Objectives This article examines a national cohort of patients with nasopharyngeal adenoid cystic carcinoma (ACC) for incidence, skull base invasion, overall survival, and treatment paradigms. Design, Setting, and Participants Retrospective national population-based study using Surveillance, Epidemiology, and End Results program data of patients with ACC of the nasopharynx (NACC) and skull base between 2004 and 2016. Main Outcomes and Measures Primary outcomes included 5-year overall survival and odds of radiation treatment. Statistical analysis was performed using STATA 15.0 (STATACorp). p -Values < 0.05 were considered statistically significant. Results Of the 2,385 cases of ACC, 70 cases were classified as NACC. Twenty-one percent (15) involved invasion of the skull base or posterior pharyngeal wall, and 42% (30) were either stage 3 or stage 4. The 5-year overall survival for patients with NACC without skull base invasion was 67% which dropped to 40% with invasion into the skull base. Radiation was used as the primary form of therapy for 62% of NACC and 73% of NACC invading into skull base. Odds of receiving radiation therapy and 5-year survival were not affected by socioeconomic status or density of providers. Conclusion NACC is rare in incidence and was most commonly treated with radiation therapy when advanced in stage. Prognosis was dependent on invasion through posterior pharyngeal wall and skull base. Provider density and socioeconomic status did not affect odds of radiation or overall survival for NACC.
Laryngeal fractures are rare injuries; recent data describing these injuries and associated examination findings are limited. This study aims to describe injury etiology and outcomes associated with laryngeal fractures.Retrospective case series.Academic tertiary center.Patients with laryngeal fractures from 2005 to 2020 were identified in a retrospective chart review. Patient demographics, injury mechanisms, management, and voice outcomes were examined. Fracture type, radiologic, and endolaryngeal examination findings were analyzed for associations between fracture etiology and examination characteristics.Laryngeal fractures most commonly occurred at the thyroid cartilage. Fractures were most commonly due to sport-related injuries. Mechanism of injury was not associated with specific radiologic or endolaryngeal findings. Mechanism of injury was additionally not significantly associated with the need for intubation, surgical intervention, or tracheotomy. Fracture location was significantly associated with intubation requirement (P = .015), with 40% of patients with concomitant thyroid and cricoid fractures requiring intubation. Mechanism of injury significantly correlated with dysphonia at follow-up (P = .033). Mechanism of injury, fracture location, and surgical management were not associated with increased vocal fold injury or dysphonia.There are no significant correlations between injury mechanism and fracture location, characteristics, radiologic findings, or endolaryngeal findings. These features emphasize the importance of a thorough and comprehensive laryngeal examination.
Abstract Objective Injuries in professional ice hockey players are common, however significant laryngeal trauma is rare. Here, we present a case series of professional and semiprofessional ice hockey players to demonstrate the mechanism and nature of laryngeal injuries they sustain during play, and to recommend best practices for treatment, prevention, and return to the ice. Methods A retrospective case review was done of hockey‐related laryngeal injuries between 2016 and 2019 at a tertiary laryngology practice. Only semiprofessional and professional hockey players were included. Results In total, four cases were included. All cases involved trauma from a hockey puck to the neck. No cases were the result of punching, fighting, high sticks or routine checking. Notably, 1 of 4 presented with severe airway compromise, requiring urgent intubation, whereas most presented with pain or a significant voice complaint. Two patients required operative intervention with open reduction and internal fixation of significantly displaced fractures. One patient experienced significant mucosal disruption with cartilaginous exposure at the posterior vocal complex requiring microflap. The average return to ice was 6 weeks for those who required operative intervention and 4 weeks for those who were managed conservatively. One patient had persistent mild dysphonia and all others had a return to baseline phonation. None were wearing neck guards or other protective equipment at the time of injury. Conclusion Though voice and airway injuries are rarely sustained by ice hockey players, they may require urgent intervention. We recommend that protective equipment be worn and improved to prevent laryngeal trauma. Level of Evidence 4
Two years after a woman underwent a retrosigmoid approach for gross resection of a vestibular schwannoma, follow-up imaging revealed residual tumor growth and a region of enhancing tissue involving the left mastoid and jugular foramen. What is your diagnosis?
4124 Background: This study reports the final analysis (n=50) of a prospective phase II study evaluating the efficacy of the combination of sorafenib and doxorubicin eluting bead transarterial chemoembolization (DEB-TACE) in patients with unresectable hepatocellular carcinoma (HCC). Methods: Protocol consisted of 6-week cycles with sorafenib at 800 mg/day beginning 1 week prior to DEB-TACE; up to 4 DEB-TACE treatments within 6 months. Tumor response was assessed by RECIST and EASL criteria using MRI at baseline and at 1 month follow-up. Time to untreatable progression (TTUP) was defined as the interval from initiation of sorafenib therapy until inability of patient to further receive intra-arterial therapy. Overall survival (OS) and TTUP were calculated with the Kaplan-Meier method; outcomes were stratified by BCLC A/B and C and compared with the log-rank test. Results: DEB-TACE + sorafenib successfully performed in 50 patients: mean 62yrs (range, 31-88 yrs), Child-Pugh A/B (92%/8%), BCLC A/B/C (10%/28%/62%), ECOG 0/1 (52%/48%), HCV/HBV (44%/8%), mean tumor burden 20%, mean tumor size 7.2cm (range, 1–17.6), and mean tumor enhancement 78%. Patients were enrolled for a median of 3 (range, 1-22) cycles including a median of 1 (range, 0-6) DEB-TACE procedure. Median dose regimen was 400mgQD and the median dose taken while on study was 318 mg/day (range, 100-800). 1 month follow-up showed a mean tumor enhancement reduction of 48.2% (n=46, p<0.001) and an average reduction in lesion diameter of 8.5%(n=48, p=0.02). The Disease Control Rate was 98% using the EASL amendment and RECIST. Median TTUP was 11.9 mths (95% CI, 1.8-22 mths) with a significant difference between BCLC A/B (median 22.9 mths) and BCLC C (median 6.2mths) patients (log-rank, p=0.01). Median OS was 24.5 mths (95% CI, 14.3-35 mths) with a significant difference between BCLC C (median 17.1 mths) and BCLC A/B (median 33.7 mths) patients (log-rank, p=0.001). Conclusions: The results of this phase II study suggest a potential benefit to the combination of sorafenib and DEB-TACE. Single arm and non-randomization are limitations of the study. Clinical trial information: NCT00844883.
Background Previous studies have identified subdomains of the 22‐item Sino‐Nasal Outcome Test (SNOT‐22), reflecting distinct and largely independent categories of chronic rhinosinusitis (CRS) symptoms. However, no study has validated the subdomain structure of the SNOT‐22. This study aims to validate the existence of underlying symptom subdomains of the SNOT‐22 using confirmatory factor analysis (CFA) and to develop a subdomain model that practitioners and researchers can use to describe CRS symptomatology. Methods A total of 800 patients with CRS were included into this cross‐sectional study (400 CRS patients from Boston, MA, and 400 CRS patients from Reno, NV). Their SNOT‐22 responses were analyzed using exploratory factor analysis (EFA) to determine the number of symptom subdomains. A CFA was performed to develop a validated measurement model for the underlying SNOT‐22 subdomains along with various tests of validity and goodness of fit. Results EFA demonstrated 4 distinct factors reflecting: sleep, nasal, otologic/facial pain, and emotional symptoms (Cronbach's alpha, >0.7; Bartlett's test of sphericity, p < 0.001; Kaiser‐Meyer‐Olkin >0.90), independent of geographic locale. The corresponding CFA measurement model demonstrated excellent measures of fit (root mean square error of approximation, <0.06; standardized root mean square residual, <0.08; comparative fit index, >0.95; Tucker‐Lewis index, >0.95) and measures of construct validity (heterotrait‐monotrait [HTMT] ratio, <0.85; composite reliability, >0.7), again independent of geographic locale. Conclusion The use of the 4‐subdomain structure for SNOT‐22 (reflecting sleep, nasal, otologic/facial pain, and emotional symptoms of CRS) was validated as the most appropriate to calculate SNOT‐22 subdomain scores for patients from different geographic regions using CFA.
To investigate the effect of skin incision location for total laryngectomy with pharyngectomy (TLP) on postoperative outcomes including wound dehiscence and infection rate.Case series with chart review.Academic tertiary care center.A retrospective analysis was conducted of all patients undergoing TLP with flap closure at Johns Hopkins Medical Institutes between August 2005 and February 2013. The effects of patient characteristics and skin incision technique on postoperative wound dehiscence and infection were analyzed using cross-tabulations and multivariate regression modeling.A total of 49 patients were included in the analysis; 31 received low-neck apron (LNA) incisions with an incorporated tracheostoma, while the remaining 18 had mid-neck apron (MNA) incisions with separate tracheostoma fashioned inferior to their incisions. Of these patients, 17 experienced incisional wound dehiscence (35%), and 18 contracted postoperative infections (37%). Generalized linear regression models demonstrated a significantly increased odds of wound dehiscence for patients with LNA incisions (odds ratio 29.8; 95% CI, 1.4-631.5, P = .029). There were no significant predictive variables for postoperative infection.These results demonstrate that the use of a separately fashioned tracheostoma with MNA incision is associated with decreased rate of wound dehiscence in patients undergoing TLP.
Free tissue transfer from the subscapular system provides a wide array of options for both soft tissue and bony reconstruction. When bone stock is required for head and neck reconstruction, both the lateral scapular border free flap (LSBFF), supplied by the circumflex scapular artery, and the scapular tip free flap (STFF), supplied by the angular artery, are excellent options. Issues with positioning had previously prevented the widespread use of these bony subscapular system flaps. However, through the use of a Spider Limb Positioner, current clinical practice patterns allow for two team approaches in both of these free flaps. The following pictorial essay compares and contrasts the specific positioning and harvesting technique used for both the LSBFF and STFF, while discussing the clinical advantages and drawbacks of each. Both the lateral border scapula and scapular tip free flaps provide excellent bone stock for head and neck reconstruction. By positioning with currently available technology, both of these free flaps can be harvested through a two team approach.
