Introduction
Patients who become severely ill from coronavirus disease 2019 (COVID‐19) have a high likelihood of needing prolonged intubation, making tracheostomy a likely consideration. The ...infectious nature of COVID‐19 poses an additional risk of transmission to healthcare workers that should be taken into consideration.
Methods
We explore current literature and recommendations for tracheostomy in patients with COVID‐19 and look back at previous data from severe acute respiratory syndrome coronavirus 1 (SARS‐CoV‐1), the virus responsible for the SARS outbreak of 2003.
Results
Given the severity and clinical uncertainty of patients with COVID‐19 and the increased risk of transmission to clinicians, careful consideration should be taken prior to performing tracheostomy. If tracheostomy is performed, we recommend a bedside approach to limit exposure time and number of exposed personnel. Bronchoscopy use with a percutaneous approach should be limited in order to decrease viral exposure.
Conclusion
Thorough preprocedural planning, use of experienced personnel, enhanced personal protective equipment where available, and a thoughtful anesthesia approach are instrumental in maximizing positive patient outcomes while successfully protecting the safety of healthcare personnel. Laryngoscope, 130:2546–2549, 2020
ABSTRACTHead and neck structures govern the vital functions of breathing and swallowing. Additionally, these structures facilitate our sense of self through vocal communication, hearing, facial ...animation, and physical appearance. Loss of these functions can lead to loss of life or greatly affect quality of life. Regenerative medicine is a rapidly developing field that aims to repair or replace damaged cells, tissues, and organs. Although the field is largely in its nascence, regenerative medicine holds promise for improving on conventional treatments for head and neck disorders or providing therapies where no current standard exists. This review presents milestones in the research of regenerative medicine in head and neck surgery.
The purpose of this study was to determine if dose de-escalation from 60 to 66 Gy to 30 to 36 Gy of adjuvant radiotherapy (RT) for selected patients with human papillomavirus-associated oropharyngeal ...squamous cell carcinoma could maintain historical rates for disease control while reducing toxicity and preserving swallow function and quality of life (QOL).
MC1273 was a single-arm phase II trial testing an aggressive course of RT de-escalation after surgery. Eligibility criteria included patients with p16-positive oropharyngeal squamous cell carcinoma, smoking history of 10 pack-years or less, and negative margins. Cohort A (intermediate risk) received 30 Gy delivered in 1.5-Gy fractions twice per day over 2 weeks along with 15 mg/m
docetaxel once per week. Cohort B included patients with extranodal extension who received the same treatment plus a simultaneous integrated boost to nodal levels with extranodal extension to 36 Gy in 1.8-Gy fractions twice per day. The primary end point was locoregional tumor control at 2 years. Secondary end points included 2-year progression-free survival, overall survival, toxicity, swallow function, and patient-reported QOL.
Accrual was from September 2013 to June 2016 (N = 80; cohort A, n = 37; cohort B, n = 43). Median follow-up was 36 months, with a minimum follow-up of 25 months. The 2-year locoregional tumor control rate was 96.2%, with progression-free survival of 91.1% and overall survival of 98.7%. Rates of grade 3 or worse toxicity at pre-RT and 1 and 2 years post-RT were 2.5%, 0%, and 0%. Swallowing function improved slightly between pre-RT and 12 months post-RT, with one patient requiring temporary feeding tube placement.
Aggressive RT de-escalation resulted in locoregional tumor control rates comparable to historical controls, low toxicity, and little decrement in swallowing function or QOL.
Article Note: Editor's Note: This Manuscript was accepted for publication on December 11, 2020. The authors have no funding, financial relationships, or conflicts of interest to disclose. Byline: ...Jeffrey C. Mecham, Olivia J. Thomas, Phillip Pirgousis, Jeffrey R. Janus
Pleomorphic liposarcomas (PLS) are the rarest subtype of liposarcomas, representing only 5-10% of liposarcomas. Pleomorphic liposarcomas are extremely aggressive and have a poor prognosis. Here, we ...present the case of a 66-year-old female who presented with difficulty swallowing, talking, and hearing. An extensive investigation revealed the presence of an aggressively growing parapharyngeal space mass. The patient underwent a left parapharyngeal space exploration and left deep lobe parotidectomy by the cervicoparotid approach. Histopathological evaluation of the surgical specimen further confirms the presence of pleomorphic subtype of liposarcoma. The patient received adjuvant radiotherapy following the procedure. At 6 months postop, the patient is in good health and shows no evidence of recurrence. In addition to this treatment, we discuss the radiologic and histologic findings of this current case.
Background
Parotid gland mucoepidermoid carcinoma (MEC) has published five‐year cancer‐specific survival (CSS) rates of 77%–97%, with variance related to grade.
Methods
Patients receiving primary ...surgery for parotid gland MEC from 1995 to 2014 at a tertiary medical center underwent clinical review, histopathologic review, and cytogenetic analysis. Survival outcomes were evaluated.
Results
Among 58 patients, T/N/M classification was as follows: T1 in 35 patients, T2 in 14, T4a in 9, N0 in 53, N1 in 2, N2b in 3. Histologic grade was low in 27, intermediate in 17, and high in 12 patients with 98% MAML2 positivity. All patients underwent parotidectomy, and seven patients received adjuvant radiation therapy. CSS was 100% at 5 years and 94.1% at 10 and 15 years. Two patients experienced locoregional recurrence.
Conclusions
Treatment with adequate surgical resection and adjuvant radiation therapy for high‐grade or advanced‐stage tumors yields excellent survival, independent of clinical stage or pathologic grade.
Objectives/Hypothesis
Sinonasal mucosal melanoma (SNMM) is a rare malignant neoplasm. No study to date has analyzed the impact that nodal metastases and distant metastases at diagnosis have on ...overall survival (OS) and disease‐specific survival (DSS).
Study Design
Retrospective database review.
Methods
The Surveillance, Epidemiology, and End Results database was queried for cases of SNMM. Descriptive statistics were used analyze patient demographic and clinicopathologic variables. The Kaplan‐Meier model was used to analyze survival, and the Cox proportional hazards model was used for multivariate analysis.
Results
Three hundred twenty‐eight cases of SNMM were identified. The most frequent sinonasal anatomic location was the nasal cavity in 279 (73.0%) patients, followed by the maxillary sinus in 60 (15.7%) patients. Regional nodal metastases at diagnosis occurred in 33 (8.6%) patients, whereas distant metastases at diagnosis occurred in 41 (10.7%) patients. Five‐year OS was 22.7%, and 5‐year DSS was 26.8%. The presence of positive nodes at diagnosis (OS P < .0001, DSS P < .0001), distant metastases at diagnosis (OS P = .0442, DSS P = .0442), primary tumor site (OS P < .0001, DSS P < .0001), and increasing age (OS P = .0012, DSS P = .0016) were found to be significant as negative predictors of OS and DSS.
Conclusions
SNMM is a rare pathologic entity with a poor prognosis. The presence of nodal and distant metastases at diagnosis are negative prognostic factors in OS and DSS. These factors can be used in the development of new models of risk stratification and to inform treatment strategies and surveillance patterns.
Level of Evidence
NA
Laryngoscope, 130:622–627, 2020
The ongoing coronavirus disease 2019 (COVID-19) pandemic has increased the need for safe and efficient testing as a key containment strategy. Drive-through testing with nasopharyngeal swab has been ...implemented in many places in the USA as it allows for expeditious testing of large numbers of patients, limits healthcare workers’ risk of exposure, and minimizes the use of personal protective equipment. We present a case where the aluminum shaft of the nasopharyngeal swab fractured during specimen collection at a drive-through testing facility and was suspected to have remained in the asymptomatic patient. Initial evaluation with a series of radiographs covering the skull base, neck, chest, and abdomen did not reveal the swab. On further clinical evaluation, the swab was found endoscopically, lodged between the left inferior turbinate and nasal floor, and was removed by an otorhinolaryngologist. Using a phantom model, we aimed to delineate an imaging technique to better visualize the aluminum shaft of the nasopharyngeal swab on radiographs to help in identification. A technique using lower tube voltage (kVp) with tight collimation centered at the nasal bones area produced the best visualization of the aluminum shaft of the swab. Recognition that aluminum foreign bodies may be difficult to visualize radiographically and optimization of radiograph acquisition technique may help guide clinical management in unusual cases. Further evaluation with computed tomography or endoscopy should be considered in suspected cases where radiographs are negative.
The management of clival chordoma in our group shifted around 2013 to mostly endoscopic, and proton beam was introduced for our multidisciplinary team. Consecutive patients who had surgical resection ...from 1987 to 2021 were reviewed. A total of 58 patients (39 patients after 2013) were analyzed. The mean tumor size was 3.7 cm, and the most common location was the upper clivus (43%). Compared to before 2013, after 2013, the endoscopic endonasal approach was more common (90%, p < 0.001), and more gross or near total resections (64%, p = 0.002) were attained. Ten cases (17%) were revision surgeries referred from elsewhere, and three cases (5%) underwent additional surgery elsewhere before adjuvant radiation. The postoperative cerebrospinal fluid leak occurred in 7%. Post-operative new cranial nerve deficits occurred in 32% before 2013, compared to 2.6% after 2013 (p = 0.004). For cases before 2013, 10 patients (53%) recurred during the median follow-up of 144 months (mean, 142 months), whereas for cases after 2013, seven patients (18%) recurred with a median follow-up of 35 months (mean, 42 months). 5-year progression-free survival was 58%, and 5-year overall survival was 87%. A specialized multidisciplinary team improved the resection rate compared to a historical cohort with an excellent morbidity profile.
Objectives
To assess the outcomes of abdominal dermal‐fat grafting following superficial and total parotidectomy.
Methods
A retrospective chart review of parotidectomy patients was performed. ...Patients were divided into four groups based on surgical extent and grafting status: superficial parotidectomy (SP), superficial parotidectomy with grafting (SPg), total parotidectomy (TP), and total parotidectomy with grafting (TPg). Complication rates and operative times were then compared between surgically matched groups (SP vs. SPg, TP vs. TPg). Complications included graft necrosis, gustatory sweating, first‐bite syndrome, infection, hematoma, sialocele, and seroma. Data was analyzed via chi‐square and two‐sample t testing, logistic regression, and one‐way analysis of variance.
Results
The cohort consisted of 330 patients: 106 SP (32.12%), 61 SPg (18.48%), 82 TP (24.85%), and 81 TPg (24.55%). No donor site complications occurred. TPg resulted in seven graft necroses (8.64%), and 22 reported gustatory sweating (27.20% vs. 10 TP patients (12.2%), P = 0.016); SPg resulted in two necroses (3.28%). There were no other statistically significant differences in complication rates. Graft recipients receiving adjuvant radiation were more likely to develop necrosis (odds ratio OR 4.60, 95% confidence interval CI, 1.16–18.27, P = .0194). Patients who developed gustatory sweating were 8.38 years younger (95% CI 2.66–14.10, P = 0.002, follow‐up time > 48 days). Grafting did not increase operative times (TP/TPg: mean = 275.91/263.65 minutes, standard error of the mean = 41.96/33.75, P = 0.822).
Conclusion
An abdominal dermal‐fat graft is an excellent reconstructive choice for a parotidectomy defect and is not associated with increased complication rates or prolonged operative time.
Level of Evidence
4 Laryngoscope, 130:2144–2147, 2020
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