Publications by authors named "Arjun S Joshi"

60 Publications

Adverse effects of chronic steroid use following thyroidectomy.

J Surg Res 2021 Jun 10;267:17-24. Epub 2021 Jun 10.

Division of Otolaryngology-Head and Neck Surgery, George Washington University School of Medicine & Health Sciences. Washington, DC.

Background: Prior to thyroid surgery, a subset of patients chronically uses steroids to manage medical conditions such as Grave's disease, auto-immune conditions, or organ transplantation. Existing literature describes adverse effects of prolonged steroid use on surgical outcomes, however there remains a paucity of data investigating the specific effects of steroid use on postoperative outcomes after thyroidectomy. This study aims to identify complication risks steroid users are predisposed to after thyroidectomy.

Materials And Methods: The American College of Surgeons National Surgical Quality Improvement Program Database (ACS-NSQIP) was queried to identify and isolate all patients who had undergone thyroidectomy procedures by Current Procedure Terminology codes from 2005 through 2018. Univariate analysis was performed to compare steroid uses and non-steroid users. Coarsened exact matching was utilized to homogenize the two cohorts based on demographics and preoperative comorbidities.

Results: A total of 153,595 thyroidectomies were initially included. After Coarsened exact matching, 116,861 patients were categorized as non-steroid users, and 2,965 as steroid users. The steroid cohort demonstrated significantly higher rates of any complication (P < 0.001) as well as overall surgical, cardiopulmonary, and renal complications. Individual complications such as superficial surgical site infections (P = 0.013), pulmonary embolism (P = 0.016), deep vein thrombosis (P = 0.011), progressive renal insufficiency (P = 0.006), and unplanned readmission (P = 0.026) were also increased.

Conclusions: Patients with chronic steroid use undergoing thyroidectomy are at an increased risk for surgical, cardiopulmonary, and renal complications. Further research on preoperative steroid management is necessary for optimizing outcomes in this population.
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http://dx.doi.org/10.1016/j.jss.2021.04.042DOI Listing
June 2021

Incorporating Sialendoscopy into the Otolaryngology Clinic.

Otolaryngol Clin North Am 2021 Jun;54(3):509-520

Division of Otolaryngology-Head & Neck Surgery, George Washington University School of Medicine & Health Sciences, 2300 M. Street, 4th Floor, Washington, DC 20037, USA.

Simple sialendoscopy procedures may be performed in the outpatient clinic with few complications. This process spares patients the risks, increased cost, and time burdens of sialendoscopy under general anesthesia. Sialendoscopy procedures may be incorporated into the outpatient practice after gaining experience with these procedures in the operating room. Diagnostic sialendoscopy, dilation of stenosis, and endoscopic sialolithotomies of small, freely mobile stones are appropriate for in-office sialendoscopy in many instances.
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http://dx.doi.org/10.1016/j.otc.2021.02.003DOI Listing
June 2021

Oncologic outcomes of human papillomavirus-associated oropharynx carcinoma treated with surgery alone: A 12-institution study of 344 patients.

Cancer 2021 May 6. Epub 2021 May 6.

Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania.

Background: The oncologic outcomes of surgery alone for patients with American Joint Committee on Cancer 7th edition (AJCC 7th) pN2a and pN2b human papillomavirus-associated oropharynx squamous cell carcinoma (HPV+OPSCC) are not clear.

Methods: The authors performed a 12-institution retrospective study of 344 consecutive patients with HPV+OPSCC (AJCC 7th pT0-3 N3 M0) treated with surgery alone with 6 months or more of follow-up using univariate and multivariate analyses.

Results: The 2-year outcomes for the entire cohort were 91% (182 of 200) disease-free survival (DFS), 100% (200 of 200) disease-specific survival (DSS), and 98% (200 of 204) overall survival (OS). The 18 recurrences within 2 years were 88.9% (16 of 18) local and/or regional recurrences and 11.1% (2 of 18) distant metastases. Recurrences were not significantly associated with smoking, pT stage, or pN stage. The 16 patients with locoregional recurrences within 2 years all underwent successful salvage treatments (median follow-up after salvage: 13.1 months), 43.8% (7 of 16) of whom underwent salvage surgery alone for a 2-year overall salvage radiation need of 4.5% (9 of 200). The 2-year outcomes for the 59 evaluable patients among the 109 AJCC 7th pT0-2 N2a-N2b patients with 1 to 3 pathologic lymph nodes (LNs) were as follows: local recurrence, 3.4% (2 of 59); regional recurrence, 8.4% (5 of 59); distant metastases, 0%; DFS, 88.1% (52 of 59); DSS, 100% (59 of 59); OS, 96.7% (59 of 61); and salvage radiation, 5.1% (3 of 59).

Conclusions: With careful selection, surgery alone for AJCC 7th pT0-2N0-N2b HPV+OPSCC with zero to 3 pathologic LNs without perineural invasion, extranodal extension, or positive margins results in high DFS, DSS, OS, and salvage treatment success. Because of the short-term follow-up, these data support further investigation of treatment de-escalation in this population.
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http://dx.doi.org/10.1002/cncr.33611DOI Listing
May 2021

Transoral robotic surgery versus nonrobotic resection of oropharyngeal squamous cell carcinoma.

Head Neck 2021 Jul 26;43(7):2259-2273. Epub 2021 Apr 26.

Division of Otolaryngology - Head & Neck Surgery, The George Washington University School of Medicine & Health Sciences, Washington, DC, USA.

The aim of this study is to evaluate the impact of transoral robotic surgery (TORS) compared to nonrobotic surgery (NRS) on overall survival in oropharyngeal squamous cell carcinoma (OPSCC). We performed a retrospective study of patients with HPV+ and HPV- OPSCC undergoing TORS or NRS with neck dissection using the National Cancer Database from the years 2010-2016. Among patients with OPSCC in our cohort, 3167 (58.1%) patients underwent NRS and 2288 (41.9%) underwent TORS. TORS patients demonstrated better overall survival than NRS patients (HPV+ patients: aHR 0.74, p = 0.02; HPV- patients: aHR 0.58, p < 0.01). Subsite analysis showed TORS was correlated with improved survival in base of tongue (BoT) primaries for both HPV+ (aHR 0.46, p = 0.01) and HPV- (aHR 0.42, p = 0.01) OPSCC. Compared to NRS, TORS is associated with improved overall survival for HPV+ and HPV- OPSCC, as well as greater overall survival for BoT primaries.
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http://dx.doi.org/10.1002/hed.26724DOI Listing
July 2021

Rapid, Effective Cannulation for Salivary Duct Access: Use of Hydro-Dilation With Viscous Lidocaine.

Laryngoscope 2021 Mar 15. Epub 2021 Mar 15.

Division of Otolaryngology-Head and Neck Surgery, The George Washington University, Washington, DC, U.S.A.

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http://dx.doi.org/10.1002/lary.29456DOI Listing
March 2021

Postoperative Complications After Thyroidectomy: Time Course and Incidence Before Discharge.

J Surg Res 2021 Apr 23;260:210-219. Epub 2020 Dec 23.

Division of Otolaryngology-Head and Neck Surgery, George Washington University School of Medicine & Health Sciences, Washington, District of Columbia.

Background: Although complication rates after thyroidectomy are well described in the literature, the timing of these events is less understood. This study delineates the timeline and risk factors for early adverse events after thyroidectomy.

Materials And Methods: This study included a retrospective review of 161,534 patients who underwent thyroidectomy between 2005 and 2018 using the American College of Surgeons National Surgical Quality Improvement Program database. Time to specific complications was analyzed for all patients undergoing thyroidectomy, with further stratification of hemithyroidectomy and total thyroidectomy cohorts. Univariate analyses were conducted to analyze demographics, preoperative comorbidities, and complications. A multivariate logistic regression model was generated to identify significant risk factors for 7-day postoperative complications.

Results: The overall complication rate was 3.28%. A majority of complications arose before discharge including the following: blood transfusion (96%), hematoma formation (68%), pneumonia (53%), and cardiac arrest (67%). Approximately 37% of unplanned reoperations occurred before discharge in the hemithyroidectomy versus 63% in the total thyroidectomy cohort. Greater than 65% of mortalities occurred after discharge in both groups. Complications generally occurring within 7 d for the entire cohort included the following: pneumonia (3; 2-8 [median postoperative day; interquartile range]), pulmonary embolism (6; 2-12), cardiac arrest (1; 0-5), myocardial infarction (2; 1-6), blood transfusions (0; 0-1), and hematoma formation (0; 0-2). Superficial surgical site infection (9; 6-16) occurred later. Patients who underwent outpatient surgery had a decreased risk of complications (odds ratio 0.41) in the 7-day postoperative period.

Conclusions: Although early complications after thyroidectomy are rare, they have a distinct time course, many of which occur after discharge. However, in selected patients undergoing outpatient thyroidectomy, overall risk of complications is decreased. Understanding timing helps establish better preoperative communication and education to improve postoperative expectations for the provider and patient.
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http://dx.doi.org/10.1016/j.jss.2020.11.008DOI Listing
April 2021

Salivary gland ultrasound training: Improving anatomic identification in residents.

Am J Otolaryngol 2020 Nov - Dec;41(6):102734. Epub 2020 Sep 23.

The George Washington University, Division of Otolaryngology, Head and Neck Surgery, Washington, DC, United States of America.

Objectives/hypothesis: The aim of the study was to introduce and study the role of standardized views for ultrasound of the major salivary glands in resident learning and retention.

Study Design: Methods description and prospective case series.

Methods: Five otolaryngology residents and two patient models were recruited for this study. The participants were timed on their identification of the submandibular gland, sublingual gland, and parotid gland and associated key anatomic structures. Participants were then timed again immediately after being presented a standardized view for each salivary gland: the longitudinal submandibular gland, transverse parotid gland, and submental transverse views. The same participants were then timed one month later to determine retention. A Wilcoxon signed-rank test was used to evaluate whether time to identification was equal pre- and post-standardized view instruction.

Results: There was a significant improvement from pre- to post-standardized view instruction in all glands, which was sustained one month later. Practically speaking, assessment times for all participants at the one-month measurement were reasonable, with averages of 71, 42, and 114 s for the submandibular gland, sublingual gland, and parotid gland respectively.

Conclusions: Standardized views provided otolaryngology ultrasonography learners with a reliable, fast, and memorable way to assess the salivary glands and their related structures.

Level Of Evidence: 4.
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http://dx.doi.org/10.1016/j.amjoto.2020.102734DOI Listing
January 2021

Minimum fascia tumor distance for selection of extracapsular dissection for benign parotid tumors: A preliminary study.

Am J Otolaryngol 2021 Jan - Feb;42(1):102776. Epub 2020 Oct 22.

Division of Otolaryngology-Head and Neck Surgery, George Washington University School of Medicine & Health Sciences, Washington, DC, United States of America.

Objective: There is increasing literature supporting the use of extracapsular dissection (ECD) for the treatment of select superficial lobe parotid tumors, though no objective criteria for selection has been proposed. Prior studies have suggested the minimum distance between the parotideomasseteric fascia and the tumor edge or minimum fascia-tumor distance (MFTD) as a useful measurement for the identification of superficial parotid tumors. The objective of this study is to demonstrate the utility of the minimum fascia-tumor distance in selecting candidates for extracapsular dissection of benign parotid tumors.

Methods: This is a retrospective case-control study at a tertiary academic otolaryngology clinic. Twenty-three patients with prior surgical excision of benign parotid tumors that underwent surgeon-performed ultrasonography prior to excision of tumor were identified. Ultrasound images were reviewed and the minimum fascia-tumor distance was recorded and categorized by less than 3 mm or as 3 mm or greater. The primary outcome was successful completion of extracapsular dissection versus more extensive resection.

Results: Thirteen patients had a minimum fascia-tumor distance less than 3 mm; eleven of thirteen (84.6%) successfully underwent extracapsular dissection. Ten patients had a minimum fascia-tumor distance of 3 mm or greater; one of ten (10%) successfully underwent extracapsular dissection. A minimum fascia-tumor distance less than 3 mm was sensitive, specific, and accurate in predicting successful ECD at 91.7%, 81.8%, and 87.0% respectively (OR 49.5, 95% CI 3.4-573.2).

Conclusion: Minimum fascia-tumor distance may be a useful measurement in identifying candidates for removal of benign parotid tumors with extracapsular dissection.
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http://dx.doi.org/10.1016/j.amjoto.2020.102776DOI Listing
June 2021

Intraoral midline mandibulotomy to improve access for transoral robotic surgery (TORS) base of tongue resection in a retrognathic and microstomic patient.

BMJ Case Rep 2020 Oct 22;13(10). Epub 2020 Oct 22.

Division of Otolaryngology-Head and Neck Surgery, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA.

A 74-year-old man was referred to a tertiary academic otolaryngology clinic for evaluation of a left-sided neck mass with unknown primary. Nuclear imaging modalities revealed a primary cancer located at the left tongue base. Further investigation revealed the tumour to be a p16 positive squamous cell cancer with metastatic spread to cervical lymph nodes of multiple levels. The patient was found on initial investigation to have microstomia and a retrognathic mandible, which are typically considered unsuitable for robotic surgery due to difficulties obtaining adequate exposure.The patient underwent bilateral neck dissection, followed by transoral robotic-assisted left base of tongue resection. A midline intraoral mandibulotomy was performed to improve robotic access. Following tumour resection, the mandible was repaired using open reduction with internal plate fixation. Postoperative occlusion was maintained, and the patient recovered well from mandibulotomy with none of the morbidity or cosmetic defects associated with a traditional lip-split approach.
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http://dx.doi.org/10.1136/bcr-2020-236010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7583074PMC
October 2020

Obesity is a predictor of increased morbidity after tracheostomy.

Am J Otolaryngol 2021 Jan - Feb;42(1):102651. Epub 2020 Jul 15.

Division of Otolaryngology-Head and Neck Surgery, George Washington University School of Medicine & Health Sciences, Washington, DC, United States of America.

Objective: The purpose of this study was to analyze the relationship between body mass index (BMI) and 30-day morbidity and mortality risk in patients undergoing tracheostomy using the American College of Surgeons National Quality Improvement Program (ACS-NSQIP).

Study Design: This is a retrospective, cross-sectional, cohort study.

Setting: Patients were identified with Current Procedural Terminology codes in the ACS-NSQIP database.

Subjects And Methods: Patients who underwent tracheostomy from 2005 to 2018 were queried. They were stratified into four BMI classes and matched to normal BMI cohorts. Multivariate logistic regression was used to identify independent predictors for complications, readmissions, and unplanned reoperations within 30 days.

Results: Among 3784 patients meeting inclusion and exclusion criteria, obesity was shown to be a significant independent risk factor for overall complications (OR 1.439, 95% CI 1.226-1.689, p < 0.001), postoperative acute renal failure (OR 10.715, 95% CI 1.213-94.646, p = 0.033), and unplanned readmissions (OR 1.702, 95% CI 1.095-2.647, p = 0.018). A significantly lower rate of postoperative transfusions was observed for obese patients (OR 0.581, 95% CI 0.432-0.781, p < 0.001).

Conclusions: Obesity was found to be independently associated with an increased risk of overall complication, developing acute renal failure, and having an unplanned 30-day readmission following tracheostomy. The risk of postoperative transfusion appears to be lower in obese patients.

Level Of Evidence: 4.
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http://dx.doi.org/10.1016/j.amjoto.2020.102651DOI Listing
April 2021

Outpatient vs inpatient parotidectomy: Systematic review and meta-analysis.

Head Neck 2021 Feb 3;43(2):668-678. Epub 2020 Oct 3.

Division of Otolaryngology - Head and Neck Surgery, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA.

The primary aim of this study was to conduct a systematic review and meta-analysis to compare complications between outpatient vs inpatient parotidectomy. A systematic review was performed to identify patients undergoing either outpatient or inpatient partodiectomy, in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, using PUBMED, SCOPUS, CINAHL, and the Cochrane library. Risk of bias was assessed using the Newcastle-Ottawa Scale. Postoperative complications (hematoma, seroma/sialocele, salivary fistula formation, Frey syndrome, surgical site infection [SSI]) were compared. Our search yielded 4958 nonduplicate articles, of which 13 studies were ultimately included (11 retrospective cohort, 2 prospective cohort), encompassing a total of 1323 patients (outpatient 46.33% vs inpatient 53.67%). There was no significant difference in total complications, hematoma, seroma, salivary fistula, or SSI rates between outpatient and inpatient groups. No significant difference in total complications was found between outpatient and inpatient groups when stratified by surgical approach (partial/superficial and total parotidectomy). Our findings suggest outpatient parotidectomy may be as safe as inpatient parotidectomy in appropriately selected patients.
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http://dx.doi.org/10.1002/hed.26482DOI Listing
February 2021

Adverse Events Associated with Implantable Dopplers during Microvascular Surgery.

J Reconstr Microsurg 2021 May 17;37(4):365-371. Epub 2020 Sep 17.

Division of Otolaryngology-Head and Neck Surgery, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia.

Background:  Implantable Dopplers (IDs) are widely used for postoperative free flap vascular monitoring. However, IDs may contribute to free flap complications or failure and better understanding of device malfunctions is needed.

Methods:  The U.S. Food and Drug Administration's Manufacturer and User Facility Device Experience database was queried for all reports of ID adverse events from two leading manufacturers (Cook Vascular and Synovis Life Technologies) in free flap surgery from January 2010 to March 2020. Reports were reviewed and categorized. A comparison of reoperations within select categories was performed using Chi-square analysis.

Results:  Of 209 included reports, the most common device malfunctions were venous anastomotic coupler misalignment (35.4%) and coupler ring detachment (24.4%). Synovis devices were used in 100% of reports of vessel compression and Cook Vascular devices were used in 77.7% of reports of probe detachment. Of 74 patient-related adverse events, the most common were reoperation (47.3%) and vessel occlusion (28.4%). Of five reported events of flap failure, two were associated with loss of ID signal. The proportion of Doppler signal loss events leading to reoperation was significantly greater than the proportion of any other Doppler-related event leading to reoperation. Intraoperative coupler replacement was the most commonly reported intervention ( = 86), and venous anastomosis with hand-suturing occurred in 30 device malfunctions.

Conclusion:  This study demonstrates a variety of ID-related malfunctions. One-third of device malfunctions were associated with patient complications, and false-positive Doppler signal loss contributed substantially to the requirement of surgical re-exploration. These are important considerations for surgical teams utilizing IDs in free tissue transfer procedures.
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http://dx.doi.org/10.1055/s-0040-1716858DOI Listing
May 2021

Local spikes in COVID-19 cases: Recommendations for maintaining otolaryngology clinic operations.

Am J Otolaryngol 2020 Nov - Dec;41(6):102688. Epub 2020 Aug 20.

Division of Otolaryngology - Head & Neck Surgery, George Washington University School of Medicine, United States of America.

The Coronavirus Disease-2019 (COVID-19) pandemic has created an unprecedented economic and public health crisis in the United States. Following efforts to mitigate disease spread, with a significant decline in some regions, many states began reopening their economies. As social distancing guidelines were relaxed and businesses opened, local outbreaks of COVID-19 continue to place person on healthcare systems. Among medical specialties, otolaryngologists and their staff are among the highest at risk for becoming exposed to COVID-19. As otolaryngologists prepare to weather the storm of impending local surges in COVID-19 infections there are several practical measures that can be taken to mitigate the risk to ourselves and our staff.
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http://dx.doi.org/10.1016/j.amjoto.2020.102688DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7439996PMC
November 2020

Use of Extracorporeal Membrane Oxygenation to Facilitate Removal of a Tracheal Foreign Body in an Adult.

J Cardiothorac Vasc Anesth 2021 Jun 16;35(6):1821-1823. Epub 2020 Jul 16.

Division of Otorhinolaryngology, George Washington University, Washington, DC.

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http://dx.doi.org/10.1053/j.jvca.2020.07.035DOI Listing
June 2021

A response to 'Twelve tips to maximise medical student learning during emergency medicine placements'.

Med Teach 2021 03 4;43(3):362. Epub 2020 Aug 4.

Faculty of Life Sciences and Medicine, King's College London, London, UK.

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http://dx.doi.org/10.1080/0142159X.2020.1802001DOI Listing
March 2021

Outpatient Parotidectomy: A Retrospective Series.

Ann Otol Rhinol Laryngol 2021 Mar 16;130(3):254-261. Epub 2020 Jul 16.

Division of Otolaryngology-Head & Neck Surgery, George Washington University School of Medicine & Health Sciences, Washington, DC, USA.

Objectives: Recent literature suggests that outpatient head and neck surgery is safe and may decrease costs. This study assesses whether outpatient parotidectomy differs in complication type and rate from inpatient surgery.

Methods: Patients who underwent parotidectomy at our institution from 2011 to 2019 were retrospectively reviewed and divided by inpatient or outpatient status. Complications including infection, seroma, salivary fistula, hematoma, and flap necrosis, as well as readmission rates were tabulated. Drain placement, related to tumor size, was also analyzed using a receiver operating curve.

Results: 144 patients had available data for analysis. Nine of the 144 patients had complications. Seven of 98 outpatients and two of 46 inpatients had complications. There was no statistically significant difference in complication rate between the two groups ( = .518). Tumor size ≥4.62 cm was associated with drain placement ( = .044).

Conclusion: Outpatient parotidectomy is a safe and viable alternative for carefully selected patients.
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http://dx.doi.org/10.1177/0003489420938101DOI Listing
March 2021

In Vivo Accuracy of Ultrasound for Sizing Salivary Ductal Calculi.

Otolaryngol Head Neck Surg 2021 01 30;164(1):124-130. Epub 2020 Jun 30.

Division of Otolaryngology-Head and Neck Surgery, The George Washington University, Washington DC, USA.

Objectives: The present study was developed to evaluate the accuracy of in vivo ultrasound sizing for parotid and submandibular salivary gland calculi, as compared with ex vivo pathology sizing with a standard plastic ruler after extraction.

Study Design: Retrospective chart review.

Setting: Ultrasound is frequently used to size salivary calculi and make treatment decisions, but the accuracy of measurements from this modality has not been validated.

Subjects And Methods: We evaluated and reviewed the charts and ultrasound examinations of 167 patients who underwent procedures for the treatment of sialolithiasis involving the parotid and submandibular glands. US examinations were performed between 2009 and 2016 in a tertiary-level hospital setting by the senior author. Measurements were collected from ultrasound evaluation before sialolithotomy, and pathology measurements were taken after removal. Ultrasound measurements in millimeters were compared with the measurements collected with a ruler. The differences were calculated and compared.

Results: A total of 167 calculi measurements were compared. Good concurrent validity between pathology and ultrasound measurements was suggested by a Pearson correlation of 0.92 (95% CI, 0.887-0.937). On Bland-Altman plot, correlation of the difference between US and pathology measurements showed a mean difference of 0.095 mm (95% CI, -0.19 to 0.38 mm) with a limit of agreement ranging from -3.59 mm (95% CI, -3.84 to -3.34 mm) to +3.78 mm (95% CI, +3.53 to +4.03 mm).

Conclusions: Ultrasound is an accurate, relatively precise, and minimally invasive imaging tool for salivary gland sialolithiasis. Preoperative size of calculi can be used to guide management and clinical decision making.

Level Of Evidence: 2C.
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http://dx.doi.org/10.1177/0194599820937676DOI Listing
January 2021

Unusual presentation of submandibular lingual nerve sheath tumour as sublingual stone.

BMJ Case Rep 2020 Jun 28;13(6). Epub 2020 Jun 28.

Division of Otolaryngology - Head and Neck Surgery, Department of Surgery, George Washington University School of Medicine and Health Sciences, Washington, DC, USA.

A 60-year-old woman was referred to the otolaryngologist for 18 months of left-sided tongue pain and taste changes. Surgeon-performed ultrasound of the submandibular region revealed a hyperechoic mass. Wharton's duct was dilated proximally and the submandibular gland demonstrated normal vascularity. While these findings were highly suspicious for submandibular gland sialolith, an in-office attempt at sialolithotomy suggested an alternate process or mass. After imaging failed to further elucidate an aetiology, surgical exploration revealed a well-circumscribed submandibular mass associated with the lingual nerve. The mass was removed en-bloc and pathology revealed a schwannoma of the lingual nerve.
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http://dx.doi.org/10.1136/bcr-2019-233759DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7322326PMC
June 2020

Surgical management and outcomes of accessory parotid gland neoplasms: A systematic review.

Am J Otolaryngol 2020 Sep - Oct;41(5):102610. Epub 2020 Jun 16.

Division of Otolaryngology-Head and Neck Surgery, George Washington University School of Medicine & Health Sciences, United States of America.

Objective: To evaluate surgical approaches and outcomes associated with accessory parotid gland neoplasms.

Data Sources: MEDLINE, SCOPUS, and the Cochrane Central Register of Controlled Trials.

Review Methods: A systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was performed. Studies were included if they reported surgical management and outcomes of patients with accessory parotid gland neoplasms.

Results: After screening 3532 records, 15 studies were included with a total of 187 patients. Benign tumors consisted of 61.5% of cases. External open, transoral, and preauricular endoscopic approaches were used for 82.3%, 11.3%, and 6.5% of cases, respectively. Accessory lobe resection alone, concurrent with partial parotidectomy, and concurrent with total parotidectomy were used in 54.8%, 43.0%, and 2.2% of cases, respectively. Complication rates were similar between histology groups (7.8% benign vs. 8.3% malignant, p = 0.82). Accessory lobe resection with concurrent partial parotidectomy had the lowest overall complication rate (6.3%). Resections limited to the accessory lobe were found to have an overall complication rate of 8.7%.

Conclusion: The results offer an overview of the surgical management and complications for accessory parotid gland tumors. Overall surgical complication rates found in these case series may be lower for management of accessory gland tumors than rates available in the literature for tumors within the main parotid gland.
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http://dx.doi.org/10.1016/j.amjoto.2020.102610DOI Listing
November 2020

Neoadjuvant chemotherapy followed by surgery for HPV-associated locoregionally advanced oropharynx cancer.

Head Neck 2020 08 25;42(8):2145-2154. Epub 2020 Mar 25.

Department of Hematology and Oncology, George Washington University, Washington, District of Columbia, USA.

Background: Neoadjuvant chemotherapy followed by surgery (NAC + S), a paradigm based on systemic escalation coupled with surgery-based de-escalation, is under investigation for treatment of HPV-associated oropharynx cancer (OPC).

Methods: Prospective cohort of patients with non-metastatic, p16 positive OPC enrolled in a clinical trial of NAC + S was compared to a historic cohort of patients undergoing concurrent chemoradiation (CCRT) to compare disease-free survival (DFS).

Results: Fifty-five patients were treated with NAC + S and 142 with CCRT. Stage-matched patients undergoing CCRT had higher frequency of smoking and alcohol consumption. 5-year DFS in the NAC + S group was 96.1% (95% CI 90.8-100) compared to 67.6% (95% CI 50.7-84.5) for CCRT (P = .01). At 12 months from treatment, 24.5% of patients undergoing CCRT and none of the patients in the NAC + S were feeding tube dependent (P < .0001).

Conclusion: NAC + S may be a novel approach for HPV-associated OPC as it provides lower feeding tube dependence and improved survival compared to stage-matched patients undergoing CCRT.
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http://dx.doi.org/10.1002/hed.26147DOI Listing
August 2020

Pathologic response to neoadjuvant chemotherapy in HPV-associated oropharynx cancer.

Head Neck 2020 03 27;42(3):417-425. Epub 2019 Nov 27.

Division of Hematology and Oncology, George Washington University, Washington, District of Columbia.

Background: A paradigm shift has led to de-escalation trials for the treatment of HPV-positive oropharynx cancer (OPC). The objective of this study was to assess the ability of tumor volume reduction on imaging to predict pathological response to neoadjuvant chemotherapy in patients with HPV-positive OPC.

Methods: A prospective observational study of 54 patients with HPV-positive OPC enrolled in a clinical trial of neoadjuvant chemotherapy followed by surgery was performed. Patients underwent three cycles of induction chemotherapy (cisplatin/docetaxel); prechemotherapy and postchemotherapy imaging were obtained. Receiver operating characteristic curves and logistic regression analyses were used.

Results: The complete pathologic response (pCR) rate at primary and nodal sites were 72% and 57%, respectively. Tumor volume reduction of ≥90% following induction chemotherapy predicted pCR of the primary tumor.

Conclusions: Neoadjuvant chemotherapy followed by definitive transoral surgery is a new paradigm worthy of further investigation and MRI is a reliable modality to assess preoperative response.
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http://dx.doi.org/10.1002/hed.26022DOI Listing
March 2020

Predictors of Mortality in HPV-Associated Oropharynx Carcinoma Treated With Surgery Alone.

Laryngoscope 2020 07 1;130(7):E423-E435. Epub 2019 Nov 1.

Division of Head and Neck Oncologic and Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, San Francisco, California.

Objective: Survival outcomes for human papillomavirus-associated oropharynx squamous cell carcinoma (HPV + OPSCC) treated with surgery alone are unclear. To increase understanding, we assessed overall survival (OS) outcomes using the national cancer database (NCDB).

Methods: We conducted a retrospective analysis of OS of 736 NCDB HPV + OPSCC patients who underwent surgery alone from 2010 to 2014 using univariate and multivariate analyses and the Kaplan-Meir method.

Results: Multivariable analysis found the following independent risk factors for death: American Joint Commission on Cancer (AJCC) 8th edition pathologic stage(p)N2 versus pN0 disease (hazard ratio [HR], 5.5; P = 0.000006), macroscopic extranodal extension (ENE) versus non-ENE (HR, 4.9; P < 0.02), a positive lymph nodes (LN) percentage of ≥10% (HR, 4.2; P = 0.0002), and five or more positive LNs (HR, 4.9; P = 0.00004). Three-year OS was significantly worse for AJCC 8th edition pN2 versus pN0 but not for 7th edition pN2 versus pN0 disease. Five-year OS was significantly worse for positive versus negative surgical margins, AJCC 8th edition stage II versus I, and either microscopic or macroscopic ENE versus non-ENE positive LNs. For 523 (71%) AJCC 8th edition stage I patients and for 283 (38%) patients who were pT1-T2, with negative margins, pN0-N1, with ≤4 pathologic LNs, without ENE, and with >20 LNs removed during neck dissection, the 3-year OS rates were 93% and 95%, respectively, and the 5-year OS rates were 91% and 95%, respectively.

Conclusion: In the context of the lack of detail and possible inaccuracies found in the NCDB, surgery alone for AJCC 8th edition stage I HPV + OPSCC, particularly pT1-T2, pN0-N1 with ≤4 pathologic LNs, without ENE, and with negative surgical margins has a high OS.

Level Of Evidence: 4 Laryngoscope, 130:E423-E435, 2020.
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http://dx.doi.org/10.1002/lary.28344DOI Listing
July 2020

Landmark-Guided Deformable Image Registration for Supervised Autonomous Robotic Tumor Resection.

Med Image Comput Comput Assist Interv 2019 Oct 10;11764:320-328. Epub 2019 Oct 10.

Department of Mechanical Engineering, University of Maryland, College Park, MD, USA.

Oral squamous cell carcinoma (OSCC) is the most common cancer in the head and neck region, and is associated with high morbidity and mortality rates. Surgical resection is usually the primary treatment strategy for OSCC, and maintaining effective tumor resection margins is paramount to surgical outcomes. In practice, wide tumor excisions impair post-surgical organ function, while narrow resection margins are associated with tumor recurrence. Identification and tracking of these resection margins remain a challenge because they migrate and shrink from preoperative chemo or radiation therapies, and deform intra-operatively. This paper reports a novel near-infrared (NIR) fluorescent marking and landmark-based deformable image registration (DIR) method to precisely predict deformed margins. The accuracy of DIR predicted resection margins on porcine cadaver tongues is compared with rigid image registration and surgeon's manual prediction. Furthermore, our tracking and registration technique is integrated into a robotic system, and tested using porcine cadaver tongues to demonstrate the feasibility of supervised autonomous tumor bed resections.
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http://dx.doi.org/10.1007/978-3-030-32239-7_36DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7839792PMC
October 2019

A cost effective custom dental guard for transoral robotic surgery.

J Robot Surg 2020 Feb 2;14(1):91-94. Epub 2019 Mar 2.

Department of Otolaryngology, George Washington University Medical Faculty Associates, 2300 M St. NW, 4th Floor, Washington, DC, 20037, USA.

There has been an increasing use of transoral robotic surgery (TORS) as studies have demonstrated its effectiveness for treating a variety of conditions. Postoperative complications of TORS include hemorrhage, tooth injury, dehydration, aspiration pneumonia, and prolonged percutaneous endoscopic gastrostomy (PEG) tube dependency. Dental injury has not been adequately discussed although it has been reported to be a common complication in multiple studies, with repair costs ranging from $700 to $3000 and average time spent to address the injury estimated to be 2.6 h. The incidence of this injury is likely due to the standard dental guard, which is not customizable to the patient's teeth, therefore, not optimal for dental protection. Many alternative dental guards have been proposed to reduce the rate of dental injury. However, the previously presented alternatives are high cost, not time efficient, or have the potential for molding error rendering them less effective. We propose a guard that is cheap, time efficient, and effective in preventing dental injury. A retrospective study of 124 patients who underwent TORS over a period of 6 years with the proposed dental guard was conducted. No dental complications were observed in any of these cases. A cost analysis showed that this guard saved $4526.64 for our relatively small patient cohort. This guard can save money, time, and stress for both the patient and the surgeon, as well as reduce the number and severity of medico-legal claims related to perioperative dental injury.
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http://dx.doi.org/10.1007/s11701-019-00942-1DOI Listing
February 2020

Sonolocation during submandibular sialolithotomy.

Laryngoscope 2019 12 23;129(12):2716-2720. Epub 2019 Feb 23.

The Division of Otolaryngology-Head and Neck Surgery, George Washington University, Washington, DC.

Objectives/hypothesis: Ultrasound is a proven tool for diagnostic and therapeutic purposes for treatment of salivary gland pathology. It is also useful for localization of calculi during submandibular gland transoral sialolithotomy when calculi cannot easily be palpated. Our objective was to determine the efficacy of sialolith localization using ultrasound during submandibular gland sialolithotomy.

Study Design: Retrospective case series.

Methods: A study performed utilizing data compiled from 2009 through 2016 in a tertiary academic center. Treatment was completed in 164 patients with sialadenitis and sialolithiasis by submandibular gland transoral sialolithotomy in either the office (81%) or the operating room (19%). Ultrasound was used for localization of sialoliths during submandibular gland sialolithotomy. Main treatment outcomes studied were success of the procedure, complications, and follow-up.

Results: Successful sialolithotomy was performed in (147 patients) 90% of cases. Complications were minimal and included stricture formation, which occurred in 3% (five patients) of cases, followed by ranula formation in 1.8% (three patients) of cases. There were no incidences of lingual nerve injury.

Conclusions: Ultrasound can be used effectively for precise sialolith localization intraoperatively.

Level Of Evidence: 4 Laryngoscope, 129:2716-2720, 2019.
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http://dx.doi.org/10.1002/lary.27816DOI Listing
December 2019

Isolated lymphatic malformation of the postcricoid space.

Ear Nose Throat J 2018 Aug;97(8):E52-E53

Department of Otolaryngology, Head and Neck Surgery, Stanford University, Stanford, CA, USA.

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http://dx.doi.org/10.1177/014556131809700813DOI Listing
August 2018

Minimally elevated preoperative parathyroid hormone level influences the management of primary hyperparathyroidism.

Laryngoscope 2018 04 29;128(4):1016-1021. Epub 2017 Aug 29.

Department of Radiology, George Washington University, Washington, DC, U.S.A.

Objectives/hypothesis: To determine the effect of preoperative parathyroid hormone (PTH) level on the extent of surgery and the accuracy of parathyroid imaging in primary hyperparathyroidism.

Study Design: Retrospective cohort.

Methods: Final diagnosis of single-gland adenoma and its location versus multigland disease was established in this retrospective cohort study. Positive predictive value, negative predictive value, and accuracy of imaging were analyzed in relation to preoperative PTH levels.

Results: Eighty-seven percent of the 218 patients enrolled in the study underwent unilateral targeted operation and had a 97.9% (95% confidence interval: 95.8%-100%) success rate. However, in patients with PTH <65 pg/mL, 28.6% had bilateral exploration compared to 10.3% in those with PTH ≥65 pg/mL (P = .042). In patients with PTH <65 pg/mL, 7/21 (33.3%) had inaccurate sestamibi findings compared to 24/174 (13.8%) in patients with PTH ≥65 pg/mL (P = .047).

Conclusions: Accuracy of sestamibi drops significantly, by threefold, in patients with mild primary hyperparathyroidism and PTH <65 pg/mL. Patients with PTH < 65 pg/mL have a 2.5-fold higher rate of bilateral operation to identify the hypersecreting gland(s) compared to patients with PTH ≥65 pg/mL.

Level Of Evidence: 4. Laryngoscope, 128:1016-1021, 2018.
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http://dx.doi.org/10.1002/lary.26699DOI Listing
April 2018

Importance of FNA Technique for Decreasing Non-diagnostic Rates in Thyroid Nodules.

Head Neck Pathol 2018 Jun 17;12(2):160-165. Epub 2017 Aug 17.

Division of Otolaryngology - Head and Neck Surgery, The George Washington University, Washington, DC, USA.

To identify potential interventions that may lower the high non-diagnostic rates associated with ultrasound guided (US) fine needle aspiration (FNA) biopsy of the thyroid nodule. A case series of 164 thyroid nodule US-guided FNA was identified retrospectively. The following variables were analyzed in regards to diagnostic and non-diagnostic sampling: patient age, gender, size of nodule, biopsy technique (capillary vs. aspiration), needle gauge (23 vs. 25), and physician experience. The FNA diagnosis, and final pathology, when applicable, was recorded for each sample using the Bethesda criteria. Data was analyzed using the Fisher's exact test or the chi square test. After multivariate logistic regression, capillary action was independently associated with lower non-diagnostic rates (p = 0.01), while increasing patient age was associated with higher non-diagnostic rates (p = 0.018). Physician experience (p = 0.014) was not independently associated with lower non-diagnostic rates. Nodules that were "cystic >50%" were significantly more likely to yield a non-diagnostic result (p < 0.0001). After taking into account confounding variables, including physician experience, our data reveals a statistically significant decrease in non-diagnostic rates with the use of capillary action vs. aspiration technique in US-guided FNA. A major focus in healthcare today is providing cost-effective and minimally invasive care to the patient. In the setting of a rising incidence of thyroid disease, we believe our study demonstrates the need for a prospective analysis of the relationship between technique and non-diagnostic rates.
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http://dx.doi.org/10.1007/s12105-017-0844-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5953868PMC
June 2018

Novel case examples of the submental island flap in pediatric head and neck reconstruction.

Int J Pediatr Otorhinolaryngol 2017 Jun 21;97:51-54. Epub 2017 Mar 21.

Division of Otolaryngology-Head and Neck Surgery, The George Washington University School of Medicine and Health, Washington DC, United States.

The submental island flap was first described as a tool for facial reconstruction after tumor resection. It is now widely used for reconstructing numerous structures in the head and neck region of adults. Pediatric surgical reconstruction is a challenging task that continues to evolve over time. We describe two novel uses of this flap in the pediatric population. The submental island flap is an excellent option for reconstruction in pediatrics given its ease of elevation, excellent cosmetic outcomes, and low donor site morbidity.
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http://dx.doi.org/10.1016/j.ijporl.2017.03.026DOI Listing
June 2017