Otolaryngology- Head and Neck Surgery最新文献

Objective: This study aims to evaluate the prognostic impact of surgical margin status in HPV-related oropharyngeal squamous cell carcinoma (OPSCCa) and examine the potential for revising surgical margin standards in HPV+ OPSCCa.

Study design: A retrospective cohort study.

Setting: This study was conducted across 4 tertiary oncology centers.

Methods: Charts of patients treated from 2010 to 2022 for HPV+ OPSCCa were reviewed. Eligible patients underwent surgery without adjuvant treatment for nonrecurrent, nonmetastatic HPV+ OPSCCa. Demographic, oncologic, treatment, and outcome data were collected. Patients with prior head and neck radiation or adjuvant therapy were excluded. Local control, locoregional recurrence (LRR), disease-free survival (DFS), and overall survival (OS) were compared based on surgical margins using the Kaplan-Meier method.

Results: Among 194 qualified cases, with a median follow-up of 41.63 months, most cases were pT1 (64.43%) or pT2 (34.54%). Recurrence occurred in 8.76% of patients, with most salvaged successfully. Analysis on univariable and multivariable modeling determined that margins less than 1 mm were considered close, and those ≥1 mm were considered clear. On multivariable modeling, surgical margins of <1 mm were associated with a hazard ratio of 3.69 (95% confidence interval [CI] 1.47-9.30) for LRR and 2.95 (95% CI 1.41-6.16) for DFS when compared to cases where margins were clear by 1 mm or greater.

Conclusion: In this multi-institutional cohort of early-stage HPV+ OPSCCa treated surgically without adjuvant therapy, margins <1 mm were associated with worse LRR and DFS. This suggests that traditional definitions of close margins in HPV-negative disease may not apply to HPV+ OPSCCa, warranting a revised definition for surgical margin standards.

Objective: To evaluate the association of circulating cell-free mitochondrial DNA (ccf-mtDNA) levels with the severity and treatment outcomes of sudden sensorineural hearing loss (SSNHL).

Study design: Observational prospective study.

Setting: Tertiary academic medical center.

Methods: Plasma samples were collected from patients diagnosed with SSNHL in the morning before steroid treatment, as well as from healthy controls. A quantitative polymerase chain reaction was used to measure ccf-mtDNA levels, expressed as log copy numbers per milliliter. Treatment outcomes were evaluated using hearing gain, percentage of recovery, and Siegel's criteria.

Results: The study included 80 subjects, including 50 patients and 30 healthy controls. The mean (SD) plasma ccf-mtDNA level was 8.1 (0.35), which was significantly higher than 7.78 (0.65) controls (95% CI: 0.097-0.542). Patients with good recovery exhibited significantly higher pretreatment ccf-mtDNA levels compared to those with poor recovery (mean [SD] score: 8.29 [0.34] vs 8.02 [0.33]; 95% CI: 0.04-0.48). Ccf-mtDNA levels were positively associated with hearing gain (r = 0.486, 95% CI: 0.227-0.663) and percentage of recovery (r = 0.361, 95% CI: 0.103-0.574). Multivariate analyses revealed that less than 7 days from onset of hearing loss to treatment (odds ratio [OR]: 7.389, 95% CI: 1.324-41.239) and higher ccf-mtDNA levels (OR: 24.634, 95% CI: 1.878-323.163) were independent predictors for good recovery.

Conclusion: Plasma ccf-mtDNA levels were elevated in patients with SSNHL and were significantly associated with better treatment outcomes following steroid therapy. These findings suggest that ccf-mtDNA levels may serve as a predictive biomarker for SSNHL treatment outcomes, paving the way for personalized therapeutic strategies.

Objective: To examine associations with changes in quality-of-life (QOL) outcomes following treatment of vestibular schwannoma (VS) using stereotactic radiosurgery (SRS).

Study design: Prospective longitudinal study.

Setting: Tertiary academic center.

Methods: Patients who were treated for sporadic VS using SRS from 2015 to 2022 were included. QOL outcomes were measured using the disease-specific Penn Acoustic Neuroma QOL (PANQOL) scale.

Results: Seventy-nine patients with pre-SRS and at least one post-SRS PANQOL assessments were available for analysis. The mean change in total PANQOL scores was -2 (SD 13) on a 100-point scale. The mean duration between assessments was 4.6 years (SD 2.0). Age at SRS, sex, and SRS treatment doses were not significantly associated with changes in total PANQOL scores. Total PANQOL scores improved a mean of 4 points for patients with tumors confined to the internal auditory canal but declined a mean of 5 points for patients with tumors extending into the cerebellopontine angle (P = .01); however, these changes did not exceed the minimum clinically significant threshold of 11 points. The correlation coefficient between treated tumor volume at SRS and change in total PANQOL scores was -0.30 (P = .007). Changes in PANQOL total (P = .5) and hearing domain (P = .3) scores for patients who maintained serviceable hearing or progressed to nonserviceable hearing did not significantly differ.

Conclusion: Tumor extent and treated volume at SRS had a statistically significant but likely not clinically important impact on total PANQOL scores. Progression to nonserviceable hearing did not have a significant impact on PANQOL total or hearing domain scores.

Objective: Although previous studies suggest an increased stroke risk in head and neck cancer (HNC) survivors, the risk with various treatment modalities, including radiotherapy, is less certain. This study investigates stroke incidence and risk in HNC patients, including how different treatments influence stroke risk.

Data sources: A literature search of PubMed, Scopus, and Embase was conducted.

Review methods: We included all primary studies assessing stroke as an outcome in HNC patients aged 18 and older, regardless of cancer subtype or treatment modality. Incidence rates were pooled by reconstructing individual patient time-to-event data from survival curves. Random-effects meta-analyses were employed to compare stroke risk between HNC patients, healthy controls, and treatment groups.

Results: In total, 15 studies (N = 2,295,447 patients) were included in the analyses. Among surviving HNC patients, stroke occurred at a rate of 1% per year (10% at 10 years and 15% at 15 years cumulatively). Meta-analyses showed that HNC patients had a significantly higher stroke risk compared to healthy controls (hazard ratio [HR] = 1.45; 95% CI: 1.27-1.65; I²: 20%). Among HNC patients, radiotherapy alone increased stroke risk compared to surgery alone (HR = 1.66; 95% CI: 1.35-2.03; I²: 0%). Patients who received any form of radiotherapy had higher stroke risk compared to those without (HR = 1.47; 95% CI: 1.29-1.68; I²: 60%). Patients with definitive chemoradiotherapy had heightened stroke risk compared to patients who received definitive surgery (HR = 1.28; 95% CI: 1.09-1.49; I²: 86%).

Conclusion: Patients with HNC face an elevated stroke incidence and risk, especially those treated with radiotherapy. This underscores the need for surveillance and tailored preventive strategies to reduce stroke risk in this vulnerable population.

Objective: Division of the sternothyroid muscle during thyroidectomy is a widely accepted surgical technique to provide improved exposure of the thyroid gland, superior pole vessels, and the external branch of the superior laryngeal nerve (EBSLN). Our group had previously shown no decrement in postoperative voice outcomes with this technique. However, given the known role of the strap muscles in swallowing function, this study aims to assess the impact of sternothyroid muscle division on patient-reported dysphagia.

Study design: Prospective, consecutive cohort study.

Setting: Single institution urban tertiary health care system.

Methods: Adult patients who underwent total thyroidectomy or lobectomy with a single surgeon between November 2022 and July 2023 were enrolled. Patients with clinical evidence of significant preoperative dysphagia were excluded. Complete sternothyroid muscle division was performed in all cases. The integrity of the recurrent laryngeal nerve and EBSLN (when visualized) was confirmed through intraoperative nerve monitoring and postoperative flexible laryngoscopy. Differences between preoperative and postoperative patient-reported swallowing outcomes were assessed using the Eating Assessment Tool-10 (EAT-10).

Results: A total of 114 patients were included in the study. No statistically significant difference was found between mean preoperative and postoperative EAT-10 scores (0.63 vs 0.75, P = .677). These results remained consistent regardless of sex, history of reflux, unilateral or bilateral sternothyroid muscle division, performance of substernal resection of goiter, or final histologic diagnosis.

Conclusion: Division of the sternothyroid muscle during thyroidectomy can be useful in the exposure of the thyroid gland without impact on patient-perceived swallowing disturbance.

Objective: To describe the financial toxicity (FT) associated with thyroid cancer (TC) across the care continuum and elucidate factors contributing to FT in this patient population.

Data sources: PubMed, Embase, Cochrane, Web of Science, and Scopus.

Review methods: A systematic review was conducted of peer-reviewed studies on FT in patients with a history of TC, between 1995 and 2024, using search terms "thyroid cancer," "financial toxicity," and their relevant synonyms. Full-text, English-language studies reporting subjective (self-reported FT) and objective (out-of-pocket [OOP], employment changes, and bankruptcy) FT outcomes were included.

Results: A total of 927 studies were identified, with 13 meeting the inclusion criteria. Nine studies addressed subjective FT, with prevalence rates ranging from 16% to 47%. Younger age, lack of health insurance, belonging to a racial minority, and having a lower annual household income were significantly associated with increased FT. Patients with TC had higher OOP costs and bankruptcy rates compared to other cancer types or matched controls.

Conclusion: Despite a generally favorable prognosis, patients with TC experience significant FT, particularly among vulnerable groups such as younger individuals, the uninsured, and racial/ethnic minorities. In the setting of the rising incidence of TC, it is essential to identify and address FT in this population. Addressing FT requires a multifaceted approach, which includes incorporating financial counseling and cost discussions in routine care, ensuring comprehensive insurance coverage, and implementing employer-level protections to mitigate income and insurance loss. Further research is needed to understand the potential financial implications of different care pathways in the treatment of TC.

Objective: Endoscopy is the gold-standard diagnostic modality for many pediatric airway disorders but does not enable quantitative assessment of airway morphology. In a series of pediatric patients, we aim to demonstrate that structure from motion (SfM) photogrammetry, a computer-vision algorithm, can accurately reconstruct three-dimensional (3D) models of laryngeal anatomy directly from bronchoscopy videos.

Study design: Prospective case series.

Setting: Tertiary academic pediatric hospital.

Methods: Pediatric patients undergoing direct laryngoscopy/bronchoscopy and same-day neck and chest computed tomography (CT) as a part of clinical care were recruited. Optical calibration of the imaging system occurred after each bronchoscopy. SfM was used to reconstruct 3D surfaces from bronchoscopy videos. SfM-reconstructed surfaces were compared against CT-derived geometries to determine reconstruction accuracy at glottic and subglottic levels.

Results: SfM reconstruction was successfully completed for all four patients. Circular equivalent diameter (D_CE) of cross-sectional area slices measured from SfM-reconstructed airways was highly accurate compared to D_CE measured from the gold-standard CT scans, with root mean squared error of 0.1, 0.375, and 0.225 mm at the glottis, proximal subglottis, and distal subglottis subsites, respectively. This represents average percent errors of 2%, 4%, and 4%, for each site, respectively.

Conclusion: We demonstrate the feasibility of reconstructing laryngeal anatomy with high fidelity from SfM photogrammetry in a clinical series of pediatric patients. This reproducible method provides highly accurate anatomic models directly from endoscopy, enabling quantitative assessment without CT scanning and radiation exposure. This approach has the potential to impact many areas of otolaryngology, including virtual surgical planning, simulation, and family counseling.

Objective: To examine the association between statin use and the risk of sudden sensorineural hearing loss (SSNHL) in patients with type 2 diabetes (T2D), focusing on statin type, dosage, and treatment duration.

Study design: Retrospective cohort study.

Setting: Taiwan National Health Insurance Research Database.

Methods: We analyzed T2D patients diagnosed between 2008 and 2019, stratified into statin users and nonusers of lipid-lowering therapy. Propensity score matching was used to balance baseline characteristics. Multivariable Cox regression, adjusted for competing risks, assessed the association between statin use and SSNHL risk, as well as all-cause mortality. Statin exposure was analyzed based on cumulative and daily doses.

Results: The study cohort included 66,120 statin users and 66,120 nonusers. Statin use was associated with a significantly lower SSNHL risk (adjusted hazard ratio [aHR], 0.83; 95% CI, 0.74-0.92; P = .0008) and reduced all-cause mortality (aHR, 0.55; 95% CI, 0.52-0.57; P < .0001). A dose-response relationship was observed, with higher cumulative defined daily doses (cDDDs) linked to progressively lower SSNHL risk. Hydrophilic statins, particularly rosuvastatin, showed stronger protective effects compared to lipophilic statins.

Conclusion: Statin use in T2D patients is associated with reduced SSNHL risk and all-cause mortality, with dose-dependent effects. These findings suggest the potential otoprotective benefits of statins and emphasize the importance of personalized therapy for managing both hearing and cardiovascular health in this high-risk population.

Objective: The incidence of pediatric thyroid cancer has increased. Little is documented about which providers are diagnosing pediatric thyroid nodules and how this impacts care. Our objective was to analyze how nodules are identified and how diagnosing provider type impacts nodule size and management.

Study design: Retrospective chart review.

Setting: Tertiary care children's hospital.

Methods: Pediatric patients (aged 0-17) with at least one thyroid nodule diagnosed between 2006 and 2023 were reviewed. Diagnosing provider type, diagnostic method, nodule size, clinical management, and final diagnosis were analyzed.

Results: The study included 351 patients. Primary care providers diagnosed the largest proportion of nodules (43.0%), followed by incidental nodules by radiologists (24.2%). The proportion diagnosed by radiologists increased from 12% to 31% after 2017 (P < .001). Primary care providers were more likely to use physical exam than pediatric endocrinologists (65% vs 42%, P = .004), who more often used ultrasound (56% vs 37%, P = .02). Primary care providers diagnosed nodules with a median diameter of 1.50 cm, larger than that of pediatric endocrinologists and radiologists, both 0.8 cm (P = .01, P < .001). Compared to patients diagnosed by radiologists, patients diagnosed by primary care providers more often underwent biopsy (P = .02) or surgery (P < .001) and received a malignant diagnosis (P = .001).

Conclusion: Primary care providers play a key role in detecting pediatric thyroid nodules, and a physical exam is vital in identifying significant pathology. Radiologic incidental nodules increased in frequency over our study timespan. Future research should consider the impact of socioeconomic status or geographic location on nodule size and management.

Objective: Timely initiation of postoperative radiotherapy (PORT) for head and neck squamous cell carcinoma (HNSCC) is associated with improved survival, but rates of timely PORT initiation are low. To support uptake in a tertiary academic center, we aimed to identify implementation determinants (eg, barriers and facilitators) to timely PORT initiation and to design context-specific implementation strategies.

Methods: We created an implementation blueprint through a sequential mixed-methods study where we (1) identified determinants by fielding a 15-item survey based on the Theoretical Domains Framework (TDF), (2) prioritized determinants through focus groups with relevant stakeholders, (3) mapped barriers to implementation strategies using the Consolidated Framework for Implementation Research (CFIR)-Expert Recommendations for Implementing Change (ERIC) matching tool, and (4) operationalized strategies using the Action, Actor, Context, Target, Time (AACTT) framework.

Results: Twenty-three participants from three departments (61% Radiation Oncology, 35% Otolaryngology, 4% Medical Oncology) in a variety of roles (35% physicians, 39% nurses or advanced practice providers, 22% radiation therapists or dosimetrists, and 4% research coordinators) completed surveys. Participants identified 10 determinants affecting timely PORT initiation. After strategy selection and operationalization by focus group participants (n = 13), three ERIC strategies were selected for clinical implementation: remind clinicians, conduct educational meetings, and facilitate relay of clinical data to providers.

Discussion: This work developed a menu of implementation strategies for future deployment to support timely PORT initiation. Codesign centered the voice of frontline workers, increasing the likelihood of successful implementation.

Implications for practice: The systematic approaches to development can serve as a model for process improvement in other contexts.