Moore, Eric J.

Objectives/HypothesisWe sought to analyze key factors that influence the management of lateral skull base defects and implement an algorithm to improve outcomes of reconstruction.Study DesignRetrospective chart review.SettingSingle tertiary academic referral center.MethodsAdults who underwent temporal bone resection were included. Variables included tumor characteristics, ablative procedure, reconstructive method, and wound complications.ResultsSeventy‐one patients were studied. Lateral temporal bone resection was performed in 55 patients (77%), subtotal temporal bone resection in 14 (20%), and total petrosectomy in two (3%). Primary closure was achieved in 46 patients (35%), with rotational muscle flaps in 21 (46%). The pectoralis major myocutaneous flap (PMMF) was used in nine patients (13%) without major complications. Single‐stage free tissue transfer was undertaken in 10 patients (14%) with no flap failures. Primary closure was achieved in 16 of 32 of previously untreated cases (50%) compared to nine of 39 cases of previously treated disease (23%) (P = 0.03). Pedicled or free flaps were used in 18 of 39 cases of previously treated disease (46%) compared to three of 32 previously untreated cases (9%) (P < 0.001). Pedicled or free flaps were used in 13 of 22 cases (59%) in which partial or total auriculectomy was performed, whereas primary closure was achieved in 39 of 49 cases (80%) in which the pinna was preserved (P < 0.001).ConclusionAdvanced tumors that require adjuvant therapy, revision cases for recurrent disease, and cases involving auriculectomy warrant free flap or PMMF reconstruction, with the latter preferred in poor free flap candidates.Level of Evidence4. Laryngoscope, 126:1911–1917, 2016

Abstract Background: Traditional adjuvant therapy for oropharyngeal squamous cell carcinoma (OPSCC) consists of 60-66 Gy of radiation therapy (XRT) given in 2 Gy daily fractions along with high dose cisplatin if the patient has high risk factors. Despite the excellent cure rates for HPV+ OPSCC, one in three patients treated with conventional treatment will develop grade &gt;3 long-term sequelae from therapy. There is intense interest in de-intensifying adjuvant therapy for this patient population in order to maximize quality of life while maintaining excellent historical rates of disease control. Methods: MC1273 is a phase II non-randomized trial open at Mayo Clinic Rochester testing a novel course of aggressive therapy de-escalation following surgery for HPV+ OPSCC. The primary endpoint is local/regional control at 2 years while secondary endpoints include toxicity and quality of life (QOL). The eligibility criteria include all patients with p16-positive OPSCC with less than a ten pack-year smoking history who have had a complete surgical resection. Exclusion criteria include positive surgical margins, prior history of malignancy, and history of connective tissue disorders. Patients are divided into two prospective cohorts depending upon risk factors found at surgery. Patients with intermediate risk disease (≥T3, ≥N2, lymphovascular invasion, or perineural invasion) are enrolled in MC1273A while patients with extracapsular extension (ECE) are enrolled in MC1273B. Patients on MC1273A receive 30 Gy of radiation delivered in 1.5 Gy twice-daily fractions over the course of two weeks along with weekly docetaxel (15 mg/m2) given on day 1 and day 8. Patients on MC1273B receive a similar treatment regimen but also have the nodal level with positive ECE concurrently boosted to 36 Gy in 1.8 Gy twice-daily fractions. In addition to standard of care follow-up, patients receive a swallowing assessment with speech therapy immediately before XRT, one month post-XRT, and one year post-XRT. Patients also have QOL assessment consisting of the XeQOLS, Eq-5D, FACT H&N (Vers 4) and Dermatology Life Quality Index assessed at pre-XRT and 3, 12, and 24 months post-XRT. Results: Each cohort of MC1273 is powered to detect a 10% local/regional failure rate with 85% confidence. Each cohort will accrue 35 evaluable patients and 5 additional patients to account for ineligibilities and violations (40 patients total per cohort.) MC1273A began accrual in September 2013. The first five patients were monitored for grade ≥4 acute toxicities before proceeding to open accrual. MC1273B began accrual in May 2014 and has also proceeded to open accrual. Accrual will also begin in Mayo Clinic Scottsdale in the first quarter of 2015. Conclusions: MC1273 is meeting its accrual targets and should finish accrual by 2016. We anticipate that preliminary results for toxicity will be available by 2017 and local/regional data will be available by 2018. Citation Format: Daniel J. Ma, Katharine A. Price, Eric J. Moore, Joaquin J. Garcia, Scott H. Okuno, Daniel L. Price, Jeff A. Sloan, Nathan R. Foster, Robert L. Foote. MC1273: Phase II evaluation of aggressive dose de-escalation for adjuvant chemoradiation in HPV associated oropharynx cancer. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr CT227. doi:10.1158/1538-7445.AM2015-CT227

This case describes a subtotal cricoid cartilage defect reconstructed with a prefabricated composite free flap. A 61‐year‐old man with a chondrosarcoma of the cricoid cartilage required a subtotal cricoidectomy. The resulting defect was successfully reconstructed with a two‐stage prefabricated radial forearm free flap utilizing auricular cartilage. Our case further adds to the evidence that prefabricated flaps are reliable in airway reconstruction. Additionally, this provides another option for laryngeal preservation in patients with laryngeal chondrosarcoma. Laryngoscope, 125:2514–2517, 2015

ObjectiveWe aim to create a model of mandibular osteoradionecrosis in athymic rats. Athymic rats provide an immunosuppressed environment whereby human stem cells and biomaterials can be used to investigate regenerative solutions for osteoradionecrosis, bridging the gap between in vivo testing and clinical application.Study DesignProspective animal study.SettingAcademic otolaryngology department laboratory.Subjects and MethodsAfter Institutional Animal Care and Use Committee approval, 10 athymic nude rats were divided into 2 groups. The experimental group (n = 6) underwent irradiation (20 Gy), while the control group (n = 4) underwent sham irradiation catheter placement only. All 10 rats underwent extraction of the second mandibular molar 7 days later. The rats were sacrificed 28 days after dental extraction, and their mandibles were harvested. The mandibles were examined with histologic analysis and bone volume analysis based on 3‐dimensional micro–computed tomography.ResultsAll 10 rats survived the experiment period. Radiographic and histologic analysis revealed decreased bone formation in the experimental group compared with the control group. Jaw region volume ratio was 0.83 for the experimental group versus 0.97 in the control group (P =. 003). The region‐of‐interest volume ratio was 0.75 in the experimental group and 0.97 in the control group (P =. 005). Histologically, there were increased osteoclasts (P =. 02) and decreased osteoblasts (P =. 001) as well as increased fibrosis in the experimental group versus the control group.ConclusionMandibular osteoradionecrosis can be effectively and reproducibly produced in an athymic rat model. This will allow further research to study regenerative medicine in an athymic rat model.

ObjectiveTo characterize disease presentation and outcomes following surgical treatment of parotid malignancies with occult temporal bone facial nerve (FN) involvement.Study DesignCase series with chart review.SettingTertiary academic referral center.Subjects and MethodsThirty consecutive patients (mean age 58 years; 77% men) who underwent surgery for parotid malignancies with occult perineural involvement of the intratemporal FN were included. Primary outcome measures included margin status and recurrence.ResultsThe mean duration of clinical follow‐up was 49 months, and the most common presenting symptom was FN paresis (n = 23; 77%) followed by pain (n = 15; 50%). To obtain a proximal FN margin, 27 patients (90%) underwent mastoidectomy, and 3 patients (10%) had lateral temporal bone resection. The intratemporal FN margin was cleared in 26 patients (87%), most commonly in the mastoid segment (60%). Adjuvant therapy was given in 25 patients (83%). Ten patients (33%) experienced locoregional (4; 13%) and/or distant (8; 27%) recurrence at a median of 19 months (mean 26, 2–54 months) following surgery. Locoregional failure was significantly more common in cases with a positive intratemporal FN margin (66% vs 8%; P =. 045). Overall 1‐, 3‐, and 5‐year disease‐specific survival rates were 83%, 79%, and 72%, respectively.ConclusionsPerineural invasion of the intratemporal FN by parotid malignancy is uncommon. Normal preoperative FN function does not preclude histopathologic involvement. Temporal bone FN exploration should be considered when a positive margin is encountered at the stylomastoid foramen, as failure to do so is associated with an increased rate of locoregional recurrence.

Object Swallowing dysfunction is common following transoral (TO) odontoidectomy. Preliminary experience with newer endoscopic transnasal (TN) approaches suggests that dysphagia may be reduced with this alternative. However, the reasons for this are unclear. The authors hypothesized that the TN approach results in less disruption of the pharyngeal plexus and anatomical structures associated with swallowing. The authors investigate the histological and gross surgical anatomical relationship between pharyngeal plexus innervation of the upper aerodigestive tract and the surgical approaches used (TN and TO). They also review the TN literature to evaluate swallowing outcomes following this approach. Methods Seven cadaveric specimens were used for histological (n = 3) and gross anatomical (n = 4) examination of the pharyngeal plexus with the TO and TN surgical approaches. Particular attention was given to identifying the location of cranial nerves (CNs) IX and X and the sympathetic chain and their contributions to the pharyngeal plexus. S100 staining was performed to assess for the presence of neural tissue in proximity to the midline, and fiber density counts were performed within 1 cm of midline. The relationship between the pharyngeal plexus, clivus, and upper cervical spine (C1-3) was defined. Results Histological analysis revealed the presence of pharyngeal plexus fibers in the midline and a significant reduction in paramedian fiber density from C-2 to the lower clivus (p < 0.001). None of these paramedian fibers, however, could be visualized with gross inspection or layer-by-layer dissection. Laterally based primary pharyngeal plexus nerves were identified by tracing their origins from CNs IX and X and the sympathetic chain at the skull base and following them to the pharyngeal musculature. In addition, the authors found 15 studies presenting 52 patients undergoing TN odontoidectomy. Of these patients, only 48 had been swallowing preoperatively. When looking only at this population, 83% (40 of 48) were swallowing by Day 3 and 92% (44 of 48) were swallowing by Day 7. Conclusions Despite the midline approach, both TO and TN approaches may injure a portion of the pharyngeal plexus. By limiting the TN incision to above the palatal plane, the surgeon avoids the high-density neural plexus found in the oropharyngeal wall and limits injury to oropharyngeal musculature involved in swallowing. This may explain the decreased incidence of postoperative dysphagia seen in TN approaches. However, further clinical investigation is warranted.

Objectives/HypothesisApplication to otolaryngology–head and neck surgery residency is highly competitive, and the interview process strives to select qualified applicants with a high aptitude for the specialty. Commonly employed criteria for applicant selection have failed to show correlation with proficiency during residency training. We evaluate the correlation between the results of a surgical aptitude test administered to otolaryngology resident applicants and their performance during residency.Study DesignRetrospective study at an academic otolaryngology–head and neck surgery residency program.MethodsBetween 2007 and 2013, 224 resident applicants participated in a previously described surgical aptitude test administered at a microvascular surgical station. The composite score and attitudinal scores for 24 consecutive residents who matched at our institution were recorded, and their residency performance was analyzed by faculty survey on a five‐point scale. The composite and attitudinal scores were analyzed for correlation with residency performance score by regression analysis.ResultsTwenty‐four residents were evaluated for overall quality as a clinician by eight faculty members who were blinded to the results of surgical aptitude testing. The results of these surveys showed good inter‐rater reliability. Both the overall aptitude test scores and the subset attitudinal score showed reliability in predicting performance during residency training.ConclusionsThe goal of the residency selection process is to evaluate the candidate's potential for success in residency and beyond. The results of this study suggest that a simple‐to‐administer clinical skills test may have predictive value for success in residency and clinician quality.Level of Evidence4 Laryngoscope, 125:E57–E61, 2015