O'Byrne, Thomas J

ImportanceAsymmetric oropharynx uptake on positron emission tomography (PET)/computed tomography (CT) is a common incidental finding and often prompts otolaryngology referral to rule out malignancy; however, the true risk of malignancy based on this finding is unknown.ObjectiveTo identify the incidence of oropharynx cancer in patients with incidental asymmetric oropharynx PET uptake.Design, Setting, and ParticipantsIn this retrospective cohort study, patients 18 years and older undergoing PET/CT scans at Mayo Clinic between January 2001 and December 2018 were included. Patients with a history or pretest suspicion of oropharynx cancer were excluded. Data were analyzed from March 2021 to December 2023.ExposureBlinded radiologic review of imaging studies, including measurement of maximum standardized uptake values (SUVmax) of the ipsilateral side of concern and contralateral side. Retrospective medical record review for associated clinical data.Main Outcomes and MeasuresThe primary study outcome was the incidence of oropharynx cancer diagnosis in patients with asymmetric oropharynx PET uptake. The primary outcome was formulated before data collection.ResultsOf the 1854 patients identified with asymmetric oropharynx PET uptake, 327 (17.6%) met inclusion criteria. Of these, 173 (52.9%) were male, and the median (range) age was 65.0 (24.8-90.7) years. The mean (SD) follow-up interval was 52.1 (43.4) months. A total of 18 of 327 patients (5.5%) were newly diagnosed with oropharynx cancer. The most common diagnosis was squamous cell carcinoma (n = 9), followed by lymphoma (n = 8), and sarcoma (n = 1). Patients with an incidental diagnosis of oropharynx cancer had higher mean (SD) ipsilateral SUVmax (8.7 [3.7] vs 5.3 [1.9]) and SUVmax ratio (3.0 [1.6] vs 1.6 [0.6]) compared with patients with normal examination findings. SUVmax ratio and difference were found to be good discriminators of oropharynx cancer, with areas under the receiver operating characteristic curve of 86.3% (95% CI, 76.4-94.6) and 85.8% (95% CI, 74.8-94.6), respectively. Patients with a new diagnosis of oropharynx cancer were more likely to have a corresponding CT abnormality than those with normal examination findings (6 of 18 [33%] vs 24 of 295 [8.1%]). Patients with concerning lesions on oropharynx palpation by an otolaryngology health care professional were significantly more likely to be diagnosed with oropharynx cancer compared with patients with normal examination findings (odds ratio, 28.4; 95% CI, 6.6-145.8).Conclusions and RelevanceIn this cohort study, while incidental asymmetric oropharynx PET uptake was common, a new diagnosis of oropharynx cancer was not and potentially results in a large volume of unnecessary referrals and work-up. Using SUVmax ratio, SUVmax difference, and CT correlation may increase the benefit of referral. Patients with a palpable oropharynx lesion and asymmetric oropharynx PET uptake should undergo confirmatory biopsy.

AbstractObjectiveAnalyze the duration of symptom‐free intervals following laser wedge excision (LWE) for recurrent idiopathic subglottic stenosis (iSGS). Secondary aim includes evaluating the influence of patient‐related or disease factors.Study DesignRetrospective review.SettingTertiary center.MethodsReview of iSGS patients who underwent LWE between 2002 and 2021. LWE patients without prior airway surgery were labeled LWE primary (LWEP) and those with prior history of dilation were labeled LWE secondary (LWES). A conditional frailty repeated events model was used to analyze the median time to recurrence (MTR) for each nth recurrence. Secondary analysis included stratification by use of medical therapy and initial preoperative characteristics of scar (Myer‐Cotton grade, distance between the glottis and superior‐most aspect of scar, DGS; length of scar, DL).ResultsTwo hundred and ten iSGS patients underwent LWE (131 LWEP, 79 LWES). The proportion of patients experiencing at least 1, 3, 6, and 12 recurrences, respectively, was 68.0% (n = 143), 40.7% (n = 85), 20.0% (n = 42), and 5.2% (n = 11). There was exponential time‐shortening from the 1st to 12th recurrence (P < .0001). While MTR was 4.1 years after the first LWE, this fell to 2.8, 1.7, 1.0, and 0.7 years for the 2nd, 3rd, 6th, and 12th recurrences. Furthermore, LWEP patients experienced longer MTR than LWES counterparts within the first 6 recurrences (P < .01). There was no significant relationship between intersurgical interval and medication adherence, DL, DGS, or grade for recurrences beyond the first (P = .207, P = .20, P = .43, P = .16).ConclusionSymptom‐free intervals in iSGS shorten with each subsequent recurrence and LWE. The difference in MTR between LWEP and LWES groups was significant within the first 6 recurrences with LWEP having longer MTR.Level of Evidence3.

AbstractObjectiveTo describe the outcomes of patients undergoing open stapler versus transoral rigid and flexible endoscopic therapies for symptomatic Zenker's diverticulum.Study DesignSingle institution retrospective review.SettingTertiary care academic hospital.MethodsWe retrospectively evaluated the outcomes of 424 consecutive patients who underwent Zenker's diverticulotomy via an open stapler, rigid endoscopic CO2 laser, rigid endoscopic stapler, rigid endoscopic harmonic scalpel, or flexible endoscopic technique from January 2006 to December 2020.ResultsA total of 424 patients (173 females, mean age 73.1 ± 11.2 years) from a single institution were included. A total of 142 patients (33%) underwent endoscopic laser treatment, 33 (8%) underwent endoscopic harmonic scalpel, 92 (22%) underwent endoscopic stapler, 70 (17%) underwent flexible endoscopic, and 87 (20%) underwent open stapler. All open and rigid endoscopic procedures and most of the flexible endoscopic procedures (65%) were performed under general anesthesia. The flexible endoscopic group had a higher percentage of procedure‐related perforation, defined as subcutaneous emphysema or contrast leak on imaging (14.3%). The recurrence rates were higher in the harmonic stapler, flexible endoscopic, and endoscopic stapler groups at 18.2%, 17.1%, and 17.4%, respectively, and lower in the open group (1.1%). Length of hospital stay and return to oral intake were similar among groups.ConclusionThe flexible endoscopic technique was associated with the highest rate of procedure‐related perforation, while the endoscopic stapler had the lowest number of procedural complications. Recurrence rates were higher among the harmonic stapler, flexible endoscopic, and endoscopic stapler groups and lower in the endoscopic laser and open groups. Prospective comparative studies with long‐term follow‐up are needed.

ObjectivesTo measure baseline human papillomavirus (HPV) vaccination rates among tertiary and community‐based Otolaryngology – Head and Neck Surgery (Oto‐HNS) clinic patients and to determine risk factors for under‐vaccination.MethodsRetrospective chart review of patients aged 9 to 26 years presenting to an Oto‐HNS clinic from 2017 to 2019. Patients were considered complete for HPV vaccination if they received two doses of HPV vaccine with the first dose received before age 15 years or three doses of HPV vaccine otherwise.Results8,532 unique patients met the criteria. At the index visit, 3,110 (36.5%) had completed the HPV series, 5,422 (63.5%) were due for one or more doses, with 4,981 (58.4%) eligible for vaccination at the time of their appointment. Of those dues, most (3,148/5,422 or 58%) were past due by age (≥13 years old). Of the 3,148 patients past due, 745 (23.7%) were partially vaccinated and 2,403 (76.3%) were vaccine naïve. Male sex and younger age were both independently associated with incomplete vaccination (p < 0.0001).ConclusionThis study demonstrates that the implementation of on‐site HPV vaccination has the potential to increase the opportunities for vaccination among vaccine‐eligible patients, especially among young males. Otolaryngologists have the potential to provide meaningful preventive services in the fight against HPV‐mediated disease.Level of Evidence3 Laryngoscope, 133:116–123, 2023

ObjectiveDiagnostic delay in human papillomavirus–associated oropharynx squamous cell carcinoma (HPV(+)OPSCC) is common due to nonspecific symptoms. We aim to describe the disease burden and oncologic outcomes of patients with HPV(+)OPSCC diagnosed >12 months after symptom onset.Study DesignThis is a retrospective cohort study of HPV(+)OPSCC patients receiving intent‐to‐cure treatment (including surgery ± adjuvant therapy or primary chemoradiation).Setting2006‐2016, tertiary care center.MethodsTumor stage was compared between patients with and without delayed diagnosis using χ2 tests. Kaplan‐Meier survival analysis with univariate and multivariable Cox regressions were used to determine the effect of diagnostic delay on oncologic outcomes.ResultsIn total, 664 patients were included. Compared to patients diagnosed <12 months from symptom onset (n = 601), those diagnosed at >12 months (n = 63) were more likely to have T4 disease and higher overall American Joint Committee on Cancer (AJCC) clinical stage at presentation (P <. 01 for both). At 5 years, rates of overall survival, cancer‐specific survival, progression‐free survival, and distant metastases–free survival in the delayed diagnosis cohort were 80%, 90%, 80%, and 89%, respectively. A >12‐month delay in diagnosis did not significantly impact overall survival (adjusted hazard ratio [aHR], 1.16; 95% CI, 0.58‐2.31), cancer‐specific survival (aHR, 0.83; 95% CI, 0.29‐2.39), progression‐free survival (aHR, 1.15; 95% CI, 0.56‐2.37), or distant metastases–free survival (aHR, 1.00; 95% CI, 0.42‐2.40) after adjusting for age, sex, and clinical AJCC stage (P >. 05 for all).ConclusionsDelayed diagnosis of HPV(+)OPSCC is associated with greater burden of disease at presentation, but oncologic outcomes remain favorable across treatment modalities. When appropriate, intent‐to‐cure therapy should be pursued despite diagnostic delay.Level of EvidenceLevel III.

ObjectiveFailure to recognize symptoms of human papillomavirus–associated oropharyngeal squamous cell carcinoma (HPV(+)OPSCC) at presentation can delay diagnosis and treatment. This study aims to identify patient factors and provider patterns that contribute to delayed diagnosis.Study DesignRetrospective case series.SettingTertiary care center.MethodsPatients with HPV(+)OPSCC receiving intent‐to‐cure treatment from 2006 to 2016. Clinical data, workup, and care timelines were abstracted. Univariate and multivariable linear regressions were performed to determine associations.ResultsOf 703 included patients, 627 (89%) were male, and mean (SD) age at diagnosis was 59 (9) years. The mean (SD) delay to diagnosis was 148.8 (243.51) days, with an average delay of 63 (154.91) days from symptom onset to first presentation and 82.8 (194.25) days from first presentation to diagnosis. Most patients visited at least 2 providers (n = 546, 78%) before diagnosis and saw their primary care physician at first presentation (n = 496, 71%). The most common imaging and biopsy obtained before diagnosis was neck computed tomography (n = 391, 56%) and neck fine‐needle aspiration (n = 423, 60%), respectively. On multivariable linear regression, being a homemaker, being a current smoker, seeing 3 or more providers, and getting a magnetic resonance imaging scan were associated with significant delays in diagnosis (P <. 01, all). Treatment with antibiotics and a suspicion for HPV(+)OPSCC at first presentation were associated with decreased delays in diagnosis (P <. 01, both).ConclusionsPatient delays in seeking medical attention and provider delays in recognizing the appropriate diagnosis both contribute to delays of care in HPV(+)OPSCC. Improved patient and provider education is necessary to expedite the diagnosis of HPV(+)OPSCC.