•Hypopharyngeal squamous cell carcinoma has a reported 5-year overall survival rate of approximately 30–35%.•Nearly 50% of patients exhibitrecurrence within the first year after diagnosis.•Laryngeal ...preservation strategies are well supported although long term toxicity is significant.•Salvage surgery a common occurrence.•Future directions will focus on immunotherapy/targeted therapies to improve survival outcomes.
Cancer of the hypopharynx is relatively rare and accounts for roughly 3% of all head and neck cancers. Unfortunately, hypopharyngeal carcinoma has one of the worst prognosis of all head and neck cancers with a reported 5-year overall survival rate of approximately 30–35%. Toxicity related to therapy, and the need for surgical salvage continue to dominate the landscape in this disease. In this article, we set out to discuss a comprehensive overview of the current management principles, recent literature and evidence based therapeutic options surrounding treatment for hypopharyngeal squamous cell carcinoma, with a special focus on the evolution of an organ sparing paradigm.
Background
The concept of reserve flow perfusion for free flap reconstruction has been demonstrated in various applications in the literature. As it relates to the anterolateral thigh (ALT) free ...flap, the reserve flow principle has been primarily described to either augment or “supercharge” a large ALT to optimize skin perforator supply or lengthen the vascular pedicle.
Methods
We report a case of a 77‐year old male with chronic renal failure who had extensive atherosclerosis of the proximal descending lateral circumflex femoral artery (LCFA) where arterial anastomosis was unable to be performed.
Results
We were able to circumvent this limitation by establishing reserve flow perfusion solely through the distal end of the descending LCFA. We describe our technique within the context of current literature on the topic of reverse flow perfusion in free flap reconstruction.
Conclusion
This report uniquely describes applying the distally based, reverse arterial flow principle in an ALT flap to circumvent an atherosclerotic proximal pedicle.
We describe our experience using the extracorporeal video microscope, the "exoscope" for various applications within the field of lateral skull base surgery.
A retrospective case series was performed ...investigating patient demographics, indications for surgery, procedure type, operative time, approach to the skull base, complications, adequacy of visualization, and surgeon comfortability.
Six cases were performed with a three dimensional surgical exoscope, obviating the use of a traditional binocular microscope.
Academic, tertiary referral center.
Type of surgical approach, operative time, patient demographics, surgical complications, and surgeon comfortability.
The following procedures were performed; four vestibular schwannoma resections via suboccipital craniotomy and two combined transmastoid and transtemporal approaches for temporal lobe encephalocele repairs. The average operative time was 227 and 577 minutes for temporal lobe encephalocele repairs and vestibular schwannoma cases, respectively. No intraoperative complications were encountered during these cases. None of the procedures required abandonment of the exoscope in favor of the microscope during the procedure. Advantages include high-resolution three-dimensional visualization, increased degrees of freedom for exoscope adjustment, and reduced surgeon fatigue in a fixed, unnatural posture. Limitations include decreased depth perception and increased operative time.
The exoscope system is a safe and effective alternative or adjunct to the existing binocular operating microscope for lateral skull based procedures. The exoscope provides the surgeon with a comfortable, high-resolution visualization without compromising surgical exposure and patient safety.
4.
Objectives/Hypothesis
Patients who present to the emergency department (ED) with various otolaryngologic disorders are frequently referred to an otolaryngologist for follow‐up care. Our aim was to ...further characterize this group as it has not been well described in the literature.
Study Design
Cross‐sectional retrospective study.
Methods
We reviewed the charts of patients seen during an 18‐month period in an urban public hospital trauma center adult ED and referred to an otolaryngology clinic for follow‐up care.
Results
Seven hundred thirty‐eight patients were seen and referred; the most common diagnoses made by ED providers were peripheral vertigo (12%), otitis externa (8%), and nasal fractures (8%). Nine percent of patients were evaluated during their ED visit by an otolaryngology provider. Three hundred seventy‐two (50%) patients returned for their otolaryngology clinic visit; facial trauma patients were least likely to return. The most common diagnoses made by otolaryngology providers were otitis externa (12%), peripheral vertigo (12%), and nasal fractures (7%). There was 50% concordance between patients’ diagnoses made by ED and otolaryngology providers. The most common differences were otitis media versus otitis externa (10%) and acute pharyngitis versus laryngopharyngeal reflux (8%). During 37% of follow‐up visits, an in‐office procedure was performed, most commonly flexible fiberoptic laryngoscopy, cerumen removal, and nasal endoscopy.
Conclusions
Our analysis reports comprehensive characteristics of this referral group, identifying potential areas for improvement in patient management, resident education and efficiency. Otolaryngologists covering EDs should be familiar with this population in terms of types of cases that may affect their practices.
Level of Evidence
4. Laryngoscope, 128:1062–1067, 2018
Background
Postparotidectomy sialocele is a frustrating challenge. Published rates of postparotidectomy fluid collections range from 6% to 39%. We report our experience of 398 parotidectomies ...performed over a 6‐year period.
Methods
A retrospective chart review of parotidectomies performed over a 6‐year period was completed. Drain placement, smoking status, tumor size, and postoperative utilization of scopolamine were analyzed. Binary logistical regression and odds ratio calculations were performed.
Results
Postparotidectomy sialocele occurred in 25% of patients. Neither suction drain placement nor usage of immediate postoperative scopolamine (in a 22‐patient subset) prevented sialocele formation. Smoking status also did not correlate. Increasing resection size was linearly correlated with the risk of sialocele.
Conclusion
Drain placement and smoking status do not correlate with sialocele prevention after parotidectomy. Sialocele formation directly correlates with the resection size. These data may guide preoperative counseling; however, additional work is necessary to identify effective prevention mechanisms for postparotidectomy sialocele.
Background
Oncocytic carcinoma (OCA) was recently reclassified as a distinct differentiated thyroid carcinoma (DTC). Given its rarity, OCA studies are limited. This study describes the ...characteristics of OCA in a 20‐year cohort.
Methods
Retrospective analysis of patients with OCA at a single tertiary care hospital from 2000 to 2021.
Results
Fifty‐one OCA patients (22M:29F) were identified. The mean age at diagnosis was 60.3 years; 90% presented as palpable mass; 24% had a family history of thyroid cancer. None had vocal fold paresis. On ultrasound, most tumors were solid and hypoechoic. FNA (n = 14) showed Bethesda‐4 lesions in 93%. All were treated surgically. Histologically, 63% demonstrated angioinvasion, 35% had lymphovascular invasion, and 15% had extrathyroidal extension. Radioactive iodine was used as adjunct therapy in 77%.
Conclusion
OCA has distinct features that distinguish it from other DTCs, and additional focused studies will help clarify the aggressive nature, treatment options, and prognosis of the disease.
We describe our experience using the extracorporeal video microscope, the "exoscope" for repair of a temporal bone encephalocele.
The patient is a 69-year-old male with a right temporal lobe ...encephalocele herniating through a tegmen defect. He underwent definitive tegmen defect repair and bipolar cauterization of the encephalocele. The authors elected for a combined transmastoid and transtemporal approach in order to isolate the tegmen defect and provide watertight repair. The Synaptive robotic BrightMatter (Toronto, ON) drive video exoscope monitor system was used for the entirety of the case including both the transmastoid approach and transtemporal craniotomy.
No intraoperative complications were encountered during either the transmastoid (mastoidectomy) or transtemporal craniotomy. The authors were able to complete the entire case without abandonment of the exoscope in favor of the traditional binocular microscope. Advantages of this technology in clinical practice includes high-resolution three-dimensional visualization, increased degrees of freedom for exoscope adjustment, and reduced surgeon fatigue in a fixed, unnatural posture. Limitations include decreased depth perception and increased operative time.
The exoscope system is a safe and effective alternative or adjunct to the existing binocular operating microscope for lateral skull based procedures. The exoscope provides the surgeon with a comfortable, high-resolution visualization without compromising surgical exposure and patient safety.SDC video link: http://links.lww.com/MAO/A837.
There is a lack of biomarkers for accurately prognosticating outcome in both human papillomavirus-related (HPV+) and tobacco- and alcohol-related (HPV-) oropharyngeal squamous cell carcinoma (OPSCC). ...The aims of this study were to i) develop and evaluate radiomic features within (intratumoral) and around tumor (peritumoral) on CT scans to predict HPV status; ii) investigate the prognostic value of the radiomic features for both HPV- and HPV+ patients, including within individual AJCC eighth edition-defined stage groups; and iii) develop and evaluate a clinicopathologic imaging nomogram involving radiomic, clinical, and pathologic factors for disease-free survival (DFS) prediction for HPV+ patients.
This retrospective study included 582 OPSCC patients, of which 462 were obtained from The Cancer Imaging Archive (TCIA) with available tumor segmentation and 120 were from Cleveland Clinic Foundation (CCF, denoted as S
) with HPV+ OPSCC. We subdivided the TCIA cohort into training (S
, 180 patients) and validation (S
, 282 patients) based on an approximately 3:5 ratio for HPV status prediction. The top 15 radiomic features that were associated with HPV status were selected by the minimum redundancy-maximum relevance (MRMR) using S
and evaluated on S
. Using 3 of these 15 top HPV status-associated features, we created radiomic risk scores for both HPV+ (RRS
) and HPV- patients (RRS
) through a Cox regression model to predict DFS. RRS
was further externally validated on S
. Nomograms for the HPV+ population (M
) were constructed. Both RRS
and M
were used to prognosticate DFS for the AJCC eighth edition-defined stage I, stage II, and stage III patients separately.
RRS
was prognostic for DFS for i) the whole HPV+ population hazard ratio (HR) = 1.97, 95% confidence interval (CI): 1.35-2.88,
< 0.001, ii) the AJCC eighth stage I population (HR = 1.99, 95% CI: 1.04-3.83,
= 0.039), and iii) the AJCC eighth stage II population (HR = 3.61, 95% CI: 1.71-7.62,
< 0.001). HPV+ nomogram M
(C-index, 0.59; 95% CI: 0.54-0.65) was also prognostic of DFS (HR = 1.86, 95% CI: 1.27-2.71,
= 0.001).
CT-based radiomic signatures are associated with both HPV status and DFS in OPSCC patients. With additional validation, the radiomic signature and its corresponding nomogram could potentially be used for identifying HPV+ OPSCC patients who might be candidates for therapy deintensification.
To determine the diagnostic efficacy and clinical value of preoperative computed tomography (CT) and magnetic resonance imaging (MRI) among patients with suspected temporal bone encephaloceles (TBE).
...Retrospective chart review from 2006 to 2018.
Tertiary referral center.
The subjects underwent surgery for a clinically suspected TBE or cerebrospinal fluid (CSF) leak. Preoperative imaging test characteristics of CT and MRI, including sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV), were calculated for TBE scans and compared with intraoperative findings.
Fifty-seven subjects with otorrhea, middle ear effusion, hearing loss, and/or meningitis with suspected TBE or CSF leak were identified. All had preoperative CT scans, and 61% (35/57) had preoperative MRI scans. Intraoperatively, 37 of 57 patients (65%) were found to have a TBE. CT scans (17% sensitivity, 100% specificity, 100% PPV, 46% NPV) were less sensitive than MRI (58% sensitivity, 100% specificity, 100% PPV, 24% NPV) for detecting TBEs. Furthermore, the time from initial scan to operative repair was significantly longer in those who had a CT followed by MRI scan compared with CT alone or a fused CT-MRI scan (mean = 68 vs 15 days, respectively;
= .004).
CT and MRI provide complementary information that may aid surgical planning. However, imaging cannot always rule out TBE. In cases with high clinical suspicion, surgical confirmation is often required for definitive diagnosis and treatment. The cost of an additional preoperative study should be considered before its use.
This paper introduces feature gradient flow, a new technique for interpreting deep learning models in terms of features that are understandable to humans. The gradient flow of a model locally defines ...nonlinear coordinates in the input data space representing the information the model is using to make its decisions. Our idea is to measure the agreement of interpretable features with the gradient flow of a model. To then evaluate the importance of a particular feature to the model, we compare that feature's gradient flow measure versus that of a baseline noise feature. We then develop a technique for training neural networks to be more interpretable by adding a regularization term to the loss function that encourages the model gradients to align with those of chosen interpretable features. We test our method in a convolutional neural network prediction of distant metastasis of head and neck cancer from a computed tomography dataset from the Cancer Imaging Archive.
PDF