close surveillance following surgery.

ImportanceStudies comparing perioperative outcomes of fibula free flaps (FFFs), osteocutaneous radial forearm free flaps (OCRFFFs), and scapula free flaps (SFFs) have been limited by insufficient sample size.ObjectiveTo compare the perioperative outcomes of patients who underwent FFFs, OCRFFFs, and SFFs.Design, Setting, and ParticipantsThis cohort study assessed the outcomes of 1022 patients who underwent FFFs, OCRFFFs, or SFFs for head and neck reconstruction performed at 1 of 6 academic medical centers between January 2005 and December 2019. Data were analyzed from September 17, 2021, to June 9, 2022.Main Outcomes and MeasuresPatients were stratified based on the flap performed. Evaluated perioperative outcomes included complications (overall acute wound complications, acute surgical site infection [SSI], fistula, hematoma, and flap failure), 30-day readmissions, operative time, and prolonged hospital length of stay (75th percentile, >13 days). Patients were excluded if data on flap type or clinical demographic characteristics were missing. Associations between flap type and perioperative outcomes were analyzed using logistic regression, after controlling for other clinically relevant variables. Adjusted odds ratios (aORs) with 95% CIs were generated.ResultsPerioperative outcomes of 1022 patients (mean [SD] age, 60.7 [14.5] years; 676 [66.1%] men) who underwent major osseous head and neck reconstruction were analyzed; 510 FFFs (49.9%), 376 OCRFFFs (36.8%), and 136 SFFs (13.3%) were performed. Median (IQR) operative time differed among flap types (OCRFFF, 527 [467-591] minutes; FFF, 592 [507-714] minutes; SFF, 691 [610-816] minutes). When controlling for SSI, FFFs (aOR, 2.47; 95% CI, 1.36-4.51) and SFFs (aOR, 2.95; 95% CI, 1.37-6.34) were associated with a higher risk of flap loss than OCRFFFs. Compared with OCRFFFs, FFFs (aOR, 1.77; 95% CI, 1.07-2.91) were associated with a greater risk of fistula after controlling for the number of bone segments and SSI. Both FFFs (aOR, 1.77; 95% CI, 1.27-2.46) and SFFs (aOR, 1.68; 95% CI, 1.05-2.69) were associated with an increased risk of 30-day readmission compared with OCRFFFs after controlling for Charlson-Deyo comorbidity score and acute wound complications. Compared with OCRFFFs, FFFs (aOR, 1.78; 95% CI, 1.25-2.54) and SFFs (aOR, 1.96; 95% CI, 1.22-3.13) were associated with a higher risk of prolonged hospital length of stay after controlling for age and flap loss.Conclusions and RelevanceFindings of this cohort study suggest that perioperative outcomes associated with OCRFFFs compare favorably with those of FFFs and SFFs, with shorter operative times and lower rates of flap loss, 30-day readmissions, and prolonged hospital length of stay. However, patients undergoing SFFs represented a more medically and surgically complex population than those undergoing OCRFFFs or FFFs.

Introduction: Access to care is a known challenge for head and neck cancer patients. The coronavirus disease 2019 (COVID-19) pandemic has placed further demands on the US health care system and oncologic care. This study aims to explore the impact of the COVID-19 pandemic on head and neck cancer care delivery. Method: A retrospective chart review was performed at a single tertiary care center from March 2020 to July 2020 (encompassing the initial outbreak of COVID-19) and March 2019 to July 2019 (serving as a control). All adult patients presenting as new referrals to the otolaryngology head and neck cancer clinic with known or suspected malignancy were included. Demographic variables collected included age, gender, race, insurance status, and distance traveled. Referral and treatment dates, telemedicine encounters, presenting symptoms, type of malignancy, and prior treatment were also collected. Results: In total, 449 new cancer patients were included, and comparison of 2019 (n = 236) vs 2020 (n = 213) revealed no significant differences in age, gender, race, insurance status, or malignancy type. Median distance traveled decreased from 61.7 miles (greatest distance of 713.8 miles) in 2019 to 48.4 miles (greatest distance of 302.2 miles) in 2020 (P = .588). Median time from referral to clinic significantly decreased from 11 days in 2019 to 9 days in 2020 (P < .001). Median time from referral to surgery also decreased (38 days in 2019 vs 27 days in 2020, P < .001). Thirteen telemedicine encounters occurred in 2020 for postoperative and surveillance follow-ups. Conclusion: Patients at our institution were seen in clinic and underwent surgery more quickly during the COVID-19 pandemic without significant amplification of any preexisting demographic disparities. Expedited care may be a result of initial slowdown of clinical and surgical volume at the start of the pandemic, prioritization of oncologic surgical cases, cancellation of elective procedures, and the use of telemedicine. The median decrease in distance traveled suggests a reduced catchment area and a potential barrier to care during the disruptions related to the pandemic.

Background: Accurate assessment of parathyroid gland vascularity is important during thyroidectomy to preserve the function of parathyroid glands and to prevent postoperative hypocalcemia. Laser speckle contrast imaging (LSCI) has been shown to be accurate in detecting differences in parathyroid vascularity. In this surgeon-blinded prognostic study, we evaluate the relationship between intraoperative LSCI measurements and postoperative outcomes of total thyroidectomy patients. Methods: Seventy-two thyroidectomy patients were included in this study. After thyroid resection, an LSCI device was used to image all parathyroid glands identified, and a speckle contrast value was calculated for each. An average value was calculated for each patient, and the data were grouped according to whether the patient had normal (16–77 pg/mL) or low levels of parathyroid hormone (PTH) measured on postoperative day 1 (POD1). The aim of this study was to establish a speckle contrast threshold for classifying a parathyroid gland as adequately perfused and to determine how many such glands are required for normal postoperative parathyroid function. Results: A speckle contrast limit of 0.186 separated the normoparathyroid and hypoparathyroid groups with 87.5% sensitivity and 84.4% specificity: 7 of 8 patients with low PTH on POD1 had an average parathyroid speckle contrast above this limit, while 54 of 64 patients with normal postoperative PTH had an average parathyroid speckle contrast below this limit. Taking this value as the threshold for adequate parathyroid perfusion, it was determined that only one vascularized gland was needed for normal postoperative parathyroid function: 64 of 69 patients (92.8%) with at least one vascularized gland (determined by LSCI) had normal postoperative PTH, while all 3 patients (100%) with no vascularized glands had low postoperative PTH. Overall, the rates of temporary and permanent hypoparathyroidism in this study were 8.3% and 1.4%, respectively. Conclusions: LSCI is a promising technique for assessing parathyroid gland vascularity. It has the potential to help reduce the incidence of hypocalcemia after thyroidectomy by providing surgeons with additional information during surgery to aid in the preservation of parathyroid function.

Early studies estimate that 5% to 10% of oropharyngeal squamous cell carcinomas overexpress p16 but are unassociated with transcriptionally-active high-risk human papillomavirus (HPV). Patients with discordant HPV testing may experience clinical outcomes that differ from traditional expectations. To document the rate of p16 and HPV mRNA positivity, characterize patients with discordant testing, and identify features that may warrant selective use of HPV-specific testing after p16 IHC, a multi-institutional, retrospective review of oropharyngeal squamous cell carcinoma patients with p16 IHC and HPV mRNA testing by reverse transcriptase polymerase chain reaction was performed. Of the 467 patients, most had T1 or T2 tumors (71%), 82% were p16 positive, and 84% were HPV mRNA positive. Overall, most tumors were nonkeratinizing (378, 81%), which was strongly associated with p16 and HPV positivity (93% and 95%, respectively). Overall, 81% of patients were double positive, 14% double negative, and 4.9% discordant (3.4% p16 negative/HPV mRNA positive and 1.5% p16 positive/HPV mRNA negative). The survival rates of these discordant patient groups fell squarely between the 2 concordant groups, although in multivariate analysis for both disease-free survival and overall survival, discordant patients were not found to have statistically significantly different outcomes. Reclassifying patients by applying HPV mRNA testing when p16 results and morphology do not match, or when p16 results are equivocal, improved prognostication slightly over p16 or HPV mRNA testing alone. Patients with discordant testing demonstrate a borderline significant trend toward survival differences from those with concordant tests. When evaluated independently, patients who were p16 negative but HPV mRNA positive had a prognosis somewhat closer to double-positive patients, while those who were p16 positive, but HPV mRNA negative had a prognosis closer to that of double-negative patients. We suggest an algorithm whereby confirmatory HPV mRNA testing is performed in patients where p16 status is not consistent with tumor morphology. This captures a majority of discordant patients and improves, albeit modestly, the prognostication.

Introduction Neuroendocrine tumors of the head and neck are rare and arise either from epithelial or neuronal origin. Debate continues over the classification systems and appropriate management of these pathologies. Objective By investigating a small set of cases of high grade epithelial-derived neuroendocrine tumors of the head and neck (neuroendocrine carcinomas or NEC) from one institution, we compare survival rates of NEC of the head and neck to pulmonary NEC. Methods We identified patients from pathology records with neuroendocrine carcinomas of the head and neck and retrospectively collected clinical data as well as immunohistochemical (IHC) staining data. Results We identified 14 patients with NEC, arising from the parotid (n = 5), nasal cavity (n = 4), larynx (n = 2), and other regions (n = 2). One additional patient had NEC arising in two sites simultaneously (parotid and nasal). Staining patterns using IHC were relatively consistent across specimens, showing reactivity to chromogranin and synaptophysin in 73% and 100% of specimens, respectively. Treatment courses varied across patients and included combinations of surgery, chemotherapy, and/or radiation. The overall survival rate at 1, 2, and 5 years of these patients was 56%, 56%, and 43% with a mean follow-up time of 2.12 years. Conclusion Compared to NEC arising in the lung, this subset of patients had better survival rates, but worse survival rates than the more common squamous cell carcinoma of the head and neck.

Given that early-stage oral cavity squamous cell carcinoma (OCSCC) has a high propensity for subclinical nodal metastasis, elective neck dissection has become standard practice for many patients with clinically negative nodes. Unfortunately, for most patients without regional metastasis, this risk-averse treatment paradigm results in unnecessary morbidity.To develop and validate predictive models of occult nodal metastasis from clinicopathological variables that were available after surgical extirpation of the primary tumor and to compare predictive performance against depth of invasion (DOI), the currently accepted standard.This diagnostic modeling study collected clinicopathological variables retrospectively from 7 tertiary care academic medical centers across the US. Participants included adult patients with early-stage OCSCC without nodal involvement who underwent primary surgical extirpation with or without upfront elective neck dissection. These patients were initially evaluated between January 1, 2000, and December 31, 2019.Largest tumor dimension, tumor thickness, DOI, margin status, lymphovascular invasion, perineural invasion, muscle invasion, submucosal invasion, dysplasia, histological grade, anatomical subsite, age, sex, smoking history, race and ethnicity, and body mass index (calculated as weight in kilograms divided by height in meters squared).Occult nodal metastasis identified either at the time of elective neck dissection or regional recurrence within 2 years of initial surgery.Of the 634 included patients (mean [SD] age, 61.2 [13.6] years; 344 men [54.3%]), 114 (18.0%) had occult nodal metastasis. Patients with occult nodal metastasis had a higher frequency of lymphovascular invasion (26.3% vs 8.1%; P .001), perineural invasion (40.4% vs 18.5%; P .001), and margin involvement by invasive tumor (12.3% vs 6.3%; P = .046) compared with those without pathological lymph node metastasis. In addition, patients with vs those without occult nodal metastasis had a higher frequency of poorly differentiated primary tumor (20.2% vs 6.2%; P .001) and greater DOI (7.0 vs 5.4 mm; P .001). A predictive model that was built with XGBoost architecture outperformed the commonly used DOI threshold of 4 mm, achieving an area under the curve of 0.84 (95% CI, 0.80-0.88) vs 0.62 (95% CI, 0.57-0.67) with DOI. This model had a sensitivity of 91.7%, specificity of 72.6%, positive predictive value of 39.3%, and negative predictive value of 97.8%.Results of this study showed that machine learning models that were developed from multi-institutional clinicopathological data have the potential to not only reduce the number of pathologically node-negative neck dissections but also accurately identify patients with early OCSCC who are at highest risk for nodal metastases.

Virtual three-dimensional (3D) scanning of pathologic specimens may allow for improved communication between the surgeon and pathologist, as well as enhanced patient counseling and engagement. We report the rare case of a giant cell tumor of the thyroid cartilage and present a multimodal 3D representation. Preoperative 3D printing of the anatomic structures from cross-sectional imaging, as well as novel ex vivo 3D scanning of the fresh pathologic specimen for virtual 3D specimen mapping, was performed.

Summary Patient-derived cancer organoids hold great potential to accurately model and predict therapeutic responses. Efficient organoid isolation methods that minimize post-collection manipulation of tissues would improve adaptability, accuracy, and applicability to both experimental and real-time clinical settings. Here we present a simple and minimally invasive fine-needle aspiration (FNA)-based organoid culture technique using a variety of tumor types including gastrointestinal, thyroid, melanoma, and kidney. This method isolates organoids directly from patients at the bedside or from resected tissues, requiring minimal tissue processing while preserving the histologic growth patterns and infiltrating immune cells. Finally, we illustrate diverse downstream applications of this technique including in vitro high-throughput chemotherapeutic screens, in situ immune cell characterization, and in vivo patient-derived xenografts. Thus, routine clinical FNA-based collection techniques represent an unappreciated substantial source of material that can be exploited to generate tumor organoids from a variety of tumor types for both discovery and clinical applications., Graphical Abstract, Highlights • Fine-needle aspiration (FNA) is safe, minimally invasive, and widely used clinically • FNA is a source of material for organoid culture and personalized medicine • This technique requires minimal processing, preserving histology, and immune cells • Downstream applications: high-throughput screens, immune analysis, and xenografts, Clinical Medicine; Tissue Engineering; Cancer

Background Human papillomavirus 16 (HPV-16) E6 seropositivity is a promising early marker of human papillomavirus-driven oropharyngeal cancer (HPV-OPC), yet more sensitive imaging modalities are needed before screening is considered. The objective of this study was to determine the sensitivity of transcervical sonography (TCS) for detecting clinically apparent HPV-OPC in comparison with computed tomography (CT) and positron emission tomography (PET)/CT. Methods Fifty-one patients with known or suspected HPV-OPC without prior treatment underwent oropharyngeal TCS and blood collection (for HPV multiplex serology testing). Eight standard sonographic images were collected; primary-site tumors were measured in 3 dimensions if identified. Each patient underwent a full diagnostic workup as part of standard clinical care. The pathologic details, HPV status, final staging, and imaging findings were abstracted from the medical record. The sensitivity of each imaging modality was compared with the final clinical diagnosis (the gold standard). Results Twenty-four base of tongue cancers (47%), 22 tonsillar cancers (43%), and 2 unknown primary cancers (4%) were diagnosed; 3 patients (6%) had no tumors. All p16-tested patients were positive (n = 47). Primary-site tumors were correctly identified in 90.2% (95% confidence interval [CI], 78.6%-96.7%) with TCS, in 69.4% (95% CI, 54.6%-81.7%) with CT, and in 83.3% (95% CI, 68.6%-93.0%) with PET/CT. TCS identified tumors in 10 of 14 cases missed by CT and recognized the absence of tumors in 3 cases for which CT or PET/CT was falsely positive. The smallest sonographically identified primary-site tumor was 0.5 cm in its greatest dimension; the average size was 2.3 cm. Among p16-positive patients, 76.1% (95% CI, 61.2%-87.4%) were seropositive for HPV-16 E6. Conclusions TCS and HPV-16 E6 antibodies are sensitive for the diagnosis of HPV-OPC.

The incidence of early onset oral tongue squamous cell carcinoma (OTC) has been increasing in the United States, and no clear etiology has been identified. Studies on this topic have generally been small and presented varied results. The goal of this review is to analyze and synthesize the literature regarding early onset OTC risk factors, outcomes, and molecular analyses within the US. To date, studies suggest that early onset OTC patients tend to have less heavy cigarette use than typical onset patients, but there may be an association between early onset OTC and smokeless tobacco (chewing tobacco and snuff) use. Early onset OTC is associated with similar or possibly improved survival compared to typical onset OTC. There has been no evidence to support a significant role for human papillomavirus in development of early onset OTC. Further research with larger cohorts of these patients is needed to better characterize this disease entity.

Objectives Ablative procedures of the head and neck often result in significant facial and cervical irregularities and cosmetic asymmetry. The deformity resulting from ablative procedures of the head and neck is a significant source of cosmetic morbidity and postoperative dissatisfaction. Reconstruction of post-ablative defects in the head and neck can employ a broad range of techniques, ranging from primary closure to free tissue transfer. The free dermal fat graft (FDFG) is one such option and has been used to repair volume defects of varying sizes after common head and neck procedures such as parotidectomy. However, its use is largely undocumented in the literature. We seek to further illustrate the FDFG as an alternate method of reconstruction of head and neck defects. Study design Non-randomized retrospective analysis. Methods The medical records of all patients who underwent primary autologous abdominal FDFG reconstruction of head and neck defects by a single surgeon at Vanderbilt University Medical Center from January 1997 to August 2010 were reviewed. All patients were called in order to assess their post-operative cosmetic satisfaction. Results Sixty-two patients were analyzed. Only three patients were found to have post-operative complications directly related to the FDFG. No complications were found at the donor site. Based on a telephone survey, the majority of patients were satisfied post-operatively with their cosmetic outcomes in the primary site and donor site. Conclusions From our experience the FDFG is a cosmetically and functionally advantageous option for reconstruction of ablative procedures of the head and neck.

Olfactory neuroblastoma is a rare and often locally aggressive malignancy that invades the orbit via local destruction. It is known to recur in a delayed fashion, particularly to the neck lymph nodes. This is a case of a 65-year-old gentleman who presents with recurrence in the orbit and a neck lymph node 19 years after treatment for his initial disease. This report describes the longest known interval in orbital recurrence and should alert the monitoring physician that extreme delays in recurrence can occur.

Background There are several reports of ossification occurring along the pedicle of fibular free flaps in head and neck microvascular reconstruction, but the incidence of pedicle ossification of other osseous flaps in head and neck surgery has never been investigated. Methods A retrospective chart review was conducted for all patients undergoing free flap reconstruction in the head and neck between 2005 and 2016. Patients were included if they had reconstruction with an osseous free flap and if they had computed tomography (CT) scans at least 1 month post-operatively. Available CT images were reviewed for each patient. Results Three-hundred thirty four osteocutaneous free flaps were performed. The average age was 64 years (range 8–89). There was slight male predominance with 63.5% of the cohort being male (n = 212). One hundred fifty-five patients had fibular flaps (45%), 108 had radial forearm flaps (34%) and 71 had scapular flaps (21%). One hundred fibulas had available imaging, 73 forearms had available imaging, and 44 scapulas had imaging post-operatively. Of the images reviewed, pedicle ossification was identified in 21 fibular flaps (21%). None of the radial forearm or scapular flaps developed pedicle ossification. Discussion Pedicle ossification is relatively common in osteocutaneous free flap reconstruction and is uniquely associated with fibular. The presence of pedicle ossification is benign and does not compromise the flap, though it can create concern in cancer surveillance as the lesion is often identified as a new neck mass. As such, head and neck surgeons should be aware of this relatively frequent finding.

Postoperative pulmonary complications (PPCs) are common following major surgical procedures. Risk stratification tools have been developed to identify patients at risk for PPCs. While otolaryngology cases were included in the development of common predictive tools, they comprised small percentages in each tool. It is unclear how these tools perform in patients undergoing major head and neck surgery with free flap reconstruction. This retrospective review studied all free flap reconstructions in head and neck surgery over a 12-year period at a single institution in the southeastern US. Baseline demographic and medical information were included for each case. All cases were reviewed for development of major PPCs, including pneumonia and respiratory failure. The cohort underwent risk stratification using the ARISCAT and Gupta pulmonary risk indices. Performance of these predictive models for head and neck surgery was determined through receiver-operator curve comparison. 794 patients were identified with a median age of 62 years (IQR 41–83). Sixty-five percent were male. Forty-three (5.4%) developed pneumonia, 23 patients developed respiratory failure (2.9%), and 38 patients developed both (4.8%), resulting in a total PPC proportion of 13.1% (n = 104). Both ARISCAT and Gupta pulmonary risk indices demonstrated low discrimination to predict PPCs in head and neck free flap reconstruction, with areas under the curve of 0.60 and 0.65, respectively. Two major indices for prediction of postoperative pulmonary complications do not accurately identify risk in patients undergoing major head and neck surgery. Further studies are needed to develop predictive tools for PPCs in this high-risk population.

To measure disease-free, disease-specific, and overall survival among patients with T4aN0M0 mandibular gingival squamous cell carcinoma who were treated with surgery alone.Case series with chart review.Tertiary care center.A retrospective chart review was performed of all adult patients treated surgically with an oral cavity composite resection between January 2005 and March 2017. Among other data, patient preoperative characteristics were recorded (eg, age, sex, smoking history, alcohol use, and clinical stage); operative notes were reviewed to determine tumor subsite involvement, reconstruction method, and intraoperative surgical complications; and pathology reports were evaluated for various pathologic findings. Survival outcomes were determined with Kaplan-Meier analysis.The mean follow-up was 18.5 months (range, 0.1-100). The 1- and 5-year disease-free survival rates were 90.5% and 84.5%, respectively, while the 1- and 5-year disease-specific survival rates were 87.8% and 81.9%. The 1- and 5-year overall survival rates were 86.4% and 80.6%.Patients with T4aN0M0 squamous cell carcinoma of the mandibular gingiva treated with surgery alone have a 5-year overall survival of 80.6%. Treatment with surgery alone obviates morbidities associated with adjuvant therapy while upholding survival outcomes.

Importance Surgical treatment comparisons in rare diseases are difficult secondary to the geographic distribution of patients. Fortunately, emerging technologies offer promise to reduce these barriers for research. Objective To prospectively compare the outcomes of the 3 most common surgical approaches for idiopathic subglottic stenosis (iSGS), a rare airway disease. Design, Setting, and Participants In this international, prospective, 3-year multicenter cohort study, 810 patients with untreated, newly diagnosed, or previously treated iSGS were enrolled after undergoing a surgical procedure (endoscopic dilation [ED], endoscopic resection with adjuvant medical therapy [ERMT], or cricotracheal resection [CTR]). Patients were recruited from clinician practices in the North American Airway Collaborative and an online iSGS community on Facebook. Main Outcomes and Measures The primary end point was days from initial surgical procedure to recurrent surgical procedure. Secondary end points included quality of life using the Clinical COPD (chronic obstructive pulmonary disease) Questionnaire (CCQ), Voice Handicap Index-10 (VHI-10), Eating Assessment Test-10 (EAT-10), the 12-Item Short-Form Version 2 (SF-12v2), and postoperative complications. Results Of 810 patients in this cohort, 798 (98.5%) were female and 787 (97.2%) were white, with a median age of 50 years (interquartile range, 43-58 years). Index surgical procedures were ED (n = 603; 74.4%), ERMT (n = 121; 14.9%), and CTR (n = 86; 10.6%). Overall, 185 patients (22.8%) had a recurrent surgical procedure during the 3-year study, but recurrence differed by modality (CTR, 1 patient [1.2%]; ERMT, 15 [12.4%]; and ED, 169 [28.0%]). Weighted, propensity score–matched, Cox proportional hazards regression models showed ED was inferior to ERMT (hazard ratio [HR], 3.16; 95% CI, 1.8-5.5). Among successfully treated patients without recurrence, those treated with CTR had the best CCQ (0.75 points) and SF-12v2 (54 points) scores and worst VHI-10 score (13 points) 360 days after enrollment as well as the greatest perioperative risk. Conclusions and Relevance In this cohort study of 810 patients with iSGS, endoscopic dilation, the most popular surgical approach for iSGS, was associated with a higher recurrence rate compared with other procedures. Cricotracheal resection offered the most durable results but showed the greatest perioperative risk and the worst long-term voice outcomes. Endoscopic resection with medical therapy was associated with better disease control compared with ED and had minimal association with vocal function. These results may be used to inform individual patient treatment decision-making.

BACKGROUND Incidence of oral tongue squamous cell carcinoma (OTC) is rising among those under age 50 years. The etiology is unknown. METHODS A total of 395 cases of OTC diagnosed and/or treated at Vanderbilt University Medical Center between 2000 and 2017 were identified. Of those, 113 (28.6%) were early onset (age < 50 years). Logistic regression was used to identify factors associated with early onset OTC. Cox proportional hazards models evaluated survival and recurrence. RESULTS Compared to typical onset patients, patients with early onset OTC were more likely to receive multimodality treatment (surgery and radiation; adjusted odds ratio [aOR], 2.7; 95% confidence interval [CI], 1.2-6.3) and report a history of snuff use (aOR, 5.4; 95% CI, 1.8-15.8) and were less likely to report a history of cigarette use (aOR, 0.5; 95% CI, 0.2-0.9). Early onset patients had better overall survival (adjusted hazard ratio, 0.6). CONCLUSIONS This is the largest study to evaluate factors associated with early onset OTC and the first to report an association with snuff.

Objective To determine if there is a critical depth of invasion that predicts micrometastasis in early oral tongue cancer. Methods Retrospective series identifying patients undergoing primary surgical resection of T1 or T2 oral tongue cancer who elected against neck treatment between 2000 and 2015. Cox proportional-hazard model compared the relative hazard and cumulative incidence of recurrence to depth of invasion. The model used a 2 parameter quadratic effect for depth that was chosen based on Akaike's information criterion. Results Ninety-three patients were identified with T1 or T2 oral tongue squamous cell carcinoma and clinically N0 neck undergoing glossectomy without elective neck treatment. 61% were male and median age was 60 years. Median follow up was 45 months, and 76 patients had at least two years of follow up. Thirty-six of 76 patients recurred (47.4%), with 15 recurring in the oral cavity (19.7%) and 21 developing nodal metastasis (27.6%). Cox proportional-hazards quadratic polynomial showed increasing hazard of recurrence with depth of invasion and the cumulative incidence increased sharply within the range of data from 2 to 6 mm depth of invasion. Conclusions Depth of invasion is significantly associated with nodal metastasis and has been added to the 8th AJCC staging guidelines. Variable depths of invasion have been associated with regional metastasis; however, there is likely not a critical depth that predicts neck recurrence due to progressive hazards and cumulative risk of occult metastasis. The risk of regional metastasis is likely much greater than previously believed and increases progressively with increasing depth.

Objectives To evaluate the factors associated with need for removal of fixation plates in mandibular free flap reconstruction. Methods This retrospective cohort analysis reviews patients undergoing mandibular free flap reconstruction at a tertiary care center from 2005 to 2016. Patients requiring removal of fixation plates were identified through electronic medical records. Factors including demographics, adjuvant therapy, surgical site infection (SSI) and fistula rates were compared. Removal rates based on flap type were determined. Results Between 2004 and 2016, 307 patients underwent osteocutaneous mandibular free flap reconstruction. 83 required removal of their fixation plates (27%). Age, tobacco use, and BMI were similar between patients requiring removal versus not requiring removal. Primary indications for removal were plate exposure (n = 41), and/or chronic drainage (n = 31), infection (n = 25), and pain (n = 17). Patients undergoing removal were significantly more likely to have had adjuvant radiation therapy (OR 2.09, CI 1.82–3.81), surgical site infection (OR 13.9, CI 5.15–43.2), and post-operative fistula (OR 13.0, 6.85–24.8). 35% of all fibula flaps (n = 52), 21% of osteocutaneous radial forearm (n = 21), and 11% of osteocutaneous scapular flaps (n = 6) required removal. 90% of patients (n = 75) had resolution of their symptoms following hardware removal. Conclusion Surgical site infection and fistula are strongly associated with the need for plate removal. Fibular free flaps carry the highest rate of plate removal. Plate removal leads to resolution of plate-associated symptoms in a majority of cases.

Objective To analyze rates, risk factors, and complications for 30-day readmission among head and neck cancer (HNC) patients. Methods Retrospective review of administrative records from Vizient (Irving, Texas) Clinical Data Base/Resource Manager on HNC patients who underwent a head and neck surgical procedure from January 2013 through September 2015 at 176 academic and community medical centers. Results Of the 18,121 patients included in the study, 2502 patients were readmitted within 30 days (13.8%). Mean time to readmission was 11 ± 8.2 days. Cancer of the hypopharynx, oropharynx, pharynx, and larynx all had higher odds of readmission compared to oral cavity (odds ratio [OR], 1.8, 1.7, 1.6, and 1.5; 95% confidence interval [CI], 1.4-2.2, 1.4-1.9, 1.2-2.3, and 1.3-1.7, respectively). Consistent with this, flap procedures and laryngectomy had the highest odds of readmission (OR, 1.4 and 1.3; 95% CI, 1.3-1.6 and 1.0-1.5 vs glossectomy, respectively). The most common surgical causes for readmission were postoperative infection (17.6%) and surgical wound dehiscence (16.8%), which most commonly presented on postdischarge days 4 to 5. Acute cardiac events occurred in up to 15.4% of patients depending on complexity of surgery. Dysphagia and electrolyte disturbances were common (15.8% and 15.4%, respectively); patients with these complications typically presented earlier, between days 3 and 4. Discussion Patients with HNC are at high risk of readmission. The cancer subsite and procedure significantly influenced the risk, rate, and reason for readmission. Implications for Practice Findings from this study can help quality improvement and patient safety administrators develop interventions that uniquely target HNC populations.

Objective To determine if immediate postoperative uncuffed tracheostomy placement following oral cavity or oropharyngeal head and neck free flap reconstruction is associated with shorter hospital length of stay and higher inpatient decannulation rates without an increase in respiratory complications, as compared with immediate placement of cuffed tracheostomy. Study Design Retrospective cohort. Setting Tertiary referral center. Subjects and Methods Patients were included if they underwent free flap reconstruction for oral cavity or oropharyngeal squamous cell carcinoma and had an intraoperative tracheostomy placed between 2005 and 2016. In 2012, head and neck surgeons changed from routine placement of cuffed to uncuffed tracheostomy tubes immediately after free flap reconstruction. This study compares length of hospital stay, inpatient decannulation rates, and respiratory complications between patients who had cuffed and uncuffed tracheostomies. Analysis of variance and chi-square test were used to examine continuous and categorical variables, respectively. Multivariable regression analyses were performed to determine whether cuff status was independently associated with primary outcomes of length of hospital stay, decannulation, and respiratory complications. Results Of 752 patients who underwent free flap reconstruction, 493 patients met inclusion criteria (cuffed, n = 366; uncuffed, n = 127). Patient variables (ie, age, sex, body mass index, prior chemoradiation) and tumor characteristics (ie, location, stage) did not differ significantly between groups. Adjusted analysis showed that an uncuffed tracheostomy (vs a cuffed tracheostomy) was associated with shorter length of stay (7.7 vs 9.7 days, P < .001) and did not increase the rate of respiratory complications. Conclusion Immediate placement of a uncuffed tracheostomy after oral cavity or oropharyngeal free flap reconstruction is associated with shorter hospital stays without an increase in respiratory complications.

Objective: To evaluate whether the standardized letter of recommendation (SLOR), commonly used for medical students applying to otolaryngology residency, correlates with objective data in the application. Background: Standardized letters of recommendation using Likert-type scales for different attributes are commonly used by evaluators because of their high interrater reliability and efficiency in preparation and interpretation. Given that these are subjectively scored, it is unknown how well these correlate with objective data. Methods: Applications to the University of Cincinnati otolaryngology residency were evaluated in the academic cycle of 2017-2018. Standardized letters of recommendation were scored to determine whether certain attributes were correlated with objective data (United States Medical Licensing Examination [USMLE] scores and number of presentations/publications) provided in their application. Spearman correlations were used to evaluate the strength of the relationship between the subjective score in certain attributes with objective data. Results: There were 217 applications to the University of Cincinnati that contained SLORs. Of these applications, 474 standardized letters were scored in categories of medical knowledge, research, and commitment to academic medicine. Total publications and presentations were weakly correlated with commitment to academic medicine (0.35, P Conclusions: Subjective research and commitment to academic medicine rating scores were weakly correlated with greater academic productivity. Similarly, medical knowledge scores were weakly correlated with Step 1/2 scores. Further research may be needed to assess how to interpret SLOR scores in addition to the information available in an otolaryngology application. Level of Evidence: 4

Surgical specialty trips to third world countries have been praised and criticized. Our objective was to learn the usefulness of a yearly head and neck surgery trip through initial analysis of 2 years of patient data.We reviewed data from a prospectively maintained repository of surgical patients treated during head and neck surgical trips to Malindi, Kenya, in 2010 and 2011. Basic demographics, distance traveled for care, access to physicians, preoperative diagnosis, surgical procedure(s), and pathology were recorded when available.In 2 years, 226 surgeries were performed. Patient age ranged between 3 months and 85 years, and gender was evenly split. Half of patients came from outside the town of Malindi, and a third traveled over 100 kilometers for care. The majority reported access to a local physician, yet very few patients were offered prior surgical treatment. The most common operations performed were adenotonsillectomy and hemithyroidectomy. A wide variety of cases were performed, including parotidectomies, maxillectomies, mandibulectomies, cleft lip and palate repair, and free flap reconstructions. Local and national visiting otolaryngologist-head and neck surgeons participated or observed throughout our visits with teaching emphasis based on their skills and specific learning goals.Annual surgical specialty trips to rural, resource-limited regions are useful and worthwhile and offer procedures not otherwise available. On such trips, it is important to collect patient, surgical, and pathology data to help visiting surgeons determine the best procedures to teach local physicians and provide needed resources.

Objective Total laryngectomy (TL) is a high-cost procedure with patients at risk for significant postoperative health care use. Face-to-face preoperative counseling provided by speech-language pathologists is a relatively inexpensive intervention that may improve care quality and decrease costs. We evaluated if preoperative counseling for patients undergoing TL was associated with differences in length of stay (LOS), use of the emergency department (ED), or unplanned readmissions within 30 days of discharge. A secondary analysis identified predictors of these 3 outcomes. Study Design Case series with chart review. Setting Academic medical center in the United States. Subjects and Methods Patients were included if they underwent TL from 2011 to 2015. Patient demographics and comorbidities, surgical characteristics, and perioperative care data were retrieved and analyzed for 116 patients. Univariate and multivariate models were constructed for 3 outcomes. Results LOS was significantly lower for patients receiving counseling (-3.0 days, P = .02). No differences were observed in rates of 30-day ED visits or unplanned readmissions. Care provided by high-volume surgeons was associated with decreased LOS ( P = .005), while having postoperative complications increased LOS ( P < .001). High rates of ED visits (12.1%) and readmissions (20.6%) were observed. Discharge to inpatient rehabilitation and the patient's home distance from the institution were predictors of ED visits. TL as salvage therapy and occurrence of postoperative complications were risk factors for readmission. Conclusion Preoperative counseling was associated with marked reduction in LOS following TL without increased readmissions, which suggests that it may promote safe, earlier patient readiness for discharge.

Objective. To evaluate clinician perception of voice quality, patient self-reported psychosocial impact of dysphonia, and glottic closure in patients who have undergone resection of the recurrent laryngeal nerve (RLN) and immediate opera- tive reconstruction during thyroid surgery. Study Design. Prospective observational study. Setting. Single tertiary care hospital. Subjects and Methods. Nine patients underwent immediate operative reconstruction of the RLN by the senior author from 2002 to present. Outcome measures included (1) per- ceptual voice ratings assessed using the GRBAS (Grade, Roughness, Breathiness, Asthenia, Strain) scale, (2) psycho- social impact of dysphonia assessed using the Voice Handicap Index (VHI), and (3) assessment of glottic closure from laryngeal videostroboscopy. Results. The RLN was reconstructed with primary anasto- mosis (4), free nerve graft (3), or vagus-RLN anastomosis (2). Seven patients had voice samples and videostroboscopy examinations obtained at a minimum of 9 months from sur- gery. Six were judged to have slight disturbance of voice based on overall Grade scoring (G = 1). Five rated their voice as normal or mild on the VHI instrument (score range 8-29). Laryngeal analysis revealed the immobile vocal fold in the median, physiologic phonating position with preserved bulk, recovered tension, and glottic closure during phona- tion. Three patients less than 9 months from surgery had an expected severe self-reported rating of dysphonia. Conclusion. Primary anastomosis, free nerve grafting, and vagus- RLN anastomosis are viable options for RLN reconstruction. Patients who undergo resection and immediate reconstruction of the RLN are able to regain self-perceived functional voices.

Cleft palate is among the most common craniofacial congenital anomalies. Up to 30 % of patients with cleft palate also have associated cardiac and vascular defects. VEGFa, a critical growth factor involved in multiple developmental processes including angiogenesis and ossification, is also required for palate development. Conditional deletion of VEGFa in cranial neural crest (CNC) cells using Wnt1-Cre (VEGFaCKO) resulted in cleft palate in mice. The phenotype included reduced proliferation of cells within the palatal shelves, abnormal palatal shelf elongation and elevation, and the inability to undergo fusion. Vascularization of the VEGFaCKO palatal shelves was greatly reduced, suggesting a non-cell autonomous role of VEGFa signaling from the CNC-derived cells to the endothelium during vessel formation. Defective vascular development was coupled with deficient intramembranous ossification of maxillary and palatal mesenchyme. In vitro assessment of CNC-derived palatal mesenchymal cells from VEGFaCKO mice demonstrated normal ossification after BMP2 stimulation, suggesting that inadequate expression of Bmp2 in VEGFaCKO mice was, in part, responsible for reduced ossification. Taken together, these data demonstrate that VEGFa produced in the CNC-derived mesenchyme drives proliferation, vascularization, and ossification, all of which are critical for palate development.

Objectives:Total glossectomy is a morbid procedure offered to patients with advanced tumors of the oral cavity and oropharynx. Reconstruction of the resultant defect is typically performed immediately after resection, with regional and free tissue transfer being most commonly used. The goals of this study are to demonstrate: 1) long-term survival, 2) long-term swallowing outcomes, 3) rate of tracheostomy dependence, and 4) reconstructive techniques utilized after total glossectomy.Methods:Retrospective chart review of patients who received total glossectomy at Vanderbilt between 2000 and 2010. Survival and functional outcomes were followed from the day of the surgery to the last outpatient note.Results:22 patients were included in this study, and 15 patients were alive 1 year post-surgery. Average length of survival after the operation was 715 days. 4 patients received concomitant total laryngectomy. 14 of 18 patients that received tracheostomy were able to be decannulated, with an average time to decannu...