Selectively sparing the submandibular gland when level Ib lymph nodes are included in the radiation target volume: An initial safety analysis of a novel planning objective

Publication date: February 2019

Source: Oral Oncology, Volume 89

Author(s): Vamsi Varra, Richard B. Ross, Aditya Juloori, Shauna Campbell, Martin C. Tom, Nikhil P. Joshi, Neil M. Woody, Matthew C. Ward, Ping Xia, Shlomo A. Koyfman, John F. Greskovich

Abstract

Background

Submandibular gland (SMG) metastases are extremely rare in head and neck cancer, even in the presence of level Ib lymph node (LN) involvement. In recent years, we have contoured the SMG and specifically attempted to limit its dose exposure even in patients in whom the level Ib LN station is targeted. This study reports our preliminary feasibility and safety experience with selective submandibular gland sparing.

Methods

Patients with squamous cell cancer (SCC) of the oral cavity or oropharynx with T1-2, N0-3, M0 disease in whom at least a single level Ib lymph node region was included in the target volume were identified. All patients were treated from 2009 to 2014 with definitive or postoperative IMRT with or without chemotherapy. Patients with recurrent disease, previous radiation or treated palliatively were excluded.

Results

A total of 174 patients met criteria for inclusion. Among the 185 level Ib LN stations that were deliberately targeted in the clinical treatment volume, 32 submandibular glands were contoured, excluded from the target volume and avoided during treatment planning. Mean dose to the spared SMG were reduced by 12% (66.6 Gy vs. 58.9 Gy, p < .001). None of these patients experienced any level 1b LN failures.

Conclusion

Selective sparing of the submandibular gland when targeting the level 1b nodes in oral cavity and oropharynx cancer is feasible, reduces the mean dose to submandibular glands and does not result in increased level 1b nodal failure rates. Additional studies with larger cohorts are needed to validate this preliminary observation.

http://bit.ly/2BEyil6

Comment on “‘Chronic traumatic ulcer of lateral tongue’ – An underestimated ‘oral potentially malignant disorder’?”

Publication date: Available online 26 December 2018

Source: Oral Oncology

Author(s): Jerónimo P. Lazos, René L. Panico, Gerardo M. Gilligan, Eduardo D. Piemonte

http://bit.ly/2QRHblP

A rare case of nasopharyngeal adenoid cystic carcinoma treated with cetuximab-based induction therapy followed by concurrent chemoradiotherapy

Publication date: Available online 26 December 2018

Source: Oral Oncology

Author(s): Shihai Wu, Jingwen Liu, Rencui Quan, Ling Han

http://bit.ly/2BEyelm

Threat of a Cycle Proof: Vertebral Artery Dissection Associated with Posterior Inferior Cerebellar Artery Infarction

This paper presents a case of a perfectly healthy 36-year-old male, who went to the emergency department with a clinical picture of diffuse headache, dizziness, and asthenia with 3 days of evolution, after a long cycling race. He was admitted to the ENT Department with suspected diagnosis of peripheral vertigo. The patient developed hypoesthesia of the face, diplopia, right lateropulsion, and Romberg with preferential rightward fall, and imaging studies demonstrated an extracranial vertebral artery dissection concomitant with PICA territory infarction. This is a rare described case of a vertebral artery dissection concomitant with an infarction of the PICA territory. This case demonstrates the importance of maintaining a high degree of suspicion of stroke in patients with signs/symptoms of nystagmus/vertigo and the relevance of magnetic resonance imaging instead of tomography in the detection of these serious clinic conditions.

http://bit.ly/2TeKjoS

Utility of response assessment PET-CT to predict residual disease in neck nodes: A comparison with the Histopathology

Publication date: Available online 26 December 2018

Source: Auris Nasus Larynx

Author(s): Khuzema Saifuddin Fatehi, Shivakumar Thiagarajan, Harsh Dhar, Nilendu Purandare, Anil K. DCruz, Devendra Chaukar, Sarbani Ghosh Laskar, Kumar Prabhash, Venkatesh Rangarajan

Abstract

Objective

To assess the ability of Positron Emission Tomography-Computed Tomography (PET-CT) scans to detect residual disease in neck nodes with the Histopathology (HPR) as the gold standard. To obtain a Standardized Uptake Value max cutoff in these patients to predict residual disease in neck.

Methods

Head and neck squamous cell carcinoma patients who underwent Salvage neck dissection with or without primary site surgery post Concurrent Chemo-Radiotherapy (CCRT) during the period January 2008–December 2017 were included. All patients had response assessment PET-CT scan at 10–14 weeks. Agreement analysis was performed between PET-CT and HPR, fine needle aspiration cytology and HPR. Positive predictive value, Negative predictive value of PET-CT to detect residual neck nodal disease in comparison to HPR was analyzed. A Receiver Operating Characteristic (ROC) curve was plotted between the SUV max values and the HPR. A SUV max cutoff value was obtained from the ROC curve.

Results

A total of 75 patients were included. Thirty-one underwent salvage neck dissection along with surgery for primary disease and 45 underwent salvage neck dissection alone. PET-CT showed good agreement with the HPR to detect residual disease in neck nodes (Kappa = 0.604). PET-CT had a PPV and NPV of 87.5% and 79.15% respectively as compared against the HPR. A SUV max cutoff of 4.62 had a specificity of 92.3% and sensitivity of 73.5% to detect residual disease in neck nodes on the HPR.

Conclusion

PET-CT surveillance is an accepted treatment strategy. A neck node with SUV max of 4.62 and above is most likely to harbor residual nodal disease.

Level of evidence: Level 2b

http://bit.ly/2TglGIl

Sclerostin injection enhances orthodontic tooth movement in rats

Publication date: Available online 26 December 2018

Source: Archives of Oral Biology

Author(s): Wenxin Lu, Xuan Zhang, Fiona Firth, Li Mei, Jianru Yi, Changyang Gong, Hanshi Li, Wei Zheng, Yu Li

Abstract

Objective

It was aimed to investigate the in vivo effects of local injection of sclerostin protein on orthodontic tooth movement.

Design

A total of 48 rats underwent orthodontic mesialization of the maxillary first molars on both sides. Local injection was given at the compression side in the alveolar bone on both maxillary sides, with sclerostin protein carried by hydrogel on one side, and the same volume of normal saline carried by hydrogel on the other side serving as the control. After two weeks, the tooth movement amount and effects on the periodontium were assessed through micro-computed tomography (μCT) analysis, tartrate-resistant acid phosphatase (TRAP) staining and immunohistochemistry (IHC) analysis.

Results

After two weeks of intervention, tooth movement was significantly greater in the 4 μg/kg and 20 μg/kg sclerostin injection groups, compared to the control. Analysis of the furcation area of the maxillary first molar showed that the 20 μg/kg group had significantly decreased BV/TV. At the compression side, the number of TRAP-positive osteoclasts was significantly increased in 20 μg/kg group compared to the control. The expression of RANKL was statistically higher in all the sclerostin groups, while the expression of OPG was statistically lower in the 4 μg/kg and 20 μg/kg groups, compared to the control. At the tension side, the expression of RUNX2 and COL-1 was statistically higher in the 20 μg/kg group compared to the control.

Conclusions

Local injection of sclerostin protein in the alveolar bone at the compression side accelerates OTM in rats by promoting osteoclastogenesis.

http://bit.ly/2AfDpsg

Effect of dentinal fluid on enamel permeability under simulated pulpal pressure

Publication date: Available online 26 December 2018

Source: Archives of Oral Biology

Author(s): Narinee Chinajitphan, Ekachai Chunhacheevachaloke, Orapin Ajcharanukul

Abstract

Objective

To determine the effect of pulpal perfusion on the fluid flow through human tooth after different treatments at the enamel surface. Changes in mineral density along with fluid flow rate were also analyzed before and after etching.

Design

The experiments were carried out on 97 human premolars. Ringer's solution and distilled water (DW) were applied under pressure of 20 mm Hg to the pulpal cavity of tooth crowns in the Ringer's-perfused and water-perfused groups respectively. Fluid flow through each specimen was recorded before and 0, 30, 60, 180 min after treatments at the enamel surface. The treatments included DW, 0.2% sodium fluoride solution, 1.23% acidulated phosphate fluoride gel (APF), 2.26% fluoride varnish (FV), 37% phosphoric acid gel (Etch) and artificial saliva (AS). Mineral density of the enamel was evaluated using micro-computed tomography.

Results

In water-perfused group, fluid flow rates recorded after etching were significantly increased (p = 0.005) with the significant reduction of mineral density (p = 0.018) from baseline. A significant negative correlation was found (r = -0.78, p = 0.015). After FV, the percentage reduction from baseline was significant at 180 min (p = 0.003). In Ringer's-perfused group, etching immediately produced the greatest mean flow rate and subsequently returned to the baseline within 60 min after treatment (p < 0.001). There were approximately 40, 55, and 63% reductions of flow rates within 60 min after AS, APF and FV respectively.

Conclusion

Under simulated pulpal pressure, enamel fluid involves the process of enamel remineralization, particularly after etching.

http://bit.ly/2So8Nfc

English Translation and Validation of the Zurich Chronic Middle Ear Inventory (ZCMEI‐21‐E) Assessing Quality of Life in Chronic Otitis Media: A Prospective International Multicenter Study

Abstract

Objectives

To translate and validate the Zurich Chronic Middle Ear Inventory (ZCMEI‐21) for the English language in order to provide an English instrument to assess health‐related quality of life in chronic otitis media (COM).

Design

Pilot translation study including cognitive debriefings, prospective multicenter cross‐sectional psychometric validation study.

Setting

Four tertiary referral centers in three different English‐speaking countries (United Kingdom, United States of America and Australia).

Participants

Adult patients suffering from COM.

Main outcome measures

The English translation of the ZCMEI‐21 (ZCMEI‐21‐E) and the five‐level version of the EQ‐5D questionnaire. The EQ‐5D, which constitutes a generic measure of health‐related quality of life, consists of a descriptive system score and a visual analogue scale. Statistical outcomes included single item descriptive statistics, internal consistency (Cronbach's α) as an indicator of reliability, as well as construct validity.

Results

A total of 124 patients suffering from COM were included. The mean age was 50.1 years (SD 16.9 years) and 72 (58.1%) were males. The Cronbach's α of the ZCMEI‐21‐E was 0.91, suggesting an excellent internal consistency. The Spearman's correlation coefficient of the ZCMEI‐21‐E total score was 0.55 (p < 0.0001) for convergent construct validity with EQ‐5D descriptive system score and 0.57 (p < 0.0001) with the EQ‐5D visual analogue scale.

Conclusions

The ZCMEI‐21‐E is a new validated questionnaire that provides clinicians with a short, comprehensive and reliable instrument to quantify health‐related quality of life in patients suffering from COM. The ZCMEI‐21‐E may be of use in clinical routine as well as in outcome research and monitoring.

This article is protected by copyright. All rights reserved.

http://bit.ly/2BG0ap1

Quality of life improvement following parathyroid surgery: a preliminary three‐year review of fifty‐six patients from a single surgical centre

Abstract

We describe our experience of quality of life outcomes in patients who underwent parathyroid surgery for primary hyperparathyroidism within a single surgical centre at a district general hospital. We present a retrospective cohort analysis of all patients who underwent parathyroid surgery for primary hyperparathyroidism over a three‐year period within a new surgical service. We describe our experience of surgical outcomes between symptomatic and asymptomatic patients with PHPT. To our knowledge, this is the first paper to describe patient reported outcome measures (PROM) in parathyroid surgery for PHPT using the Glasgow Benefit Inventory.

This article is protected by copyright. All rights reserved.

http://bit.ly/2QUqma6

The glottis is not round: Teardrop‐shaped glottic dilation for early posterior glottic stenosis

Objectives

Posterior glottic stenosis (PGS) results in severe derangement of laryngeal configuration and function with significant morbidity as a sequalae. Presently, there is no treatment for patients with "early" PGS. Dilation is often used for stenotic disease, but present dilation methods are limited to a round shape and the glottis is a sector (teardrop‐shaped). Round dilation of the larynx results in compression of the membranous vocal folds (with potential for injury) and minimal expansion of the posterior larynx. We present a novel laryngeal dilation method that matches the unique anatomic shape of the glottis: teardrop‐shaped glottis dilation (TSGD).

Methods

We present a clinical series of early PGS patients treated with a TSGD. Five patients with dyspnea and significantly reduced vocal fold mobility due to early PGS were treated with TSGD, which involves placement of a triangular static stent in the anterior glottis, with simultaneous use of a round balloon dilator in the posterior glottis.

Results

All patients reported improved ease of breathing and decrease in Dyspnea Index score and were decannualated following treatment. Video perceptual analysis of pre‐/postlaryngoscopy examinations was performed with five blinded reviewers, and all patients were scored to have improved posterior glottic airway space following treatment with a mean improvement of 2.4 on a 11‐point scale.

Conclusion

These clinical results demonstrate that there is enormous potential for the identification and treatment of patients with early PGS and use of a laryngeal dilation technique that matches the anatomic configuration of the glottis.

Level of Evidence

4. Laryngoscope, 2018

http://bit.ly/2LAlWiK

Subpectoral implantation of the hypoglossal nerve stimulator: An effective technical modification

Upper airway stimulation is now a well‐established treatment option for selected patients with obstructive sleep apnea. The implanted pulse generator of this system activates the hypoglossal nerve and is routinely placed in a subcutaneous pocket overlying the pectoralis muscle. This case report describes a patient with a history of bilateral mastectomy and radiation for breast cancer who required explantation due to device exposure and infection. The patient was successfully reimplanted by placing the implantable pulse generator deep to the pectoralis major muscle. Clinical circumstances involving the chest wall may warrant subpectoral placement of the implanted pulse generator. Laryngoscope, 2018

http://bit.ly/2rVB8xF

Is routine genetic testing warranted in head and neck paragangliomas?

http://bit.ly/2LB8lHV

The medial sural artery perforator flap: A better option in complex head and neck reconstruction?

Objectives

The medial sural artery perforator (MSAP) free flap is an uncommonly utilized soft tissue flap in head and neck reconstruction. It is a thin, pliable, fasciocutaneous flap that provides significant pedicle length. The donor site can be closed primarily, and its location is more aesthetically pleasing to patients. We aim to describe the MSAP flap and compare it to other commonly used free flaps in the head and neck.

Study Design

Retrospective case series.

Methods

A retrospective review of all MSAP cases performed at New York University Langone Health was performed from July 2016 to November 2017. We examined the patients' age, diagnosis, history of prior radiation therapy, and comorbidities, as well as flap‐specific information and recipient site.

Results

Twenty‐one patients underwent a variety of different head and neck procedures with coverage using an MSAP flap. Recipient sites included tongue, cheek, soft and hard palate, cervical esophagus, and pharynx. Pedicle length ranged from 8 cm to 12 cm. The smallest surface area harvested was 24 cm² (6 cm × 4 cm), and the largest was 120 cm² (15 cm × 8 cm). The flaps ranged from 5 to 12 mm in thickness. Venous coupler size ranged from 2.0 to 3.5 mm. Primary closure of the donor site was achieved in 18 of 21 flaps. Twenty of 21 flaps were transferred successfully.

Conclusion

The MSAP flap is a highly versatile and reliable option for a thin, pliable soft tissue flap with a donor site that may be preferable over the radial forearm free flap and anterolateral thigh flap in complex head and neck reconstruction.

Level of Evidence

4. Laryngoscope, 2018

http://bit.ly/2rTj5IA

A novel silk‐based vocal fold augmentation material: 6‐month evaluation in a canine model

Objectives

Ideal long‐term vocal fold augmentation materials should be biocompatible, easily administered, allow tissue integration for long‐term effect, and remain at the site of injection. A novel silk protein particle suspended in hyaluronic acid (Silk‐HA) has been developed specifically for vocal fold augmentation to address this unmet need. This article presents the 6‐month, preclinical findings of a canine vocal fold injection trial for Silk‐HA.

Methods

Twelve beagle dogs were injected transorally in the lateral/deep aspect of their right thyroarytenoid muscles with 0.3 cc of Silk‐HA or calcium hydroxylapatite in carboxymethyl cellulose (CaHA‐CMC). The Silk‐HA particle injectable was delivered via a custom catheter, whereas CaHA‐CMC was delivered through a commercially available malleable needle. The six dogs from each material group were sacrificed 6 months from the injection date for the evaluation of implant longevity, immune response, and material migration.

Results

Silk‐HA provides immediate medialization of the right vocal fold, lasting for a minimum of 6 months in a canine model. Silk‐HA and CaHA‐CMC both demonstrate similar inflammatory responses. The Silk‐HA was shown to remain without migration at the site of injection in all six canine subjects, whereas CaHA‐CMC demonstrated migration in four of the six canines. In two canines implanted with CaHA‐CMC, material was discovered to migrate to the retropharyngeal lymph nodes.

Conclusion

In a canine subject model, the Silk‐HA material compares favorably in terms of longevity and immune response to CaHA‐CMC. The lack of migration of the Silk‐HA material demonstrates a promising potential for vocal fold injection in the clinic.

Level of Evidence

NA Laryngoscope, 2018

http://bit.ly/2SnIgyz

Management of difficult airway among patients with oropharyngeal angioedema

Objective

The objective of our study was to assess the impact of a multidisciplinary difficult airway response team (DART), a quality improvement program, in the management of patients with difficult airway associated with oropharyngeal angioedema patients.

Methods

Individual retrospective cohort study. Retrospective review of patient charts from July 2003 to June 2008 (pre‐DART) and retrospective review of prospectively collected data from July 2008 to June 2013 (post‐DART). Patients with angioedema were identified using International Classification of Disease codes 995.1 and 277.6. Patients were included in the study if an otolaryngologist was consulted for airway management. Patients were excluded if they had a history of angioedema but no active issues. Patient characteristics, airway evaluation, and interventions (intubation/surgical airway) were compared between the pre‐DART and post‐DART cohort.

Results

The DART team attended to 27 patients with advanced oropharyngeal angioedema. Response time averaged 3.36 minutes. Preintubation fiberoptic airway evaluations were performed in 81% of the post‐DART cohort and 56% of the pre‐DART cohort. The incidence of patients requiring intubation was higher in the post‐DART cohort (18 out of 27 [67%]) than the pre‐DART (14 out of 36 [39%]) cohort. One emergency cricothyroidotomy was performed in each of the post‐DART and pre‐DART cohorts.

Conclusion

Angioedema of the larynx is a predictor of intubation or cricothyroidotomy. Fiberoptic‐guided intubation is primarily used for establishing airway in angioedema patients. A multidisciplinary standardized approach such as the DART program offers adequate time and resources for airway evaluation prior to intervention and allows fewer number of attempts to secure an airway.

Level of Evidence

3. Laryngoscope, 2018

http://bit.ly/2AeZd79

Safe use of systemic bevacizumab for respiratory recurrent papillomatosis in two children

Recurrent respiratory papillomatosis can be a devastating condition for a child, with severe consequences. Currently, there is no proven successful medical treatment. We describe the use of systemic bevacizumab to treat two children affected by aggressive recurrent respiratory papillomatosis. Respiratory symptoms and quality of life improved dramatically in both patients, without observing any toxicity. The only complication was mild proteinuria. Systemic bevacizumab is a promising adjuvant treatment in aggressive recurrent respiratory papillomatosis in children. It is effective and well tolerated. Further studies are needed to establish the optimal dosing frequency and duration of therapy. Laryngoscope, 2018

http://bit.ly/2SnbdL8

Safety of outpatient unilateral medialization laryngoplasty across two academic institutions

Objectives/Hypothesis

Unilateral ML is a commonly performed surgery for dysphonia secondary to glottic insufficiency. The safety of this procedure performed in the outpatient setting has not been extensively examined. The purpose of the study was to assess the safety of outpatient unilateral ML in adults and determine the incidence and timing of postoperative complications across two tertiary‐care academic medical centers.

Study Design

Retrospective chart review,

Methods

A review of patients undergoing unilateral ML at two tertiary‐care academic centers from 2011 to 2017 was performed. Patients undergoing bilateral medialization laryngoplasty, revision surgery, or those undergoing additional laryngeal framework procedures including arytenoid adduction were excluded. Patient demographics, operative details, and perioperative and postoperative complications were recorded. Comparisons were made between those individuals who underwent inpatient versus outpatient ML.

Results

One hundred three total procedures met inclusion criteria. Fifty‐seven were performed as outpatient procedures, and 46 individuals were observed for at least 23 hours following surgery. Silastic or Gore‐Tex implants were used in all but two surgeries. There were no postoperative complications in either setting, including hematoma, dyspnea, wound infections or seromas.

Conclusions

The incidence of adverse events during and immediately following unilateral ML is very low. Patients can be discharged safely the day of surgery without geographic restrictions.

Level of Evidence

4 Laryngoscope, 2018

http://bit.ly/2AjzHxG

Table of contents

http://bit.ly/2SkuxZi

Tracheal replacement revisited: Use of a vascularized tracheal transplant in a porcine model

Objectives/Hypothesis

To determine if a long segment of trachea can be transplanted as a vascularized organ and to determine if a tracheal transplant is a potential surgical option for a long‐segment circumferential tracheal defect.

Study Design

Animal model.

Methods

Four (two donors and two recipients) adult domestic Yorkshire swine were used. Two sets of transplants were performed from a donor to recipient pig. The transplant was placed heterotopically (not in continuity with the airway), and the recipient animals were monitored for 14 days to ensure the transplants were well vascularized. Immunosuppressive therapies included methylprednisolone, cyclosporine, and azathioprine. Gross as well as histological examination of multiple tissues types including mucosa, cartilage, muscle, and blood vessels were performed postsacrifice on day 14.

Results

Recipient animal weights ranged from 40 to 42 kilograms. Both recipient pigs survived the full 14 days of study and exhibited normal activity and appetite. Ischemia time of transplanted grafts ranged from 63 to 72 minutes. Transplanted tracheas included a minimum of 15 cartilaginous rings and measured greater than 10 cm in length. Both grafts maintained a robust blood supply throughout the duration of study.

Conclusions

The entire visceral compartment can be reliably transplanted, either as a single component (trachea) or as a chimeric flap with multiple components (trachea, esophagus, larynx, and pharynx). Further studies in the swine model should be considered to study the effects of transplanting the trachea orthotopically into the native airway. Further studies are needed into the reliability of this technique of transplantation in humans.

Level of Evidence

NA Laryngoscope, 128:S1–S9, 2018

http://bit.ly/2AjAyhR

Masthead

http://bit.ly/2SnL2Uq