Olsen, Kerry D.

Objectives/HypothesisTransoral surgery (TOS) is commonly performed in a supine patient with an oral retractor. Paradoxically, this strategy can create difficulty with visualizing and accessing pathology at the base of tongue, inferior pharynx, and larynx. We investigate the feasibility of TOS with the patient in the seated position.Study DesignPilot study.MethodsTOS utilizing the da Vinci Robotic Surgical Xi and Si systems (Intuitive Surgical, Sunnyvale, CA) was performed on a fresh cadaver placed in both the traditional supine position and the seated position. Transoral robotic surgery (TORS) in the seated position was then performed on two patients for a supraglottic laryngectomy and a hypopharyngeal carcinoma resection.ResultsVisualization of the entire upper aerodigestive tract was possible in the cadaver and two patients in the seated position. The Si was superior for docking, instrumentation, and assistant access. The minimum operating table height is critical for successful access. Advantages of this position included increased posterior airway/operative space by approximately 2 cm, ability to manipulate the surgical field (nonrigid retraction), and improved visualization. Surgical procedures were completed in comparable times compared with standard TORS procedures. There were no complications related to seated TORS.ConclusionsTORS in the seated position was both safe and effective in this pilot study. It allows the surgeon to optimally operate in the inferior pharynx and larynx without the limitation of line of site access and visualization. A paradigm shift in patient positioning during TOS may allow improved surgical access and even greater patient candidacy. Further clinical investigation into this technique is warranted.Level of EvidenceNA Laryngoscope, 127:122–126, 2017

OBJECTIVE Vagus nerve and sympathetic chain cervical schwannomas (VNCSs and SCCSs) are benign nerve sheath tumors that arise in the head and neck. Despite similar presentations that make accurate preoperative diagnosis more difficult, the potential for morbidity following resection is significantly higher for patients with VNCS. Therefore, the authors analyzed a retrospective case series and performed a comparative analysis of the literature to establish diagnostic criteria to facilitate more accurate preoperative diagnoses. METHODS The authors conducted a blinded review of imaging studies from retrospectively collected, operatively confirmed cases of VNCS and SCCS. They also performed a systematic review of published series that reported patient-specific preoperative imaging findings in VNCS or SCCS. RESULTS Nine patients with VNCS and 11 with SCCS were identified. In the study cohort, splaying of the internal carotid artery (ICA) and internal jugular vein (IJV) did not significantly predict the nerve of origin (p = 0.06); however, medial and lateral ICA displacement were significantly associated with VNCS and SCCS, respectively (p = 0.01 and p = 0.003, respectively). Multivariate analysis demonstrated that ICA and IJV splaying with medial ICA displacement carried an 86% probability of VNCS (p = 0.001), while the absence of splaying with lateral ICA displacement carried a 91% probability of SCCS (p = 0.006). The presence of vocal cord symptoms or peripheral enhancement significantly augmented the predictive probability of VNCS, as did Horner's syndrome or homogeneous enhancement for SCCS. A review of the literature produced 25 publications that incorporated a total of 106 patients, including the present series. Splaying of the ICA and IJV was significantly, but not uniquely, associated with VNCS (p < 0.0001); multivariate analysis demonstrated that ICA and IJV splaying with medial ICA displacement carries a 75% probability of VNCS (p < 0.0001), while the absence of such splaying with lateral ICA displacement carries an 87% probability of SCCS (p = 0.0003). CONCLUSIONS ICA and IJV splaying frequently predicts VNCS; however, this finding is also commonly observed in SCCS and, among the 9 cases in the present study, was observed more often than previously reported. When congruent with splaying, medial or lateral ICA displacement significantly enhances the reliability of preoperative predictions, empowering more accurate prognostication.

The tetrad of bronchial asthma, nasal disease, eosinophilia, and systemic vasculitis is the main feature of allergic granulomatosis and angiitis. Twenty‐two of 32 patients (69%) with this disorder had nasal manifestations, including nasal polyps, thick crusts, rhinitis, sinusitis, and occasionally septal perforations. Histopathologic study of involved tissue from the nose or subcutaneous nodules in conjunction with clinical evaluation will aid in establishing the correct diagnosis. Treatment with corticosteroids favorably influences symptoms and prognosis.

Otolaryngologists‐head and neck surgeons and surgical pathologists should be aware of the potential for acinic cell carcinomas to dedifferentiate so that adequate histologic tumor sampling can be performed. Dedifferentiated acinic cell carcinoma is a highly malignant, newly recognized parotid malignancy. Clinical clues that may help identify this more ominous lesion must be recognized.

Giant cell granuloma is a benign lesion that generally involves the mandible and maxilla. It may be locally aggressive and result in extensive tissue destruction in advanced cases. A retrospective analysis of giant cell granuloma during the Interval 1970 to 1990 revealed 18 cases of advanced disease, as defined by bone destruction and a greatest dimension of 2.0 cm or more. Epidemiologic factors, physical findings, Imaging studies, pathologic specimens, treatment modalities, and outcome were reviewed for each case. Eight lesions were treated by local excision and curettage, and 10 were treated by partial mandibulectomy. Five mandibular defects were reconstructed with lilac bone grafts and one with a free flap. Only one patient with maxillary giant cell granuloma who underwent curettage had regrowth of what is suspected to have been residual disease. Individualized treatment, tailoring the extent of resection to the extent of disease, provided excellent results.

Select early glottic carcinomas in patients with normal vocal cord mobility can be successfully treated with cordectomy, performed either endoscopicaliy or by means of an open operation (laryngofissure‐cordectomy). From 1976 to 1986, 95 patients underwent cordectomy at our institution. There were 88 men and 7 women, with an age range at the time of surgery of 27 to 84 years. A laryngofissure was used to perform a cordectomy in 61 patients and an endoscopic approach was used in 34. The median number of days in the hospital for the endoscopic group was 2, and for the laryngofissure group it was 6. The Kaplan‐Meier product‐limit method showed the probability of no recurrence in the first 3 years after an endoscopic cordectomy was 0.9099, and in the laryngofissure‐cordectomy group it was 0.9502. To date, there have been four recurrences (11.8%) in the endoscopic group and three (4.9%) in the laryngofissure group. Only one patient with recurrent tumor is known to have died of the cancer. Laryngectomy was necessary for ultimate control in three patients. The Kaplan‐Meier survival curve for the 95 patients was the same as that for a sex‐ and age‐matched control group. Cordectomy is an effective treatment option that results in minimal morbidity for select early glottic carcinomas.

Our experience with 14 patients treated for synovial cell sarcoma during the past 30 years is described. These tumors were manifested in young people whose ages ranged from 12 to 43 years. The diagnosis of synovial cell sarcoma proved difficult because approximately one third of the patients initially received incorrect pathologic diagnoses. A painless neck mass was the most common presenting symptom. Initial treatment included surgical excision in five patients and surgical excision and radiation therapy in nine. Recurrent or metastatic tumor occurred from 4 months to 62 months later; thus, long‐term followup is important. Four of the nine patients who were followed more than 5 years died of their disease. Favorable prognostic findings included early diagnosis and the performance of wide surgical removal.

Purpose: This project examined potential changes in health behaviors following wellness coaching. Design: In a single cohort study design, wellness coaching participants were recruited in 2011, data were collected through July 2012, and were analyzed through December 2013. Items in the study questionnaire used requested information about 11 health behaviors, self-efficacy for eating, and goalsetting skills. Setting: Worksite wellness center. Participants: One-hundred employee wellness center members with an average age of 42 years; 90% were female and most were overweight or obese. Intervention: Twelve weeks of in-person, one-on-one wellness coaching. Method: Participants completed study questionnaires when they started wellness coaching (baseline), after 12 weeks of wellness coaching, and at a 3-month follow-up. Results: From baseline to week 12, these 100 wellness coaching participants improved their self-reported health behaviors (11 domains, 0- to 10-point scale) from an average of 6.4 to 7.7 ( p < .001), eating selfefficacy from an average of 112 to 142 (on a 0- to 180-point scale; p < .001), and goal-setting skills from an average of 49 to 55 (on a 16- to 80-point scale; p < .001). Conclusion: These results suggest that participants improved their current health behaviors and learned skills for continued healthy living. Future studies that use randomized controlled trials are needed to establish causality for wellness coaching.

Lymphoepithelioma is common in the nasopharynx, but its presence elsewhere in Waldeyer's ring is rare. Thirteen patients with lymphoepithelioma in the tonsil and base of the tongue have been treated at our institution. At Initial examination, all 13 patients had advanced clinical disease. Five years after their initial treatment, seven patients were alive and free of disease. Radiation therapy controlled local and regional disease in 10 (77%) patients, yet three of these died of distant metastasis. Patients with lymphoepithelioma have a significantly better prognosis (p < 0.05) than do patients with either nonkerafinizing or keratinizing high‐grade oropharyngeal carcinoma. Early recognition and combined therapy may further improve the prognosis. Differentiation of lymphoepithelioma from other high‐grade squamous cell carcinomas of the oropharynx is important to guide treatment and to provide prognostic information.