Publications by authors named "David C Shonka"

35 Publications

Phase II randomized study of preoperative calcitriol to prevent hypocalcemia following thyroidectomy.

Head Neck 2021 Oct 2;43(10):2935-2945. Epub 2021 Jun 2.

Department of Otolaryngology-Head and Neck Surgery, University of Virginia Health System, Charlottesville, Virginia, USA.

Background: A prospective, stratified, randomized, double-blind, placebo-controlled study was conducted to observe the impact of preoperative calcitriol supplementation on serum calcium levels following total thyroidectomy.

Methods: Subjects were randomized 1:1 to receive 1 μg calcitriol or placebo for 1 week preceding thyroidectomy. The primary outcome measure was change in serum calcium from baseline to 18 h post-thyroidectomy. Subjects were also assessed for incidence of symptomatic hypocalcemia, length of stay, readmission for hypocalcemia, and intravenous calcium supplementation.

Results: Forty-seven patients underwent thyroidectomy; 23 received preoperative calcitriol supplementation, and 24 received placebo. Repeated measures regression demonstrated no difference in postoperative serum calcium over time (p = 0.22). There were no occurrences of hypocalcemia, intravenous calcium supplementation, or readmission in either group. No difference was observed in length of stay (p = 0.38). One patient in the calcitriol group developed Grade 3 hypercalcemia.

Conclusions: Preoperative calcitriol supplementation had no impact on postoperative serum calcium levels compared to placebo.
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http://dx.doi.org/10.1002/hed.26775DOI Listing
October 2021

Airway Management in Substernal Goiter Surgery.

Ann Otol Rhinol Laryngol 2021 May 25:34894211014794. Epub 2021 May 25.

Department of Otolaryngology-Head & Neck Surgery, University of Iowa Hospitals & Clinics, Iowa City, IA, USA.

Objective(s): To review the experience of 3 hospitals with airway management during surgery for substernal goiter and identify preoperative factors that predict the need for advanced airway management techniques.

Methods: A retrospective chart review between 2009 and 2017 of patients with substernal goiter treated surgically at 1 of 3 hospitals was performed.

Results: Of the 179 patients included in the study, 114 (63.7%) were female, the mean age was 55.1 years (range 20-87). Direct laryngoscopy or videolaryngoscopy was successful in 162 patients (90.5%), with fiberoptic intubation used for the remaining 17 patients. Thirty-one patients (17.4%) required >1 intubation attempt; these patients had larger thyroids (201.3 g, 95% CI 155.3-247.2 g) than those intubated with 1 attempt (144.7 g, 95% CI 127.4-161.9 g,  = .009). Those who required >1 attempt had higher BMI (38.3, 95% CI 34.0-42.6 vs. 32.9, 95% CI 31.5-34.3,  = .02). Mallampati score was found to be a predictor of >1 attempt, though tracheal compression and tracheal shift were not found to be predictors of >1 attempt, nor was the lowest thyroid extent. BMI was the only independent factor on multivariable logistic regression of needing >1 attempt (odds ratio 1.056, 95% CI 1.011-1.103,   .015).

Conclusions: The majority of patients undergoing surgery for substernal goiter can be intubated routinely without the need for fiberoptic intubation. Thyroid-specific factors such as lowest thyroid extent and mass effect of the gland on the trachea do not appear to be associated with difficult intubation, whereas classic patient factors associated with difficulty intubation are.

Level Of Evidence: VI.
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http://dx.doi.org/10.1177/00034894211014794DOI Listing
May 2021

2015 American Thyroid Association guidelines and thyroid-stimulating hormone suppression after thyroid lobectomy.

Head Neck 2021 02 30;43(2):639-644. Epub 2020 Oct 30.

Department of Otolaryngology - Head and Neck Surgery, University of Virginia Health System, Charlottesville, Virginia, USA.

Background: 2015 American Thyroid Association (ATA) guidelines recommended more conservative treatment in low-risk well-differentiated thyroid cancer (WDTC), stating that lobectomy alone may be sufficient. The guidelines further recommend mild thyroid-stimulating hormone (TSH) level suppression (0.5-2 mU/L) for this population. Our goal is to evaluate the natural history of patients undergoing lobectomy to determine the percentage that would require postoperative levothyroxine supplementation under these guidelines.

Methods: Retrospective chart review of 168 patients that underwent lobectomy between 2010 and 2019 was performed. Preoperative and postoperative TSH values and the rate of patients prescribed levothyroxine were analyzed.

Results: Thirty-five percent of patients were prescribed levothyroxine postoperatively. At 6 weeks postoperatively, 66% had TSH value of >2; this increased to 76% by 6 to 12 months.

Conclusion: To adhere to ATA guidelines for WDTC managed with lobectomy alone, the majority of patients (76%) would require postoperative levothyroxine supplementation. Low preoperative TSH was found to be the most significant predictor for postoperative TSH < 2.
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http://dx.doi.org/10.1002/hed.26524DOI Listing
February 2021

An Intravagal Parathyroid Adenoma in the Poststyloid Parapharyngeal Space.

Laryngoscope 2021 02 3;131(2):453-456. Epub 2020 Aug 3.

Department of Otolaryngology-Head and Neck Surgery, University of Virginia Health System, Charlottesville, Virginia, U.S.A.

Objectives: Describe a case of an intravagal parathyroid adenoma.

Case: A 35-year-old male presented with symptomatic primary hyperparathyroidism and non-localizing imaging studies. Intraoperative venous sampling revealed a substantial gradient within the right internal jugular vein. Repeat imaging identified an enhancing lesion in the right parapharyngeal space at the skull base. An intravagal parathyroid adenoma was discovered intraoperatively. Microdissection of the adenoma out of the nerve allowed preservation of laryngeal function and an appropriate drop in ioPTH.

Conclusions: Intraneural parathyroid adenomas are exceedingly rare. The clinical, radiologic, and histologic findings of an intravagal parathyroid adenoma in the post-styloid parapharyngeal space are described. Laryngoscope, 131:453-456, 2021.
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http://dx.doi.org/10.1002/lary.28961DOI Listing
February 2021

ECTOPIC THYROID TISSUE MASQUERADING AS A FUNCTIONAL CAROTID BODY PARAGANGLIOMA.

AACE Clin Case Rep 2020 Jul-Aug;6(4):e189-e192. Epub 2020 Jul 10.

Objective: Ectopic thyroid tissue (ETT) is a rare entity resulting from thyroid gland dysembryogenesis. We present a case of ETT confirmed by histopathology that was misdiagnosed clinically as a carotid body tumor.

Methods: A 34-year-old female with a history of thyroidectomy for a goiter presented with 1 year of worsening tachycardia (heart rate ranging from 82 to 111 beats per minute), anxiety, hot flashes, and intolerance to heat. For further evaluation, we obtained imaging of her neck, including a thyroid ultrasound, a computed tomography (CT) scan, and an octreotide scan. We also performed laboratory studies including fractionated 24-hour urine meta-nephrines and thyroid function tests.

Results: Her thyroid ultrasound showed a mass at the right carotid bifurcation, which was confirmed on CT as well as on an octreotide scan. Her free thyroxine was 0.6 ng/dL (normal, 0.7 to 1.5 ng/dL) and her thyroid-stimulating hormone was 4.51 mIU/L (normal, 0.45 to 4.5 mIU/L). Her fractionated 24-hour total urine metanephrines were 1,502 mcg/24-hour (normal, 149 to 535 mcg/24-hour). She underwent resection of a vascular mass from the carotid bifurcation. Histologic examination revealed ETT with dilated follicles filled with colloid with no evidence of paraganglioma/carotid body tumor.

Conclusion: The somatostatin receptor is typically present in paragangliomas; however, there are reports of octreotide uptake within thyroid goiters. It has been demonstrated that psychoactive medications can increase urine metanephrines. Given the patient's psychiatric history and that no other tumors were identified on imaging, it was felt that the elevated urine normetanephrine in this case was most likely due to psychoactive medication use. This case demonstrates the preoperative imaging findings and postoperative pathologic confirmation of an unusual presentation of ETT.
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http://dx.doi.org/10.4158/ACCR-2019-0553DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7357606PMC
July 2020

Non-HPV-Related Head and Neck Squamous Cell Carcinoma in a Young Patient Cohort.

Ear Nose Throat J 2020 Jun 25:145561320935839. Epub 2020 Jun 25.

Department of Otolaryngology-Head and Neck Surgery, University of Virginia Health System, Charlottesville, VA, USA.

Objectives: Head and neck squamous cell carcinoma (HNSCC) is rare in patients younger than 40 years. Many practitioners suspect HNSCC is a more aggressive disease in this age group, and perhaps increasing in incidence; however, there are scant and conflicting data to support this assertion. We sought to compare outcomes for young patients with non-human papillomavirus (HPV)-related HNSCC to those of older patients.

Methods: A retrospective chart review of patients with HNSCC treated from 2004 to 2016 at 2 tertiary referral centers. Patients aged 18 to 40 with p16-negative HNSCC were included in the young patient cohort (n = 59). A randomly selected stage- and subsite-matched cohort aged 55 to 65 was analyzed for comparison (n = 114).

Results: When considering all patients with HNSCC, patients younger than 40 were more likely to have oral tongue cancer (62.7%) compared to patients age 55 to 65 (16.9%). When an older patient cohort was stage- and subsite-matched to the young patient cohort, there were more never smokers (49.2% vs 17.5% of older patients, < .01) and females (40.7% vs 24.6% of older patients, = .028) in the young patient group. The young patient cohort had better average overall survival than the older group (14.4 vs 8.1 years, respectively, = .02), but similar average disease-free survival (6.2 years vs 6.6 years, respectively, = .67); 50.9% of young patients had tumors with adverse histologic features versus 42.0% of older patients ( = .28). The young patients demonstrated a superior average conditional survival after recurrence (9.8 years vs 3.2 years for older patients, < .01).

Conclusions: Despite the limitations of study design, these data suggest that young patients who develop non-HPV-related HNSCC tend to have similarly aggressive disease, but longer overall survival and better survival after recurrence. These findings may be attributable to better overall health as evidenced by fewer comorbidities.
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http://dx.doi.org/10.1177/0145561320935839DOI Listing
June 2020

American Head and Neck Society Endocrine Section clinical consensus statement: North American quality statements and evidence-based multidisciplinary workflow algorithms for the evaluation and management of thyroid nodules.

Head Neck 2019 04 18;41(4):843-856. Epub 2018 Dec 18.

Department of Otolaryngology, Massachusetts General Hospital, Boston, Massachusetts.

Background: Care for patients with thyroid nodules is complex and multidisciplinary, and research demonstrates variation in care. The objective was to develop clinical guidelines and quality metrics to reduce unwarranted variation and improve quality.

Methods: Multidisciplinary expert consensus and modified Delphi approach. Source documents were workflow algorithms from Kaiser Permanente Northern California and Cancer Care of Ontario based on the 2015 American Thyroid Association management guidelines for adult patients with thyroid nodules and differentiated thyroid cancer.

Results: A consensus-based, unified preoperative, perioperative, and postoperative workflow was developed for North American use. Twenty-one panelists achieved consensus on 16 statements about workflow-embedded process and outcomes metrics addressing safety, access, appropriateness, efficiency, effectiveness, and patient centeredness of care.

Conclusion: A panel of Canadian and United States experts achieved consensus on workflows and quality metric statements to help reduce unwarranted variation in care, improving overall quality of care for patients diagnosed with thyroid nodules.
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http://dx.doi.org/10.1002/hed.25526DOI Listing
April 2019

Association of Preoperative Calcium and Calcitriol Therapy With Postoperative Hypocalcemia After Total Thyroidectomy.

JAMA Otolaryngol Head Neck Surg 2017 07;143(7):679-684

Department of Otolaryngology-Head and Neck Surgery, University of Virginia Health System, Charlottesville.

Importance: Hypocalcemia is the most common complication after total thyroidectomy and can result in prolonged hospital admissions and increased hospital charges.

Objective: To determine the effectiveness of preoperative calcium and calcitriol supplementation in reducing hypocalcemia following total thyroidectomy.

Design, Setting, And Participants: A retrospective cohort study was conducted at a tertiary care center in 65 patients undergoing total thyroidectomy by a single surgeon. Patients were divided into 2 groups: those receiving preoperative as well as postoperative supplementation with calcium carbonate, 1000 to 1500 mg, 3 times daily and calcitriol, 0.25 to 0.5 µg, twice daily, and those receiving only postoperative supplementation with those agents at the same dosages. Data on patients who underwent surgery between January 1, 2008, and December 31, 2011, were acquired, and data analyses were conducted from March through June 2012, and from October through December 2016.

Interventions: Calcium and calcitriol therapy.

Main Outcomes And Measures: Postoperative serum calcium levels and development of postoperative hypocalcemia.

Results: Of the 65 patients who underwent total thyroidectomy 27 (42%) were men; mean (SD) age was 49.7 (16.7) years. Thirty-three patients received preoperative calcium and calcitriol supplementation, and 32 patients received only postoperative therapy. In the preoperative supplementation group, 15 of 33 (45%) patients underwent complete central compartment neck dissection and 11 of 33 (33%) had lateral neck dissection, compared with 16 of 32 (50%) and 12 of 32 (38%), respectively, patients without preoperative supplementation. The mean measured serum calcium level in those without preoperative supplementation vs those with supplementation are as follows: preoperative, 9.6 vs 9.4 mg/dL (absolute difference, 0.16; 95% CI, -0.12 to 0.49 mg/dL); 12 hours postoperative, 8.3 vs 8.6 mg/dL (absolute difference, -0.30; 95% CI,  -0.63 to 0.02 mg/dL); and 24 hours postoperative, 8.4 vs 8.5 mg/dL (absolute difference, -0.13; 95% CI, -0.43 to 0.16 mg/dL). In patients not receiving preoperative supplementation, 5 of 32 (16%) individuals became symptomatically hypocalcemic vs 2 of 33 (6%) in the preoperative supplementation group; an absolute difference of 10% (95% CI, -6.6% to 26.3%). Compared with the group not receiving preoperative supplementation, the mean [SD] length of stay was significantly shorter in the preoperative supplementation group (3.8 [1.8] vs 2.9 [1.4] days; absolute difference, -0.9; 95% CI, -1.70 to -0.105 days). Preoperative supplementation resulted in an estimated $2819 savings in charges per patient undergoing total thyroidectomy.

Conclusions And Relevance: Preoperative calcium and calcitriol supplementation, in addition to routine postoperative supplementation, was associated with a reduced incidence of symptomatic hypocalcemia, length of hospital stay, and overall charges following total thyroidectomy.
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http://dx.doi.org/10.1001/jamaoto.2016.4796DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5824198PMC
July 2017

Microvascular anastomosis simulation using a chicken thigh model: Interval versus massed training.

Laryngoscope 2017 11 13;127(11):2490-2494. Epub 2017 Apr 13.

Department of Otolaryngology-Head and Neck Surgery, University of Virginia Health System, Charlottesville, Virginia, U.S.A.

Objectives/hypothesis: To compare the effectiveness of massed versus interval training when teaching otolaryngology residents microvascular suturing on a validated microsurgical model.

Study Design: Otolaryngology residents were placed into interval (n = 7) or massed (n = 7) training groups. The interval group performed three separate 30-minute practice sessions separated by at least 1 week, and the massed group performed a single 90-minute practice session. Both groups viewed a video demonstration and recorded a pretest prior to the first training session. A post-test was administered following the last practice session.

Methods: At an academic medical center, 14 otolaryngology residents were assigned using stratified randomization to interval or massed training. Blinded evaluators graded performance using a validated microvascular Objective Structured Assessment of Technical Skill tool. The tool is comprised of two major components: task-specific score (TSS) and global rating scale (GRS). Participants also received pre- and poststudy surveys to compare subjective confidence in multiple aspects of microvascular skill acquisition.

Results: Overall, all residents showed increased TSS and GRS on post- versus pretest. After completion of training, the interval group had a statistically significant increase in both TSS and GRS, whereas the massed group's increase was not significant. Residents in both groups reported significantly increased levels of confidence after completion of the study.

Conclusions: Self-directed learning using a chicken thigh artery model may benefit microsurgical skills, competence, and confidence for resident surgeons. Interval training results in significant improvement in early development of microvascular anastomosis skills, whereas massed training does not.

Level Of Evidence: NA. Laryngoscope, 127:2490-2494, 2017.
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http://dx.doi.org/10.1002/lary.26586DOI Listing
November 2017

Preoperative vitamin D level as predictor of post-thyroidectomy hypocalcemia in patients sustaining transient parathyroid injury.

Head Neck 2017 07 29;39(7):1378-1381. Epub 2017 Mar 29.

Department of Otolaryngology - Head and Neck Surgery, Division of Head and Neck Oncologic and Microvascular Surgery, University of Virginia Health System, Charlottesville, Virginia.

Background: Several studies have sought to identify predictors of postoperative hypocalcemia after total thyroidectomy; however, there have been conflicting results regarding the impact of preoperative vitamin D deficiency.

Methods: The medical records of patients undergoing total thyroidectomy were retrospectively reviewed. The number of parathyroid glands identified or reimplanted at the time of surgery was used as a marker of transient parathyroid gland damage.

Results: Sixty-seven patients were included in the study. Vitamin D deficiency was a significant predictor of hypocalcemia in patients in whom ≥3 parathyroid glands were identified, but not in patients in whom 0-2 parathyroid glands were identified intraoperatively (odds ratio [OR] 5.8; P = .036).

Conclusion: Vitamin D deficiency is a significant predictor of postoperative hypocalcemia in patients in whom ≥3 parathyroid glands are identified intraoperatively, but not in patients who sustain minimal transient damage to the parathyroid glands.
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http://dx.doi.org/10.1002/hed.24775DOI Listing
July 2017

Suprafascial Harvest of the Radial Forearm Free Flap Decreases the Risk of Postoperative Tendon Exposure.

Ann Otol Rhinol Laryngol 2017 Mar 6;126(3):224-228. Epub 2017 Jan 6.

1 Department of Otolaryngology-Head and Neck Surgery, University of Virginia Health System, Charlottesville, Virginia, USA.

Objective: To determine if suprafascial harvest of the radial forearm free flap improves postoperative donor site outcomes compared to subfascial harvest.

Methods: Retrospective chart review.

Results: Forty-six patients underwent reconstruction of a head and neck defect with a radial forearm free flap (RFFF). Subfascial harvest of the RFFF was performed in 25 (53%) patients and suprafascial harvest performed in 22 (47%) patients. All donor sites were covered with a split thickness skin graft and a bolster that remained in place for 6 days. Postoperative tendon exposure at the donor site occurred in 5 (20%) of the patients in the subfascial group and in 0 (0%) of the patients in the suprafascial group ( P = .05; Fisher's exact test). Average tourniquet time was 117 minutes in the subfascial group and 102 minutes in the suprafascial group. Hematoma formation occurred at the donor site in 2 (8%) and 1 (5%) patients in the subfascial and suprafascial groups, respectively. There were no complete or partial flap losses in either group.

Conclusions: Suprafascial harvest of the RFFF decreases the risk of postoperative tendon exposure. The suprafascial harvest technique does not increase harvest time or donor site complications, nor does it negatively impact flap vascularity.
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http://dx.doi.org/10.1177/0003489416685322DOI Listing
March 2017

Prognostic value of albumin in patients with head and neck cancer.

Laryngoscope 2016 07 10;126(7):1567-71. Epub 2016 Feb 10.

Department of Otolaryngology-Head and Neck Surgery, University of Virginia Health System, Charlottesville, Virginia, U.S.A.

Objectives/hypothesis: Albumin is an indicator of nutritional status and has been investigated as a predictor of cancer survival and perioperative outcomes. This study investigated the prognostic value of preoperative serum albumin in surgical patients with head and neck cancer (HNC).

Study Design: Retrospective cohort study.

Methods: A chart review was performed of patients who underwent HNC resection over a 6-year period at a single institution. Statistical analyses including Cox proportional hazards models, Pearson's correlation, and logistic regression were used to identify relationships between preoperative serum albumin and postoperative outcomes. Albumin was analyzed as a continuous variable.

Results: A total of 604 patients were studied representing all cancer types. There was no association between albumin and pneumonia, flap complications, or length of stay. Albumin was found to have statistically significant inverse associations with overall survival (OS) (hazard ratio [HR] = 0.685, P < .001) and postoperative wound infection (HR = 0.455, P = .001). In multivariate analysis of OS, albumin did not achieve significance as an independent predictor (HR = 0.78, P = .064), whereas hemoglobin, age, and cancer stage remained significant. In a subgroup of 280 patients with upper aerodigestive squamous cell carcinoma (SCCA), albumin maintained significance in multivariate analysis of OS (HR = 0.74, P = .046). When controlling for preoperative radiotherapy, salvage surgery, and cancer stage in multivariate analysis, albumin was a significant predictor of wound infection (OR = 0.55, P = .018).

Conclusions: In patients with HNC, lower preoperative serum albumin is associated with an increased rate of wound infection and poorer OS. The effect on OS is most pronounced in patients with upper aerodigestive SCCA.

Level Of Evidence: 2b Laryngoscope, 126:1567-1571, 2016.
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http://dx.doi.org/10.1002/lary.25877DOI Listing
July 2016

The American Thyroid Association Guidelines on Voice Assessment-Have We Done Enough?

JAMA Otolaryngol Head Neck Surg 2016 Feb;142(2):115-6

GRU Thyroid Center, Georgia Regents University, Augusta.

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http://dx.doi.org/10.1001/jamaoto.2015.3222DOI Listing
February 2016

Rigid Esophagoscopy for Head and Neck Cancer Staging and the Incidence of Synchronous Esophageal Malignant Neoplasms.

JAMA Otolaryngol Head Neck Surg 2016 Jan;142(1):40-5

Division of Head and Neck Oncologic and Microvascular Surgery, Department of Otolaryngology-Head and Neck Surgery, University of Virginia Health System, Charlottesville.

Importance: Rigid esophagoscopy (RE) was once an essential part of the evaluation of patients with head and neck squamous cell carcinoma (HNSCC) due to the high likelihood of identifying a synchronous malignant neoplasm in the esophagus. Given recent advances in imaging and endoscopic techniques and changes in the incidence of esophageal cancer, the current role for RE in HNSCC staging is unclear.

Objective: To analyze the current role of RE in evaluating patients with HNSCC, and to determine the incidence of synchronous esophageal malignant neoplasms in patients with HNSCC.

Design, Setting, And Participants: In this retrospective study performed at an academic tertiary care center, 582 patients were studied who had undergone RE for HNSCC staging from July 1, 2004, through October 31, 2012. To assess the incidence of synchronous esophageal malignant neoplasms, a literature review was performed, and the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) data set was queried.

Main Outcomes And Measures: The primary outcome measure was the incidence of synchronous esophageal malignant neoplasms, as measured by retrospective review at our institution, SEER data set analysis, and literature review. Secondary outcome measures were RE complications and nonmalignant findings during RE.

Results: A total of 601 staging REs were performed in 582 patients. The mean age was 60.2 years and 454 (78.0%) were men. There were 9 complications (1.5%), including 1 esophageal perforation (0.2%). Rigid esophagoscopy was aborted in 50 cases. Of the 551 completed REs, no abnormal findings were noted in 523 patients (94.9%), and nonmalignant pathologic findings were identified in 28 patients (5.1%). No synchronous primary esophageal carcinomas were detected. The incidence of synchronous esophageal malignant neoplasms found on screening endoscopy based on literature review and on SEER data set analysis was very low and has decreased from 1980 to 2010 in North America. The incidence reported in South America and Asia was relatively high.

Conclusions And Relevance: Rigid esophagoscopy is safe, but the utility is low for cancer staging and for detection of nonmalignant esophageal disease. Review of the literature and analysis of a large national cancer data set indicate that the incidence of synchronous esophageal malignant neoplasms in patients with HNSCC is low and has been decreasing during the past 3 decades. Thus, screening esophagoscopy should be limited to patients with HNSCC who are at high risk for synchronous esophageal malignant neoplasms.
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http://dx.doi.org/10.1001/jamaoto.2015.2815DOI Listing
January 2016

Development and evaluation of a rigid esophagoscopy simulator for residency training.

Laryngoscope 2016 Mar 24;126(3):616-9. Epub 2015 Nov 24.

Department of Otolaryngology-Head and Neck Surgery, University of Virginia Health System, Charlottesville, Virginia, U.S.A.

Objectives/hypothesis: Rigid esophagoscopy is performed less frequently by resident trainees. Nonetheless, it remains important for certain indications, including foreign body extraction. This study describes the construction of a simulator and evaluates its utility in training residents.

Study Design: Simulator development, fabrication, and procedural evaluation of postgraduate trainees.

Methods: A simulator was developed and constructed in collaboration with a biomedical engineering team. Residents with varied experience in upper aerodigestive procedures performed rigid esophagoscopy on the model. Key steps and Accreditation Council for Graduate Medical Education's Objective Structured Assessment of Technical Skills (OSATS) criteria for rigid esophagoscopy were evaluated by a faculty surgeon. Pressure measurements were obtained from force sensors at the tip of the endoscope and incisors.

Results: Fourteen trainees were evaluated. Operative rigid esophagoscopy and direct laryngoscopy case numbers were noted for each subject. OSATS scores and key steps of the procedure correlated with resident experience (R(2)  = 0.75, P < .0001 and R(2)  = 0.66, P < .001, respectively). Maximal pressure exerted on the simulator esophagus by the esophagoscope was inversely correlated with case number and was statistically significant (R(2)  = 0.51, P = .02), whereas length of procedure did not correlate (R(2)  = 0.04, P = .49). Maximal pressure on the incisors did not correlate (R(2)  = 0.25, P = .15).

Conclusions: A simulator for training residents to perform rigid esophagoscopy was developed and utilized by a faculty proctor to objectively evaluate trainees. OSATS scores, performance of key procedural steps, and pressure exerted on the simulator tissue correlated with upper aerodigestive cases performed, demonstrating validity of the simulator.

Level Of Evidence: NA Laryngoscope, 126:616-619, 2016.
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http://dx.doi.org/10.1002/lary.25439DOI Listing
March 2016

Submental Neck Mass in an Adolescent Female.

JAMA Otolaryngol Head Neck Surg 2015 Sep;141(9):851-2

Department of Otolaryngology-Head and Neck Surgery, University of Virginia Health System, Charlottesville.

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http://dx.doi.org/10.1001/jamaoto.2015.1501DOI Listing
September 2015

Neck mass with progressive shortness of breath. Riedel sclerosing thyroiditis.

JAMA Otolaryngol Head Neck Surg 2015 Mar;141(3):285-6

Department of Otolaryngology-Head and Neck Surgery, University of Virginia Health System, Charlottesville.

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http://dx.doi.org/10.1001/jamaoto.2014.3411DOI Listing
March 2015

Open reduction internal fixation for midline mandibulotomy: lag screws vs plates.

JAMA Otolaryngol Head Neck Surg 2014 Dec;140(12):1184-90

Division of Head and Neck Surgical Oncology, Department of Otolaryngology-Head and Neck Surgery, University of Virginia Health System, Charlottesville.

Importance: Midline mandibulotomy is a common approach for resection of head and neck oral cavity and oropharyngeal tumors; however, there are limited data available on the outcomes of lag screw vs plate fixation.

Objective: To compare outcomes for midline mandibulotomy open reduction and internal fixation using plates vs lag screw technique.

Design, Setting, And Participants: Retrospective cohort study at a tertiary care academic medical center of patients undergoing midline mandibulotomy for head and neck tumor resection over a 6-year period.

Interventions: Mandibular fixation using lag screws or plates.

Main Outcomes And Measures: The medical records and computed tomographic (CT) scans of patients undergoing midline mandibulotomy for head and neck tumor resection over a 6-year period were retrospectively reviewed. The postoperative CT scans were reviewed by a neuroradiologist who graded the fusion site on a scale of 0 to 2 using a 2-pass method. The rates and grades of union were compared, as well as several factors that affect healing, for fixations performed with plates vs lag screws.

Results: Thirty-seven patients were included. The overall rate of radiologic union was 90% (9 out of 10) for lag screw technique and 41% (11 out of 27) for plates (P = .01). The average grade of radiologic union was 1.3 for lag screws and 0.67 for plates (P = .04). Hardware exposure occurred in 4 (15%) of the plate group and fistulae formed in 3 (11%); neither complication occurred in the lag screw group. In univariate analysis, both presence of dentition (odds ratio [OR], 5.50 [95% CI, 1.33-22.73]; P = .02) and plate technique (OR, 13.09 [95% CI, 1.45-11.62]; P = .02) were significantly associated with nonunion. In multivariate analysis, plate technique had an OR of 8.32 (95% CI, 0.85-81.75) for nonunion (P = .07).

Conclusions And Relevance: Fixation of midline mandibulotomy with lag screws results in a significantly increased rate of radiologic union compared with plates. Lag screws were also significantly better at achieving radiologic union in patients who underwent postoperative radiation, and the rates of fistula formation and hardware exposure were lower. Thus, lag screw fixation of midline mandibulotomy should be considered an excellent option, especially when patients will undergo postoperative adjuvant therapy and in patients at high risk for wound complications.
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http://dx.doi.org/10.1001/jamaoto.2014.2005DOI Listing
December 2014

Impact of blood transfusions on patients with head and neck cancer undergoing free tissue transfer.

Laryngoscope 2015 Jan 14;125(1):86-91. Epub 2014 Aug 14.

Department of Otolaryngology-Head and Neck Surgery, University of Virginia Health System, Charlottesville, Virginia, U.S.A.

Objectives/hypothesis: To determine whether blood transfusions are associated with adverse outcomes in patients with head and neck cancer (HNC) undergoing microvascular free tissue transfer.

Study Design: Retrospective cohort study.

Methods: The records of all patients who underwent free flaps for reconstruction after HNC resection from July 2007 through February 2013 at a single institution were reviewed. Rates of overall survival (OS), recurrence free survival (RFS), and postoperative wound infection were determined. Statistical analyses included Cox proportional hazards models and chi-square tests.

Results: Of 167 patients, 90 received 0 to 2 units of blood and 77 received ≥ 3. After controlling for age, preoperative hemoglobin, preoperative albumin, cancer stage, and adverse pathologic features, transfusion of ≥ 3 (versus 0 to 2) units was associated with poorer OS (P = 0.0006; hazard ratio [HR] = 2.96) and RFS (P = 0.003; HR = 2.35). The rates of wound infection in patients who received 0, 1, 2, or ≥ 3 units were 13.3%, 21.2%, 33.3%, and 31.2%, respectively. There was a statistically significant difference in wound infection rates between those patients receiving 0 to 1 versus ≥ 2 units (P = 0.04).

Conclusions: Patients who receive ≥ 3 units of blood after free tissue transfer for HNC had a significantly increased risk of death after controlling for age, preoperative hemoglobin and albumin, cancer stage, and adverse pathologic features. Increased transfusions are also associated with higher wound infection rates. The increased tendency to transfuse free flap patients in order to maintain a threshold hematocrit may have a detrimental impact on survival and wound infections and should be revisited.
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http://dx.doi.org/10.1002/lary.24847DOI Listing
January 2015

Prognostic significance of p16 and its relationship with human papillomavirus in pharyngeal squamous cell carcinomas.

JAMA Otolaryngol Head Neck Surg 2014 Jul;140(7):647-53

Department of Radiation Oncology, University of Virginia, Charlottesville.

Importance: The prognostic significance of p16 in squamous cell carcinoma (SCC) of the hypopharynx (HP) and nasopharynx (NP) and relationship between human papillomavirus (HPV) and p16 is unclear.

Objectives: To evaluate the prognostic significance of p16 in pharyngeal subsites (oropharynx [OP], HP, and NP) and assess the relationship between HPV and p16 in the HP and NP.

Design, Setting, And Participants: Retrospective medical record review of 172 patients with SCC of the pharynx treated with definitive radiation therapy from 2002 to 2013 at a university tertiary referral center, with tissue available for immunohistochemical analysis. The median follow-up was 30.1 months.

Interventions: A total of 118 patients were treated with chemoradiation, and 54 patients were treated with radiation alone. Immunohistochemical analysis for p16 was performed for all tumors. Hypopharynx and NP tumors were tested for HPV using in situ hybridization, and NP tumors were tested for Epstein-Barr virus.

Main Outcomes And Measures: Overall survival, locoregional control, and disease-free survival were analyzed according to p16, HPV, and Epstein-Barr virus status.

Results: Thirty-two patients had HP SCC, 127 had OP SCC, and 13 had NP SCC. p16 Was positive in the HP (34%), OP (66%), and NP (46%). Prevalence of HPV was 14% in the HP and 50% in the NP. As a test for HPV, p16 had a positive predictive value of 38% (HP) and 67% (NP) and a negative predictive value of 100% in HP and NP tumors. p16 Status was a significant predictor of all clinical outcomes for patients with OP SCC (P<.001), but not for patients with HP or NP SCC. Patients with Epstein-Barr virus- or HPV-associated NP SCC had improved clinical outcomes.

Conclusions And Relevance: p16 Was not associated with improved outcomes in patients with HP or NP SCC. The positive predictive value of p16 as a test for HPV is too low for p16 testing alone in the HP and NP. However, p16 negativity is sufficient to rule out HPV. As a research approach, we recommend p16 immunohistochemistry as a screening test for HPV in NP SCC and HP SCC followed by confirmatory HPV in situ hybridization when p16 positive.
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http://dx.doi.org/10.1001/jamaoto.2014.821DOI Listing
July 2014

Utility of abdominal imaging to assess for liver metastasis in patients with head and neck cancer and abnormal liver function tests.

Am J Otolaryngol 2014 Mar-Apr;35(2):137-40. Epub 2013 Oct 29.

Department of Otolaryngology-Head and Neck Surgery, University of Virginia Health System, Charlottesville, VA. Electronic address:

Purpose: To determine the utility of abdominal imaging to further evaluate abnormal pre-operative liver function tests (LFTs) in patients with head and neck squamous cell carcinoma (HNSCC).

Methods: Records of patients evaluated by the head and neck surgery service from January 2004 through December 2009 were reviewed. For patients with abnormal alkaline phosphatase, alanine transaminase, or aspartate transaminase, subsequent abdominal imaging was assessed.

Results: Of the 862 patients with HNSCC who had documented LFTs, 109 (12.6%) had one or more abnormal values. In the same time period, LFTs were also obtained on 361 patients with benign head and neck tumors; of these, 40 (11.1%) had abnormalities. Of the 109 patients with HNSCC and abnormal LFTs, 78 (71.6%) underwent abdominal imaging (ultrasound, CT, MRI, or PET/CT). Overall, liver metastasis was demonstrated in only 1 of 109 patients with abnormal LFTs (0.92%) and in only 1 of 862 patients with HNSCC (0.12%).

Conclusions: While HNSCC patients rarely present with liver metastasis, they often have abnormal LFTs. Although the presence of liver metastasis can dramatically change patient management, the yield of follow-up liver imaging for all patients with elevated LFTs is exceedingly low. Thus, the use of risk-stratified abdominal imaging may be prudent and cost effective in a select group of patients in whom distant metastasis is more likely. However, characteristics of this group are difficult to define given the rarity of liver metastasis in HNSCC.
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http://dx.doi.org/10.1016/j.amjoto.2013.10.004DOI Listing
November 2014

Validation of a task-specific scoring system for a microvascular surgery simulation model.

Laryngoscope 2012 Oct 7;122(10):2164-8. Epub 2012 Sep 7.

Department of Otolaryngology-Head and Neck Surgery, University of Iowa, Iowa City, Iowa 52242, USA.

Objective/hypothesis: Simulation models can help develop procedural skills outside the clinical setting while also providing a means for evaluation of trainees. Objective Structured Assessment of Technical Skills (OSATS) have been developed for several procedures. The purpose of this study was to demonstrate the construct validity of an OSATS for microvascular anastomosis performed on a simulation model using chicken thigh vessels.

Study Design: Validation study.

Methods: An expert panel constructed a task-specific checklist for an OSATS for microvascular anastomosis. Twenty surgical staff and trainees performed a microvascular anastomosis of a chicken ischiatic artery. Training level and microsurgical experience were assessed by questionnaire. The performances were recorded and scored by two experts using the task-specific and global scales of the OSATS.

Results: Analysis of variance revealed a significant effect of training and microvascular experience for both the task-specific score and global rating scale score (P < .005). Interrater reliability was 0.7. Experience level demonstrated a logarithmic relationship with task time.

Conclusions: The microvascular OSATS applied to the chicken thigh simulator model differentiated between levels of microvascular experience. It demonstrated construct validity and reliability for the assessment of procedural competence using a cost-effective and easily accessible model.
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http://dx.doi.org/10.1002/lary.23525DOI Listing
October 2012

p16, Cyclin D1, and HIF-1α Predict Outcomes of Patients with Oropharyngeal Squamous Cell Carcinoma Treated with Definitive Intensity-Modulated Radiation Therapy.

Int J Otolaryngol 2012 24;2012:685951. Epub 2012 Jul 24.

Department of Radiation Oncology, University of Texas Southwestern, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA.

We evaluated a panel of 8 immunohistochemical biomarkers as predictors of clinical response to definitive intensity-modulated radiotherapy in patients with oropharyngeal squamous cell carcinoma (OPSCC). 106 patients with OPSCC were treated to a total dose of 66-70 Gy and retrospectively analyzed for locoregional control (LRC), disease-free survival (DFS), and overall survival (OS). All tumors had p16 immunohistochemical staining, and 101 tumors also had epidermal growth factor receptor (EGFR) staining. 53% of the patients had sufficient archived pathologic specimens for incorporation into a tissue microarray for immunohistochemical analysis for cyclophilin B, cyclin D1, p21, hypoxia-inducible factor-1α (HIF-1α), carbonic anhydrase, and major vault protein. Median followup was 27.2 months. 66% of the tumors were p16 positive, and 34% were p16 negative. On univariate analysis, the following correlations were statistically significant: p16 positive staining with higher LRC (P = 0.005) and longer DFS (P < 0.001); cyclin D1 positive staining with lower LRC (P = 0.033) and shorter DFS (P = 0.002); HIF-1α positive staining with shorter DFS (P = 0.039). On multivariate analysis, p16 was the only significant independent predictor of DFS (P = 0.023). After immunohistochemical examination of a panel of 8 biomarkers, our study could only verify p16 as an independent prognostic factor in OPSCC.
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http://dx.doi.org/10.1155/2012/685951DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3409529PMC
August 2012

p16 not a prognostic marker for hypopharyngeal squamous cell carcinoma.

Arch Otolaryngol Head Neck Surg 2012 Jun;138(6):556-61

Departments of Radiation Oncology, University of Virginia, Charlottesville, VA 22908, USA.

Objective: To investigate the prognostic significance of p16 in patients with hypopharyngeal squamous cell carcinoma (HPSCC) and to evaluate the relationship between p16 and human papillomavirus (HPV). Unlike in oropharyngeal SCC (OPSCC), the prognostic significance of p16 in HPSCC and its association with HPV is unclear.

Design: Retrospective medical chart review.

Setting: University tertiary referral center.

Patients: A total of 27 patients with HPSCC treated with definitive radiation therapy between 2002 and 2011 whose tissue was available for immunohistochemical analysis.

Interventions: Twenty-two patients were treated with chemoradiation, and 5 with radiation alone. All tumor biopsy specimens were analyzed for p16 and, when sufficient tissue was available, for HPV DNA.

Main Outcome Measures: Overall survival (OS), locoregional control (LRC), disease-free survival (DFS), and laryngoesophageal dysfunction-free survival (LEDFS) were analyzed according to p16 status.

Results: Findings for p16 were positive in 9 tumors and negative in 18 tumors. Median follow-up was 29.3 months. There was no significant difference in OS, LRC, DFS, or LEDFS for patients with p16-positive vs p16-negative tumors. Only 1 of the 19 tumors tested for HPV was found to be HPV positive. When used as a test for HPV, p16 had a positive predictive value of 17%.

Conclusions: In contrast to OPSCC, p16 expression in patients with HPSCC had a low positive predictive value for HPV and did not predict improved OS, LRC, DFS, or LEDFS. Thus, for HPSCC, p16 is not a prognostic biomarker. Caution must be taken when extrapolating the prognostic significance of p16 in patients with OPSCC to patients with head and neck SCC of other subsites.
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http://dx.doi.org/10.1001/archoto.2012.950DOI Listing
June 2012

Successful reconstruction of scalp and skull defects: lessons learned from a large series.

Laryngoscope 2011 Nov;121(11):2305-12

Department of Otolaryngology-Head and Neck Surgery, University of Virginia Health System, Charlottesville, Virginia 22908, USA.

Objective: To provide a framework for the management of scalp and skull defects.

Design: Retrospective chart review.

Setting: Two tertiary care hospitals.

Patients/intervention: Fifty-six consecutive patients who underwent reconstruction of scalp and/or skull defects with free flaps, rotational skin/fascia flaps, skin grafts, and implants. Defects closed primarily and those of the lateral temporal bone and skull base were excluded.

Results: Sixty-two reconstructions were performed. Treatment of skin cancers and intracranial tumors necessitated 31 (50%) and 22 (35%) of the reconstructions, respectively. Defects included partial-thickness soft tissue (9, 15%), full-thickness soft tissue (28, 45%), full-thickness soft tissue and skull (17, 27%), and full-thickness soft tissue, skull, and dura (8, 13%). Radiation or prereconstruction wound breakdown or infection was involved in 33 (53%) and 25 (40%) of cases, respectively. The most common method of reconstruction was free tissue transfer (27, 44%) followed by local skin (15, 24%) or fascia (9, 15%) flaps. There was a 15% (9/62) complication rate; 89% (8/9) of these occurred in radiated tissues and 44% (4/9) occurred in smokers. Seven of the nine patients with complications (78%) were managed with local wound care and/or removal of an implant, whereas 2 (22%) required a second reconstructive procedure. All patients ultimately achieved a safe outcome with no infection and no bone or dural exposure.

Conclusions: In addition to defect location and extent, availability of surrounding tissue and wound healing characteristics direct reconstruction. Patients who receive radiation therapy are at increased risk of complications. Use of vascularized tissue is critical for successful management, making local flaps and free tissue transfer the mainstay of reconstruction.
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http://dx.doi.org/10.1002/lary.22191DOI Listing
November 2011

Immediate postoperative extubation in patients undergoing free tissue transfer.

Laryngoscope 2011 Apr;121(4):763-8

Department of Otolaryngology-Head and Neck Surgery, University of Virginia, Charlottesville, Virginia 22908-0713, USA.

Objectives/hypothesis: Extubation (cessation of ventilatory support) is often delayed in free flap patients to protect the microvascular anastomosis, presumably by reducing emergence-related agitation. We sought to determine if immediate extubation in the operating room (OR) would improve the postoperative course compared to delayed extubation in the intensive care unit (ICU).

Study Design: Retrospective chart review.

Methods: Medical records of all patients undergoing free tissue transfer for head and neck reconstruction between January 2009 and July 2010 were reviewed (n = 52). Patients extubated immediately postoperatively in the OR (immediate group, n = 26) were compared to patients extubated in the ICU (delayed group, n = 26).

Results: Tobacco use, alcohol use, pulmonary history, case length, and free flap type were not significantly different between the two groups. Although the average ICU stay for the immediate group was significantly shorter than the delayed group (2.0 days vs. 3.4 days; P = .008), the reduction in overall hospital stay for the immediate group did not achieve statistical significance (8.2 days vs. 9.5 days; P = .21). Use of treatment for agitation (27% vs. 65%) and physical restraints (8% vs. 69%) were significantly lower in the immediate versus delayed group (P = .01 and P < .001, respectively). Although flap-related, surgical, and medical complication rates were not significantly different between the two groups, the delayed extubation group had a significantly higher incidence of pneumonia (15% vs. 0%; P = .05).

Conclusions: Immediate postoperative extubation in the OR following head and neck microvascular free tissue transfer reduces ICU stay, anxiolytic use, restraint use, and incidence of pneumonia without an increase in flap- or wound-related complications.
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http://dx.doi.org/10.1002/lary.21397DOI Listing
April 2011

Revision aural atresia surgery: indications and outcomes.

Otol Neurotol 2011 Feb;32(2):252-8

Department of Otolaryngology - Head and Neck Surgery, University of Virginia, Charlottesville, Virginia, USA.

Objective: To determine the most common indications for revision congenital aural atresia (CAA) surgery and the postoperative healing and hearing outcomes of revision surgery.

Study Design: Retrospective case review.

Setting: Tertiary care academic otologic practice.

Patients: Patients undergoing revision surgery for CAA.

Intervention: Revision surgery for CAA.

Main Outcome Measures: Indications for revision atresiaplasty, time to revision surgery, postoperative external auditory canal (EAC) patency, incidence of chronic drainage and/or infection, and postoperative speech reception thresholds (SRTs), and air-bone gaps.

Results: Indications for 75 ears (69 patients) undergoing 107 revision operations for CAA included 58% for EAC stenosis, 19% for chronic drainage and/or infection, and 20% for conductive hearing loss (CHL) alone. Fifty ears (67%) required a single revision. Twenty-five ears (33%) required more than 1 revision. With follow-up longer than 3 months (mean, 41 mo), 69% of ears revised for EAC stenosis achieved a patent canal (29% required >1 revision); 75% of ears revised for chronic drainage and/or infection (mean follow-up, 53 mo) realized a dry canal (22% required >1 revision). For all revision surgeries with adequate follow-up (n = 80), the mean postoperative short-term SRT of 24 dB HL was a significant improvement from the mean preoperative SRT of 39 dB HL (p < 0.01, paired t test).

Conclusion: EAC stenosis is the most common indication for revision atresiaplasty. Despite the challenges of revision surgery, improvement in canal patency, epithelialization, and hearing utcomes can be achieved.
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http://dx.doi.org/10.1097/MAO.0b013e3182015f27DOI Listing
February 2011

Predicting residual neck disease in patients with oropharyngeal squamous cell carcinoma treated with radiation therapy: utility of p16 status.

Arch Otolaryngol Head Neck Surg 2009 Nov;135(11):1126-32

Department of Otolaryngology-Head and Neck Surgery, University of Virginia Health System, Charlottesville, VA 22908, USA.

Objective: To identify factors that predict complete response of cervical nodal disease to radiation therapy (RT) in patients with oropharyngeal squamous cell carcinoma (OP-SCCA).

Design: Histologic analysis of prospectively collected specimens and retrospective medical chart review.

Setting: Tertiary referral center.

Subjects: Sixty-nine patients with OP-SCCA treated from January 1, 2002, through June 1, 2008.

Intervention: Definitive RT, with or without chemotherapy and with or without neck dissection (ND).

Main Outcome Measure: Presence of a viable tumor in post-RT ND specimen.

Results: Tissue specimens from 69 patients with OP-SCCA treated primarily with RT, with or without chemotherapy, were evaluated. Of these, 47 (68.1%) were strongly and diffusely positive for p16 expression by immunohistochemical analysis, signifying human papillomavirus positivity. Patients with p16-positive and p16-negative tumors (hereinafter, p16+ and p16-, respectively) had similarly sized primary tumors on presentation, but p16+ primary tumors were associated with more advanced neck disease (nodal stages N2c-N3; 31.9% vs 4.5% for p16- tumors) and more contralateral nodes (27.7% vs 4.5% for p16- tumors). Forty-seven patients (59.0%) underwent planned posttreatment ND (a total of 55 NDs). The NDs performed for p16- tumors were significantly more likely to have viable tumor in the specimen (50.0% vs 18.0% for p16+ tumors; P = .02). In addition, p16+ necks with residual viable cancer were characterized by incomplete response on post-RT imaging, tobacco and alcohol use, and extracapsular spread on pretreatment imaging.

Conclusions: In conjunction with other clinical parameters, p16 status can help predict the need for post-RT ND in patients with OP-SCCA. Although close observation may be warranted in selected patients with p16+ tumors, patients with p16- tumors are at much higher risk for residual neck disease, even when initial nodal disease is less advanced.
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http://dx.doi.org/10.1001/archoto.2009.153DOI Listing
November 2009

Septal hematoma after balloon dilation of the sphenoid.

Otolaryngol Head Neck Surg 2009 Sep 12;141(3):424-5. Epub 2009 Jun 12.

Department of Otolaryngology-Head and Neck Surgery, University of Virginia, Charlottesville, VA 22908, USA.

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http://dx.doi.org/10.1016/j.otohns.2009.03.027DOI Listing
September 2009

Ear defects.

Facial Plast Surg Clin North Am 2009 Aug;17(3):429-43

Department of Otolaryngology-Head & Neck Surgery, University of Virginia Health System, Charlottesville, USA.

The projection and exposure of the auricle make it particularly susceptible to actinic injury and thus to cutaneous malignancies. Auricular reconstruction is challenging because of its unique surface anatomy and undulating topography. This article organizes auricular defects into different categories based on anatomic location and extent of tissue loss, including skin-only defects, small composite defects, full-thickness defects involving or sparing the upper third of the ear, and total auricular loss. The authors share an algorithm for repair of the array of auricular defects.
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http://dx.doi.org/10.1016/j.fsc.2009.05.006DOI Listing
August 2009
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