Effect of distance of treatment center on survival for HPV-negative head and neck cancer patients

BACKGROUND

In rural states, travel burden for complex cancer care required for head and neck squamous cell carcinoma (HNSCC) may affect patient survival, but its impact is unknown.

METHODS

Patients with HPV-negative HNSCC were retrospectively identified from a statewide, population-based study. Euclidian distance from the home address to the treatment center was calculated for radiation therapy, surgery, and chemotherapy. Multivariable Cox proportional hazards models were used to examine the risk of 5-year mortality with increasing travel quartiles.

RESULTS

There were 936 patients with HPV-negative HNSCC with a mean age of 60. Patients traveled a median distance of 10.2, 11.1, and 10.9 miles to receive radiation therapy, surgery, and chemotherapy, respectively. Patients in the fourth distance quartile were more likely to live in a rural location (p < 0.001) and receive treatment at an academic hospital (p < 0.001). Adjusted overall survival (OS) improved proportionally to distance traveled, with improved OS remaining significant for patients who traveled the furthest for care (third and fourth quartile by distance). Relative to patients in the first quartile, patients in the fourth had a reduced risk of mortality with radiation (HR 0.59, 95% CI 0.42-0.83; p = 0.002), surgery (HR 0.47, 95% CI 0.30-0.75; p = 0.001), and chemotherapy (HR 0.56, 95% CI 0.35-0.91; p = 0.020).

CONCLUSION

For patients in this population-based cohort, those traveling greater distances for treatment of HPV-negative HNSCC had improved OS. This analysis suggests that the benefits of coordinated, multidisciplinary care may outweigh the barriers of travel burden for these patients.

Comparative Outcomes by Surgical Approach in Patients with Malignant Sinonasal Disease

Objective There is a paucity of data on comparative outcomes for open versus endoscopic surgery for patients with malignant sinonasal pathology. Most of the available studies are limited by a sample size <100 patients.

Design This is a retrospective cohort study.

Setting The findings of this study come from a single-institution tertiary care center from 2008 to 2019.

Participants In total, 199 patients who underwent surgery for malignant sinonasal disease participated in this study.

Main Outcome Measures The main outcome measures were perioperative complications and reoperation.

Results Patients in our sample had a mean age of 59.7 years (SD, 20.4). In total, 62% were male and 72% were white. An endoscopic-only approach was used in 41% of patients and an open or combined approach in 59% of patients. Squamous cell carcinoma was the most common pathology (43.0%), followed by sarcoma (9.5%), skin cancer (6.5%), sinonasal undifferentiated carcinoma (6.5%), and adenocarcinoma (5.5%). The all-cause complication rate was 14.6%. Patients with an open resection had a higher rate of intraoperative complications (5.9 vs. 0%; p = 0.043), postoperative complications (19.5 vs. 3.7%; p = 0.001), and all-cause complications (21.0 vs. 3.7%; p < 0.001). The likelihood of early reoperation (<6 months) or late reoperation (>6 months) did not significantly differ by surgical approach (p = 1.000 and 0.741, respectively).

Conclusion The endoscopic approach for resection of malignant sinonasal disease is viable for select patients and may be associated with a favorable complication rate compared with the open approach.

Socioeconomic status, access to care, risk factor patterns, and stage at diagnosis for head and neck cancer among black and white patients

BACKGROUND

Little is known about how factors combine to influence progression of squamous cell carcinoma of the head and neck (HNSCC). We aimed to evaluate multidimensional influences of factors associated with HNSCC stage by race.

METHODS

Using retrospective data, patients with similar socioeconomic status (SES), access to care (travel time/distance), and behavioral risk factors (tobacco/alcohol use and dental care) were grouped by latent class analysis. Relative frequency differences (RFD) were calculated to evaluate latent classes by stage, race, and p16 status.

RESULTS

We identified three latent classes. Advanced T-stage was higher for black (RFD = +20.2%; 95% CI: -4.6 to 44.9) than white patients (RFD = +10.7%; 95% CI: 2.1-19.3) in the low-SES/high-access/high-behavioral risk class and higher for both black (RFD = +29.6%; 95% CI: 4.7-54.5) and white patients (RFD = +23.9%; 95% CI: 15.2-32.6) in the low-SES/low-access/high-behavioral risk class.

CONCLUSION

Results suggest that SES, access to care, and behavioral risk factors combine to underly the association with advanced T-stage. Additionally, differences by race warrant further investigation.

Sinonasal Squamous Cell Carcinoma Survival Outcomes Following Induction Chemotherapy vs Standard of Care Therapy

Objective

To compare oncologic outcomes in sinonasal squamous cell carcinoma (SNSCC) treated with standard of care (SOC) definitive therapy, consisting of surgery or chemoradiotherapy, vs induction therapy followed by definitive therapy.

Study Design

Retrospective review.

Setting

Academic tertiary care hospital.

Methods

The medical records of patients with biopsy-proven SNSCC treated between 2000 and 2020 were reviewed for demographics, tumor characteristics, staging, treatment details, and oncologic outcomes. Patients were matched 1-to-1 by age, sex, and cancer stage according to treatment received. Time-to-event analyses were conducted.

Results

The analysis included 26 patients with locally advanced SNSCC who received either induction therapy (n = 13) or SOC (n = 13). Baseline demographics, Charlson Comorbidity Index, and median follow-up time were well balanced. Weekly cetuximab, carboplatin, and paclitaxel were the most common induction regimen utilized. Tolerance and safety to induction were excellent. Objective responses were observed in 11 of 13 patients receiving induction. No difference in disease-free survival was found between the induction and SOC groups at 1 or 3 years. However, when compared with SOC, induction therapy resulted in significant improvement in overall survival at 2 years (100% vs 65.3%, P = .043) and 3 years (100% vs 48.4%, P = .016) following completion of definitive therapy. Two patients in the SOC group developed metastatic disease, as compared with none in the induction group.

Conclusions

Induction therapy was safe and effective. When compared with SOC, induction therapy improved 3-year overall survival.

Outcomes in Pediatric Endoscopic Skull Base Surgery: A Systematic Review

Objectives  The frequency of endoscopic skull base surgery in pediatric patients is increasing. This study aims to systematically review the literature for endoscopic skull base surgery outcomes in children/adolescents aged 0 to 18 years. Design  A systematic review of the literature was performed in PubMed and SCOPUS databases querying studies from 2000 to 2020 using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Final inclusion criteria included: case series with more than 10 patients with pediatric patients aged ≤18 years, endoscopic or endoscopic-assisted skull base surgery, and outcomes reported. Setting  This study was conducted at a tertiary care medical center. Participants  Children/adolescents aged 0 to 18 years who underwent endoscopic skull base surgery were participated in this study. Main Outcome Measures  Patient demographics, pathology, reconstructive technique, intraoperative findings, intraoperative, and postoperative surgical complications were measured through this study. Results  Systematic literature search yielded 287 publications. Of these, 12 studies discussing a total of 399 patients aged 0 to 18 years met inclusion criteria for final analysis. Seven of the 12 studies discussed a single pathology. The most common pathology was a skull base defect causing cerebrospinal fluid (CSF) leak. The majority of skull base repairs were made with free tissue grafts. The most common postoperative complication was CSF leak ( n  = 40). Twelve cases of meningitis occurred postoperatively with two of these episodes resulting in death. Conclusion  Endoscopic skull base surgery has been performed recently in the pediatric population in a variety of disease states. Inconsistent individual-level data and reporting standards are present in existing studies posing challenges for comparative analysis. Standardized reporting will aid future reviews and meta-analysis for rare skull base pathology.

Evaluation of Patient-Reported Delays and Affordability-Related Barriers to Care in Head and Neck Cancer

Objective

To examine the prevalence and predictors of patient-reported barriers to care among survivors of head and neck squamous cell carcinoma and the association with health-related quality of life (HRQOL) outcomes.

Study Design

Retrospective cohort study.

Setting

Outpatient oncology clinic at an academic tertiary care center.

Methods

Data were obtained from the UNC Health Registry/Cancer Survivorship Cohort. Barriers to care included self-reported delays in care and inability to obtain needed care due to cost. HRQOL was measured with validated questionnaires: general (PROMIS) and cancer specific (FACT-GP).

Results

The sample included 202 patients with head and neck squamous cell carcinoma with a mean age of 59.6 years (SD, 10.0). Eighty-two percent were male and 87% were White. Sixty-two patients (31%) reported at least 1 barrier to care. Significant predictors of a barrier to care in unadjusted analysis included age ≤60 years ( P = .007), female sex ( P = .020), being unmarried ( P = .016), being uninsured ( P = .047), and Medicaid insurance ( P = .022). Patients reporting barriers to care had significantly worse physical and mental HRQOL on the PROMIS questionnaires ( P < .001 and P = .002, respectively) and lower cancer-specific HRQOL on the FACT-GP questionnaire ( P < .001), which persisted across physical, social, emotional, and functional domains. There was no difference in 5-year OS (75.3% vs 84.1%, P = .177) or 5-year CSS (81.6% vs 85.4%, P = .542) in patients with and without barriers to care.

Conclusion

Delay- and affordability-related barriers are common among survivors of head and neck cancer and appear to be associated with significantly worse HRQOL outcomes. Certain sociodemographic groups appear to be more at risk of patient-reported barriers to care.

Association of self-reported financial burden with quality of life and oncologic outcomes in head and neck cancer

BACKGROUND

There is a paucity of data on financial toxicity among patients with head and neck squamous cell carcinoma (HNSCC).

MATERIALS

This was a retrospective, cross-sectional study of patients with HNSCC surveyed at an outpatient oncology clinic.

RESULTS

The sample included 202 patients with HNSCC with a mean age of 59.6 years (SD 10.0). There were 53 patients (26%) with self-reported financial burden. Education of high school or less was a significant predictor of self-reported financial burden (OR 2.52, 95% CI 1.03-6.14, p = 0.042). Patients reporting financial burden had significantly worse physical (p = 0.003), mental (p = 0.003), and functional (p = 0.036) health-related quality of life (HRQOL). Patients reporting financial burden appeared to have lower 5-year overall survival (74.3% vs. 83.9%, p = 0.165), but this association did not reach statistical significance.

CONCLUSION

Financial burden or toxicity may affect approximately a quarter of patients with HNSCC and appears to be associated with worse HRQOL outcomes.

Postoperative Pain Management and Perceived Patient Outcomes following Endoscopic Pituitary Surgery

Objectives Pain management remains a point of emphasis given the ongoing opioid crisis. There are no studies in the literature interrogating opioid prescribing and use following endoscopic pituitary surgery. This study investigates provider prescribing tendency, patient utilization of analgesics, and patient outcomes regarding pain management after endoscopic pituitary surgery.

Methods We identified 100 patients undergoing endoscopic pituitary surgery at one institution from 2016 to 2018 in the electronic medical record (EMR) and state narcotic database to determine postoperative analgesic regimens. A telephone survey was used to characterize postoperative analgesic use and satisfaction with prescribed regimen.

Results Fifty-two different pain control regimens were prescribed to the study patients. Also, 93% of study patients were prescribed an opioid postoperatively. The average quantity of opioids prescribed per patient in morphine milligram equivalents (MMEs) was 625 (equivalent 83 oxycodone 5-mg tablets) with an average MME/day of 59 (equivalent 8 oxycodone 5-mg tablets). A total of 71% survey respondents who used opioids reported using <25% of their prescription. The majority of prescription narcotic users consumed >50% of their postoperative opioid intake in the first 24 to 48 hours after discharge. There were no significant differences in pain outcome between opioid users and nonopioid users.

Conclusion Vast heterogeneity exists in narcotic prescribing by providers at our institution following endoscopic pituitary surgery. Narcotic prescribing patterns exceeded most patients' analgesic needs. Opioid analgesics were not superior to nonopioids regimens in patient-reported pain outcomes in this study population.

Heterogeneity in Outcome Reporting in Endoscopic Endonasal Skull Base Reconstruction: A Systematic Review

Objective  Presently, there are no standards for reporting outcomes of endoscopic endonasal skull base reconstruction (ESBR). This is problematic as a lack of consistent reporting makes synthesizing findings in systematic reviews and meta-analysis challenging. Thus, the aim of this study was to systematically review and describe the patterns of reporting outcomes in ESBR as a foundation for developing reporting guidelines. Study Design  Present study is a systematic review. Methods  Embase, PubMed, CINAHL, Cochrane Library, and Web of Science were searched for all publications with ≥25 patients and a focus on ESBR. The reporting patterns of each study's variables and outcomes were assessed. Results  A total of 112 studies were included in the review. The most commonly reported demographic variables were the number of included patients ( n  = 112, 100%) and types of pathologies treated ( n  = 104, 92.9%). Meanwhile, the most routinely described preoperative variable was history of prior treatment ( n  = 48, 42.9%). Type of reconstruction was a commonly reported intraoperative variable ( n  = 110, 98.2%), though the rate of intraoperative cerebrospinal fluid (CSF) leak was noted in only 76 studies (67.9%). With regard to postoperative outcomes, postoperative CSF leak rate was routinely provided ( n  = 101, 90.2%), but reporting of other surgical complications was more inconsistent. Ultimately, of the 43 variables and outcomes reviewed, a median of 12 (range: 4-22) was reported in each study. Conclusion  There is significant heterogeneity in the outcomes reported in studies relating to ESBR. This highlights the need for the development of standard reporting guidelines to minimize bias and improve interstudy comparability.

COVID-19 related olfactory dysfunction prevalence and natural history in ambulatory patients

Background

Evidence regarding prevalence of COVID-19 related Olfactory dysfunction (OD) among ambulatory patients is highly variable due to heterogeneity in study population and measurement methods. Relatively few studies have longitudinally investigated OD in ambulatory patients with objective methods.

Methods

We performed a longitudinal study to investigate OD among COVID-19 ambulatory patients compared to symptomatic controls who test negative. Out of 81 patients enrolled, 45 COVID-19 positive patients and an age- and sex-matched symptomatic control group completed the BSIT and a questionnaire about smell, taste and nasal symptoms. These were repeated at 1 month for all COVID-19 positive patients, and again at 3 months for those who exhibited persistent OD. Analysis was performed by mixed-effects linear and logistic regression.

Results

46.7% of COVID-19 patients compared to 3.8% of symptomatic controls exhibited OD at 1-week post diagnosis (p<0.001). At 1 month, 16.7%, (6 of 36), of COVID-19 patients had persistent OD. Mean improvement in BSIT score in COVID-19 patients between 1-week BSIT and 1 month follow-up was 2.0 (95% CI 1.00 - 3.00, p<0.001). OD did not correlate with nasal congestion (r= -0.25, 95% CI, -0.52 to 0.06, p=0.12).

Conclusions

Ambulatory COVID-19 patients exhibited OD significantly more frequently than symptomatic controls. Most patients regained normal olfaction by 1 month. The BSIT is a simple validated and objective test to investigate the prevalence of OD in ambulatory patients. OD did not correlate with nasal congestion which suggests a congestion-independent mechanism of OD.

A case of metastatic NUT carcinoma with prolonged response on gemcitabine and nab-paclitaxel

BACKGROUND

NUT carcinoma is an aggressive malignancy characterized by translocations in the NUTM1 gene. There are currently no consensus treatment recommendations for NUT carcinomas.

METHODS

Here, we describe the case of a previously healthy male diagnosed with NUT carcinoma after presenting with sinus pressure, found to have a sinonasal mass and distant metastatic disease in the lungs. While pathologic evaluation and immunohistochemistry were consistent with NUT carcinoma, initial genomic profiling did not demonstrate a NUTM1 translocation.

RESULTS

Whole transcriptomic RNA sequencing of the tumor revealed a YAP1-NUTM1 fusion. Based on an in vitro drug sensitivity screen, the patient was treated with gemcitabine and nab-paclitaxel, achieving a partial response that persisted for 9 months.

CONCLUSIONS

Unbiased transcriptomic sequencing may identify previously uncharacterized NUTM1 fusion partners. Gemcitabine and nab-paclitaxel is a well-tolerated combination chemotherapy regimen and could offer a novel treatment approach for NUT carcinoma.

Prognostic impact of socioeconomic status compared to overall stage for HPV-negative head and neck squamous cell carcinoma

OBJECTIVE

To estimate the relative prognostic ability of socioeconomic status (SES) compared to overall stage for HPV-negative head and neck squamous cell carcinoma (HNSCC) MATERIALS AND METHODS: Data were obtained from the Carolina Head and Neck Cancer Epidemiology Study (CHANCE). An empirical 4-category SES classification system was created. Cox proportional hazards models, survival gradients, Bayesian information criterion (BIC), and Harrell's C index were used to estimate the prognostic ability of SES compared to stage on overall survival (OS).

RESULTS

The sample consisted of 1229 patients with HPV-negative HNSCC. Patients with low SES had significantly increased risk of mortality at 5 years compared to patients with high SES (HR 3.11, 95% CI 2.07-4.67; p < 0.001), and the magnitude of effect was similar to overall stage (HR 3.01, 95% CI 2.35-3.86; p < 0.001 for stage IV versus I). Compared to overall stage, the SES classification system had a larger total survival gradient (35.8% vs. 29.1%), similar model fit (BIC statistic of 7412 and 7388, respectively), and similar model discriminatory ability (Harrell's C index of 0.61 and 0.64, respectively). The association between low SES and OS persisted after adjusting for age, sex, race, alcohol, smoking, overall stage, tumor site, and treatment in a multivariable model (HR 2.96, 95% CI 1.92-4.56; p < 0.001).

CONCLUSION

SES may have a similar prognostic ability to overall stage for patients with HPV-negative HNSCC. Future research is warranted to validate these findings and identify evidence-based interventions for addressing barriers to care for patients with HNSCC.

HPV in the malignant transformation of sinonasal inverted papillomas: A meta-analysis

OBJECTIVES

To date, there is still a significant debate on the role of human papilloma virus (HPV) infection in transformation of inverted papillomas (IPs) to squamous cell carcinoma (SCC). This study was designed to determine if the presence of HPV in a sinonasal IP increases the risk of malignant transformation to IPSCC.

METHODS

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, 19 high-quality case-control and cohort studies with tissue-diagnosed IP or IPSCC and HPV diagnosis were analyzed. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using the Mantel-Haenszel method with correction for random effects. Subgroup, publication bias and a sensitivity analyses were also performed.

RESULTS

Nineteen studies with minimal bias met the inclusion criteria for quality and identified HPV infection in an IP. The pooled data revealed a strong association with progression to malignancy with an unweighted, pooled OR of 2.38 (CI₉₅ 1.47 to 3.83) and a weighted OR of 2.80 (CI₉₅ 1.42 to 5.51). Sensitivity analysis revealed that no single study contributed significantly to our pooled OR calculations (ORs 2.52 to 3.57). Subgroup analyses stratified by publication date, nucleic acid target, HPV detection method and type, sample size, and region all demonstrated a positive association of HPV with IPSCC.

CONCLUSIONS

There appears to be a significant association between HPV infection and malignant transformation of IPs. While HPV testing is not currently the standard of care for IPs, these data suggest a link between the two and suggest further studies should be performed to identify a link between the virus and malignant transformation.

Quantification of Aerosol Concentrations During Endonasal Instrumentation in the Clinic Setting

OBJECTIVE

Recent anecdotal reports and cadaveric simulations have described aerosol generation during endonasal instrumentation, highlighting a possible risk for transmission of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) during endoscopic endonasal instrumentation. This study aims to provide a greater understanding of particle generation and exposure risk during endoscopic endonasal instrumentation.

STUDY DESIGN

Prospective quantification of aerosol generation during office-based nasal endoscopy procedures.

METHODS

Using an optical particle sizer, airborne particles concentrations 0.3 to 10 microns in diameter, were measured during 30 nasal endoscopies in the clinic setting. Measurements were taken at time points throughout diagnostic and debridement endoscopies and compared to preprocedure and empty room particle concentrations.

RESULTS

No significant change in airborne particle concentrations was measured during diagnostic nasal endoscopies in patients without the need for debridement. However, significant increases in mean particle concentration compared to preprocedure levels were measured during cold instrumentation at 2,462 particles/foot3 (95% CI 837 to 4,088; P = .005) and during suction use at 2,973 particle/foot3 (95% CI 1,419 to 4,529; P = .001). In total, 99.2% of all measured particles were ≤1 μm in diameter.

CONCLUSION

When measured with an optical particle sizer, diagnostic nasal endoscopy with a rigid endoscope is not associated with increased particle aerosolization in patient for whom sinonasal debridement is not needed. In patients needing sinonasal debridement, endonasal cold and suction instrumentation were associated with increased particle aerosolization, with a trend observed during endoscope use prior to tissue manipulation. Endonasal debridement may potentially pose a higher risk for aerosolization and SARS-CoV-2 transmission. Appropriate personal protective equipment use and patient screening are recommended for all office-based endonasal procedures.

LEVEL OF EVIDENCE

3 Laryngoscope, 131:E1415-E1421, 2021.

Subcutaneous Versus Sublingual Immunotherapy for Adults with Allergic Rhinitis: A Systematic Review with Meta-Analyses

OBJECTIVES

To determine whether subcutaneous immunotherapy (SCIT) or sublingual immunotherapy (SLIT) better improves patient outcomes and quality of life for adults with allergic rhinitis or rhinoconjunctivitis (AR/C) with or without mild to moderate asthma.

METHODS

Systematic review methodology was based on the Cochrane Collaboration handbook and Preferred Reporting Items for Systematic Reviews and Meta-analyses. Four databases (PubMed, Cochrane Library, EMBASE, and Web of Science) were queried from inception to July 30, 2020. Two independent reviewers screened potentially relevant studies and assessed risk of bias. Outcomes of interest were symptom score (SS), medication score (MS), combined symptom medication score (CSMS), and Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ). Meta-analyses with an adjusted indirect comparison were conducted in RevMan 5.4.1.

RESULTS

Seven SCIT versus SLIT randomized controlled trials (RCTs) demonstrated no significant differences for any outcomes, but insufficient data precluded direct meta-analysis. For the adjusted indirect comparison, 46 RCTs over 39 studies were included for SCIT versus placebo (n = 13) and SLIT versus placebo (n = 33). Statistically significant results favoring SCIT were found for SS (standardized mean difference [SMD] = 0.40; 95% confidence interval [CI] = 0.31-0.49), MS (SMD = 0.26; 95% CI = 0.14-0.39), CSMS (SMD = 0.42; 95% CI = 0.17-0.67), and RQLQ (MD = 0.24; 95% CI = 0.04-0.44). Statistically significant results favoring SLIT were found for SS (SMD = 0.42; 95% CI = 0.32-0.53), MS (SMD = 0.40; 95% CI = 0.28-0.53), CSMS (SMD = 0.37; 95% CI = 0.29-0.45), and RQLQ (MD = 0.32; 95% CI = 0.20-0.43). No significant differences were found between SCIT and SLIT for SS (SMD = -0.02; 95% CI = -0.15 to 0.11), MS (SMD = -0.14; 95% CI = -0.31 to 0.03), CSMS (SMD = 0.05; 95% CI = -0.21 to 0.31), or RQLQ (MD = -0.08; 95% CI = -0.31 to 0.15).

CONCLUSION

SCIT and SLIT are comparably effective treatments for adults with AR/C. More RCTs analyzing SCIT versus SLIT are needed to directly compare the two. Laryngoscope, 2021.

Predictors of otolaryngology applicant success using the Texas STAR database

OBJECTIVES

To examine applicant characteristics and behaviors associated with a successful match into otolaryngology residency.

METHODS

Self-reported survey data from applicants to otolaryngology residency between 2018 and 2020 were obtained from the Texas STAR database. Characteristics and predictors associated with a successful match were examined using Chi-square tests, two-sided t-tests, and logistic regression models.

RESULTS

A total of 315 otolaryngology residency applicants responded to the survey of whom 274 matched (87%) and 41 did not match (13%). Matched applicants had a significantly higher mean USMLE Step 1 score (P = .016) and Step 2 CK score (P = .007). There were no significant differences in AOA status (45% vs 36%; P = .207), mean number of applications submitted (70 vs 69; P = .544), and mean number of away rotations (2.1 vs 2.0; P = .687) between matched and unmatched applicants. Significant predictors of a successful match included receiving honors in 5 or more clerkships (OR 2.0, 95% CI 1.0-4.0; P = .040), receiving honors in an ENT clerkship (OR 3.7, 95% CI 1.0-12.9; P = .044), and having 3 or more peer-reviewed publications (OR 2.3, 95% CI 1.1-4.5; P = .020). The majority of applicants (79.9%) matched at a program where they either did an away rotation, had a personal geographic connection, or attended medical school in the same geographic region.

CONCLUSIONS

Board scores, excelling on clinical rotations, and having productive research experience appear to be strong predictors of a successful match in otolaryngology. The majority of applicants report a personal or geographic connection to the program at which they match.

LEVEL OF EVIDENCE

4.

Socioeconomic Status Drives Racial Disparities in HPV-negative Head and Neck Cancer Outcomes

OBJECTIVES/HYPOTHESIS

To determine drivers of the racial disparity in stage at diagnosis and overall survival (OS) between black and white patients with HPV-negative head and neck squamous cell carcinoma (HNSCC).

STUDY DESIGN

Retrospective cohort study.

METHODS

Data were examined from of a population-based HNSCC study in North Carolina. Multivariable logistic regression and Cox proportional hazards models were used to assess racial disparities in stage at diagnosis and OS with sequential adjustment sets.

RESULTS

A total of 340 black patients and 864 white patients diagnosed with HPV-negative HNSCC were included. In the unadjusted model, black patients had increased odds of advanced T stage at diagnosis (OR 2.0; 95% CI [1.5-2.5]) and worse OS (HR 1.3, 95% CI 1.1-1.6) compared to white patients. After adjusting for age, sex, tumor site, tobacco use, and alcohol use, the racial disparity persisted for advanced T-stage at diagnosis (OR 1.7; 95% CI [1.3-2.3]) and showed a non-significant trend for worse OS (HR 1.1, 95% CI 0.9-1.3). After adding SES to the adjustment set, the association between race and stage at diagnosis was lost (OR: 1.0; 95% CI [0.8-1.5]). Further, black patients had slightly favorable OS compared to white patients (HR 0.8, 95% CI [0.6-1.0]; P = .024).

CONCLUSIONS

SES has an important contribution to the racial disparity in stage at diagnosis and OS for HPV-negative HNSCC. Low SES can serve as a target for interventions aimed at mitigating the racial disparities in head and neck cancer.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:1301-1309, 2021.

Outcomes of Endoscopic Versus Open Skull Base Surgery in Pediatric Patients

OBJECTIVE/HYPOTHESIS

To characterize the pathology and outcomes of skull base surgery in the pediatric population by open versus endoscopic surgical approach.

STUDY DESIGN

Retrospective cohort study.

METHODS

A retrospective review of pediatric patients (<18 years) who underwent skull base surgery for nonmalignant disease from May 2000 to August 2019 was performed. Patient demographics, pathology, and operative characteristics by surgical approach were recorded and analyzed. Patients with a combined endoscopic/open approach were classified as open for the analysis.

RESULTS

Eighty-two pediatric skull base patients were identified with a mean age of 11.3 years (standard deviation 5.2). A purely endoscopic approach was used in 63 (77%) patients, a purely open approach was used in nine (11%) patients, and a combined open/endoscopic approach was used in 10 (12%) patients. The all-cause complication rate was 9.8%. There was no statistically significant difference in rate of complications between patients with an open versus endoscopic approach for resection (15.8% vs. 7.9%; P = .379). Risk of having a complication did not significantly vary by patient age. The odds of having a complication with an open approach was not statistically significant in a multivariable model adjusted for age, sex, race, intraoperative cerebrospinal fluid leak, tracheostomy requirement, and vascular flap use (odds ratio 2.76, 95% confidence interval 0.28-26.94; P = .383).

CONCLUSIONS

Our retrospective study demonstrates a similar risk of complication for open versus endoscopic approach to resection in pediatric skull base patients at our institution. Safety and feasibility of the endoscopic approach has previously been demonstrated in children, and this is the first study to directly compare outcomes with open approaches.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:996-1001, 2021.

Quantification of Aerosol Particle Concentrations During Endoscopic Sinonasal Surgery in the Operating Room

BACKGROUND

Recent indirect evidence of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) transmission during endoscopic endonasal procedures has highlighted the dearth of knowledge surrounding aerosol generation with these procedures. As we adapt to function in the era of Coronavirus Disease 2019 (COVID-19) a better understanding of how surgical techniques generate potentially infectious aerosolized particles will enhance the safety of operating room (OR) staff and learners.

OBJECTIVE

To provide greater understanding of possible SARS-CoV-2 exposure risk during endonasal surgeries by quantifying increases in airborne particle concentrations during endoscopic sinonasal surgery.

METHODS

Aerosol concentrations were measured during live-patient endoscopic endonasal surgeries in ORs with an optical particle sizer. Measurements were taken throughout the procedure at six time points: 1) before patient entered the OR, 2) before pre-incision timeout during OR setup, 3) during cold instrumentation with suction, 4) during microdebrider use, 5) during drill use and, 6) at the end of the case prior to extubation. Measurements were taken at three different OR position: surgeon, circulating nurse, and anesthesia provider.

RESULTS

Significant increases in airborne particle concentration were measured at the surgeon position with both the microdebrider (p = 0.001) and drill (p = 0.001), but not for cold instrumentation with suction (p = 0.340). Particle concentration did not significantly increase at the anesthesia position or the circulator position with any form of instrumentation. Overall, the surgeon position had a mean increase in particle concentration of 2445 particles/ft3 (95% CI 881 to 3955; p = 0.001) during drill use and 1825 particles/ft3 (95% CI 641 to 3009; p = 0.001) during microdebrider use.

CONCLUSION

Drilling and microdebrider use during endonasal surgery in a standard operating room is associated with a significant increase in airborne particle concentrations. Fortunately, this increase in aerosol concentration is localized to the area of the operating surgeon, with no detectable increase in aerosol particles at other OR positions.

Readability of patient-reported outcome measures for chronic rhinosinusitis and skull base diseases

OBJECTIVE

Outcome measures in healthcare that presume a higher level of patient health and overall literacy may inadequately estimate the disease experiences of less-educated patients and further disadvantage them. Patient-Reported Outcome Measures (PROMs) are widely used communication tools for clinical practice and are often used to evaluate and guide management for chronic rhinosinusitis (CRS) and skull base diseases. However, their readability and subsequent incomprehensibility for patients have not been assessed. The aim of this study is to evaluate the readability of commonly used PROMs for these conditions and whether they meet recommended readability levels.

METHODS

Three readability measures, Gunning Fog, Simple Measure of Gobbledygook (SMOG), and FORCAST were used in the evaluation of commonly used PROMs for CRS and skull base disease. PROMs with sixth-grade readability level or lower were considered to meet health literacy experts' recommendations.

RESULTS

A total of 11 PROMs were reviewed (8 CRS, 3 skull base). Gunning Fog consistently estimated the easiest readability, whereas FORCAST the most difficult. One hundred percent of CRS and 67% of skull base PROMs were above National Institutes of Health and health literacy experts' recommended reading levels. PROMs developed more recently had easier readability.

CONCLUSION

PROMs are important clinical tools in otolaryngology that help guide management of disease for improved patient-centered care. Like many other fields of medicine, those used in otolaryngology are beyond recommended reading levels. Development of PROMs in the future should meet recommended readability levels to fully assess the disease experience of our patients.

LEVEL OF EVIDENCE

4 Laryngoscope, 130:2305-2310, 2020.

Age and risk of recurrence in oral tongue squamous cell carcinoma: Systematic review

The incidence of oral tongue squamous cell carcinoma has been increasing in young patients (≤45 years) without a clear etiologic driver. It is unknown if younger patients have an increased risk of recurrence compared to older patients. A literature search was conducted through January 2020 using PubMed/MEDLINE, Embase, Cochrane, Scopus, Science Direct, and clinicaltrials.gov. This review was registered with PROSPERO (ID: CRD42020167498) and the PRISMA statement was followed. Studies were eligible for inclusion if they assessed risk of recurrence by age using a time-to-event analysis, used an age cutoff of ≤45 years or less for the younger cohort, and limited the analysis to the oral tongue subsite. Data were extracted independently by two reviewers using a form with a prespecified list of variables. There were 13 articles that met criteria for the qualitative synthesis (n = 1763 patients). The reported 5-year rates of disease-free survival ranged from 30% to 72% for the younger cohorts and 42% to 81% for the older cohorts. Three studies reported a statistically significant increased risk of recurrence in younger patients, three studies reported a nonsignificant increased risk in younger patients, and seven studies reported a similar risk in younger patients based on the time-to-event analyses. There may be an increased risk of recurrence for younger patients with oral tongue cancer. A definitive conclusion is precluded by limitations among individual studies, and additional research is warranted to examine this question.

Evaluation of pathologic staging using number of nodes in p16-negative head and neck cancer

OBJECTIVES

The 8th edition AJCC staging guidelines for head and neck squamous cell carcinoma (HNSCC) recently introduced pathologic staging criteria for nodal disease among p16-positive patients. In this study we evaluate pathologic staging in p16-negative HNSCC.

MATERIALS AND METHODS

We compared pathologic staging to the 7th and 8th edition AJCC staging systems using a statewide population-based cohort. All M0 p16-negative surgical patients were included. The outcome was five-year overall survival.

RESULTS

Of 304 patients identified, 113 were N0, 157 had 1-4 positive nodes, and 34 had ≥4 nodes. Survival was 71% (95% CI 61-78%) with no nodes, 48% (36%-60%) for 1-4 nodes, and 24% (11 - 39%) for > 4 nodes. When compared to the AJCC systems, the pathologic staging yielded a larger total survival gradient, more montonic survival, better consistency across primary sites, and a slightly lower Bayesian information criterion (1510 vs 1538). After adjusting for disease characteristics, demographics, and tobacco use, hazard ratios for survival were similar using pathologic and AJCC criteria.

CONCLUSION

In this cohort, pathological staging was more prognostic than AJCC staging. This is the first study to evaluate pathologic staging in p16-negative cancer; if these findings are verified, a universal nodal staging system could be introduced.

A Comparison of Sphenoid Sinus Osteoneogenesis in Aspirin-Exacerbated Respiratory Disease

BACKGROUND

Aspirin-exacerbated respiratory disease (AERD) is characterized by excessive leukotriene production, diffuse polyp burden and osteitic bone changes. These bony changes have not been previously characterized.

OBJECTIVE

The aim of this radiographic study is to characterize the bony changes noted on computed tomography (CT) scans of the sphenoid sinus in patients with AERD compared to other diseased sinonasal inflammatory states and non-diseased controls.

METHODS

A retrospective review of 43 patients with clinically confirmed AERD were included and compared to 22 non-diseased, 9 allergic fungal sinusitis, and 43 chronic rhinosinusitis controls (23 without polyps and 18 with polyps). Comparative measurements were performed using fine-cut CT scans. Sites of comparison were the intersinus septum, the left and right lateral sphenoid wall, the roof, and left and right floor of the sphenoid sinus. Standardized measurements were averaged by two separate rhinologists.

RESULTS

Patients with AERD had an average statistically significant increase in bone thickness compared to healthy and diseased controls in nearly every site with the most pronounced changes in the intersinus septum (p < 0.05).

CONCLUSION

Patients with AERD have significantly increased thickness of the sphenoid bone compared to control groups with the most pronounced difference in the intersinus septum. These findings may help clinicians increase suspicion for a diagnosis of AERD who clinically have diffuse nasal polyposis.

Radiologic Analysis of Balloon Sinuplasty in a Human Cadaver Model: Observed Effects on Sinonasal Anatomy

BACKGROUND

Balloon sinuplasty is increasingly used in the outpatient clinic for treatment of chronic rhinosinusitis, but radiologic analysis of its effects on sinonasal anatomy is largely uncharacterized in the known literature.

OBJECTIVE

The purpose of this study is to examine the anatomic effects of balloon sinuplasty in a cadaveric model.

METHODS

Five fresh cadaver heads underwent sequential endoscopic balloon dilation of maxillary ostia, frontal recess outflow tracts, and sphenoid ostia bilaterally by fellowship-trained rhinologists. Pre- and post-procedural CT imaging was obtained. CT scans were imported into Mimics™ software and sinonasal anatomy was analyzed systematically.

RESULTS

Visual confirmation of balloon dilation was achieved in all 3 sites bilaterally in each cadaver. Radiologic analysis demonstrated that the frontal sinus outflow tract was appropriately dilated 60% (6/10 sites) of the time while the agger was inadvertently dilated 30% of the time (3/10). The sphenoid os was successfully dilated 70% (7/10 sites) of the time. In two cases, a posterior sphenoethmoid (Onodi) cell was dilated instead of the sphenoid. Successful dilation of maxillary os was noted 60% of the time (6/10 sites). No significant change in maxillary os was noted after balloon dilation. Normal middle turbinates were significantly medialized following balloon dilation 75% (6/8 sites) of the time.

CONCLUSIONS

While the goal of balloon sinuplasty is to improve natural sinonasal drainage by dilating existing outflow tracts, as evidenced by radiologic evaluation the procedure appears not to achieve this in all cases, while occasionally creating unintended changes in sinonasal anatomy as well. These unrecognized changes in anatomy may be responsible for the post-procedure change in symptomatology that some patients experience.

Numerical evaluation of spray position for improved nasal drug delivery

Topical intra-nasal sprays are amongst the most commonly prescribed therapeutic options for sinonasal diseases in humans. However, inconsistency and ambiguity in instructions show a lack of definitive knowledge on best spray use techniques. In this study, we have identified a new usage strategy for nasal sprays available over-the-counter, that registers an average 8-fold improvement in topical delivery of drugs at diseased sites, when compared to prevalent spray techniques. The protocol involves re-orienting the spray axis to harness inertial motion of particulates and has been developed using computational fluid dynamics simulations of respiratory airflow and droplet transport in medical imaging-based digital models. Simulated dose in representative models is validated through in vitro spray measurements in 3D-printed anatomic replicas using the gamma scintigraphy technique. This work breaks new ground in proposing an alternative user-friendly strategy that can significantly enhance topical delivery inside human nose. While these findings can eventually translate into personalized spray usage instructions and hence merit a change in nasal standard-of-care, this study also demonstrates how relatively simple engineering analysis tools can revolutionize everyday healthcare. Finally, with respiratory mucosa as the initial coronavirus infection site, our findings are relevant to intra-nasal vaccines that are in-development, to mitigate the COVID-19 pandemic.

Sinus Development and Pneumatization in a Primary Ciliary Dyskinesia Cohort

Background

Primary ciliary dyskinesia (PCD) is a genetically diverse disease which causes impaired mucociliary clearance, and results in pulmonary, otologic, and rhinologic disease in affected patients. Genetic mutations in multiple genes impair the ability of patients to clear mucous from the lungs, middle ear, and sinonasal cavity and lead to chronic pulmonary and sinonasal symptoms.

Methods

We identified 17 PCD patients who had available CT scans. Volumes for bilateral maxillary, sphenoid, and frontal sinuses were calculated. A control population of patients who had preoperative CT scans for endoscopic endonasal resection of skull base pathology without sinonasal cavity involvement was also identified.

Results

The mean age of PCD was 33 and ranged from 13 to 54 years. Patients were age- and gender-matched to a control group that underwent resection of anterior skull-base tumors and had a mean age of 35 that ranged between 17–53 years old. The volumes for all thee sinus cavities were significantly smaller (p < 0.007) compared to the control population. The average Lund-Mackay score was 10.6 in the PCD cohort (range 6–16) in comparison to an average of 0.7 in the control cohort (range 0–2).

Conclusions

Overall sinus volumes were smaller in patients with PCD compared to our control population. Future studies will be aimed at understanding defects in sinus development as a function of specific genetic mutations in PCD patients. Ultimately, a better understanding of the underlying pathophysiology of PCD will allow us to identify the optimal treatment practices for this unique patient group.

Understood? Evaluating the readability and understandability of intranasal corticosteroid delivery instructions

BACKGROUND

Allergic rhinitis is a widespread disease that has significant quality-of-life ramifications. Symptoms include rhinorrhea, nasal obstruction, cough, and postnasal drip. Intranasal corticosteroids are a hallmark of treatment of allergic rhinitis. However, the benefits of treatment are dependent on correct nasal spray technique, of which many patients are not aware. Patient instructions are included with the purchase of these medications. The readability and understandability for these educational materials has been minimally assessed in the medical literature. The aim of this study was to evaluate the readability and understandability of commonly used intranasal steroids.

METHODS

Three readability measures (Gunning Fog, Simple Measure of Gobbledygook [SMOG], and FORCAST) and an understandability assessment (Patient Education Materials Assessment Tool for Printable Materials [PEMAT-P]) were used to evaluate the instructions for use of commonly prescribed intranasal steroids. Instructions with 6th grade readability level or lower were considered to meet health literacy experts' recommendations. Higher understandability values correlate to easier understandability.

RESULTS

Instructions for 10 intranasal corticosteroid brands were reviewed. Gunning Fog consistently estimated easiest readability, whereas FORCAST estimated most difficult readability. Twenty percent (20%) of analyzed instructions met National Institutes of Health and health literacy experts' recommended reading levels. Understandability of instructions ranged from 33% to 90%, with an average of 66%.

CONCLUSION

The benefit of intranasal corticosteroids is contingent on correct use by patients. However, the prepackaged instructions provided are most often above recommended reading levels and are difficult to understand. Future development of intranasal steroid instructions should meet recommended readability levels and be understandable to maximize their utility.

Academic Affiliation and Surgical Volume Predict Survival in Head and Neck Cancer Patients Receiving Surgery

OBJECTIVE

To determine whether the academic affiliation or surgical volume affects the overall survival (OS) of human papillomavirus (HPV)-negative head and neck squamous cell carcinoma (HNSCC) patients receiving surgery.

METHODS

A retrospective study of 39 North Carolina Medical Centers was conducted. Treatment centers were classified as academic hospitals, community cancer centers, or community hospitals and were divided into thirds by volume. The primary outcome was 5-year OS. Hazard ratios (HR) were determined using Cox proportional hazard models, adjusting for demographics, tumor site, stage, insurance status, tobacco use, alcohol use, stage, chemotherapy, and radiation therapy. Patients were also stratified by stage (early stage and advanced stage).

RESULTS

Patients treated at community cancer centers had significantly better 5-year OS (HR 0.68, 95% confidence interval [CI] = 0.48-0.98), and patients treated at academic hospitals trended toward better 5-year OS (HR 0.72, 95% CI = 0.50-1.04) compared to patients treated at community hospitals. The effect for academic affiliation on survival was more pronounced for patients with advanced stage cancer at diagnosis (HR 0.60, 95% CI = 0.37-0.95). There were no significant survival differences among early stage patients by treatment center type. Top-third (HR = 0.64, 95% CI = 0.42-0.96) centers by surgical volume had significantly better 5-year OS, and middle-third (HR = 0.71, 95% CI = 0.51-1.03) centers by volume trended toward better 5-year OS when compared to the bottom-third centers by volume.

CONCLUSION

Patients treated at academic hospitals, community cancer centers, and hospitals in the top third by case volume have favorable survival for HPV-negative HNSCC. The effect for academic hospitals is most pronounced among advanced stage patients.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E479-E488, 2021.

ICAR: endoscopic skull-base surgery

BACKGROUND

Endoscopic skull-base surgery (ESBS) is employed in the management of diverse skull-base pathologies. Paralleling the increased utilization of ESBS, the literature in this field has expanded rapidly. However, the rarity of these diseases, the inherent challenges of surgical studies, and the continued learning curve in ESBS have resulted in significant variability in the quality of the literature. To consolidate and critically appraise the available literature, experts in skull-base surgery have produced the International Consensus Statement on Endoscopic Skull-Base Surgery (ICAR:ESBS).

METHODS

Using previously described methodology, topics spanning the breadth of ESBS were identified and assigned a literature review, evidence-based review or evidence-based review with recommendations format. Subsequently, each topic was written and then reviewed by skull-base surgeons in both neurosurgery and otolaryngology. Following this iterative review process, the ICAR:ESBS document was synthesized and reviewed by all authors for consensus.

RESULTS

The ICAR:ESBS document addresses the role of ESBS in primary cerebrospinal fluid (CSF) rhinorrhea, intradural tumors, benign skull-base and orbital pathology, sinonasal malignancies, and clival lesions. Additionally, specific challenges in ESBS including endoscopic reconstruction and complication management were evaluated.

CONCLUSION

A critical review of the literature in ESBS demonstrates at least the equivalency of ESBS with alternative approaches in pathologies such as CSF rhinorrhea and pituitary adenoma as well as improved reconstructive techniques in reducing CSF leaks. Evidence-based recommendations are limited in other pathologies and these significant knowledge gaps call upon the skull-base community to embrace these opportunities and collaboratively address these shortcomings.

Long-Term Academic Outcomes of Triological Society Research Career Development Award Recipients

OBJECTIVES/HYPOTHESIS

Each year, the Triological Society awards several Research Career Development Awards (CDAs) to support early-career otolaryngologists. The objective of this study was to evaluate academic outcomes of CDA recipients including National Institutes of Health (NIH) funding acquisition and h-index. A secondary objective was to appraise gender differences in outcomes among awardees.

STUDY DESIGN

Cross-sectional study.

METHODS

Recipients' practice setting, degree type, academic rank, and leadership titles were determined through review of academic and private practice profiles in October 2019. NIH funding was assessed using the NIH Research Portfolio Online Reporting Tool and the h-index was calculated using the Scopus database.

RESULTS

Between 2004 and 2019, 70 investigators received a CDA. Of the 65 awardees prior to 2019, 26 (40.0%) obtained NIH grants after the CDA. Having an MD/PhD or MD/master's was not associated with NIH funding attainment (P = .891) nor with higher funding total (P = .109). However, funding total was significantly higher for full professors compared to assistant professors (P = .022). The median h-index among awardees was 16 (interquartile range = 11-21) and differed significantly by academic rank (P < .001). Moreover, 23 CDAs (32.9%) were awarded to women. However, fewer female recipients obtain NIH funding after the CDA compared to men (10.5% vs. 52.2%, P = .002), and they had significantly lower h-indices than men (10 vs. 17, P < .001).

CONCLUSIONS

As a cohort, CDA awardees achieve higher academic success than academic otolaryngologists in general. However, female CDA recipients lag behind their male colleagues, highlighting the need for more research to uncover contributors to gender differences and ways to foster equity in research.

LEVEL OF EVIDENCE

NA Laryngoscope, 131:288-293, 2021.

Concurrent Definitive Immunoradiotherapy for Patients with Stage III-IV Head and Neck Cancer and Cisplatin Contraindication

PURPOSE

Although cisplatin plus radiotherapy is a standard treatment of locally advanced head and neck squamous cell carcinoma (LA-HNSCC), cisplatin contraindication is common. Radiation elicits and promotes tumor-directed immune stimulation, which may potentiate anti-PD-1 therapy. We provide the first efficacy report of combined pembrolizumab and definitive radiotherapy in LA-HNSCC.

PATIENTS AND METHODS

This single-arm, multi-institution, phase II study (NCT02609503) enrolled 29 cisplatin-ineligible patients. Patients received radiotherapy concurrently with three cycles of pembrolizumab 200 mg every 3 weeks followed by three adjuvant cycles. The primary endpoint was a progression-free survival (PFS) of ≥16 months. Correlative studies included peripheral blood flow cytometry and Luminex cytokine profiling.

RESULTS

Reasons for cisplatin ineligibility included otopathy (69.0%), nephropathy (20.7%), and neuropathy (6.9%). With median follow-up of 21 months, estimated 24-month PFS and overall survival rates were 71% (95% confidence interval, 49%-84%) and 75% (51%-88%). The primary PFS endpoint has exceeded the hypothesis and its median has not been reached. Toxicities were typical of radiotherapy; however, high rates of grade 3/4 lymphopenia (58.6%) were observed. Flow cytometry revealed a relative decline in CD4 T cells and B cells, but not CD8 T cells. Upon treatment, frequencies of transitional B cells and tissue-like memory B cells increased, while resting memory B cells decreased. Patients with progression had greater percentages of baseline naïve B cells and fewer marginal zone B cells.

CONCLUSIONS

Pembrolizumab and radiotherapy is efficacious in LA-HNSCC and should be evaluated in a randomized trial. The observed changes in B-cell markers deserve further study both as potential biomarkers and as therapeutic targets.

Extramedullary Hematopoiesis in the Sinonasal Cavity: A Case Report and Review of the Literature

Background

Extramedullary hematopoiesis (EMH) occurs in patients with hematologic disorders, but rarely within the paranasal sinuses. We report a case of EMH in a 17-year-old male with sickle cell disease (SCD) who presented with occipital pain and sinusitis. A computed tomography (CT) scan demonstrated heterogeneous opacification of the right maxillary sinus concerning for allergic fungal sinusitis or a fungal ball with bony erosion. He was taken to the operating room for endoscopic biopsy and a limited endoscopic sinus surgery. Grossly, his maxillary sinus was filled with spiculated osseous tissue. Final pathology demonstrated active hematopoietic bone marrow filling the sinus.

Methods

We present a case report and literature review of sinonasal EMH.

Results

We identified 14 articles with 15 patients. EMH was typically associated with SCD or beta thalassemia. The average age of presentation was 30. There was a male sex predilection with a ratio of 11:15. The most common presenting symptom was a headache and nasal obstruction (33% for both). The most common finding on CT was a soft tissue expansile mass (73%). The most commonly affected location was the maxillary sinus (60%).

Conclusions

This case report serves as a reminder to consider EMH as an uncommon cause of sinus opacification, particularly in patients with SCD or beta thalassemia. The expansion of hematopoietic tissue may be identified as a sinus mass on CT. By recognizing the potential manifestations of chronic anemia, an accurate and timely diagnosis can be made.

Prolonged Implantation of Sinus Devices and Implications for Chronic Rhinosinusitis: A Case Report and Review of the Literature

BACKGROUND

Implantation of sinus stents and spacers can be used as adjuvant management to maintain patency of sinuses after endoscopic sinus surgery for chronic rhinosinusitis. These implants are typically removed several weeks after surgery. We present two cases of different patients who were initially treated by different physicians and were found to have retained sinus spacers in their paranasal sinuses 6-10 years after implantation.

CASE PRESENTATION

Case 1: a 40-year old male with chronic rhinosinusitis and history of balloon sinuplasty six years prior presented with worsening symptoms of chronic rhinosinusitis refractory to medical management. He underwent revision functional endoscopic sinus surgery and was found to have retained sinus implants in the left and right frontal sinus recesses. Case 2: a 48-year-old female with long-standing chronic rhinosinusitis refractory to medical management presented after two prior sinus surgeries most recently 10 years ago. She underwent revision functional endoscopic surgery and was found to have a retained sinus implant from prior surgery in the right frontal recess outflow tract embedded within scar tissue and reactive hyperostosis. Foreign bodies from both patients were removed without complication and patients were healing appropriately in the post-operative period.

CONCLUSIONS

While sinus stents and spacers can help with post-operative scarring, leaving then unmonitored and in place will eventually result in them becoming a nidus for scarring and infection. It is critical that patients are aware of any foreign bodies we place, if they need scheduled removal or routine observation, and what symptoms may indicate that they are causing a problem.

Cystic Fibrosis Transmembrane Conductance Regulator Modulator Therapy: A Review for the Otolaryngologist

Background

Cystic fibrosis (CF) is a genetic disease that may result in multiple systemic disorders and potentially fatal severe respiratory compromise. However, the advent of CF transmembrane conductance regulator (CFTR) modulators has changed the management of CF for patients with select mutations. Although clinical trials have highlighted increased pulmonary function and decreased exacerbations as a result of these novel therapies, their effect on the sinuses has not been well-described.

Objective

Our objective is to review the CFTR modulators to provide otolaryngologists, physicians who frequently care for patients with CF, a basic understanding of these drugs and their effects on chronic rhinosinusitis (CRS) in patients with CF.

Methods

The clinically approved and available CFTR modulators and specific indications for their use are reviewed. Additionally, a systematic review of these therapies and effects on CRS in CF was performed.

Results

Four Food and Drug Administration approved CFTR modulators are available for patients with CF. Current drugs are approved for gating, residual function, or F508del mutations. Multiple reports describe CFTR modulators’ increase in transepithelial ion transport in nasal epithelial cultures; however, clinical studies regarding effects of these modulators on sinonasal health are limited to 5 studies that present new data of the effects of CFTR modulators in CRS.

Conclusions

CFTR modulators have changed management of CF. Initial studies of these medications demonstrate promising results in CF; however, there is a paucity of literature describing the effect of CFTR modulators on CF-associated CRS, although initial results are encouraging.

Recent Trends in Female and Racial/Ethnic Minority Groups in U.S. Otolaryngology Residency Programs

OBJECTIVES

Our objectives were to analyze the recent trends in applicants of otolaryngology-head and neck surgery (Oto-HNS) residency programs, including evolutions in sex and racial/ethnic distribution within the applicant pool and subsequent residency cohort.

METHODS

Retrospective database and literature review. Data regarding applicants to Oto-HNS programs as well as Oto-HNS residents in the United States from 2008 to 2017 were analyzed from the Electronic Residency Application Service, National Resident Matching Program, and Journal of the American Medical Association.

RESULTS

Between 2008 and 2018, the number of Oto-HNS residency programs and residency positions offered increased from 105 to 112 and from 273 to 315, respectively. There was no statistically significant difference between applicant sex in 2008 to 2012 compared to 2013 to 2018 (P > .05), but significantly more females made up the residency workforce from 2013 to 2018 compared to 2008 to 2012 (P < .001). However, the percentage increase in female residents from 2008 to 2017 was only 6.1% (29.8% to 35.9%). No statistically significant difference was present between applicant race in 2008 to 2012 compared to 2013 to 2018 (P > .05), but significantly more minority residents made up the residency workforce from 2013 to 2018 compared to 2008 to 2012 (P < .0001). However, the percentage increase in minority residents from 2008 to 2017 was only 4.9% (35.1% to 40%).

CONCLUSION

Women and minority racial and ethnic groups continue to be underrepresented among Oto-HNS applicants. However, the presence of these groups among current residents has increased. Understanding and tracking these national trends yearly is critical for training a diverse future otolaryngology workforce.

LEVEL OF EVIDENCE

VI Laryngoscope, 131:277-281, 2021.

Readability of Patient-Reported Outcome Measures for Head and Neck Oncology

OBJECTIVES/HYPOTHESIS

Patient-reported outcome measures (PROMs) are communication tools to help patients convey their disease experience to medical providers and guide management decisions. However, the utility of healthcare outcome measures is dependent on patient literacy and readability of PROMs. If written for a more advanced literacy level, they can misestimate symptoms and add significant barriers to care, especially in the underserved. However, readability of head and neck (H&N) oncology PROMs has not been assessed. The aim of this study was to evaluate the readability of H&N oncology PROMs to assess whether they meet recommended readability levels.

STUDY DESIGN

Bibliometric review.

METHODS

Three readability measures: Gunning Fog, Simple Measure of Gobbledygook, and FORCAST were used to evaluate the readability level of commonly used H&N PROMs. PROMs with sixth grade readability level or lower were considered to meet the recommendations of health literacy experts.

RESULTS

Eight H&N oncology PROMs were reviewed. None of H&N PROMs met health literacy experts' and National Institutes of Health recommended reading levels. Gunning Fog consistently estimated easiest readability and FORCAST the most difficult.

CONCLUSIONS

PROMs are important clinical tools that drive patient-centric care in H&N oncology. All H&N PROMs are written above recommended reading levels and do not meet suggested standards. Future PROMs should be written with easier readability to accurately convey patients' H&N oncology disease experiences.

LEVEL OF EVIDENCE

4 Laryngoscope, 2020.

Nasopharyngeal Hyalinizing Clear Cell Carcinoma: A Case Report and Review of the Literature

Background

Hyalinizing clear cell carcinomas (HCCCs) are rare, low-grade, malignant tumors which most often arise from the minor salivary glands primarily in palate and tongue but can arise in any location with minor salivary glands including the nasopharynx.

Methods

A case report of primary nasopharyngeal HCCC is presented. Because of the rarity of this tumor and location, a literature search was conducted to determine the most common presenting symptoms, treatment strategies, and outcomes.

Results

A 48-year-old man underwent biopsy of a 4.5 cm mass of the right nasopharynx with pathology suggesting an intermediate grade mucoepidermoid carcinoma. After discussing management with the patient, an endoscopic resection was performed. Final pathology revealed an HCCC which was confirmed after negative Mastermind-like 2 (MAML2) and positive Ewing sarcoma breakpoint region 1 (ESWR1) gene rearrangements on fluorescence in situ hybridization (FISH) studies. Literature review of other nasopharyngeal HCCC cases shows diverse presentation and overall excellent prognosis through surgical and radiation therapy.

Conclusion

HCCCs are rare, low-grade malignant tumors of the minor salivary glands and can present as a nasopharyngeal mass. Presenting symptoms are diverse but frequently involve otologic and sinonasal disturbances. HCCC is an indolent tumor with an excellent prognostic outcome when treated appropriately with surgical resection and adjuvant radiotherapy.

Mometasone absorption in cultured airway epithelium

BACKGROUND

Topical mometasone is frequently used as an intranasal spray, on drug-eluting stents, and compounded by specialty pharmacies as a sinus rinse. A typical sinus rinse contains 1.2 mg of mometasone dissolved in 240 mL of buffered saline and is flushed through the sinonasal cavity. The mometasone irrigation rapidly flows to the contralateral sinonasal cavity or the nasopharynx with a contact time on the order of 5 to 10 seconds. However, no information is available on the absorption rate of topical mometasone on the sinonasal surface.

METHODS

To determine the absorption characteristics of mometasone, we harvested nasal epithelium from 2 healthy donors and differentiated them into a mature ciliated epithelium on Millicell membranes. We applied mometasone to the apical surface for various time intervals and then rinsed off non-absorbed mometasone with phosphate-buffered saline. Millicell membranes with the adherent epithelial cells were then harvested and stored in guanidine hydrochloride for quantification using high-performance liquid chromatography-mass spectrometry.

RESULTS

Fifty percent of the maximal absorption occurred after an average of 38 minutes after application, and maximal absorption occurred after an average of 114 minutes.

CONCLUSION

Our data provide an estimate for rates of absorption of mometasone applied to the sinonasal cavity and suggest that the absorption rates poorly match contact time during saline lavage.

Outcomes of Open vs Endoscopic Skull Base Surgery in Patients 70 Years or Older

Importance

The use of skull base surgery in patients 70 years or older is increasing, but its safety in this age group has not been evaluated to date.

Objectives

To describe outcomes in a cohort of patients 70 years or older undergoing skull base surgery and to evaluate whether age, type of disease process, and approach (endoscopic vs traditional open surgery) are associated with increased intraoperative and postoperative complications in this population.

Design, Setting, and Participants

This retrospective cohort study analyzed a population-based sample of 219 patients 70 years or older from a database of 1720 patients who underwent skull base surgery at University of North Carolina Hospitals, Chapel Hill, a tertiary referral center, between October 2007 and June 2017. Data were collected from June 2016 to July 2017 and analyzed in July 2017 and August 2017.

Exposure

Skull base surgery.

Main Outcomes and Measures

Data collected included demographic characteristics, surgical approach, and disease process. Intraoperative findings and postoperative complications were analyzed by age, surgical approach, and malignancy status.

Results

Of the 219 patients, 166 were aged 70.0 to 79.9 years and 53 patients were older than 80 years (mean [SD] age, 76.4 [4.7] years); 120 (54.8%) were men and 160 (73.7%) were white. There were 161 (73.5%) endoscopic and 58 (26.5%) open operations. The most common pathologic processes among the 219 patients were nonsellar malignant (81 [37.0%]), nonsellar benign (53 [24.2%]), and pituitary (49 [22.4%]) tumors. The most common intraoperative and postoperative complications were intraoperative major bleeding (5 of 219 patients [2.3%]) and postoperative bleeding (9 [4.1%]). Thirty-day mortality was zero. There was no clinically meaningful difference in complications between patients aged 70.0 to 79.9 years vs those older than 80 years, endoscopic vs open surgery, or benign vs malignant neoplasms. Specifically, between the endoscopic and open surgery groups, there was no difference in intraoperative major bleeding (3.9%; 95% CI, -0.7% to 12.9%), postoperative cerebrospinal fluid leak (-0.6%; 95% CI, -3.4% to 5.6%), or postoperative bleeding (1.5%; 95% CI, -3.9% to 10.6%).

Conclusions and Relevance

Skull base surgery is a safe option in persons 70 years or older, with similar outcomes across age ranges, surgical approaches, and disease processes.

A computational fluid dynamics analysis of the effects of size and shape of anterior nasal septal perforations

BACKGROUND

Nasal septal perforations (NSPs) often cause bleeding, crusting, obstruction, and/or whistling. The objective was to analyze the impact of anterior NSP size and shape on nasal physiology using computational fluid dynamics (CFD).

METHODS

A 3-dimensional model of the nasal cavity was constructed from a radiologically normal CT scan using imaging software. Anterior NSPs (ovoid (ONSP): 0.5, 1, 2, and 3 cm long anterior-to-posteriorly and round (RNSP, 0.5 and 1 cm)) were virtually created in the model and divided into ventral, dorsal, anterior, and posterior regions. Steady-state inspiratory airflow, heat, and water vapor transport were simulated using Fluent CFD software. Air crossover through the perforation, wall shear, heat flux, water vapor flux, resistance, and humidification were analyzed.

RESULTS

Air crossover and wall shear increased with perforation size. Regionally, wall shear and heat and water vapor flux were highest posteriorly and lowest anteriorly, generally increasing with size in those regions. RNSPs had greater heat and water vapor flux compared to corresponding size ONSPs. Resistance decreased by 10% or more from normal only in the 3 cm ONSP. Maximum water content was achieved more posteriorly in larger NSP nasal cavities.

CONCLUSIONS

High wall shear and heat and water vapor flux in posterior perforation regions may explain the crusting most commonly noted on posterior NSP edges. This preliminary study suggests that larger NSPs have a greater effect on nasal resistance and water content. Decrease in resistance with larger NSP size may be implicated in reported symptomatic improvement following enlargement of NSPs for treatment.

Blinded Evaluation of Endoscopic Skill and Instructability After Implementation of an Endoscopic Simulation Experience

Background

Interest in endoscopic simulation is increasing. Past studies have used virtual reality or nonhuman models or residents with varying experience. Our aim was to evaluate the effect of simulation on procedural and psychomotor competence of medical students—surgical novices—performing endoscopic tasks on human cadavers and assess student perceptions.

Methods

Students (n = 22) completed a baseline sinus model skill evaluation graded by 2 blinded Rhinology fellows. Intervention and control groups with equal baselines were assigned. Intervention students practiced endoscopic tasks on the model for 45 minutes minimum over 2 weeks. All students reviewed sinus anatomy/disease and sinus surgery materials. The final cadaver evaluation was similar to the baseline. Fellows graded students on anatomy identification (sinuses, turbinates), psychomotor (navigation, camera alignment, instrument handling), and timed procedural (sinus object retrieval) skills, confidence, and instructability via fellow-guided frontal balloon placement.

Results

Participants included 16 males (72.7%) and 6 females (27.3%). Intervention and control groups contained 10 (45.4%) and 12 (54.6%) students, respectively. Intervention group final “Total Psychomotor” scores were higher (10.1/15 vs 7.8/15, P = .0231). “Surgical confidence” was 3.3/5 versus 2.5/5, and “Instructability” was 3.9/5 versus 3.4/5 in intervention versus control groups, respectively ( P < .050). Multivariate regression analysis demonstrated superior psychomotor skills, navigation, and confidence in the intervention group ( P < .036). Activity perception scores were higher in intervention students versus controls, 26.13 versus 18.36/40 ( P = .022).

Conclusion

In surgical novices, endoscopic simulation leads to superior endoscopic navigation and task performance in cadavers. This simulation presents a novel method for incorporating Otolaryngology simulation in medical student education.

Mature results of the LCCC1413 phase II trial of de-intensified chemoradiotherapy for HPV-associated oropharyngeal squamous cell carcinoma

6022

Background: To report the mature results from a prospective phase II clinical trial of highly de-intensified chemoradiotherapy (CRT) for patients with HPV-associated oropharyngeal squamous cell carcinoma (OPSCC). Methods: The major inclusion criteria were: 1) T0-T3, N0-N2, M0, 2) p16 positive, and 3) minimal/remote smoking history. Treatment was limited to 60 Gy intensity modulated radiotherapy with concurrent weekly intravenous cisplatin 30 mg/m2(second choice was cetuximab). Patients with T0-T2 N0-1 disease did not receive chemotherapy. All patients had a 10 to 12-week post-treatment PET/CT to determine need for planned neck dissection. The primary study endpoint was 2 year progression free survival (PFS). Secondary endpoint measures include 2 year local control (LC), regional control (RC), distant metastasis free survival (DMFS), cause specific survival (CSS) and overall survival (OS), and patient reported symptoms (PRO-CTCAE) and quality of life (EORTC QLQ-C30 & H&N35). Results: 114 patients were enrolled (median f/u of 28.8 months, range 2.6 to 51.4) with 84 having a minimum follow-up of 2 years. Smoking status was as follows: 47% never, 33% ≤ 10 pack years, and 19% > 10 pack years. Post-treatment PET/CT complete response rate was 93% at the primary site and 80% in the neck. Eleven patients had planned neck dissection with 4 having pathological residual disease. Two year LC, RC, DMFS, PFS, CSS, and OS were the following: 96%, 99%, 91%, 88%, 97%, and 95%. Neither smoking status nor receipt of cetuximab correlated with recurrence. Four patients with recurrent disease had PIK3CA mutations. Thirty four percent of patients required a feeding tube (none permanent) for a median of 10.5 weeks. Mean pre- and 2-year post-treatment EORTC QOL scores were: Global 79/83 (lower worse), Swallowing 8/9 (higher worse), Dry Mouth 14/45 (higher worse), and Sticky Saliva 9/28 (higher worse). Mean pre- and 2 year post-treatment PRO-CTCAE (0 to 4 scale, higher worse) scores were: Swallowing 0.5/0.7 and Dry mouth 0.4/1.4. There were no ≥ Grade 3 late adverse events. Conclusions: Clinical outcomes with a highly de-intensified CRT regimen of 60 Gy IMRT with concurrent low-dose cisplatin are excellent in patients with HPV-associated OPSCC. Clinical trial information: NCT02281955.

Multiplexed digital PCR for detection of HPV in tissue samples from oropharyngeal cancer patients

e17552

Background: p16 immunohistochemistry (IHC) is a commonly used method for identifying HPV-associated oropharyngeal squamous cell carcinoma (OPSCC). However, p16 overexpression in a minority of HPV negative OPSCC can give rise to false positive results. In contrast, HPV nucleic acid testing lacks adequate sensitivity for routine diagnostic testing. The goal of this study was to investigate whether a multiplexed digital PCR assay can detect and quantify HPV DNA in p16 positive OPSCC treated with definitive chemo-radiotherapy (CRT). Methods: Formalin-fixed paraffin embedded (FFPE) residual diagnostic biopsy specimens were collected from 57 patients. Macrodissection was performed to ensure tumor cellularity > 70%. Extracted genomic DNA was analyzed by next generation sequencing (NGS) using a hybrid capture assay (UNCSeq) targeting > 200 cellular genes and HPV 16/18 genomes. We also designed, validated, and implemented an multiplexed droplet digital PCR (dPCR) assay to detect and quantify HPV DNA (strains 16, 18, 31, 33 and 35) in tissue samples, relative to a genomic control locus (chromosome 6). Results: HPV strain 16 DNA was identified in 50 patients (87.7%), whereas 5 patients (8.8%) had HPV DNA from an alternative high-risk strain (18/31/33/35). HPV DNA was undetectable in 2 patients, indicating a false positive rate of 3.5% for p16 IHC testing in this cohort. HPV DNA copy number per diploid genome equivalent varied significantly across samples, with a median value of 19.7 (range 0.23-1712). A significant correlation was observed between the copies of HPV detected by dPCR and NGS (R2 = 0.5853, p < 0.0001). Evidence for HPV integration was detected by NGS in 23 out of 56 evaluable tumors (42%). There was a trend towards a higher prevalence of HPV integration in tumors with less than 10 HPV copies per diploid genome relative to cancers with > / = 10 HPV copy number (63% versus 34%, p = 0.07). Conclusions: Multiplexed digital PCR demonstrates excellent sensitivity for detection and typing of HPV DNA in diagnostic FFPE specimens from patients with p16 positive oropharyngeal cancer. HPV copy number varies significantly across samples, with a possible association with HPV integration status. Future investigations of potential correlation between HPV copy number, integration status, and clinical outcomes are warranted. Clinical trial information: NCT02281955, NCT03077243.

PIK3CA mutation as a prognostic factor in HPV-associated oropharynx cancer

6011

Background: PIK3CA is the most frequently mutated gene in HPV-associated oropharyngeal SCC (OPSCC), with a prevalence of 20-30%. While PIK3CA mutations have been associated with adverse outcomes in cervical cancer, their prognostic significance in HPV-associated OPSCC remains unknown. We sought to elucidate the significance of PIK3CA mutations in a prospective cohort of HPV-associated OPSCC patients treated with definitive chemoradiation (CRT). Methods: Seventy-eight patients with HPV-associated OPSCC were prospectively enrolled on three protocols: LCCC 1121 (NCT03161821) or two phase II clinical trials of de-intensified CRT (NCT02281955 / NCT03077243). De-intensified regimen was 60 Gy IMRT with concurrent cisplatin (30mg/m2). Next-generation sequencing of tumor samples was performed using a targeted panel-based assay (UNCSeq), including over 200 genes. We estimated disease-free survival (DFS) using the Kaplan-Meier method and compared treatment groups with two-sided log-rank test (Medcalc). Results: Sequencing was performed in 78 patients with a median follow-up of 24 months. Seventy-five patients received 60Gy; three patients received 70Gy. Ten patients had disease recurrence (2 regional only, 5 distant only, 3 regional and distant). Thirty-eight of 78 patients had at least one mutation identified (17 PIK3CA, 4 PTEN, 3 KRAS, 3 FBXW7, 3 FGFR3, 2 TP53, 2 prothrombin 20210, 1 NRAS, 1 BRCA1, 1 factor V Leiden, 1 FLT3, 1 RAD50, 1 PIK3R1). The most common site of PIK3CA mutation was the helical domain (E545K – 8/17, E542K – 2/17). Despite similar T/N staging and tobacco pack years, patients with WT-PIK3CA had significantly higher DFS (93%) compared with 65% for patients with PIK3CA mutations (p = 0.0009). Patients with mutations other than PIK3CA also had improved DFS relative to those with PIK3CA mutations (96% vs. 65%; p = 0.0147). Conclusions: PIK3CA mutation is associated with worse DFS in a prospective cohort of newly diagnosed HPV-associated OPSCC patients treated with definitive CRT. These findings suggest that patients with PIK3CA mutations may not be suitable for de-intensified therapy and investigation of novel treatment strategies may be appropriate.

International consensus statement on endoscopic skull-base surgery: executive summary

BACKGROUND

Endoscopic skull-base surgery (ESBS) is a rapidly growing discipline that often combines the expertise of otolaryngology-head and neck surgeons and neurosurgeons to provide care for these challenging conditions. As the field has grown, so too has the literature evaluating this surgical approach and the challenges and complications associated with these interventions. An international, multidisciplinary effort to critically evaluate and grade the current literature on ESBS has resulted in the International Consensus Statement on Endoscopic Skull Base Surgery (ICAR:SB). This Executive Summary highlights the key findings of the ICAR:SB document.

METHODS

Following the prior methodology of the ICAR statements, the ICAR:SB document consists of 98 topics in ESBS that underwent a systematic review. When sufficient evidence exists, an evidence-based review with recommendation (EBRR) or evidence-based review (EBR) was created and then underwent an iterative review process until consensus was achieved. This Executive Summary recapitulates these findings.

RESULTS

This summary complies the EBR and EBRR from the ICAR:SB document in the management of numerous skull-base pathologies including cerebrospinal fluid rhinorrhea, intradural tumors, sinonasal malignancies, and clival tumors, as well as the key issues of reconstruction after and the complications associated with ESBS.

CONCLUSION

The ICAR:SB Executive Summary recaps the evidenced-based recommendations concerning the advantages, limitations and challenges of ESBS in the management of diverse skull-base pathologies. Although multifactorial in nature, the overall level of evidence in ESBS is modest. This represents an opportunity to address these knowledge gaps moving forward.