During the coronavirus 2019 pandemic, medical student involvement in direct patient care has been severely limited. Rotations mandatory not only for core curricula but also for informing decisions ...regarding specialty choice have been postponed during a critical window in the application cycle. Existing virtual rotations are largely observational or lack patient-facing components.
A virtual Otolaryngology - Head and Neck Surgery rotation at the University of Pennsylvania (Philadelphia, Pennsylvania) was implemented for medical students, comprising interactive live-streamed surgeries, outpatient telehealth visits, and virtual small group didactics.
Medical students enrolled in the virtual surgical rotation were able to engage with attending surgeons and operating room staff while remotely viewing surgical procedures captured with first-person audiovisual technology. Students participated in several different aspects of care delivery in both the inpatient and outpatient setting, similar to their typical responsibilities of an in-person rotation.
The authors will continue to develop the virtual surgical education methodology to further disseminate an interactive video-based medical student elective to other procedural specialties and institutions.
Objective
To analyze the patterns, risk factors, and salvage outcomes for locoregional recurrences (LRR) after treatment with transoral robotic surgery (TORS) for HPV‐associated oropharyngeal ...squamous cell carcinoma (HPV+ OPSCC).
Study Design
Retrospective analysis of HPV+ OPSCC patients completing primary TORS, neck dissection, and NCCN‐guideline‐compliant adjuvant therapy at a single institution from 2007 to 2017.
Methods
Features associated with LRR, detailed patterns of LRR, and outcomes of salvage therapy were analyzed. Disease‐free survival (DFS) and overall survival (OS) were calculated for subgroups of patients receiving distinct adjuvant treatments.
Results
Of 541 patients who completed guideline‐indicated therapy, the estimated 5‐year LRR rate was 4.5%. There were no identifiable clinical or pathologic features associated with LRR. Compared to patients not receiving adjuvant therapy, those who received indicated adjuvant radiation alone had a lower risk of LRR (HR 0.28, 95% CI 0.09–0.83, P = .023), but there was no difference in DFS (P = .21) and OS (P = .86) between adjuvant therapy groups. The 5‐year OS for patients who developed LRR was 67.1% vs. 93.9% for those without LRR (P < .001). Patients who initially received adjuvant chemoradiation and those suffering local, in‐field, and/or retropharyngeal node recurrences had decreased disease control after salvage therapy.
Conclusion
LRR rates are low for HPV+ OPSCCs completing TORS and guideline‐compliant adjuvant therapy. Patients without indication for adjuvant therapy more often suffer LRR, but these recurrences are generally controllable by salvage therapy. Improved understanding of the patterns of recurrence most amenable to salvage therapy may guide treatment decisions, counseling, and adjuvant therapy de‐escalation trials.
Level of Evidence
3 Laryngoscope, 131:E2865–E2873, 2021
Background
Perioperative management of advanced osteoradionecrosis of the head and neck requiring free flap (FF) reconstruction varies. Our objectives included assessment of practice patterns and ...outcomes.
Methods
Multi‐institutional, retrospective review of FF reconstruction for head and neck osteoradionecrosis (n = 260).
Results
Administration of preoperative antibiotics did not correlate with reduction in postoperative complications. Preoperative alcohol use correlated with higher rates of hardware exposure (p = 0.03) and 30‐day readmission (p = 0.04). Patients with FF compromise had higher TSH (p = 0.04) and lower albumin levels (p = 0.005). Prealbumin levels were lower in patients who required neck washouts (p = 0.02) or a second FF (p = 0.03). TSH levels were higher in patients undergoing postoperative debridement (p = 0.03) or local flap procedures (p = 0.04).
Conclusion
Malnutrition, hypothyroidism, and substance abuse correlated with a higher incidence of postoperative wound complications in patients undergoing FF reconstruction for advanced osteoradionecrosis. Preoperative antibiotics use did not correlate with a reduction in postoperative wound complications.
Objectives:
To determine whether 2 different methods of post-operative head and neck free flap monitoring affect flap failure and complication rates.
Methods:
A retrospective chart review of 803 free ...flaps performed for head and neck reconstruction by the same microvascular surgeon between July 2013 and July 2020 at 2 separate hospitals within the same healthcare system. Four-hundred ten free flaps (51%) were performed at Hospital A, a medical center where flap checks were performed at frequent, scheduled intervals by in-house resident physicians and nurses; 393 free flaps (49%) were performed at Hospital B, a medical center where flap checks were performed regularly by nursing staff with resident physician evaluation as needed. Total free flap failure, partial free flap failure, and complications (consisting of wound infection, fistula, and reoperation within 1 month) were assessed.
Results:
There were no significant differences between Hospitals A and B when comparing rates of total free flap failure, partial free flap failure, complication, or re-operation (P = .27, P = .66, P = .65, P = .29, respectively). There were no significant differences in urgent re-operation rates for flap compromise secondary to thrombosis and hematoma (P = .54).
Conclusions:
In our series, free flap outcomes did not vary based on the degree of flap monitoring by resident physicians. This data supports the ability of a high-volume, well-trained, nursing-led flap monitoring program to detect flap compromise in an efficient fashion while limiting resident physician obligations in the age of resident duty hour restrictions.
Background
Transoral robotic surgery (TORS) for oropharyngeal malignancy optimizes oncologic outcomes while preserving functionality. This study identifies patterns of functional recovery after TORS ...with free flap reconstruction (FFR).
Methods
Retrospective cohort study at a tertiary care center of patients with primary oropharyngeal tumors treated with TORS with FFR between 2010 and 2022. Patients were categorized into: adjuvant chemoradiation or radiation, or no adjuvant therapy (NAT). Functional outcomes were measured by functional oral intake scale (FOIS).
Results
241 patients were included. FOIS declined at first postoperative appointment (median = 7.0 to 2.0, IQR = 7.0, 7.0, 2.0, 4.0), and progressively improved to 6.0 (5.0, 6.0) after 1 year, with NAT having the highest FOIS (7.0, p < 0.05). Predictors of poor long‐term FOIS included RT and hypoglossal nerve (CN XII) involvement (p < 0.05).
Conclusions
TORS with FFR leads to good long‐term function with minimal intake restrictions. Radiation therapy and CN XII involvement increase risk of worse functional outcomes.
Background
We aim to define a set of terms for common free flap complications with evidence‐based descriptions.
Methods
Clinical consensus surveys were conducted among a panel of head and ...neck/reconstructive surgeons (N = 11). A content validity index for relevancy and clarity for each item was computed and adjusted for chance agreement (modified kappa, K). Items with K < 0.74 for relevancy (i.e., ratings of “good” or “fair”) were eliminated.
Results
Five out of nineteen terms scored K < 0.74. Eliminated terms included “vascular compromise”; “cellulitis”; “surgical site abscess”; “malocclusion”; and “non‐ or mal‐union.” Terms that achieved consensus were “total/partial free flap failure”; “free flap takeback”; “arterial thrombosis”; “venous thrombosis”; “revision of microvascular anastomosis”; “fistula”; “wound dehiscence”; “hematoma”; “seroma”; “partial skin graft failure”; “total skin graft failure”; “exposed hardware or bone”; and “hardware failure.”
Conclusion
Standardized reporting would encourage multi‐institutional research collaboration, larger scale quality improvement initiatives, the ability to set risk‐adjusted benchmarks, and enhance education and communication.
The utility of preoperative circulating tumor tissue-modified viral human papillomavirus DNA (TTMV-HPV DNA) levels in predicting human papillomavirus (HPV)-associated oropharyngeal squamous cell ...carcinoma (HPV+ OPSCC) disease burden is unknown.
To determine if preoperative circulating tumor HPV DNA (ctHPVDNA) is associated with disease burden in patients with HPV+ OPSCC who have undergone transoral robotic surgery (TORS).
This cross-sectional study comprised patients with HPV+ OPSCC who underwent primary TORS between September 2021 and April 2023 at one tertiary academic institution. Patients with treatment-naive HPV+ OPSCC (p16-positive) and preoperative ctHPVDNA levels were included, and those who underwent neck mass excision before ctHPVDNA collection were excluded.
The main outcome was the association of increasing preoperative ctHPVDNA levels with tumor size and lymph node involvement in surgical pathology. The secondary outcome was the association between preoperative ctHPVDNA levels and adverse pathology, which included lymphovascular invasion, perineural invasion, or extranodal extension.
A total of 70 patients were included in the study (65 men 93%; mean SD age, 61 8 years). Baseline ctHPVDNA levels ranged from 0 fragments/milliliter of plasma (frag/mL) to 49 452 frag/mL (median IQR, 272 30-811 frag/mL). Overall, 58 patients (83%) had positive results for ctHPVDNA, 1 (1.4%) had indeterminate results, and 11 (15.6%) had negative results. The sensitivity of detectable ctHPVDNA for identifying patients with pathology-confirmed HPV+ OPSCC was 84%. Twenty-seven patients (39%) had pathologic tumor (pT) staging of pT0 or pT1, 34 (49%) had pT2 staging, and 9 patients (13%) had pT3 or pT4 staging. No clinically meaningful difference between detectable and undetectable preoperative ctHPVDNA cohorts was found for tumor size or adverse pathology. Although the median preoperative ctHPVDNA appeared to be higher in pT2 through pT4 stages and pN1 or pN2 stages, effect sizes were small (pT stage: η2, 0.002 95% CI, -1.188 to 0.827; pN stage: η2, 0.043 95% CI, -0.188 to 2.600). Median preoperative log(TTMV-HPV DNA) was higher in active smokers (8.79 95% CI, 3.55-5.76), compared with never smokers (5.92 95% CI, -0.97 to 1.81) and former smokers (4.99 95% CI, 0.92-6.23). Regression analysis did not show an association between tumor dimension or metastatic lymph node deposit size and preoperative log(TTMV-HPV DNA). After univariate analysis, no association was found between higher log(TTMV-HPV DNA) levels and adverse pathology.
In this cross-sectional study, preoperative ctHPVDNA levels were not associated with disease burden in patients with HPV+ OPSCC who underwent TORS.
Background
Management of the neck in laryngeal squamous cell carcinoma (LSCC) is essential to oncologic control and survival. We aim to describe patterns and rates of clinical/pathologic lymph node ...disease, elective neck dissection (END), and occult lymph node metastasis (LNM) in patients with surgically‐managed LSCC.
Methods
Retrospective cohort study of patients in the National Cancer Database (NCDB) diagnosed with LSCC between January 2004 and December 2016 who underwent primary surgery.
Results
Seven thousand eight hundred and seventy‐six patients met inclusion criteria. For cN0 patients, the rates of END and occult LNM both increased with tumor stage and were highest for supraglottic tumors. Predictors of occult LNM included supraglottic site, pathologic T3 and T4 stage, positive margins, and presence of lymphovascular invasion (p < 0.05).
Conclusions
The propensity for cervical LNM in surgically‐managed LSCC varies based on primary tumor site and stage, and a variety of disease factors increase risk of occult LNM.
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