Publications by authors named "Daniel G Deschler"

157 Publications

Diagnostic challenges and successful organ-preserving therapy in a case of secretory carcinoma of minor salivary glands.

Cancer Rep (Hoboken) 2021 Jul 7:e1491. Epub 2021 Jul 7.

Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA.

Background: Secretory carcinoma is a more recently described subtype of salivary gland carcinoma that may pose diagnostic challenges and frequently harbors NTRK fusions that may successfully be targeted by TRK inhibitors in advanced disease.

Case: We present the case of a female patient with secretory carcinoma arising in the base of tongue with persistent disease after debulking surgery and definitive chemoradiation. As an alternative to salvage surgery, which would have resulted in significant impairment of swallowing and speech function, a targeted therapy with the TRK-inhibitor larotrectinib against an identified ETV6-NTRK3 fusion product was initiated. Larotrectinib treatment has been well tolerated, resulted in durable complete response and the patient maintains good swallowing and speech function.

Conclusion: The presented case underscores the importance of the accurate diagnosis of secretory carcinoma. It further highlights the impact of molecular testing as targeted therapies may play an important role in the management of advanced salivary gland cancers.
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http://dx.doi.org/10.1002/cnr2.1491DOI Listing
July 2021

Feeding Tube Placement Following Transoral Robotic Surgery for Oropharyngeal Squamous Cell Carcinoma.

Otolaryngol Head Neck Surg 2021 Jun 22:1945998211020302. Epub 2021 Jun 22.

Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA.

Objective: To identify factors that may predict the need for feeding tubes in patients undergoing transoral robotic surgery (TORS) in the perioperative setting.

Study Design: Retrospective chart review.

Setting: Academic tertiary center.

Methods: A retrospective series of patients undergoing TORS for oropharyngeal squamous cell carcinoma (OPSCC) was identified between October 2016 and November 2019 at a single tertiary academic center. Patient data were gathered, such as frailty information, tumor characteristics, and treatment, including need for adjuvant therapy. Multiple logistic regression was performed to identify factors associated with feeding tube placement following TORS.

Results: A total of 138 patients were included in the study. The mean age was 60.2 years (range, 37-88 years) and 81.9% were male. Overall 82.9% of patients had human papilloma virus-associated tumors, while 28.3% were current or former smokers with a smoking history ≥10 pack-years. Eleven patients (8.0%) had a nasogastric or gastrostomy tube placed at some point during their treatment. Five patients (3.6%) had feeding tubes placed perioperatively (<4 weeks after TORS), of which 3 were nasogastric tubes. Six patients (4.3%) had feeding tubes placed in the periadjuvant treatment setting for multifactorial reasons; 5 of which were gastrostomy tubes. Only 1 patient (0.7%) was gastrostomy dependent 1 year after surgery. Multiple logistic regression did not demonstrate any significant predictive variables affecting perioperative feeding tube placement following TORS for OPSCC.

Conclusions: Feeding tubes are seldom required after TORS for early-stage OPSCC. With appropriate multidisciplinary planning and care, patients may reliably avoid the need for feeding tube placement following TORS for OPSCC.
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http://dx.doi.org/10.1177/01945998211020302DOI Listing
June 2021

Assessment of Preoperative Functional Status Prior to Major Head and Neck Surgery: A Pilot Study.

Otolaryngol Head Neck Surg 2021 Jun 22:1945998211019306. Epub 2021 Jun 22.

Massachusetts Eye and Ear, Boston, Massachusetts, USA.

Objective: To demonstrate feasibility of a recently developed preoperative assessment tool, the Vulnerable Elders Surgical Pathways and Outcomes Analysis (VESPA), to characterize the baseline functional status of patients undergoing major head and neck surgery and to examine the relationship between preoperative functional status and postoperative outcomes.

Study Design: Case series with planned data collection.

Setting: Two tertiary care academic hospitals.

Methods: The VESPA was administered prospectively in the preoperative setting. Data on patient demographics, ablative and reconstructive procedures, and outcomes including total length of stay, discharge disposition, delay in discharge, or complex discharge planning (delay or change in disposition) were collected via retrospective chart review. VESPA scores were calculated and risk categories were used to estimate risk of adverse postoperative outcomes using multivariate logistic regression for categorical outcomes and linear regression for continuous variables.

Results: Fifty-eight patients met study inclusion criteria. The mean (SD) age was 66.4 (11.9) years, and 58.4% of patients were male. Nearly one-fourth described preoperative difficulty in either a basic or instrumental activity of daily living, and 17% were classified as low functional status (ie, high risk) according to the VESPA. Low functional status did not independently predict length of stay but was associated with delayed discharge (odds ratio [OR], 5.0; 95% CI, 1.2-21.3; = .030) and complex discharge planning (OR, 5.7; 95% CI, 1.34-24.2; = .018).

Conclusion: The VESPA can identify major head and neck surgical patients with low preoperative functional status who may be at risk for delayed or complex discharge planning. These patients may benefit from enhanced preoperative counseling and more comprehensive discharge preparation.
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http://dx.doi.org/10.1177/01945998211019306DOI Listing
June 2021

Intraductal carcinoma of the salivary gland with NCOA4-RET: expanding the morphologic spectrum and an algorithmic diagnostic approach.

Hum Pathol 2021 May 12;114:74-89. Epub 2021 May 12.

Pathology Service, Massachusetts General Hospital, 02114 USA; Department of Otolaryngology, Massachusetts Eye and Ear, 02114 USA; Department of Pathology, Harvard Medical School, Boston, MA, 02115 USA. Electronic address:

After the publication of the 2017 World Health Organization Classification of Head and Neck Tumours, there has been increasing interest in the classification of newly categorized intraductal carcinomas. Intraductal carcinoma (IC) is an indolent tumor, typically arising in the parotid gland, with an intact myoepithelial layer and a cystic, papillary, often cribriform architecture. Early studies of IC identified a heterogeneous group of molecular alterations driving neoplasia, and recent studies have defined three primary morphological/immunohistochemical variants, subsequently linking these morphologic variants with defined molecular signatures. Although studies to date have pointed toward distinct molecular alterations after histological classification, this study used a novel approach, focusing primarily on six cases of IC with NCOA4-RET gene rearrangement as determined by next-generation sequencing and describing the spectrum of clinicopathologic findings within that molecularly-defined group, among them a unique association between the NCOA4-RET fusion and hybrid variant IC and the first case of IC arising in association with a pleomorphic adenoma. RET-rearranged IC show histological and immunohistochemical overlap with the more widely recognized secretory carcinoma, including low-grade morphology, a lumen-forming or microcystic growth pattern, and co-expression of S100, SOX10, and mammaglobin, findings undoubtedly leading to misdiagnosis. Typically regarded to have ETV6-NTRK3 fusions, secretory carcinomas may alternatively arise with RET fusions as well. Adding our cohort of six NCOA4-RET fusion-positive IC compared with four cases of secretory carcinoma with ETV6-RET fusions and a single case of fusion-negative IC with salivary duct carcinoma-like genetics, we propose a diagnostic algorithm that integrates histological elements, including atypia and invasiveness, and the likelihood of specific molecular alterations to increase diagnostic accuracy in what can be a very subtle diagnosis with important clinical implications.
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http://dx.doi.org/10.1016/j.humpath.2021.05.004DOI Listing
May 2021

Nasal and paranasal sinus mucosal melanoma: Long-term survival outcomes and prognostic factors.

Am J Otolaryngol 2021 Apr 19;42(6):103070. Epub 2021 Apr 19.

Department of Otolaryngology, Washington University School of Medicine, St. Louis, MO, USA.

Objective: To determine prognostic factors and survival patterns for different treatment modalities for nasal cavity (NC) and paranasal sinus (PS) mucosal melanoma (MM).

Methods: Patients from 1973 to 2013 were analyzed using the Surveillance, Epidemiology, and End Results (SEER) database. Kaplan-Meier method and multivariable cox proportional hazard modeling were used for survival analyses.

Results: Of 928 cases of mucosal melanoma (NC = 632, PS = 302), increasing age (Hazard Ratio [HR]:1.05/year, p < 0.001), T4 tumors (HR: 1.81, p = 0.02), N1 status (HR: 6.61, p < 0.001), and PS disease (HR: 1.50, p < 0.001) were associated with worse survival. Median survival length was lower for PS versus NC (16 versus 26 months, p < 0.001). Surgery and surgery + radiation therapy (RT) improved survival over non-treatment or RT alone (p < 0.001). Adding RT to surgery did not yield a survival difference compared with surgery alone (p = 0.43). Five-year survival rates for surgery and surgery + RT were similar, at 27.7% and 25.1% (p = 0.43).

Conclusion: Surgery increased survival significantly over RT alone. RT following surgical resection did not improve survival.
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http://dx.doi.org/10.1016/j.amjoto.2021.103070DOI Listing
April 2021

Impact of surgical margins on local control in patients undergoing single-modality transoral robotic surgery for HPV-related oropharyngeal squamous cell carcinoma.

Head Neck 2021 Aug 15;43(8):2434-2444. Epub 2021 Apr 15.

Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA.

Background: The impact of close surgical margins on oncologic outcomes in HPV-related oropharyngeal squamous cell carcinoma (HPV + OPSCC) is unclear.

Methods: Retrospective case series including patients undergoing single modality transoral robotic surgery (TORS) for HPV + OPSCC at three academic medical centers from 2010 to 2019. Outcomes were compared between patients with close surgical margins (<1 mm or requiring re-resection) and clear margins using the Kaplan-Meier method.

Results: Ninety-nine patients were included (median follow-up 21 months, range 6-121). Final margins were close in 22 (22.2%) patients, clear in 75 (75.8%), and positive in two (2.0%). Eight patients (8.1%) recurred, including two local recurrences (2.0%). Four patients died during the study period (4.0%). Local control (p = 0.470), disease-free survival (p = 0.513), and overall survival (p = 0.064) did not differ between patients with close and clear margins.

Conclusions: Patients with close surgical margins after TORS for HPV + OPSCC without concurrent indications for adjuvant therapy may be considered for observation alone.
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http://dx.doi.org/10.1002/hed.26708DOI Listing
August 2021

Prospective assessment of multiple HPV-positive oropharyngeal squamous cell carcinomas.

Oral Oncol 2021 Jun 15;117:105212. Epub 2021 Feb 15.

Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.

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http://dx.doi.org/10.1016/j.oraloncology.2021.105212DOI Listing
June 2021

Single-surgeon parotidectomy outcomes in an academic center experience during a 15-year period.

Laryngoscope Investig Otolaryngol 2020 Dec 21;5(6):1096-1103. Epub 2020 Oct 21.

Department of Otolaryngology Harvard Medical School Boston Massachusetts USA.

Objective: As large single-surgeon series in the literature are lacking, we sought to review a single-surgeon's experience with parotidectomy in an academic center, with a focused analysis of pathology, technique, and facial nerve (FN) weakness. Benchmark values for complications and operative times with routine trainee involvement and without continuous FN monitoring are offered.

Materials And Methods: All patients who underwent parotidectomy, performed by D. G. D., for benign and malignant disease between January 2004 and December 2018 at an academic center were reviewed.

Results: A total of 924 parotidectomies, with adequate evaluatable data were identified. The majority of patients had benign tumors (70.9%). Partial/superficial parotidectomy was the most common approach (65.7%). Selective FN branch sacrifice was rare (12.3%), but significantly more common among patients with malignant pathology (33.8% vs 3.5% for benign,  < .0001). Among patients with intact FN, post-operative short- and long-term FN weaknesses were rare (6.5% and 1.7%, respectively). These rates were lower among patients with benign tumors (5.4% and 1.3%). Partial/superficial parotidectomy for benign tumors was associated with a low rate of short- and long-term FN weaknesses (2.7% and 0.9%). Mean OR time was 185 minutes.

Conclusion: This is the largest single-surgeon series on parotidectomy, spanning 15 years. We demonstrate excellent long- and short-term FN paresis rates with acceptable operative times without regular use of continuous FN monitoring and with routine trainee involvement. These findings may provide valuable insight into parotid tumor pathology, FN outcomes, and feasibility and expectations of performing parotidectomy in an academic setting.

Level Of Evidence: 4.
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http://dx.doi.org/10.1002/lio2.480DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7752052PMC
December 2020

Multispecialty surgical management of carotid body tumors in the modern era.

J Vasc Surg 2021 Jun 27;73(6):2036-2040. Epub 2020 Nov 27.

Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass. Electronic address:

Objective: The objective of this study was to assess the perioperative and long-term outcomes of carotid body tumor (CBT) resection with a multispecialty (head and neck surgery/vascular surgery) approach.

Methods: Our institutional data registry was queried for Current Procedural Terminology codes (60600, 60605) pertaining to CBT excision. These patient records and operative reports were individually reviewed to determine laterality, preoperative tumor embolization, operative time, estimated blood loss, need for intraoperative transfusion, intraoperative electroencephalogram changes, intraoperative division of the external carotid artery, carotid artery repair, resection of the carotid bifurcation, tumor volume, final pathology, cranial nerve injury, stroke, death, and clinical or radiographic evidence of recurrence.

Results: From 1996 to 2018, 74 CBT resections were identified in 68 patients (41 [60%] females; mean age, 50.83 years). The mean tumor volume was 9.92 ± 14.26 cm (range, 0.0250-71.0627 cm). Embolization was performed by a neurointerventional specialist in 27 CBT resections (36%) based on size (embolization 14.27 ± 16.84 cm vs 7.17 ± 11.86 cm; P = .063) and superior extension. This practice resulted in one asymptomatic vertebral dissection, which postponed the surgery. There was a trend toward greater blood loss in the embolization group (embolization 437 ± 545 mL vs 262 ± 222 mL; P = .17); however, no transfusions were required in any patient. The mean operative time was also significantly longer in the embolization group (198.33 ± 61.13 minutes vs 161.5 ± 55.56 minutes; P = .03). Three resections had reversible intraoperative electroencephalogram changes, one of which occurred during carotid clamping. These changes resolved with shunting. Eight external carotid resections (11%) and 6 carotid reconstructions (8.1%; two primary, two patch, and two primary anastomosis) were required. Malignancy was identified in four tumors (5.4%), accounting for four of the six carotid reconstructions. There were no postoperative cranial nerve injuries, no strokes, no reexplorations, and no deaths. One patient developed transient dysphagia from pharyngeal tumor infiltration. Long-term follow-up (mean, 43 ± 54 months), available in 61 of the 68 patients (89.7%), revealed three (4.4%) recurrences.

Conclusions: This large, single-institution series demonstrates that a multispecialty team combining two surgical skill sets for the treatment of this rare, challenging condition yields unparalleled low complication rates with short operative times. This approach, including long-term surveillance for recurrent disease, should be considered to optimize outcomes of CBT resection.
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http://dx.doi.org/10.1016/j.jvs.2020.10.072DOI Listing
June 2021

Opioid Usage and Prescribing Predictors Following Transoral Robotic Surgery for Oropharyngeal Cancer.

Laryngoscope 2021 06 19;131(6):E1888-E1894. Epub 2020 Nov 19.

Department of Otolaryngology, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, U.S.A.

Objective/hypothesis: Pain management following transoral robotic surgery (TORS) varies widely. We aim to quantify opioid usage following TORS for oropharyngeal squamous cell carcinoma (OPSCC) and identify prescribing predictors.

Study Design: Retrospective cohort study.

Methods: A consecutive series of 138 patients undergoing TORS for OPSCC were reviewed from 2016 to 2019. Opioid usage (standardized to morphine milligram equivalents [MME]) was gathered for 12 months post-surgery via prescribing record cross-check with the Massachusetts Prescription Awareness Tool.

Results: Of 138 OPSCC TORS patients, 92.8% were human papillomavirus (HPV) positive. Adjuvant therapy included radiation (XRT;67.4%) and chemoradiation (cXRT;6.5%). Total MME usage from start of treatment averaged 1395.7 MMEs with 76.4% receiving three prescriptions or less. Categorical analysis showed age <65, male sex, overweight BMI, lower frailty, former smokers, HPV+, higher T stage, and BOT subsite to be associated with increased MMEs. Adjuvant therapy significantly increased MMEs (TORS+XRT:1646.2; TORS+cXRT:2385.0; TORS alone:554.7 [P < .001]) and 12-month opioid prescription totals (TORS+XRT:3.2; TORS+cXRT:5.5; TORS alone:1.6 [P < .001]). Adjuvant therapy increased time to taper (total MME in TORS alone versus TORS+XRT/cXRT: 0 to 3 months:428.2 versus 845.5, 4 to 6 months:46.8 versus 541.8, 7 to 9 months:12.4 versus 178.6, 10 to 12 months:11.0 versus 4.4,[P < .001]). Positive predictors of opioid prescribing at the 4- to 6-month and 4- to 12-month intervals included adjuvant therapy (odds ratio [OR]:5.56 and 4.51) and mFI-5 score ≥3 (OR:36.67 and 31.94). Following TORS at 6-, 9-, and 12-month, 15.7%, 6.6%, and 4.1% were still using opioids.

Conclusions: In OPSCC treated with TORS, opioid use tapers faster for surgery alone versus with adjuvant therapy. Opioid prescribing risks include adjuvant therapy and higher frailty index.

Level Of Evidence: 4 Laryngoscope, 131:E1888-E1894, 2021.
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http://dx.doi.org/10.1002/lary.29276DOI Listing
June 2021

Management of the Embedded Tracheoesophageal Prosthesis: Retrograde Removal and Replacement.

Ann Otol Rhinol Laryngol 2021 Jul 23;130(7):840-842. Epub 2020 Oct 23.

Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA.

Objective: To describe the retrograde removal of a tracheoesophageal (TE) prosthesis embedded in the common wall between the trachea and esophagus with preservation of the original tracheoesophageal puncture (TEP) tract with subsequent placement of new tracheoesophageal prosthesis for voice restoration.

Methods: The Blom-Singer TEP Set (InHealth Technologies, Carpinteria, CA) was used to facilitate this procedure. The coated wire leader cable was threaded through the small opening in the posterior tracheal wall and into the lumen of the old TE prosthesis. The wire was pulled through the mouth in retrograde fashion - bringing the old TE prosthesis out with it and dilating the existing TEP tract. A new prosthesis was then placed over the end of the wire and returned through the stoma, delivering the prosthesis through the TE tract and into the stoma.

Results: Safe, voice restoration with avoidance of need for multiple procedures.

Conclusion: Removal of an embedded prosthesis and simultaneous replacement of a new prosthesis was safely and efficiently achieved using a retrograde technique which maintained the patency of the prior TE tract and restored voice.
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http://dx.doi.org/10.1177/0003489420967700DOI Listing
July 2021

Role of physician density in predicting stage and survival for head and neck squamous cell carcinoma.

Head Neck 2021 02 4;43(2):438-448. Epub 2020 Oct 4.

Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Massachusetts Eye and Ear, Boston, Massachusetts, USA.

Background: Identifying and linking barriers to access to head and neck cancer care, specifically provider density, to stage of diagnosis and survival outcomes is important to serve as a foundation for policy interventions.

Methods: Retrospective cohort study using patients with head and neck squamous cell (HNSCC) in the Surveillance, Epidemiology, and End Results (SEER) database from 2007 to 2016 and Area Resource File. Primary outcomes included stage of presentation and cancer-specific 5-year survival and relation to provider density.

Results: The initial cohort consisted of 18 342 patients with oral cavity, 21 809 oropharyngeal, 15 860 laryngeal, and 2887 patients with hypopharyngeal malignancy. Non-Hispanic Black race and being uninsured increased the odds of presenting with advanced stage HNSCC and increased hazard of death. There was no significant and consistent association identified between Health Service Areas provider density and advanced stage at diagnosis or cancer-specific 5-year mortality.

Conclusions: Provider density of otolaryngologists and primary care physicians and dentists was not significantly associated with stage of presentation or cancer-specific survival for HNSCC while race and insurance status remained independent predictors for worse outcomes.
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http://dx.doi.org/10.1002/hed.26495DOI Listing
February 2021

Behind the Mask.

J Gen Intern Med 2020 11 9;35(11):3379-3380. Epub 2020 Sep 9.

Department of Otolaryngology - Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, USA.

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http://dx.doi.org/10.1007/s11606-020-06095-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7661585PMC
November 2020

Cost-effectiveness analysis of using the heat and moisture exchangers compared with alternative stoma covers in laryngectomy rehabilitation: US perspective.

Head Neck 2020 12 4;42(12):3720-3734. Epub 2020 Sep 4.

Division of Psychosocial Research and Epidemiology, Netherlands Cancer Institute, Amsterdam, The Netherlands.

Background: This study aims to evaluate the cost-effectiveness of using heat and moisture exchangers (HMEs) vs alternative stoma covers (ASCs) following laryngectomy in the United States.

Methods: A cost-effectiveness and budget impact analysis were conducted including uncertainty analyses using real-world survey data with pulmonary events and productivity loss.

Results: HME use was more effective and less costly compared with ASCs. Quality-adjusted life years were slightly higher for HME-users. Total costs per patient (lifetime) were $59 362 (HME) and $102 416 (ASC). Pulmonary events and productivity loss occurred more frequently in the ASC-users. Annual budget savings were up to $40 183 593. Costs per pulmonary event averted were $3770.

Conclusions: HME utilization in laryngectomy patients was cost-effective. Reimbursement of HME devices is thus recommended. Utilities may be underestimated due to the generic utility instrument used and sample size. Therefore, we recommend development of a disease-specific utility tool to incorporate in future analyses.
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http://dx.doi.org/10.1002/hed.26442DOI Listing
December 2020

Risk Factors for Laryngectomy for Dysfunctional Larynx After Organ Preservation Protocols: A Case-Control Analysis.

Otolaryngol Head Neck Surg 2021 03 18;164(3):608-615. Epub 2020 Aug 18.

Harvard Medical School, Boston, Massachusetts, USA.

Objective: (1) To identify factors associated with severe dysfunctional larynx leading to total laryngectomy after curative treatment of head and neck squamous cell carcinoma and (2) to describe swallowing and voice outcomes.

Study Design: Retrospective single-institution case-control study.

Setting: Tertiary care referral center.

Methods: A 10-year chart review was performed for patients who had previously undergone radiation or chemoradiation for head and neck mucosal squamous cell carcinoma and planned to undergo total laryngectomy for dysfunctional larynx, as well as a control group of matched patients. Controls were patients who had undergone radiation or chemoradiation for mucosal squamous cell carcinoma but did not have severe dysfunction warranting laryngectomy; these were matched to cases by tumor subsite, T stage, and time from last treatment to video swallow study. Main outcomes assessed were postoperative diet, alaryngeal voice, pharyngeal dilations, and complications.

Results: Twenty-six patients were scheduled for laryngectomy for dysfunctional larynx, of which 23 underwent surgery. Originally treated tumor subsites included the larynx, oropharynx, hypopharynx, oral cavity, and a tumor of unknown origin. The median time from end of cancer treatment to laryngectomy was 11.5 years. All cases were feeding tube or tracheostomy dependent or both prior to laryngectomy. As compared with matched controls, cases were significantly less likely to have undergone IMRT (intensity-modified radiotherapy) and more likely to have pulmonary comorbidities. Eighty-nine percent of cases with follow-up achieved functional alaryngeal voice, and all were able to have oral intake.

Conclusion: Non-IMRT approaches and pulmonary comorbidities are associated with laryngectomy for dysfunction after radiation or chemoradiation.
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http://dx.doi.org/10.1177/0194599820947702DOI Listing
March 2021

Programmed cell death ligand-1 and cytotoxic T cell infiltrates in metastatic cutaneous squamous cell carcinoma of the head and neck.

Head Neck 2020 11 1;42(11):3226-3234. Epub 2020 Aug 1.

Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA.

Background: Metastatic cutaneous squamous cell carcinoma (cSCC) carries a poor prognosis. Increased numbers of CD8+ cytotoxic T cells are associated with a favorable prognosis and programmed cell death receptor-1 is a suppressor of the CD8+ cytotoxic T cell response. We aim to define their expression in metastatic cutaneous squamous cell carcinoma.

Methods: Cytotoxic T cell infiltrates and tumoral PD-L1 expression in lymph node metastases from patients with cSCC of the head and neck were analyzed.

Results: High tumoral PD-L1 expression, intratumoral and peritumoral CD8+ cell density in metastases were significantly associated with poor primary tumor differentiation. Low PD-L1 expression, intratumoral and peritumoral CD8+ density were associated with lower grade primary tumor differentiation. Low PD-L1 expression correlated with disease progression.

Conclusions: Increased expression of PD-L1 correlates with increased CD8+ cell density. Increased expression of PD-L1 in poorly differentiated tumors may be more likely to benefit from anti PD-1/PD-L1 therapy.
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http://dx.doi.org/10.1002/hed.26370DOI Listing
November 2020

Preservation of Portacath With Ipsilateral Pectoralis Major Flap Harvest-Waste Not, Want Not.

JAMA Otolaryngol Head Neck Surg 2020 09;146(9):870-872

Harvard Medical School, Massachusetts Eye and Ear, Department of Otolaryngology, Boston, Massachusetts.

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http://dx.doi.org/10.1001/jamaoto.2020.1762DOI Listing
September 2020

Predicting length of stay in head and neck patients who undergo free flap reconstruction.

Laryngoscope Investig Otolaryngol 2020 Jun 28;5(3):461-467. Epub 2020 May 28.

Department of Otolaryngology Massachusetts Eye and Ear Infirmary Boston Massachusetts USA.

Objective: Understanding factors that affect postoperative length of stay (LOS) may improve patient recovery, hasten postoperative discharge, and minimize institutional costs. This study sought to (a) describe LOS among head and neck patients undergoing free flap reconstruction and (b) identify factors that predict increased LOS.

Methods: A retrospective cohort was performed of 282 head and neck patients with free flap reconstruction for oncologic resection between 2011 and 2013 at a tertiary academic medical center. Patient demographics, tumor characteristics, and surgical and infectious complications were characterized. Multivariable regression identified predictors of increased LOS.

Results: A total of 282 patients were included. Mean age was 64.7 years (SD = 12.2) and 40% were female. Most tumors were located in the oral cavity (53.9% of patients), and most patients underwent radial forearm free flap (RFFF) reconstruction (RFFF-73.8%, anterolateral thigh flap-11.3%, and fibula free flap-14.9%). Intraoperative complications were rare. The most common postoperative complications included nonwound infection (pneumonia [PNA] or urinary tract infection [UTI]) (15.6%) and wound breakdown/fistula (15.2%). Mean and median LOS were 13 days (SD = 7.7) and 10 days (interquartile range = 7), respectively. Statistically significant predictors of increased LOS included flap take back (Beta coefficient [] = +4.26,  < .0001), in-hospital PNA or UTI ( = +2.52, = .037), wound breakdown or fistula ( = +5.0,  < .0001), surgical site infection ( = +3.54, = .017), and prior radiation therapy ( = +2.59, = .004).

Conclusion: Several perioperative factors are associated with increased LOS. These findings may help with perioperative planning, including the need for vigilant wound care, optimization of antibiotics prophylaxis, and institution-level protocols for postoperative care and disposition of free flap patients.

Level Of Evidence: 2b; retrospective cohort.
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http://dx.doi.org/10.1002/lio2.410DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7314462PMC
June 2020

Intralaryngeal paraganglioma workup and discussion of surgical approach.

BMJ Case Rep 2020 Jun 2;13(6). Epub 2020 Jun 2.

Otolarynology-Head & Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA.

Laryngeal paragangliomas are an uncommon presentation of head and neck paragangliomas, with laryngeal paragangliomas along with a synchronous paraganglioma being exceptionally rare. We present two challenging cases of laryngeal paragangliomas with extralaryngeal extension, completely resected through a transcervical approach without endolaryngeal disruption, with one case having synchronous bilateral carotid body tumours. Both patients had excellent results with complete tumour resection and no resultant functional impact. The surgical approaches for large laryngeal paraganglioma are discussed with considerations for endolaryngeal, transcervical and combined approaches as well as decision-making when approaching these rare lesions in the setting of synchronous head and neck paragangliomas.
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http://dx.doi.org/10.1136/bcr-2020-234745DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7269545PMC
June 2020

Commentary on the management of total laryngectomy patients during the COVID-19 pandemic.

Head Neck 2020 06 23;42(6):1137-1143. Epub 2020 Apr 23.

Department of Otolaryngology-Head and Neck Surgery, The Pennsylvania State University, College of Medicine, Hershey, Pennsylvania, USA.

The coronavirus disease-2019 (COVID-19) pandemic has rapidly spread across the world, placing unprecedented strain on the health care system. Health care resources including hospital beds, ICUs, as well as personal protective equipment are becoming increasingly rationed and scare commodities. In this environment, the laryngectomee (patient having previously undergone a total laryngectomy) continues to represent a unique patient with unique needs. Given their surgically altered airway, they pose a challenge to manage for the otolaryngologist within the current COVID-19 pandemic. In this brief report, we present special considerations and best practice recommendations in the management of total laryngectomy patients. We also discuss recommendations for laryngectomy patients and minimizing community exposures.
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http://dx.doi.org/10.1002/hed.26183DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7262329PMC
June 2020

Variation in the Geographic Distribution of the Otolaryngology Workforce: A National Geospatial Analysis.

Otolaryngol Head Neck Surg 2020 May 3;162(5):649-657. Epub 2020 Mar 3.

Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.

Objective: To examine the current geographic distribution of otolaryngologists in the United States and the disparities in socioeconomic demographics at the county and hospital referral region (HRR) level.

Study Design: Cross-sectional study.

Setting: National cohort analysis including all otolaryngologists in the United States.

Subjects And Methods: All otolaryngologists board certified by the American Board of Otolaryngology-Head and Neck Surgery in the United States in 2018 were compared with overlaid demographic data from the 2010 United States Census Bureau by county and HRR. Associations between the density of otolaryngologists per population and socioeconomic characteristics were assessed and stratified by region.

Results: The average number of otolaryngologists was 3.6 (SD 9.6) per 100,000. On multivariable regression analysis, the density of otolaryngologists was positively associated with counties with the highest quartile of college education (1.8 providers per 100,000 [95% confidence interval [CI] 0.89, 2.90], < .001) and income (2.1 providers per 100,000 [95% CI 1.03, 3.07], = .01). Significant regional variation existed in access to otolaryngology care.

Conclusion: There are significant areas with disparate densities of otolaryngologists in the United States. Lower socioeconomic status, more severe poverty, and a lower number of college graduates in a county correlated with reduced density of otolaryngologists.
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http://dx.doi.org/10.1177/0194599820908860DOI Listing
May 2020

Predictive factors for prolonged operative time in head and neck patients undergoing free flap reconstruction.

Am J Otolaryngol 2020 Mar - Apr;41(2):102392. Epub 2020 Jan 3.

Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, MA, USA; Department of Otolaryngology, Harvard Medical School, Boston, MA, USA. Electronic address:

Purpose: Defining the predictive factors associated with prolonged operative time may reduce post-operative complications, improve patient outcomes, and decrease cost of care. The aims of this study are to 1) analyze risk factors associated with prolonged operative time in head and neck free flap patients and 2) determine the impact of lengthier operative time on surgical outcomes.

Methods: This retrospective cohort study evaluated 282 head and neck free flap reconstruction patients between 2011 and 2013 at a tertiary care center. Perioperative factors investigated by multivariate analyses included gender, age, American Society of Anesthesiologists class, tumor subsite, stage, flap type, preoperative comorbidities, and perioperative hematocrit nadir. Association was explored between operative times and complications including flap take back, flap survival, transfusion requirement, flap site hematoma, and surgical site infection.

Results: Mean operative time was 418.2 ± 88.4 (185-670) minutes. Multivariate analyses identified that ASA class III (beta coefficient + 24.5, p = .043), stage IV tumors (+34.8, p = .013), fibular free flaps (-44.8, p = .033 for RFFF vs. FFF and - 67.7, p = .023 for ALT vs FFF) and COPD (+36.0, p = .041) were associated with prolonged operative time. History of CAD (-43.5, p = .010) was associated with shorter operative time. There was no statistically significant association between longer operative time and adverse flap outcomes or complications.

Conclusion: As expected, patients who were medically complex, had advanced cancer, or underwent complex flap reconstruction had longer operative times. Surgical planning should pay special attention to certain co-morbidities such as COPD, and explore innovative ways to minimize operative time. Future research is needed to evaluate how these factors can help guide planning algorithms for head and neck patients.
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http://dx.doi.org/10.1016/j.amjoto.2020.102392DOI Listing
August 2020

Outcomes and prognostic factors in parotid gland malignancies: A 10-year single center experience.

Laryngoscope Investig Otolaryngol 2019 Dec 13;4(6):632-639. Epub 2019 Nov 13.

Department of Otolaryngology Massachusetts Eye and Ear Infirmary Boston Massachusetts.

Objectives: To describe a 10-year single center experience with parotid gland malignancies and to determine factors affecting outcomes.

Study Design: Retrospective review.

Methods: The institutional cancer registry was used to identify patients treated surgically for malignancies of the parotid gland between January 2005 and December 2014. Clinical and pathologic data were collected retrospectively from patient charts and analyzed for their association with overall survival (OS) and disease-free survival (DFS).

Results: Two hundred patients were identified. Mean age at surgery was 57.8 years, and mean follow-up time was 52 months. One hundred two patients underwent total parotidectomy, while 77 underwent superficial parotidectomy, and 21 underwent deep lobe resection. Seventy patients (35%) required facial nerve (FN) sacrifice. Acinic cell carcinoma was the most common histologic type (22%), followed by mucoepidermoid carcinoma (21.5%) and adenoid cystic carcinoma (12.5%). Twenty-nine patients (14.5%) experienced recurrences, with mean time to recurrence of 23.6 months (range: 1-82 months). Five- and 10-year OS were 81% and 73%, respectively. Five- and 10-year DFS were 80% and 73%, respectively. In univariate analyses, age > 60, histologic type, positive margins, high grade, T-stage, node positivity, perineural invasion, and FN involvement were predictors of OS and DFS. In the multivariate analysis, histology, positive margins, node positivity, and FN involvement were independent predictors of OS and DFS.

Conclusions: Our single-center experience of 200 patients suggests that histology, positive margins, node positivity, and FN involvement are independently associated with outcomes in parotid malignancies.

Level Of Evidence: 4.
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http://dx.doi.org/10.1002/lio2.326DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6929571PMC
December 2019

Submental flap practice patterns and perceived outcomes: A survey of 212 AHNS surgeons.

Am J Otolaryngol 2020 Jan - Feb;41(1):102291. Epub 2019 Oct 30.

Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, United States of America.

Objectives: To describe American Head and Neck Society (AHNS) surgeon submental flap (SMF) practice patterns and to evaluate variables associated with SMF complications.

Methods: The design is a cross-sectional study. An online survey was distributed to 782 AHNS surgeons between 11/11/16 and 12/31/16. Surgeon demographics, training, practice patterns and techniques were characterized and evaluated for associations with frequency of SMF complications.

Results: Among 212 AHNS surgeons, 108 (50.9%) reported performing SMFs, of whom 86 provided complete responses. Most surgeons who performed the SMF routinely reconstructed oral cavity defects with the flap (86.1%, n = 74). Thirty-seven surgeons (43.0%) experienced "very few" complications with the SMF. Surgeons who practiced in the United States versus internationally (p = 0.003), performed more total career SMFs (p = 0.02), and routinely reconstructed parotid and oropharyngeal defects (p = 0.04 and p < 0.001) with SMFs were more frequently perceived to have "very few" complications. SMF surgeons reported more perceived complications with the SMF compared to pectoralis major (p = 0.001) and radial forearm free flaps (p = 0.01). However, similar perceived complications were reported between all three flaps when surgeons performed >30 SMF. Among 94 surgeons not performing SMFs, 71.3% had interest in a SMF training course.

Conclusions: Practice patterns of surgeons performing SMFs are diverse, although most use the flap for oral cavity reconstruction. While 43% of surgeons performing the SMF reported "very few" complications, overall complication rates with the SMF were higher compared to other flaps, potentially due to limited experience with the SMF. Increased training opportunities in SMF harvest and inset are indicated.
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http://dx.doi.org/10.1016/j.amjoto.2019.102291DOI Listing
April 2020

Immunohistochemical quantification of partial-EMT in oral cavity squamous cell carcinoma primary tumors is associated with nodal metastasis.

Oral Oncol 2019 12 6;99:104458. Epub 2019 Nov 6.

Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, MA, USA; Department of Otolaryngology, Harvard Medical School, Boston, MA, USA. Electronic address:

Objectives: Quantify by immunohistochemistry (IHC) a partial epithelial-to-mesenchymal transition (p-EMT) population in oral cavity squamous cell carcinoma (OCSCC) and determine its predictive value for lymph node metastasis.

Methods: Tissue microarrays (TMA) were created using 2 mm cores from 99 OCSCC patients (47 with low volume T2 disease, 52 with high volume T4 disease, and ∼50% in each group with nodal metastasis). IHC staining was performed for three validated p-EMT markers (PDPN, LAMB3, LAMC2) and one marker of well-differentiated epithelial cells (SPRR1B). Staining was quantified in a blinded manner by two reviewers. Tumors were classified as malignant basal subtype based on staining for the four markers. In this subset, the p-EMT score was computed as the average of p-EMT markers.

Results: 84 tumors were classified as malignant basal. There was 87% inter-rater consistency in marker quantification. There were associations of p-EMT scores with higher grade (2.15 vs. 1.92, p = 0.04), PNI (2.13 vs. 1.83, p = 0.003), and node positivity (2.09 vs. 1.87, p = 0.02), including occult node positivity (56% vs. 19%, p = 0.005). P-EMT was independently associated with nodal metastasis in a multivariate analysis (OR 3.12, p = 0.039). Overall and disease free survival showed trends towards being diminished in the p-EMT high group.

Conclusions: IHC quantification of p-EMT in OCSCC primary tumors is reliably associated with nodal metastasis, PNI, and high grade. With prospective validation, p-EMT biomarkers may aid in decision-making over whether to perform a neck dissection in the N0 neck and/or for adjuvant therapy planning.
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http://dx.doi.org/10.1016/j.oraloncology.2019.104458DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7382966PMC
December 2019

Assessments of Otolaryngology Resident Operative Experiences Using Mobile Technology: A Pilot Study.

Otolaryngol Head Neck Surg 2019 12 13;161(6):939-945. Epub 2019 Aug 13.

Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, Massachusetts, USA.

Objectives: Surgical education has shifted from the Halstedian model of "see one, do one, teach one" to a competency-based model of training. Otolaryngology residency programs can benefit from a fast and simple system to assess residents' surgical skills. In this quality initiative, we hypothesize that a novel smartphone application called System for Improving and Measuring Procedural Learning (SIMPL) could be applied in an otolaryngology residency to facilitate the assessment of resident operative experiences.

Methods: The Plan Do Study Act method of quality improvement was used. After researching tools of surgical assessment and trialing SIMPL in a resident-attending pair, we piloted SIMPL across an otolaryngology residency program. Faculty and residents were trained to use SIMPL to rate resident operative performance and autonomy with a previously validated Zwisch Scale.

Results: Residents (n = 23) and faculty (n = 17) were trained to use SIMPL using a standardized curriculum. A total of 833 assessments were completed from December 1, 2017, to June 30, 2018. Attendings completed a median 20 assessments, and residents completed a median 14 self-assessments. All evaluations were resident initiated, and attendings had a 78% median response rate. Evaluations took residents a median 22 seconds to complete; 126 unique procedures were logged, representing all 14 key indicator cases for otolaryngology.

Discussion: This is the first residency-wide application of a mobile platform to track the operative experiences of otolaryngology residents.

Implications For Practice: We adapted and implemented a novel assessment tool in a large otolaryngology program. Future multicenter studies will benchmark resident operative experiences nationwide.
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http://dx.doi.org/10.1177/0194599819868165DOI Listing
December 2019

Submental Island Flap: A Technical Update.

Ann Otol Rhinol Laryngol 2019 Dec 10;128(12):1177-1181. Epub 2019 Jul 10.

Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, BA, USA.

Objectives: In recent years, the submental island flap has demonstrated decreased cost and morbidity as compared with free tissue transfer and has been widely applied to a range of head and neck defects. Several studies, however, continue to report a high rate of submental flap complications including partial necrosis and venous congestion. The object of this report is to describe a technical modification to the submental flap harvest which increases efficiency and reliability.

Methods: Single institutional case series with chart review. The essential technical details and technique modifications of the submental flap harvest are described, and a case example is discussed.

Results: Between January 2018 through January 2019, 24 submental island flaps were performed. All flaps included the mylohyoid muscle which was delineated with manual blunt dissection. Reconstructive indications included oral cavity and oropharyngeal wounds as well as facial cutaneous and lateral skullbase defects. There were no flap-related complications.

Conclusions: Manual blunt dissection of the mylohyoid muscle and its inclusion in the submental island flap increases efficiency and reliability.
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http://dx.doi.org/10.1177/0003489419862582DOI Listing
December 2019

Composite Nasoseptal Flap for Palate Reconstruction.

J Craniofac Surg 2019 Oct;30(7):1990-1993

Department of Otolaryngology-Head & Neck Surgery, Medical College of Wisconsin, Milwaukee, WI.

Palatal fistulae represent a pathological connection from the oral cavity through the hard or soft palate to the nasal cavity and can present a significant reconstructive dilemma. Surgical correction of palatal fistulae is often limited by prior treatment, including ablative procedures and radiotherapy, or previous reconstructive attempts. In light of these challenges, the nasoseptal flap represents an excellent adjacent source of vascularized tissue which may be suitable for palatal fistula repair with minimal donor site morbidity, low associated risks, and a short recovery period. The purpose of this study was to fully understand the potential utility of this reconstructive option, including the ability to harvest a composite flap including both septal cartilage and contralateral mucoperichondrium. In this single institution prospective study consisting of a series of 5 cadaver dissections, primary outcome measures were the anterior reach of the flap as compared to the anterior nasal spine and the size of the palatal defect that the nasoseptal flap could be used to successfully reconstruct. Composite flaps were successfully harvested in continuity with a disc of septal cartilage and contralateral mucoperichondrium, providing structural integrity to the reconstruction and the ability to anchor the flap to the native hard palate mucosa. The nasoseptal flap's maximum anterior reach was within 2.0 cm (standard deviation of 0.1 cm) from the anterior nasal spine and could reliably reconstruct palate defects of 2.5 cm or less. The nasoseptal flap provides a viable regional option for reconstructing defects of the hard palate. Prospective clinical trials are needed to investigate long-term reconstructive and functional outcomes of the composite nasoseptal flap in palatal reconstruction.
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http://dx.doi.org/10.1097/SCS.0000000000005652DOI Listing
October 2019

Reconstruction of total parotidectomy defects with a de-epithelialized submental flap.

Laryngoscope Investig Otolaryngol 2019 Apr 22;4(2):222-226. Epub 2019 Mar 22.

Department of Otolaryngology Massachusetts Eye and Ear, Harvard Medical School Boston Massachusetts U.S.A.

Objective: Total parotidectomy yields a large surgical defect that leads to both cosmetic and functional deficits which can be addressed with reconstruction. We evaluated the role of a pedicled submental flap for this reconstruction.

Methods: We reviewed all submental flap reconstructions that were performed for total parotidectomy defects between 2014 and 2016. Data regarding harvest technique, postoperative complications, flap survival, and adjuvant treatment details were recorded. Subjective information regarding retained volume after reconstruction was also obtained.

Results: During the time period, eight patients were identified and in all cases the patients underwent total parotidectomy with facial nerve sacrifice. All patients were discharged within 2 days of hospitalization with no complications or concerns regarding the viability of the flap. All but one patient had radiation therapy. Results with 9.9- to 37.5-month follow-up (mean 22.0 months) show limited volume loss without major contour defect or ear deformity in the follow-up period.

Conclusions: Submental flap reconstruction is a feasible and reliable method for total parotidectomy defect. The inclusion of the mylohyoid muscle aids flap reliability and adds bulk. Inclusion of the dermis helps contour the overlying skin. The flap does not add morbidity or increased complexity intraoperatively or postoperatively.

Level Of Evidence: 4.
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http://dx.doi.org/10.1002/lio2.258DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6476261PMC
April 2019

Necrotizing Sialometaplasia of the Hypopharynx.

Ear Nose Throat J 2019 Oct-Nov;98(9):NP138-NP141. Epub 2019 Apr 9.

Department of Otolaryngology, Harvard Medical School, Massachusetts Eye and Ear, Boston, MA, USA.

Necrotizing sialometaplasia (NSM) is a benign, reactive metaplastic condition of the minor salivary gland tissue typically seen in the setting of injury, chemical or traumatic, and is nonneoplastic and self-limited. The diagnosis may be challenging as it may clinically mimic malignancy. We present the case of a 74-year-old male with a 1 pack per day smoking history for 60 years who presented with a reported 20-pound weight loss, dysphagia, and dysphonia progressing over the course of 6 months and found to have a 3.5-cm hypopharyngeal mass on computed tomography imaging and fiberoptic laryngoscopy. Initial frozen section of the mass was concerning for squamous cell carcinoma in situ, but permanent specimens returned as nondiagnostic. Repeat biopsy established a diagnosis of NSM. Two-month follow-up showed complete resolution of the mass. Clinicians should be aware that NSM may present in unusual locations when considering differential diagnoses for laryngeal masses and evaluating for malignancy.
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http://dx.doi.org/10.1177/0145561319840826DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7477373PMC
April 2020
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