Yin, Linda X

ObjectiveTo describe and compare rates of metachronous and synchronous second primaries of the contralateral tonsil in patients with primary HPV(+) tonsillar squamous cell carcinoma (SCC).Study DesignRetrospective cohort study.Materials and MethodsThis is a single tertiary care center retrospective case series, from 2006 to 2019, of HPV(+) tonsillar SCC patients who underwent primary surgical resection with unilateral wide‐field tonsillectomy or bilateral tonsillectomy for diagnostic or therapeutic purposes. A metachronous second primary is one diagnosed >6 months after completion of surgical treatment. A synchronous second primary is one diagnosed during bilateral tonsillectomy for unilateral HPV(+) tonsillar SCC. Rates of second primary and patient characteristics were compared using chi‐square tests.ResultsAbout 303 patients underwent unilateral surgical resection +/− adjuvant therapy for HPV(+) tonsillar SCC. One (0.3%) developed a metachronous second primary in the contralateral tonsil 11.9 years following treatment. Fifty‐seven patients with HPV(+) tonsillar SCC underwent bilateral tonsillectomy, and 37/57 (65%) had no clinical signs for contralateral disease. Of these, only 1/37 (2.7%) was incidentally found to have a synchronous second primary. Twenty patients underwent bilateral tonsillectomy due to clinical concern for contralateral disease. Of these, 3/20 (15%) were found to have a synchronous HPV(+) SCC in the contralateral tonsil.ConclusionsThe prevalence of metachronous second primary after appropriate treatment of HPV(+) tonsillar SCC is very low (0.3%) and so is the chance of incidentally discovering a synchronous second primary during bilateral tonsillectomy (2.7%). We do not recommend bilateral tonsillectomy as a part of the routine algorithm in the surgical management of these patients.Level of Evidence3 Laryngoscope, 132:332–338, 2022

Objectives/Hypothesis To describe the pre‐implant audiometric profile of adult cochlear implant (CI) recipients to investigate whether current binaural candidacy requirements prevent access to patients who could benefit from CI. Study Design Retrospective case series. Methods Retrospective review from 2016 to 2018 evaluating preoperative pure‐tone thresholds and speech perception scores in the ipsilateral and contralateral ear. Results A total of 252 adult CI recipients undergoing 270 implants were identified. Median age at time of implantation was 70.5 years (IQR 61.3–78.3) for those undergoing unilateral implantation and 59.0 (IQR 48.0–72.3) for those undergoing bilateral implantation ( P < .01). For unilateral implantation, median pre‐implantation speech perception performance in the ear to be implanted was 8.0% (IQR 0%–26.0%) for CNC word scores, and 9.0% (IQR 0%–34.0%) for AzBio sentence scores in quiet. Median speech perception performance in the contralateral ear was 36.0% (IQR 14.0%–60.0%) on CNC word scores, and 48.5% (IQR 17.5%–76.0%) on AzBio sentence tests. Speech perception scores were significantly different between ears for word and sentence tests ( P < .01). Patients older than age 65 were significantly less likely to undergo bilateral implantation ( P = .03). Conclusions Adult CI recipients exhibit substantially poorer pre‐implant speech perception scores than the commonly utilized ipsilateral qualifying threshold of 50% on sentence testing. Yet, existing insurance paradigms limit patients by excessively stringent binaural best‐aided requirements. This limitation likely leads to worse device performance as patients often wait years for their binaural hearing to qualify while their ear to be implanted potentially experiences an unnecessarily extended duration of deafness. Older patients also experience a unique delay in referral for cochlear implantation. Level of Evidence 3‐ Retrospective review Laryngoscope , 131:E2007–E2012, 2021

Abstract Background Recurrent pleomorphic adenoma (PA) can be a lifelong disease, and rates of subsequent recurrence are high. Methods Patients between 2000 and 2015 were identified. Primary outcome was subsequent recurrence after surgical salvage. Results Twenty‐seven of 84 patients developed a subsequent recurrence. Risk factors for subsequent recurrence included a higher number of previous recurrences ( P < .01), worse preoperative facial nerve function ( P < .01), and deep parotid lesion(s) ( P < .01). Interval since last surgery was protective ( P < .01), specifically >10 years since last surgery ( P < .01). For patients with a >10‐year interval since their last surgery, the subsequent recurrence‐free rate at 10 years follow‐up was 80.2% vs 31.8%. Conclusions For patients presenting with a >10‐year interval since their last surgery, subsequent recurrence rates are low, which may allow for as needed surveillance recommendations. For patients presenting with recurrent PA and ≤10 years since their last surgery, a closer surveillance is warranted.

BackgroundFusion of diffusion‐weighted imaging (DWI) to computed tomography (CT) has been touted as a possible technique to improve cholesteatomas localization. This study set out to assess the ability of DWI images fused with thin‐slice heavily T2‐weighted images to similarly localize surgically‐confirmed cholesteatomas.Materials and MethodsA retrospective review was completed of consecutive patients that underwent MR temporal bone imaging (9/2011–3/2020) with both DWI and thin‐slice T2‐weighted imaging. Included patients underwent surgical resection of primary or recidivistic cholesteatoma after preoperative MR imaging. A neuroradiologist, who was blinded to operative and clinical notes, localized each lesion on both DWI and fused DWI‐T2 images in 11 anatomic subdivisions of the temporal bone. Surgical confirmation of cholesteatoma location was used as the gold standard for comparison.ResultsOf 24 included examinations, the average age at time of MR was 48.2 ± 24.7 years; 12/24 (50.0%) were female. Five of 24 had primary cholesteatoma, while the remainder had recidivistic disease. Sensitivity, specificity, and accuracy of unfused DWI images were 52.1%, 88.9%, and 75.8%, respectively. Sensitivity, specificity, and accuracy of fused DWI‐T2 images were 57.1%, 94.8%, and 81.8%, respectively.ConclusionFused DWI‐T2 images outperformed unfused DWI images in the anatomic localization of temporal bone cholesteatomas. This method represents a potential alternative to MR‐CT fusion for pre‐operative cholesteatoma evaluation, and warrants future investigations. Opposed to MR‐CT fusion, this method only necessitates MR sequences and removes the need for additional CT acquisition.Level of Evidence3 Laryngoscope, 131:E1662–E1667, 2021

ObjectivesThe spine is the most common site of bone metastases in differentiated thyroid cancer (DTC). The role of surgery in the management of cervical spine (C‐spine) metastases (CSpM) has not been adequately explored.MethodsThis is a retrospective cohort study at a tertiary referral center from 2002 to 2018. Inclusion criteria were pathologic diagnosis of DTC and imaging/pathologic diagnosis of CSpM. Statistical analysis utilized t tests for continuous variables and χ2 tests for categorical variables. Survival analysis was conducted using Kaplan–Meier curves with univariate and multivariate Cox regressions.ResultsFifty patients with DTC and CSpM were identified. Of those, 16 underwent surgical resection of the C‐spine, whereas 34 did not. The most common presenting symptom was neck pain (N = 37, 74%). Patients in the surgery group were more likely to report a subjective improvement of symptoms (P < .01) and to have local (P < .01) and systemic (P = .04) disease control. Five‐year overall survival was 44.7% for the surgery group (95% confidence interval [CI]: 17.1–69.3) and 11.1% (95% CI: 2.1–28.8) for the nonsurgery group (P = .01). The strongest risk factor for improved overall survival after C‐spine metastasis was local disease control at the C‐spine (multivariate hazard ratio [HR] = 0.32, 95% CI: 0.12–0.85, P = .02). Surgical intervention was significantly associated with improved survival on both univariate (HR = 0. 35, 95% CI: 0.15–0.82, P = .02) and multivariate (HR = 0.37, 95% CI: 0.14–0.98, P = .04) analysis.ConclusionSurgical management of CSpM in differentiated thyroid cancers is associated with significantly improved local disease control and overall survival. Referral to spine surgeons should be considered after diagnosis.Level of EvidenceIV. Laryngoscope, 131:E1741–E1747, 2021

AbstractBackgroundIn patients presenting with recurrent pleomorphic adenoma (rPA), clinical evaluation can fail to recognize carcinoma ex PA (cxPA). We aim to identify the risk factors for cxPA.MethodsThis is a single institution retrospective case‐control study from 2000 to 2015. CxPA was diagnosed based on surgical pathology. Demographics, clinical, and social histories were collected.ResultsA number of 13/106 (12.3%) patients were diagnosed with cxPA, of which only 4/13 (31%) had clinical features suspicious for malignancy. Compared to benign rPA, factors associated with cxPA included age >50 (odds ratio [OR] 6.67, 95% confidence interval [CI]: 1.71‐25.98, P < .01), >10 pack‐years of smoking history (OR 3.36, 95% CI: 1.01‐11.14, P = .04), and the largest tumor being >2 cm on pathology (OR 4.42, 95% CI: 1.14‐17.10, P = .03).ConclusionsIn patients presenting with rPA, risk factors for malignant transformation include age >50, significant smoking history, and tumors larger than 2 cm. Clinical signs of malignancy such as rapid growth or pain are not always present.

BackgroundAcute invasive fungal sinusitis (AIFS) is a potentially life‐threatening diagnosis in immunocompromised patients. Identifying patients who could benefit from evaluation and intervention can be challenging for referring providers and otolaryngologists alike. We aimed to develop and validate an accessible diagnostic tool to estimate the probability of AIFS.MethodsRetrospective chart review from 1999 to 2017 identified all patients evaluated for possible AIFS at a tertiary care center. AIFS was diagnosed by pathologic confirmation of fungal tissue angioinvasion. Stepwise selection and univariate logistic regression were used to screen risk factors for a multivariable predictive model. Model performance was assessed using Tukey's goodness‐of‐fit test and the area under the receiver operator characteristic curve (AUC). Model coefficients were internally validated using bootstrapping with 1000 iterations.ResultsA total of 283 patients (244 negative controls, 39 with AIFS) were included. Risk factors in our final diagnostic model included: fever ≥38°C (log‐odds ratio [LOR] 1.72; 95% CI, 0.53 to 2.90), unilateral facial swelling, pain, or erythema (LOR 2.84; 95% CI, 1.46 to 4.23), involvement of the orbit or pterygopalatine fossa on imaging (LOR 3.02; 95% CI, 1.78 to 4.26), and mucosal necrosis seen on endoscopy (LOR 5.52; 95% CI, 3.81 to 7.24), with p < 0.01 for all factors. The model had adequate goodness of fit (p > 0.05) and discrimination (AUC = 0.96).ConclusionWe present an internally validated diagnostic tool to stratify the risk for AIFS. The estimated risk may help determine which patients can be observed with serial nasal endoscopy, which ones could be biopsied, and which ones would benefit from immediate surgical intervention.

ObjectivesIdiopathic subglottic stenosis (iSGS) is an inflammatory process leading to fibrosis and narrowing of the laryngotracheal airway. There is variability in patient response to surgical intervention, but the mechanisms underlying this variability are unknown. In this pilot study, we measure expression of candidate targets at the mucosal surface of the subglottis in iSGS patients. We aim to identify putative biomarkers for iSGS that provide insights into the molecular basis of disease progression, yield a gene signature for the disease, and/or predict a response to therapy.Study DesignIn vitro comparative study of human cells.MethodsLevels of candidate transcripts and proteins were measured in healthy and stenotic laryngotracheal tissue specimens taken from the mucosal surface in 16 iSGS patients undergoing endoscopic balloon dilation. Pre‐ and post‐operative pulmonary function test and patient reported voice and breathing outcomes were also assessed. Unsupervised clustering was used to define patient subgroups based on expression profile.ResultsPulmonary function and voice and breathing outcome metrics demonstrated significant post‐operative improvement. Transcript levels of αSMA, CCL2, COL1A1, COL3A1, FN1, IFNG, and TGFB1 and protein levels of CCL2, IFNG, and IL‐6 were significantly upregulated in stenotic as compared to healthy tissues. Marked heterogeneity was observed in the patterns of expression of candidate markers across individuals and tissue types. Patient subgroups defined by expression profile did not show a statistically significant difference in dilation interval.ConclusionPro‐inflammatory and pro‐fibrotic pathways are significantly upregulated along the mucosal surface of stenotic laryngotracheal tissues, and CCL2 and IFNG merit further investigation as potential iSGS biomarkers.Level of Evidence4 Laryngoscope, 131:342–349, 2021

ObjectivesClinical variables affecting anesthetic recovery following transoral robotic surgery (TORS) to resect oropharyngeal squamous cell carcinoma have not been described. We aimed to explore risk factors associated with prolonged postanesthesia recovery following TORS.Study DesignRetrospective case‐control study.SettingTertiary referral center, January 2010 to November 2016.Subjects and MethodsPatients included adults undergoing primary TORS ± neck dissection for oropharyngeal squamous cell carcinoma. Patients were categorized by phase I recovery time into the “goal” recovery group (75th percentile [lower 3 quartiles], n = 272) and the “prolonged” recovery group (n = 91). Univariate and multivariate logistic regression analyses were performed to assess the associations between clinical characteristics and prolonged phase I recovery.ResultsA total of 363 patients were included. Median (interquartile range) duration of postanesthesia recovery was 1.5 hours (1.0‐2.0). Prolonged recovery was associated with isoflurane (odds ratio, 2.83 [95% CI, 1.56‐5.14], P <. 001), midazolam (2.77 [1.50‐5.12], P =. 001), and larger opioid doses (1.26 [1.01‐1.58] per 10‐mg intravenous morphine equivalents, P =. 040) and inversely associated with multimodal antiemetic therapy (0.34 [0.15‐0.78], P =. 011). Prolonged cases had higher rates of postoperative nausea and vomiting (n = 43 [47.2%] vs 86 [31.6%], P =. 008), respiratory depression (28 [30.8%] vs 12 [4.4%], P <. 001), sedation (Richmond Agitation‐Sedation Scale < –2; 26 [28.6%] vs 35 [12.9%], P =. 001), severe pain (numeric rating score ≥7; 31 [34.4%] vs 45 [17.2%], P =. 001), and longer hospital stays (4 vs 3 days, P <. 001).ConclusionsSeveral anesthetic factors are associated with anesthesia recovery duration, which may be shortened by efforts to reduce postoperative sedation, severe pain, and nausea/vomiting. Shortened anesthesia recovery time may reduce hospital stay.