Surgery in the Era of Immunotherapy for Advanced Head and Neck Non-melanoma Skin Cancer

PURPOSE OF REVIEW

Surgery remains the mainstay of treatment for non-melanoma skin cancer (NMSC). Immunotherapy (IO) has emerged as an alternative option. This review provides a contemporary summary of how to incorporate IO into the management of advanced NMSC. Evidence-based outcomes and recent clinical trials are provided with emphasis on the three most common NMSC diagnoses: cutaneous squamous cell carcinoma (cSCC), basal cell carcinoma (BCC), and merkel cell carcinoma (MCC).

RECENT FINDINGS

Surgical resection while preserving form and function remains the standard of care for the majority of NMSCs. In recalcitrant cases failing traditional surgery and/or primary radiation, patient ineligible for such treatments, or unresectable disease, IO has emerged as a promising alternative. In the majority of cases, it is a supplanting primary chemotherapy. Surgery remains the standard of care for NMSC. Immunotherapy has emerged as an alternative option for non-surgical candidates and as a neoadjuvant means to minimize morbidity.

Voice Restoration and Quality of Life in Larynx Cancer

Voice restoration following laryngectomy has a significant influence on quality of life (QOL). Three main techniques exist to provide voice: esophageal speech (ES), artificial larynx (electrolarynx [EL]), and tracheoesophageal puncture (TEP). Although the EL was historically the most used technique, TEP has quickly become the gold standard. ES remains the least frequently used technique in developed countries. Technique selection must be made on an individual basis, considering the patient's cancer history and comorbidities. Ultimately, the choice in voice-restoration technique requires joint decision making with the surgeon, speech pathologist, and patient.

Patient Safety/Quality Improvement Primer, Part IV: Psychological Safety-Drivers to Outcomes and Well-being

Psychological safety is the concept that an individual feels comfortable asking questions, voicing ideas or concerns, and taking risks without undue fear of humiliation or criticism. In health care, psychological safety is associated with improved patient safety outcomes, increased clinician engagement, and greater creativity. A culture of psychological safety is imperative for physician well-being and satisfaction, which in turn directly affect delivery of care. For health care professionals, psychological safety creates an environment conducive to trust and openness, enabling the team to focus on high-quality care. In contrast, unprofessional behavior reduces psychological safety and threatens the culture of the organization. This patient safety/quality improvement primer considers the barriers and facilitators to psychological safety in health care; outlines principles for creating a psychologically safe environment; and presents strategies for managing conflict, microaggressions, and lapses in professionalism. Individuals and organizations share the responsibility of promoting psychological safety through proactive policies, conflict management, interventions for microaggressions, and cultivation of emotional intelligence.

American Head and Neck Society position statement on the use of PD-1 inhibitors for treatment of advanced cutaneous squamous cell carcinoma

BACKGROUND

A position statement put forth by the American Head and Neck Society (AHNS) was constructed to provide evidence-based treatment recommendations for PD-1 inhibitor use in advanced cutaneous squamous cell carcinoma (cSCC). Secondarily, we sought to identify knowledge gaps warranting further investigation.

METHODS

A literature search utilizing key terms: cutaneous squamous cell carcinoma, cutaneous cancer, checkpoint inhibitors, systemic therapy, Program Cell Death, PD-1 (PubMed, Cochrane, and Google Scholar) was carried out to generate evidence-based statements. The statements were distributed among the AHNS membership. Delphi methodology was applied to identify statements achieving 70% or greater consensus among the leadership team.

RESULTS

Twenty-six position statements achieved consensus. Knowledge gaps for future research included: impact of immunosuppression on cSCC staging and associated treatment; role of PD-1 inhibitors in immunosuppressed patients.

CONCLUSION

This comprehensive position statement put forth by the AHNS represents majority consensus by practicing head and neck surgeons throughout the country.

COVID-19 Tracheostomy Outcomes

OBJECTIVES

(1) Assess overall COVID-19 mortality in ventilated patients with and without tracheostomy. (2) Determine the impact of tracheostomy on mechanical ventilation duration, overall length of stay (LOS), and intensive care unit (ICU) LOS for patients with COVID-19.

STUDY DESIGN

Case series with planned chart review.

SETTING

Single-institution tertiary care center.

METHODS

Patients with COVID-19 who were ≥18 years old and requiring invasive positive pressure ventilation (IPPV) met inclusion criteria. Patients were stratified into 2 cohorts: IPPV with tracheostomy and IPPV with intubation only. Cohorts were analyzed for the following primary outcome measures: mortality, LOS, ICU LOS, and IPPV duration.

RESULTS

An overall 258 patients with IPPV met inclusion criteria: 46 (18%) with tracheostomy and 212 (82%) without (66% male; median age, 63 years [interquartile range, 18.75]). Average LOS, time in ICU, and time receiving IPPV were longer in the tracheostomy cohort (P < .01). Ability to wean from IPPV was similar between cohorts (P > .05). The number of deaths in the nontracheostomy cohort (54%) was significantly higher than the tracheostomy cohort (29%, P < .01).

CONCLUSIONS

While tracheostomy placement in patients with COVID-19 did not shorten overall LOS, mechanical ventilation duration, or ICU LOS, patients with a tracheostomy experienced a significantly lower number of deaths vs those without. One goal for tracheostomy is improved pulmonary toilet with associated shortened IPPV requirements. Our study did not identify this advantage among the COVID-19 population. However, this study demonstrates that the need for tracheostomy in the COVID-19 setting does not portent a poor prognostic factor, as patients with a tracheostomy experienced a significantly higher survival rate than their nontracheostomy counterparts.

Patient Safety/Quality Improvement Primer, Part III: The Role of Simulation

Simulation training has taken a prominent role in otolaryngology-head and neck surgery (OTO-HNS) as a means to ensure patient safety and quality improvement (PS/QI). While it is often equated to resident training, this tool has value in lifelong learning and extends beyond the individual otolaryngologists to include simulation-based learning for teams and health systems processes. Part III of this PS/QI primer provides an overview of simulation in medicine and specific applications within the field of OTO-HNS. The impact of simulation on PS/QI will be presented in an evidence-based fashion to include the use of run and statistical process control charts to assess the impact of simulation-guided initiatives. Last, steps in developing a simulation program focused on PS/QI will be outlined with future opportunities for OTO-HNS simulation.

Opioid Prescribing Patterns After Head and Neck Surgery

OBJECTIVE

Postoperative prescription narcotics increase access to opioids and associated abuse among patients, family, and acquaintances. Judicious opioid stewardship is required. Best practice questions remain for larger head and neck surgeries. We aim to review opioid utilization patterns in an urban patient population to identify patients at risk for poor postoperative pain control.

STUDY DESIGN

Case series with planned chart review for patients undergoing head and neck surgery (2015-2018).

SETTING

Single urban hospital.

METHODS

Outcome measures included postoperative phone calls and emergency room visits as markers for inadequate pain control. Age, sex, race, body mass index (BMI), smoking status, comorbidities, prior narcotic filling behavior, surgery type, and duration were evaluated as potential risk factors for pain control. Chi-square and Wilcoxon tests were used for group comparisons.

RESULTS

In total, 215 patients met inclusion criteria: male (22%), white/Hispanic (47%), and African American (44%). Median BMI was 31.6 kg/m²; median age was 52 years. Surgeries included total thyroidectomy (41%), hemithyroidectomy (27%), and parathyroidectomy (15%). The 23-hour observation patients (n = 175, 81%) had a median of 20 morphine milligram equivalents (MMEs). Sixteen patients experienced inadequate pain control. Female sex (P = .03), younger age (P = .02), current smoker (P = .03), and higher inpatient MME (P = .006) were associated with inadequate pain control.

CONCLUSION

Female sex, younger age, smokers, and high inpatient opioid dose requirements are associated with inadequately controlled pain. These patients may benefit from additional education, earlier postoperative visits, and a more comprehensive nonopioid regimen.

Laryngeal inhalational injuries: A systematic review

Laryngeal inhalation injury carries a significant increase in mortality rate and often indicates immediate airway evaluation. This may be difficult in the setting of clinical deterioration necessitating immediate intubation, which itself can synergistically cause mucosal damage. Prior studies do not encompass predictive factors or long-term outcomes for the laryngotracheal complex. This systemic review of PubMed, Embase, and Cochrane identified studies investigating inhalational injuries of the upper airway. Demographic data as well as presentation, physical findings, and delayed sequelae were documented. Laryngotracheal burn patients were divided into two cohorts based on timing of laryngeal injury diagnosis (before- versus after-airway intervention). 1051 papers met initial search criteria and 43 studies were ultimately included. Airway stenosis was more common in patients that were intubated immediately (50.0%, n = 18 versus 5.2%, n = 13; p = 0.57). Posterior glottic involvement was only identified in patients intubated prior to airway evaluation (71.4%, n = 15). All studies reported a closed space setting for those patients in whom airway intervention preceded laryngeal evaluation. Laryngeal inhalational injuries are a distinct subset that can have a variety of minor to severe laryngotracheal delayed sequelae, particularly for thermal injuries occurring within enclosed spaces. Given these findings, early otolaryngology referral may mitigate or treat these effects.

American Academy of Otolaryngology-Head and Neck Surgery/Foundation Reg-ent Registry: Purpose, Properties, and Priorities

OBJECTIVE

(1) To describe the patient and membership cohort captured by the otolaryngology-based specialty-specific Reg-ent registry. (2) To outline the capabilities of the Reg-ent registry, including the process by which members can access evidence-based data to address knowledge gaps identified by the American Academy of Otolaryngology-Head and Neck Surgery/Foundation and ultimately define "quality" for our field of otolaryngology-head and neck surgery.

METHODS

Data analytics was performed on Reg-ent (2015-2020).

RESULTS

A total of 1629 participants from 239 practices were enrolled in Reg-ent, and 42 health care specialties were represented. Reg-ent encompassed 6,496,477 unique patients and 24,296,713 encounters/visits: the 45- to 64-year age group had the highest representation (n = 1,597,618, 28.1%); 3,867,835 (60.3%) patients identified as Caucasian; and "private" was the most common insurance (33%), followed by Blue Cross/Blue Shield (22%). Allergic rhinitis-unspecified and sensorineural hearing loss-bilateral were the top 2 diagnoses (9% each). Overall, 302 research gaps were identified from 17 clinical practice guidelines.

DISCUSSION

Reg-ent benefits are vast-from monitoring one's practice to defining otolaryngology-head and neck surgery quality, participating in advocacy, and conducting research. Reg-ent provides mechanisms for benchmarking, quality assessment, and performance measure development, with the objective of defining and guiding best practice in otolaryngology-head and neck surgery. To be successful, patient diversity must be achieved to include ethnicity and socioeconomic status. Increasing academic medical center membership will assist in achieving diversity so that the quality domain of equitable care is achieved.

IMPLICATIONS FOR PRACTICE

Reg-ent provides the first ever registry that is specific to otolaryngology-head and neck surgery and compliant with HIPAA (Health Insurance Portability and Accountability Act) to collect patient outcomes and define evidence-based quality care.

Reverse-Surge Planning During the COVID-19 Pandemic: A Cautionary Ramp-up for the Otolaryngologist

As the coronavirus disease 2019 (COVID-19) pandemic continues to evolve through the United States and other countries, differing rates of progression and decline are occurring based on varied population densities. While some health systems are reaching a steady state of new patient cases, others are seeing a leveling off or decline, allowing for restoration of normal practices. This "reverse-surge" planning and implementation process is a colossal undertaking for health systems trying to reacquire patient access and financial stability while preserving necessary resources and maintaining precautions for another potential surge. For the otolaryngologist, reverse-surge planning involves additional workflow adjustments in the outpatient and operating room settings given the abundance of COVID-19 virus in the upper aerodigestive tract. As the reverse-surge best practices are still under development, open communication between otolaryngology colleagues and health system leadership is paramount to optimize efficiency and maintain an adequate measure of safety for patients and our health care teams.

Impact of the COVID-19 Global Pandemic on the Otolaryngology Fellowship Application Process

On March 11, 2020, the World Health Organization declared coronavirus disease 2019 a global pandemic. In addition to massive social disruption, this pandemic affected the traditional fellowship interview season for otolaryngology subspecialties, including head and neck surgical oncology, facial plastic and reconstructive surgery, laryngology, rhinology, neurotology, and pediatric otolaryngology. The impact on the fellowship interview process, from the standpoint of the institution and the applicant, necessitated the use of alternative interview processes. This change may alter the future of how interviews and the match proceed for years to come, with nontraditional methods of interviewing becoming a mainstay. While the impact this pandemic has on the fellowship match process is not yet fully realized, this commentary aims to discuss the challenges faced on both sides of the equation and to offer solutions during these unprecedented times.

Otolaryngologists’ Role in Redeployment During the COVID-19 Pandemic: A Commentary

As otolaryngologists, we identify as subspecialists and fellowship-trained surgeons and may even identify as “super-subspecialists.” The likelihood of being redeployed and drawing from knowledge learned during our postgraduate year 1 training seemed exceedingly unlikely until physician resources became scarce in some health care systems during the COVID-19 pandemic. More now than ever, it is evident that our broad training is valuable in helping patients and allowing the otolaryngologist to meaningfully contribute to the larger health care community, especially while the majority (70%-95%) of elective care is delayed. With our skill set, otolaryngologists are poised to support various aspects of hospital wards, intensive care units, emergency departments, and beyond.

Patient Safety and Quality Improvement in Otolaryngology-Head and Neck Surgery: A Systematic Review

OBJECTIVE

The current landscape of patient safety/quality improvement (PS/QI) research dedicated to Otolaryngology-Head and Neck Surgery (OHNS) has not been established. This systematic review aims to define the breadth and depth of PS/QI research dedicated to OHNS and to identify knowledge gaps as well as potential areas of future study.

METHODS

The study protocol was developed a priori using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) process. A computerized Ovid/Medline database search was conducted (January 1, 1965-September 30, 2019). Similar computerized searches were conducted using Cochrane Database, PubMed, and Google Scholar. Articles were classified by year, subspecialty, PS/QI category, Institute of Medicine (IOM) Crossing the Chasm categories, and World Health Organization (WHO) subclass.

RESULTS

Computerized searches yielded 11,570 eligible articles, 738 (6.4%) of which met otolaryngology PS/QI inclusion criteria; 178 (24.1%) were not specific to any one subspecialty. The most prevalent subspecialty foci were head and neck (29.9%), pediatric otolaryngology (16.9%), and otology/neurotology (11.0%). Studies examining complications or risk factors (32.0%) and outcomes/quality measures (16.3%) were the most common foci. Classification by the IOM included effective care (31.4%), safety (29.9%), and safety/effective care (25.3%). Most research fell into the WHO categories of understanding causes (28.5%) or measuring harm (28.3%).

CONCLUSION

Most OHNS PS/QI projects (32.0%) focus on reporting complications or risk factors, followed by outcomes/quality measures (16.3%). Knowledges gaps for future research include healthcare disparities, multidisciplinary care, and the WHO category of studies translating evidence into safer care.

LEVEL OF EVIDENCE

NA Laryngoscope, 131:33-40, 2021.

Patient Safety/Quality Improvement Primer, Part II: Prevention of Harm Through Root Cause Analysis and Action (RCA2)

With increasing emphasis on patient safety/quality improvement, health care systems are mirroring industry in the implementation of root cause analysis (RCA) for the identification and mitigation of errors. RCA uses a team approach with emphasis on the system, as opposed to the individual, to accrue empirical data on what happened and why. While many otolaryngologists have a broad understanding of RCA, practical experience is often lacking. Part II of this patient safety/quality improvement primer investigates the manner in which RCA is utilized in the prevention of medical errors. Attention is given to identifying system errors, recording adverse events, and determining which events warrant RCA. The primer outlines steps necessary to conduct an effective RCA, with emphasis placed on actions that arise from the RCA process through the root cause analysis and action (or RCA²) rubric. In addition, the article provides strategies for the implementation of RCA into clinical practice and medical education.

Patient Safety/Quality Improvement Primer, Part I: What PS/QI Means to Your Otolaryngology Practice

Patient safety/quality improvement (PS/QI) is the cornerstone of 21st-century health care. Otolaryngology-Head and Neck Surgery is excited to provide a dedicated PS/QI primer. The overarching goal for this PS/QI series is to provide a comprehensive and practical resource that assists readers, authors, and peer reviewers in understanding PS/QI research, its unique methodology, and the associated reporting standards for trustworthy performance measures. The target audience includes resident and fellows, faculty from the private sector and academia, and allied health professionals. This inaugural primer reviews PS/QI background as it relates to otolaryngology practice. It explores the history, goals, and development of performance measurement. In addition, it highlights opportunities for integrating PS/QI into otolaryngology practice. Payers will drive patients to quality care based on outcomes. Otolaryngologists have a responsibility to embrace a culture of PS/QI. In doing so, we will define optimal, quality otolaryngology care through objective data and metrics.

Otolaryngology Resident Reviewer Development Program: Lessons Learned from Cohort 1

Objective

To implement a quality improvement project addressing the knowledge gap in the otolaryngology resident and fellow scientific peer review process.

Methods

The creation of the Resident Reviewer Development Program, cohort 1 outcomes, and subsequent lessons learned from the inaugural class are outlined using the plan-do-study-act model. Interested otolaryngology residents were paired with seasoned reviewers and conducted a minimum of 3 mentored peer reviews followed by an independent review test if competency was determined.

Results

Twenty-five residents (postgraduate years [PGYs] 2-5) were actively enrolled in cohort 1. At 24 months, 18 (72%) graduated, 6 remained actively enrolled, and 1 did not successfully complete the program. The median number of practice reviews prior to testing was 3 (range, 3-6). The median independent review score was 83 (overall journal mean = 78). Cohort 1 graduates continued on to review 130 articles with a mean score of 85. Five (28%) graduates achieved Star Reviewer status.

Discussion

The inaugural cohort demonstrated that the PGY-3 and PGY-4 class is ideal for enrollment given that completion of the program could take up to 24 months. Three mentored reviews were identified as the ideal minimum requirement for education. The accelerated achievement of Star Reviewer status (28%) and mean postgraduation score of 85 demonstrate successful and sustainable outcome measures.

Implications for Practice

With appropriate mentorship and administrative support, scientific peer review can be formally incorporated into an educational program. Lessons learned during the educational program are sustained long term as demonstrated by review scores and Star Reviewer status.

Immunosuppression Impact on Head and Neck Cutaneous Squamous Cell Carcinoma: A Systematic Review with Meta-analysis

Objective

The primary objective was to define and quantify the relationship between immunosuppression and prognosis in patients with cutaneous squamous cell carcinoma of the head and neck.

Data Sources

Ovid/Medline, PubMed, Embase, and Scopus were searched from inception through June 5, 2017, with cross-referenced subject headings of squamous cell carcinoma, skin neoplasms, head and neck neoplasms, and prognosis. Additional gray literature was queried.

Review Methods

All prospective, retrospective, and cohort studies in the English literature investigating prognosis in patients with head and neck cutaneous squamous cell carcinoma were eligible for inclusion. Meta-analysis data were pooled using the fixed-effects model. The main outcome measures were hazard ratios detailing subgroup analysis between immunosuppressed and immunocompetent patients.

Results

Seventeen studies were eligible for inclusion; 317 of the 2886 patients were immunosuppressed. Meta-analysis with pooled hazard ratios was performed for all outcome variables with at least 3 reported hazard ratios. Immunosuppression portended a worse prognosis across all outcome variables of interest: locoregional recurrence (2.20; 95% confidence interval [CI], 1.45-3.36), disease-free survival (2.69; 95% CI, 1.60-4.51), disease-specific survival (3.61; 95% CI, 2.63-4.95), and overall survival (2.09; 95% CI, 1.64-2.67).

Conclusion

This is the largest investigation into the impact of immunosuppression on head and neck cutaneous squamous cell carcinoma. Immunosuppressed patients experience worse recurrence and survival outcomes compared to immunocompetent counterparts. The data support formal inclusion of immunosuppression in head and neck cutaneous squamous cell carcinoma staging systems.

Electronic Cigarette Awareness, Use, and Perceptions among Cancer Patients

Objective

Electronic cigarettes (e-cigs) are an emerging trend, yet little is known about their use in the cancer population. The objectives of this study were (1) to describe characteristics of e-cig use among cancer patients, (2) to define e-cig advertising exposure, and (3) to characterize perceptions of traditional cigarettes versus e-cigs.

Study Design

Cross-sectional study.

Setting

Comprehensive cancer center.

Subjects and Methods

Inpatient, current smokers with a cancer diagnosis. E-cig exposure and use were defined using descriptive statistics. Wilcoxon rank test was used to compare perceptions between e-cigs and traditional cigarettes.

Results

A total of 979 patients were enrolled in the study; 39 cancer patients were identified. Most cancer patients were women (59%), with an average age of 53.3 years. Of the patients, 46.2% reported e-cig use, most of which (88.9%) was “experimental or occasional.” The primary reason for e-cig use was to aid smoking cessation (66.7%), alternative use in nonsmoking areas (22.2%), and “less risky” cigarette replacement (5.6%). The most common sources for e-cig information were TV (76.9%), stores (48.7%), friends (35.9%), family (30.8%), and newspapers or magazines (12.8%). Compared with cigarettes, e-cigs were viewed as posing a reduced health risk (P < .001) and conferring a less negative social impression (P < .001). They were also viewed as less likely to satisfy nicotine cravings (P = .002), to relieve boredom (P = .0005), to have a calming effect (P < .001), and as tasting pleasant (P = .006)

Conclusions

E-cig use and advertising exposure are common among cancer patients. E-cig use is perceived as healthier and more socially acceptable but less likely to produce a number of desired consequences of cigarette use.

Do you know your guidelines? Diagnosis and management of cutaneous head and neck melanoma

The following article is the next installment of the series "Do You Know Your Guidelines?" presented by the Education Committee of the American Head and Neck Society. Guidelines for the prevention, diagnosis, workup, and management of cutaneous melanoma are reviewed in an evidence-based fashion.

Cutaneous Head and Neck Malignancies in the Elderly

Cutaneous malignancy of the head and neck affects a large proportion of elderly patients. The severity ranges from small, easily treatable lesions to large, invasive, potentially metastatic tumors. Surgical treatment is the primary treatment of most skin cancers; however, geriatric patients are more likely to have multiple comorbidities that increase the risk of surgery. Multiple treatment modalities exist, including surgical, radiation, and medical therapy. Recommendations and treatment options for basal cell carcinoma, squamous cell carcinoma, Merkel cell carcinoma, and melanoma are outlined and reviewed.

Completion lymphadenectomy for sentinel node positive cutaneous head & neck melanoma

The application and utility of melanoma sentinel lymph node biopsy (SLNB) has evolved significantly since its inception over two decades ago. The current focus has shifted from a staging modality to potentially a therapeutic intervention. Recent research to include large multi-institutional randomized trials have attempted to answer the question: is a completion lymph node dissection (CLND) required following a positive SLNB? This review provides an evidence-based, contemporary review of the utility of CLND for SLNB positive head and neck cutaneous melanoma patients.

Level of Evidence

NA.

Patient Safety and Quality Improvement in Otolaryngology Education: A Systematic Review

Objective

The breadth and depth of patient safety/quality improvement (PS/QI) research dedicated to otolaryngology–head and neck surgery (OHNS) education remains unknown. This systematic review aims to define this scope and to identify knowledge gaps as well as potential areas of future study to improved PS/QI education and training in OHNS.

Data Sources

A computerized Ovid/Medline database search was conducted (January 1, 1965, to May 15, 2015). Similar computerized searches were conducted using Cochrane Database, PubMed, and Google Scholar.

Review Methods

The study protocol was developed a priori using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Articles were classified by year, subspecialty, Institute of Medicine (IOM) Crossing the Chasm categories, and World Health Organization (WHO) subclass.

Results

Computerized searches yielded 8743 eligible articles, 267 (3.4%) of which met otolaryngology PS/QI inclusion criteria; 51 (19%) were dedicated to resident/fellow education and training. Simulation studies (39%) and performance/competency evaluation (23.5%) were the most common focus. Most projects involved general otolaryngology (47%), rhinology (18%), and otology (16%). Classification by the IOM included effective care (45%), safety/effective care (41%), and effective and efficient care (7.8%). Most research fell into the WHO category of “identifying solutions” (61%).

Conclusion

Nineteen percent of OHNS PS/QI articles are dedicated to education, the majority of which are simulation and focus on effective care. Knowledges gaps for future research include facial plastics PS/QI and the WHO category of “studies translating evidence into safer care.”

Managing Vascular Tumors-Open Approaches

The most common vascular tumors encountered by the otolaryngologist are rare chromaffin cell tumors termed paragangliomas. Within the head and neck region, they commonly arise from the carotid body, vagus nerve (glomus vagale), and jugular vein (glomus jugulare). Other vascular head and neck tumors include sinonasal malignancies, because of proximity to or involvement of the pterygoid plexus as well as the rich vascularity of the sinonasal mucosa; juvenile nasopharyngeal angiofibroma, a vascular tumor of male adolescents; unusual vascular tumors such as hemangiopericytoma; and metastatic renal cell cancer, which has a proclivity for an unusually rich blood supply.

The State of the Otolaryngology Match: A Review of Applicant Trends, "Impossible" Qualifications, and Implications

Objective This State of the Art Review aims (1) to define recent qualifications of otolaryngology resident applicants by focusing on United States Medical Licensing Examination (USMLE) scores, Alpha Omega Alpha (AOA) status, and research/publications and (2) to summarize the current literature regarding the relationship between these measures and performance in residency. Data Sources Electronic Residency Application Service, National Residency Matching Program, PubMed, Ovid, and GoogleScholar. Review Methods Electronic Residency Application Service and National Residency Matching Program data were analyzed to evaluate trends in applicant numbers and qualifications. Additionally, a literature search was performed with the aforementioned databases to identify relevant articles published in the past 5 years that examined USMLE Step 1 scores, AOA status, and research/publications. Conclusions Compared with other highly competitive fields over the past 3 years, the only specialty with decreasing applicant numbers is otolaryngology, with the rest remaining relatively stable or slightly increased. Additionally, USMLE Step 1 scores, AOA status, and research/publications do not reliably correlate with performance in residency. Implications for Practice The consistent decline in applications for otolaryngology residency is concerning and reflects a need for change in the current stereotype of the "ideal" otolaryngology applicant. This includes consideration of additional selection measures focusing on noncognitive and holistic qualities. Furthermore, otolaryngology faculty should counsel medical students that applying in otolaryngology is not "impossible" but rather a feasible and worthwhile endeavor.

Maxillary myxoma: A case report and review

An odontogenic myxoma is a rare, benign tumor that is found almost exclusively in the facial bones, usually the mandible. The diagnosis poses a challenge because its features overlap with those of other benign and malignant neoplasms. We present an unusual case of odontogenic myxoma that involved the maxilla, and we review the clinical, radiographic, and histologic characteristics of this case. Even though it is benign, odontogenic myxoma can be locally invasive and cause significant morbidity. Complete surgical excision is the treatment of choice, but it can be challenging because of the tumor's indistinct margins.

Bridging the Otolaryngology Peer Review Knowledge Gap: A Call for a Residency Development Program

Current otolaryngology literature and future scientific direction rely heavily on a rigorous peer review process. Just as manuscripts warrant thoughtful review with constructive feedback to the authors, the same can be said for critiques written by novice peer reviewers. Formal scientific peer review training programs are lacking. Recognizing this knowledge gap, Otolaryngology-Head and Neck Surgery is excited to offer its new Resident Reviewer Development Program. All otolaryngology residents who are postgraduate year 2 and above and in excellent academic standing are eligible to participate in this mentored program, during which they will conduct 6 manuscript reviews under the direction of a seasoned reviewer in his or her subspecialty area of interest. By completing reviews alongside a mentor, participants gain the required skills to master the peer review process-a first step that often leads to journal editorial board and associate editor invitations.

Grant-Writing Pearls and Pitfalls

This invited article reviews the grant process to include the following objectives: (1) to provide an understanding of otolaryngology funding mechanisms in the context of career progression; (2) to outline key components of a well-written grant; (3) to highlight vital members of a successful research team, with emphasis on the mentor-mentee relationship; and (4) to clarify grant scoring with emphasis on common pitfalls to avoid. Current otolaryngology funding mechanisms and up-to-date resources are provided. The review is aimed to assist otolaryngology residents, faculty new to the grant process, as well as experienced researchers striving to improve their grant review scores.

Smoking Cessation and Electronic Cigarette Use among Head and Neck Cancer Patients

OBJECTIVES

(1) Investigate electronic cigarette (e-cig) use among head and neck (HN) cancer patients; (2) define quit methods, success, motivations, and barriers to smoking cessation; and (3) determine the impact of e-cig use in smoking cessation.

STUDY DESIGN

Cross-sectional study.

SETTING

Tertiary care center.

METHODS

An in-office survey was administered to HN cancer patients ≥ 19 years of age with past/present tobacco use. Patient demographics were collected. Quit methods, success, and motivations/barriers were surveyed. The Alcohol Use Disorders Identification Test was used to correlate alcohol use and cessation. Independent variables associated with cessation were studied with Fisher's exact test and Student's t test. Subgroup analysis was performed for e-cig users.

RESULTS

Of 110 eligible patients, 106 (96%) enrolled (83% male, 82% Caucasian), of whom 69 (65%) successfully quit. Age of first tobacco use did not differ between the smoking and cessation groups (P = .14), nor did hazardous drinking (30% smoking vs 14% cessation; P = .072). "Cold turkey" (ie, stopping abruptly without smoking cessation aids) was the most common method attempted (n = 88, 83%) and most successful (n = 65, 94%). There was no statistical difference in age, sex, race, drinking, or socioeconomic status between e-cig users and nonusers. Nonusers achieved higher quit rates as compared with e-cig users (72% vs 39%; P = .0057). E-cig use did not decrease the number of cigarettes smoked (463 cigarettes/month) versus that of nonusers (341 cigarettes/month; P = .2). Seventy percent of e-cig users wore a nicotine patch.

CONCLUSIONS

HN cancer patients desire smoking cessation. E-cig did not decrease tobacco use, and patients who utilize e-cigs are less likely to achieve smoking cessation.

On the horizon: Optical imaging for cutaneous squamous cell carcinoma

BACKGROUND

Surgical resection with negative margins remains the standard of care for high-risk cutaneous squamous cell carcinoma (SCC). However, surgical management is often limited by poor intraoperative tumor visualization and inability to detect occult nodal metastasis. The inability to intraoperatively detect microscopic disease can lead to additional surgery, tumor recurrence, and decreased survival.

METHODS

A comprehensive literature review was conducted to identify studies incorporating optical imaging technology in the management of cutaneous SCC (January 1, 2000-December 1, 2014).

RESULTS

Several innovative optical imaging techniques, Raman spectroscopy, confocal microscopy, and fluorescence imaging, have been developed for intraoperative surgical guidance. Fifty-seven studies review the ability of these techniques to improve cutaneous SCC localization at the gross and microscopic level.

CONCLUSION

Significant advances have been achieved with real-time optical imaging strategies for intraoperative cutaneous SCC margin assessment and tumor detection. Optical imaging holds promise in improving the percentage of negative surgical margins and in the early detection of micrometastatic disease. © 2015 Wiley Periodicals, Inc. Head Neck 38: E2204-E2213, 2016.

A ratiometric threshold for determining presence of cancer during fluorescence-guided surgery

BACKGROUND AND OBJECTIVE

Fluorescence-guided imaging to assist in identification of malignant margins has the potential to dramatically improve oncologic surgery. However, a standardized method for quantitative assessment of disease-specific fluorescence has not been investigated. Introduced here is a ratiometric threshold derived from mean fluorescent tissue intensity that can be used to semi-quantitatively delineate tumor from normal tissue.

METHODS

Open-field and a closed-field imaging devices were used to quantify fluorescence in punch biopsy tissues sampled from primary tumors collected during a phase 1 trial evaluating the safety of cetuximab-IRDye800 in patients (n = 11) undergoing surgical intervention for head and neck cancer. Fluorescence ratios were calculated using mean fluorescence intensity (MFI) from punch biopsy normalized by MFI of patient-matched tissues. Ratios were compared to pathological assessment and a ratiometric threshold was established to predict presence of cancer.

RESULTS

During open-field imaging using an intraoperative device, the threshold for muscle normalized tumor fluorescence was found to be 2.7, which produced a sensitivity of 90.5% and specificity of 78.6% for delineating disease tissue. The skin-normalized threshold generated greater sensitivity (92.9%) and specificity (81.0%).

CONCLUSION

Successful implementation of a semi-quantitative threshold can provide a scientific methodology for delineating disease from normal tissue during fluorescence-guided resection of cancer.

Optimal Management of Proliferative Verrucous Leukoplakia

Objective

Proliferative verrucous leukoplakia (PVL) is a rare and recalcitrant form of leukoplakia. The purpose of this review is to further characterize the risk factors, clinical course, and optimal treatment for this highly aggressive, premalignant lesion.

Data Sources

Twenty-six articles on PVL with a total of 329 PVL cases.

Review Methods

A systematic review of the literature using Ovid, PubMed, Cochrane Database, and gray literature was conducted of all PVL cases reported between 1985 and 2014. Inclusion criteria required reporting of patient follow-up and recurrence rates. Data were analyzed using descriptive statistics. Student t test and Fisher exact test were used to identify factors associated with malignant transformation.

Results

The mean patient age was 63.9 years. Most patients were female (66.9%) and nontobacco users (65.22%). Mean follow-up was 7.4 years, with an average of 9.0 biopsies per patient during this period. Proliferative verrucous leukoplakia exhibited histopathologic features along a progressive spectrum, evolving from leukoplakia to verrucous hyperplasia and ultimately invasive carcinoma. Surgery was the most common treatment implemented, but recurrence rates among 222 patients reached 71.2%. Subgroup analysis of 277 patients identified a 63.9% malignant transformation rate, and 39.6% of patients died of their disease. Age, sex, and tobacco use were not identified as risk factors associated with progression to cancer.

Conclusions

Proliferative verrucous leukoplakia is a rare form of leukoplakia with a high rate of malignant transformation. It necessitates high clinical suspicion, to include a lifetime of close follow-up and repeat biopsies by a health care provider well versed in oral carcinoma.

Safety and Tumor Specificity of Cetuximab-IRDye800 for Surgical Navigation in Head and Neck Cancer

PURPOSE

Positive margins dominate clinical outcomes after surgical resections in most solid cancer types, including head and neck squamous cell carcinoma. Unfortunately, surgeons remove cancer in the same manner they have for a century with complete dependence on subjective tissue changes to identify cancer in the operating room. To effect change, we hypothesize that EGFR can be targeted for safe and specific real-time localization of cancer.

EXPERIMENTAL DESIGN

A dose escalation study of cetuximab conjugated to IRDye800 was performed in patients (n = 12) undergoing surgical resection of squamous cell carcinoma arising in the head and neck. Safety and pharmacokinetic data were obtained out to 30 days after infusion. Multi-instrument fluorescence imaging was performed in the operating room and in surgical pathology.

RESULTS

There were no grade 2 or higher adverse events attributable to cetuximab-IRDye800. Fluorescence imaging with an intraoperative, wide-field device successfully differentiated tumor from normal tissue during resection with an average tumor-to-background ratio of 5.2 in the highest dose range. Optical imaging identified opportunity for more precise identification of tumor during the surgical procedure and during the pathologic analysis of tissues ex vivo. Fluorescence levels positively correlated with EGFR levels.

CONCLUSIONS

We demonstrate for the first time that commercially available antibodies can be fluorescently labeled and safely administered to humans to identify cancer with sub-millimeter resolution, which has the potential to improve outcomes in clinical oncology.

Multimodality management of high-risk head and neck basal cell carcinoma requiring free-flap reconstruction

OBJECTIVES

(1) Investigate overall survival (OS) and disease-free survival (DFS) for high-risk head and neck basal cell carcinoma (HNBCC) requiring large extirpation with free-flap reconstruction. (2) Determine impact of prognostic features-tumor size, subsite, number of high-risk features, perineural invasion, and bony invasion-on high-risk HNBCC survival. (3) Determine survival benefit of adjuvant radiation for high-risk HNBCC.

STUDY DESIGN

Case series with chart review (2002-2013).

SETTING

Academic tertiary care center.

SUBJECTS AND METHODS

Consecutive head and neck patients (N = 431) required free-flap reconstruction following tumor extirpation, 38 for aggressive HNBCC. All cases were high risk. DFS and OS were examined using Kaplan-Meier analysis. Prognostic variables and adjuvant radiation were analyzed utilizing Student's t test for continuous variables and Fisher's exact testing for categorical dependent variables. Complications were reported.

RESULTS

Mean tumor diameter was 5.17 cm (range, 1.2-15.0 cm). Mean follow-up was 19.9 months. Overall 2-year survival was 80%, falling to 66% at 5 years. Two-year disease-free survival was 72%. Six patients recurred (n = 5 local, 1 distant). Adjuvant radiotherapy improved DFS (P < .01) but not OS (P = .66). Tumors >2.5 cm did not affect OS (P = .61), regardless of subsite. Bone involvement (44.7% cases) did not affect DFS (P = .39) or OS (P = .18).

CONCLUSIONS

Larger HNBCC warranting free tissue transfer do not confer worse outcomes, independent of subsite. Adjuvant radiotherapy does not improve OS but significantly affected DFS, allowing for 13.7 additional months of DFS. Bone involvement does not influence DFS or OS and should not preclude surgery, even in advanced cases requiring free-flap reconstruction.

Multimodality Management of High-Risk Head and Neck Basal Cell Carcinoma Requiring Free Flap Reconstruction

Objectives:

(1) Determine the impact of adjuvant radiotherapy on high-risk head and neck basal cell carcinoma (H&N BCC). (2) Analyze risk factors associated with recurrence and survival.

Methods:

Case series with planned chart review (2002-2013) in an academic tertiary care center. A total of 431 consecutive patients presented with H&N defects requiring free flap reconstruction, 38 specifically for aggressive BCC. Cases were classified as high risk based on National Comprehensive Cancer Network (NCCN) criteria. Overall and disease-free survival were examined using Kaplan-Meier analysis. Independent variables included: site, recurrent tumor, radiation, bony involvement, and perineural invasion. Complications were reported.

Results:

Nineteen (50%) lesions were recurrent. Mean tumor diameter was 5.17 cm (1.2-15.0cm). Mean follow-up was 19.9 months. Overall 2-year survival was 80%, falling to 66% at 5 years. Two-year disease-free survival was 72%. Six patients recurred (5 local; 1 distant). Adjuvant radiotherapy was utilized in 17 (44.7%) and did not significantly impact recurrence ( P = .15) or survival ( P = .48). Tumors >2.5 cm did not impact survival ( P = .09), regardless of subsite. Bony involvement was identified in 17 (44.7%) cases, but did not correlate with survival ( P = .18). Complication rates: 4 exposed bone, 4 hematoma/seroma, 3 infection, 2 osteoradionecrosis, 2 donor site evisceration, 2 ear canal stenosis, 1 severe trismus, 1 flap arterial insufficiency, 1 nasal obstruction.

Conclusions:

Larger H&N BCC do not confer worse outcomes, independent of subsite. Adjuvant radiotherapy does not improve survival or recurrence. Bony involvement does not correlate with survival and should not preclude surgical intervention, even in advanced cases.

The Pearls and Pitfalls of Grant Writing: Maximizing Your Funding

Program Description:

Seeking an edge in the competitive grant world? This interactive miniseminar will provide a comprehensive review of key elements to a fundable grant. Practical tips on scientific writing, building a productive research team, and maximizing resources will be provided. An overview of basic statistics will help to maximize collaborative efforts with your statistician. Gain insight into the scoring process from an experienced National Institutes of Health reviewer who will highlight common pitfalls. Current 2014 funding mechanisms will also be provided. Residents and faculty new to the grant process, as well as researchers striving to improve their score, will benefit from this course.

Educational Objectives:

(1) Explain key components of a grant to include hypothesis, specific aims, timeline, statistics, budget, and institutional review board. (2) Describe the scoring mechanism, review process, and common pitfalls leading to an unfundable grant. (3) Recognize current grant mechanisms and funding opportunities, with emphasis of American Academy of Otolaryngology—Head and Neck Surgery Foundation CORE grants, K-awards, and R-01 funding.

Is sentinel lymph node biopsy the standard of care for cutaneous head and neck melanoma?

OBJECTIVES/HYPOTHESIS

Sentinel lymph node biopsy (SLNB) is considered one of the most important melanoma advancements to date. Since its inception in 1992, a plethora of data and associated controversies has emerged leading to the question: Is SLNB considered the standard of care for head and neck (HN) cutaneous melanoma?

STUDY DESIGN

English literature (1990-2014) review.

METHODS

The PubMed database search was conducted using key terms "melanoma" and "sentinel node." This review included both dedicated HN SLNB studies and larger prospective SLNB studies, in which HN patients were included among the cohort. Bibliography cross-referencing was conducted to ensure a comprehensive search.

RESULTS

SLNB is safe and accurate in the HN region. Review of large prospective SLNB trials identified the pathologic status of the SLN as the most important prognostic factor for recurrence and survival. Early lymphadenectomy following a positive SLNB imparts a survival benefit.

CONCLUSIONS

Our review of the current literature suggests that SLNB is the standard of care for selected cases of HN cutaneous melanoma. It is now incorporated into the American Joint Committee on Cancer staging system, the National Comprehensive Cancer Network practice guidelines, and numerous national and international consensus statements.

Utility of head and neck cutaneous squamous cell carcinoma sentinel node biopsy: a systematic review

OBJECTIVE

Sentinel lymph node biopsy (SLNB) is standard of care for melanoma, but its role in cutaneous squamous cell carcinoma (cSCC) has not been established. Study objectives include: (1) analyze the feasibility and reliability SLNB for head and neck (H&N) cSCC and (2) identify risk factors associated with a positive SLN.

DATA SOURCES

MEDLINE, PubMed, Cochrane, and ASCO databases searches conducted (1946-2013).

REVIEW METHODS

Using the PRISM model, a comprehensive systematic review of H&N cSCC SLNB studies with associated recurrence rates was conducted. Dual-blinded data extraction identify primary outcomes (successful SLN harvest and false omission rate) and secondary outcomes (risk factors associated with a +SLN).

RESULTS

Two hundred twenty-one articles were screened; 73 patients from 11 publications met inclusion criteria (3 case series; 8 prospective cohorts). Studies ranged from 1 to 15 patients (median 5). Median age was 74 years. Median follow-up was 21.5 months. Average tumor size was 3.09 cm. At least 1 SLN was identified in 100% of patients (median 2). Ten (13.5%) had a positive SLN; no additional metastatic nodes were identified in 9 patients receiving completion lymphadenectomy. Tumor diameter was not associated with SLN status (P = .09; 95% CI, -.27 to 3.02). Risk factors (tumor depth, perineural invasion, location, differentiation) were not consistently recorded. Three of 63 (4.76%) failed regionally following a negative SLNB.

CONCLUSION

H&N cSCC SLNB is feasible and reliable for staging, with a false omission rate of 4.7% mirroring melanoma. Prospective studies documenting high risk features are required to further define its role.

Intraoperative relationship of the spinal accessory nerve to the internal jugular vein: variation from cadaver studies

PURPOSE

Conflicting locations of the spinal accessory nerve (SAN) with respect to the internal jugular vein (IJV) are reported in the literature and anatomy texts. The objective of this study is to analyze this anatomic relationship specifically at the level of the posterior belly of the digastric muscle where it is encountered most often during surgery.

MATERIAL AND METHODS

This study is a case series with planned chart review of all operative reports for neck dissections/explorations performed between June 2002 to June 2008 at an academic tertiary care referral center. Inclusion criteria required intraoperative identification of the SAN at the level of the posterior belly of the digastric muscle. Patients undergoing revision neck dissection were excluded. Data is presented using descriptive statistics.

RESULTS

One hundred ninety-seven patients were identified; 175 met inclusion criteria. Thirty-two patients received bilateral neck dissections/explorations, resulting in a total of 207 SANs for analysis. The most common location of the SAN was lateral to the IJV (198; 95%). In 6 (2.8%) cases the SAN was identified medial to the IJV and 2 nerves pierced the IJV. A new variant of the SAN splitting around the SAN was identified.

CONCLUSION

The majority of SANs course lateral to the IJV at the level of the posterior belly of the digastrics muscle (95%). This intraoperative finding differs from cadaveric studies. Discrepancies may reflect variation in the level at which the nerve was identified, as well as tissue changes related to cadaver versus in vivo studies.

Grant Writing Pearls and Pitfalls: Maximizing Your Funding

Program Description:

Seeking an edge in the competitive grant world? This interactive miniseminar will provide a comprehensive review of key elements to a fundable grant. Practical tips on scientific writing, building a productive research team, and maximizing resources will be provided. An overview of basic statistics will help to maximize collaborative efforts with your statistician. Gain insight into the scoring process from an experienced National Institutes of Health reviewer who will highlight common pitfalls. Current 2013 funding mechanisms will also be provided. Residents and faculty new to the grant process, as well as researchers striving to improve their score, will benefit from this course.

Educational Objectives:

1) Describe key components of a grant to include hypothesis, specific aims, timeline, statistics, budget, and institutional review board. 2) Comprehend the scoring mechanism, review process, and common pitfalls leading to an unfundable grant. 3) Research current grant mechanisms and funding opportunities.