Abel, Kathryn M. Van

BackgroundOlfactory nerve fibers are at risk of injury during transnasal endoscopic skull‐base approaches. Olfactory outcomes for various techniques have not been thoroughly investigated. This study aims to report long‐term olfactory outcomes when a cold knife upper septal limb incision technique is used compared to monopolar cautery.MethodsA prospective cohort study was performed at a tertiary referral center. Adult patients undergoing endoscopic approaches with septal incisions were randomized to cold knife or monopolar cautery groups. Patient demographics, clinical history, surgical data, and outcomes were collected. Preoperative, 3‐month, and 12‐month postoperative scores on the University of Pennsylvania Smell Inventory Test (UPSIT) and 22‐item Sino‐Nasal Outcome Test (SNOT‐22) were measured. Fisher's exact tests were performed for categorical variables and t tests were performed for continuous variables.ResultsTwenty‐two (22) patients (10 cold knife, 12 cautery) were enrolled between March 2016 and August 2017. The average age ± standard deviation was 50.2 ± 14.0 years (p = 0.59), 54% (p = 0.69) were female, and the primary pathology was pituitary adenoma (73%, p = 1.00). Preoperative, 3‐month, and 12‐month postoperative UPSIT scores were similar between the cold knife and cautery groups (32.8 vs 32.4, p = 0.80; 33.1 vs 33.0, p = 0.96; 33.6 vs 33.3, p = 0.84). On the “sense of smell/taste” question of the SNOT‐22, there was also no difference at all time points (p > 0.22).ConclusionThere was no significant change in patient UPSIT scores 1 year after transnasal skull‐base approaches, and no short‐term or long‐term differences between cold knife and cautery upper septal limb incision techniques. Our study supports an individualized approach based on surgeon preference.

AbstractBackgroundTreatment options of Ewing sarcoma of the head and neck include surgery, radiotherapy (RT), and chemoradiotherapy. However, local control can be challenging.MethodsWe conducted a retrospective review of all patients with head and neck Ewing sarcoma treated from 1972 to 2015 at a single tertiary care hospital.ResultsSeventeen patients met criteria (median 21 years, range 5‐58 years; 5 women). Mean follow‐up was 10.4 years (range 2.2‐39 years). Tumors occurred commonly in the cervical spine (5/17), the skull (3/17), and the paranasal sinuses (3/17). A total of 14 of 17 patients underwent surgical resection, 9 with gross total resection. After multimodality therapy, the 5‐year overall survival (OS) and recurrence‐free survival (RFS) was 87% and 75%, respectively.ConclusionCombined multimodal treatment resulted in a 5‐year OS and RFS of 87% and 75%, respectively. Aggressive surgical resection with adjuvant chemoradiotherapy should be considered. Although negative margin surgery is the goal, subtotal resection may be acceptable in the setting of adjuvant treatment.

Importance The clinical and financial implications of the timing of dental rehabilitation after a fibula free tissue transfer (FFTT) for osteoradionecrosis (ORN) and osteonecrosis (ON) of the mandible have yet to be established. Objective To compare the outcomes of primary implantation vs secondary implantation after FFTT for ORN and ON of the mandible. Design, Setting, and Participants A retrospective review was conducted of 23 patients at a single tertiary academic referral center undergoing primary implantation or secondary implantation after FFTT for ORN and ON from January 1, 2006, to November 10, 2015. Interventions All patients underwent FFTT with primary implantation (n = 12) or secondary implantation (n = 11). Main Outcomes and Measures Outcomes of FFTT, dental implantation, implant use, diet, speech, and disease-free survival were reviewed. Fixed unit costs were estimated based on the mean cost analysis. Results Twenty-three patients (7 women and 16 men; mean [SD] age, 62.4 [8.2] years [range, 24-81 years]) met the inclusion criteria. Of these, 18 had ORN and 5 had ON. Dental implantation was performed at the time of FFTT for 12 patients and was performed secondarily for 11 patients. There were a mean of 5.2 implants per patient performed, for a total of 121 implants. There was 1 complete flap failure in the primary implantation group. Neither flap nor implant complications were affected by the timing of the implantation. Overall, the implant survival rate was 95% (55 of 58) in the primary implantation group and 98% (62 of 63) in the secondary implantation group. Time from FFTT to abutment placement (primary implantation, 19.6 weeks; secondary implantation, 61.0 weeks) was significantly shorter after primary implantation ( P < .001). There was no clinical difference in postoperative complications and implant outcomes for ORN vs ON. Improvement in speech and oral competence in the primary implantation group vs the secondary implantation group was not statistically significant, given an experiment-adjusted P = .001 set as significant (normal speech, 9 vs 3; P = .02; and normal oral competence, 9 vs 3; P = .02). Disease-free survival was 91% (20 of 22 patients) overall. Fixed unit (U) costs were 1.0 U for primary implantation and 1.24 U for secondary implantation. Conclusions and Relevance Patients undergoing primary implantation after FFTT for ORN and ON had a similar rate of complications compared with those undergoing secondary implantation. However, primary implantation allowed a faster return than secondary implantation to oral nutrition and prosthesis use. The fixed unit cost was reduced for those undergoing primary implantation. Although dental implantation was safe and effective in both groups, the decreased time to use and the decreased overall cost should prompt surgeons to consider primary implantation after FFTT for ORN and ON. Level of Evidence 3 .

Objectives Neck metastases in patients with esthesioneuroblastoma (ENB) constitute the most significant predictor of poor long-term survival. Recently, researchers discovered the existence of dural lymphatic channels that drain to the cervical lymph nodes. From this physiologic basis, we hypothesized that patients with ENB who develop dural invasion (DI) would exhibit a proclivity for neck metastases. Design Retrospective review. Setting Tertiary referral center. Participants All patients treated for ENB from January 1, 1994 to December 31, 2015. Main Outcome Measures Incidence, laterality, and recurrence rate of neck metastases by DI status. Results Sixty-one patients were identified (38% female; median age 49, range, 10–80), 34 (56%) of whom had DI and 27 (44%) did not. Of patients with DI, 50% presented with or developed neck disease following treatment compared with just 22% of those without DI (p = 0.026). Bilateral neck disease was more common in patients with DI (11/34, 32%) compared with those without (2/27, 7%) (p = 0.018). Five-year regional recurrence-free survival rates were 88% for those without and 64% for those with DI (p = 0.022). Kadish C patients with DI were more likely to develop regional recurrence when compared with Kadish C without DI and Kadish A/B (p = 0.083). Further, Kadish C patients with DI displayed worse overall survival than Kadish C without DI and Kadish A/B. Kadish D patients displayed the worst overall survival. The difference in overall survival among these four groups was significant (p < 0.001). Conclusion DI by ENB is associated with increased incidence of cervical nodal metastases, bilateral neck disease, worse regional recurrence-free survival, and poorer overall survival. These data support the division of Kadish C by DI status.

AbstractBackgroundThis study presents oncologic outcomes after transoral robotic surgery (TORS) ± adjuvant therapy for oropharyngeal squamous cell carcinoma (SCC).MethodsThree hundred fourteen patients undergoing TORS ± adjuvant therapy for oropharyngeal SCC from May 1, 2007, to May 31, 2015, are analyzed.ResultsMedian follow‐up was 3.3 years (interquartile range [IQR] 1.8‐5.3 years; range 1 day to 9.3 years). Estimated locoregional recurrence‐free survival, distant metastasis‐free survival (DMFS), overall survival (OS), and cancer‐specific survival (CSS) rates (95% confidence interval [CI] number still at risk) at 5 years after surgery were 92% (88‐95; 92), 90% (86‐94; 92), 86% (82‐92; 98), and 94% (91‐97; 98), respectively. Negative margins were achieved in 98% of cases. The adult comorbidity evaluation (ACE)‐27 comorbidity index, human papillomavirus (HPV) status, pathologic N classification, and number of attempts to clear margins were associated with death due to cancer (P = .003, P = .002, P = .030, and P = .002, respectively).ConclusionThe need to take ≥2 margins to achieve resection portends an increased risk of locoregional recurrence and death due to disease in oropharyngeal SCC.

Objectives The objective of this study was to identify factors that may influence the rate and location of regional metastasis in sinonasal malignancies (SNMs). Design This is a retrospective review. Setting This study was set at the single-institution tertiary referral center. Participants A total of 299 patients were treated for SNMs from 1994 to 2014. Main Outcome Measures The main outcome measures were incidence and distribution of regional metastases. Results Several histologic subtypes were treated, with squamous cell carcinoma (28.4%), esthesioneuroblastoma (18.1%), and mucosal melanoma (12.4%) being the most common. Of the 299 patients, 59 (19.7%) developed a regional metastasis, either at presentation or during follow-up. Higher cumulative incidence of regional metastases was significantly associated with histologic type (p ≤0.001) and invasion of the dura (p = 0.005), infratemporal fossa (p = 0.036), orbit (p = 0.020), or palate (p = 0.016). Ipsilateral level II lymph nodes were the most commonly involved nodes. Contralateral regional metastases were associated with higher risk histologic types (p = 0.005) and dural invasion (p = 0.008). Parotid metastases were associated with invasion of the facial soft tissue (p = 0.028), and retropharyngeal metastases were associated with invasion of the pterygoid plates and musculature (p = 0.030). Conclusion Histologic type of SNM appears to be the most important factor in predicting the rate of regional metastases. Histologic type and invasion of certain neighboring structures may help define which lymphatic basins are at highest risk for metastasis.

ObjectiveTo describe management and oncologic outcomes for patients who develop locoregional recurrence (LRR) or distant metastasis (DM) following transoral robotic surgery for human papilloma virus (HPV)–positive oropharyngeal squamous cell carcinoma (OPSCC).Study DesignCase series with chart review.SettingTertiary care referral center.Subjects and MethodsA total of 286 patients with HPV‐positive OPSCC who underwent transoral robotic surgery–based treatment from May 2007 to May 2015.ResultsOf 286 patients (12.2%), 35 met inclusion criteria. Of these, 19 experienced an LRR and 16 developed a DM; 2 patients with LRR subsequently developed DM. In those patients with an LRR, 79% had T1/T2 tumors, and 47% had N0/N1 nodal disease, compared with 75% and 6% in the DM group, respectively. The median time to LRR or DM was 0.6 years (interquartile range [IQR], 0.4‐1.0) and 1.8 years (IQR, 1.0‐2.1), respectively. Salvage treatment with intent to cure was attempted in 23 patients (16 LRR, 7 DM). The median time from LRR or DM to last follow‐up for the 18 patients who were still alive after salvage was 1.9 years (IQR, 0.4‐3.8; range, 7 days–6.2 years). Estimated cancer‐specific survival rates at 3 years following intent‐to‐cure treatment were 63% (95% CI, 39‐100; number still at risk, 5) in the LRR group and 100% (95% CI, 100‐100; number still at risk, 2) in the DM group.ConclusionOverall, LRR and DM for HPV‐positive OPSCC following transoral robotic surgery–based therapy are infrequent. In our subset of patients who underwent intent‐to‐cure treatment, cancer‐specific survival rates were favorable. Therefore, aggressive salvage treatment for LRR and DM for HPV‐positive OPSCC should be recommended for appropriate candidates.