Publications by authors named "Jason A Brant"

62 Publications

Otolaryngology for Internists.

Med Clin North Am 2021 Sep 25;105(5):xvii-xviii. Epub 2021 Jun 25.

Department of Otorhinolaryngology-, Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, 5 Ravdin, 3400 Spruce Street, Philadelphia, PA 19104, USA. Electronic address:

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http://dx.doi.org/10.1016/j.mcna.2021.06.001DOI Listing
September 2021

Evaluation and Management of Otalgia.

Med Clin North Am 2021 Sep;105(5):813-826

Department of Otolaryngology/Head and Neck Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, Silverstein 5, Philadelphia, PA 19103, USA. Electronic address:

Otalgia can be broadly categorized into primary otologic causes and secondary nonotologic causes. Isolated otalgia in the absence of hearing loss, otorrhea, or abnormal otoscopic findings is typically secondary to referred pain from nonotologic causes, as the sensory nerve supply to the ear arises from 4 cranial nerves and the cervical plexus. The most common causes of primary otalgia are acute otitis media and otitis externa, whereas the most common causes of secondary otalgia are temporomandibular joint disorders and dental pathology. Persistent unilateral ear pain and other alarm symptoms warrant further evaluation for possible neoplasm.
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http://dx.doi.org/10.1016/j.mcna.2021.05.004DOI Listing
September 2021

Postoperative Radiation Therapy Refusal in Human Papillomavirus-Associated Oropharyngeal Squamous Cell Carcinoma.

Laryngoscope 2021 Jul 13. Epub 2021 Jul 13.

Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, U.S.A.

Objectives/hypothesis: Human papillomavirus (HPV)-associated oropharyngeal squamous cell carcinoma (OPSCC) is a distinct clinical entity with good prognosis, unique demographics, and a trend toward treatment deintensification. Patients with this disease may opt out of recommended postoperative radiation therapy (PORT) for a variety of reasons. The aim of this paper was to examine factors that predict patient refusal of recommended PORT in HPV-associated OPSCC, and the association of refusal with overall survival.

Study Design: Retrospective population-based cohort study of patients in the National Cancer Database.

Methods: We conducted a retrospective cohort study of patients in the National Cancer Database diagnosed with OPSCC between January 2010 and December 2015. We primarily assessed overall survival and the odds of refusing PORT based on demographic, socioeconomic, and clinical factors. Analysis was conducted using multivariable logistic regression and multivariable Cox proportional hazards model.

Results: A total of 4229 patients were included in the final analysis, with 156 (3.7%) patients opting out of recommended PORT. On multivariable analysis, patient refusal of PORT was independently associated with a variety of socioeconomic factors such as race, insurance status, comorbidity, treatment at a single facility, and margin status. Lastly, PORT refusal was associated with significantly lower overall survival compared to receipt of recommended PORT (hazard ratio 1.69, confidence interval 1.02-2.82).

Conclusions: Patient refusal of recommended PORT in HPV-associated OPSCC is rare and associated with variety of disease and socioeconomic factors. PORT refusal may decrease overall survival in this population. Our findings may help clinicians when counseling patients and identifying those who may be more likely to opt out of recommended adjuvant therapy.

Level Of Evidence: 3 Laryngoscope, 2021.
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http://dx.doi.org/10.1002/lary.29743DOI Listing
July 2021

Impact of Race and Insurance Status on Primary Treatment for HPV-Associated Oropharyngeal Squamous Cell Carcinoma.

Otolaryngol Head Neck Surg 2021 Jul 13:1945998211029839. Epub 2021 Jul 13.

Department of Otolaryngology-Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.

Objective: To assess the impact of sociodemographic factors on primary treatment choice (surgery vs radiotherapy) in patients with human papillomavirus-associated (HPV+) oropharyngeal squamous cell carcinoma (OPSCC).

Study Design: Retrospective analysis of the National Cancer Database.

Setting: Data from >1500 Commission on Cancer institutions (academic and community) via the National Cancer Database.

Methods: Our sample consists of patients diagnosed with HPV+ OPSCC from 2010 to 2015. The primary outcome of interest was initial treatment modality: surgery vs radiation. We performed multivariable logistic models to assess the relationship between treatment choice and sociodemographic factors, including sex, race, treatment facility, and insurance status.

Results: Of the 16,043 patients identified, 5894 (36.7%) underwent primary surgery while 10,149 (63.3%) received primary radiotherapy. Black patients were less likely than White patients to receive primary surgery (odds ratio [OR], 0.80; 95% CI, 0.66-0.96). When compared with privately insured patients, those who were uninsured or on Medicaid or Medicare were also less likely to receive primary surgery (OR, 0.70 [95% CI, 0.56-0.86]; OR, 0.77 [95% CI, 0.65-0.91]; OR, 0.85 [95% CI, 0.75-0.96], respectively). Patients receiving treatment at an academic/research cancer program were more likely to undergo primary surgery than those treated at comprehensive community cancer programs (OR, 1.33; 95% CI, 1.14-1.56).

Conclusion: In this large sample of patients with HPV+ OPSCC, race and insurance status affect primary treatment choice. Specifically, Black and nonprivately insured patients are less likely to receive primary surgery as compared with White or privately insured patients. Our findings illuminate potential disparities in HPV+ OPSCC treatment.
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http://dx.doi.org/10.1177/01945998211029839DOI Listing
July 2021

Age-related Patterns of Vestibular Dysfunction in Dizziness and Imbalance: A Review of Vestibular Testing Results Among 1,116 Patients.

Otol Neurotol 2021 07;42(6):897-905

Department of Otolaryngology-Head and Neck Surgery, Hospital of the University of Pennsylvania.

Objective: To characterize differences in vestibular testing results among patients presenting with balance-related complaints; to stratify patterns of testing abnormalities by age.

Study Design: Retrospective chart review.

Setting: Academic Balance Center at a Tertiary Referral Center.

Patient Population: All patients who underwent vestibular testing in a 1-year period from 2017 to 2018.

Main Outcome Measure: Balance function test results.

Results: We reviewed 1,116 patients with age ranging from 11 to 94 years, including 521 patients ≥60 years. Most patients had at least 1 abnormal result, with only 21% of patients ≥60 years and 43% of patients <60 years yielding no test abnormalities (p < 0.001). Among 754 individuals with abnormal testing results, caloric testing did not show any significant difference between age groups. Patients ≥60 years of age were more likely to demonstrate abnormalities on saccadic and horizontal tracking eye movements (p < 0.01; sacc 20.8% vs 6.3%; HT 9.2% vs 4.7%), as well as positional and Dix-Hallpike testing with videonystagmography (p < 0.001; pos 52.3% vs 37.5%, DH 14.4% vs 6.8%). On computerized dynamic posturography, there were significantly more abnormal composite scores in the older group for both sensory organization and motor control testing (p < 0.001; SOT 31.8% vs 8.8%, MCT 7.6% vs 1.8%).

Conclusion: Among patients presenting balance-related complaints, a majority demonstrate at least one abnormality on vestibular testing. While caloric abnormalities occur across the life span, patients ≥60 years of age are more likely to have abnormal results in random saccades, positional, Dix-Hallpike testing, and posturography, with greater effect sizes in tests of central function. While the causes of imbalance and vertigo remain multifactorial, vestibular dysfunction can be considered a major contributor to balance dysfunction in the elderly population and should be thoroughly evaluated.
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http://dx.doi.org/10.1097/MAO.0000000000003094DOI Listing
July 2021

How Does the "Cookie-Bite" Audiogram Shape Perform in Discriminating Genetic Hearing Loss in Adults?

Otolaryngol Head Neck Surg 2021 Jun 1:1945998211015181. Epub 2021 Jun 1.

Department of Otorhinolaryngology-Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.

"Cookie-bite" or U-shaped audiograms-specifically, those showing midfrequency sensorineural hearing loss (HL)-are traditionally taught to be associated with genetic HL; however, their utility as a screening tool has not been reported. We aim to determine the performance of a cookie-bite audiogram shape in stratifying patients carrying putative loss-of-function variants in known HL genes from wild-type controls. We merged audiometric and exome sequencing data from adults enrolled in a large biobank at a tertiary care center. Of 321 patients, 50 carried a putative loss-of-function variant in an HL gene. The cookie-bite shape was present in 9 of those patients, resulting in low sensitivity (18%) and positive predictive value (15%) in stratifying genetic carrier status; 84% of patients with a cookie-bite audiogram did not carry a genetic variant. A cookie-bite audiogram should not be used to screen adults for possible genetic testing.
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http://dx.doi.org/10.1177/01945998211015181DOI Listing
June 2021

Palliative care in metastatic head and neck cancer.

Head Neck 2021 09 21;43(9):2764-2777. Epub 2021 May 21.

Department of Otorhinolaryngology: Head and Neck Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA.

Background: Due to inherent impact on quality of life, metastatic head and neck cancer patients are well-suited to benefit from palliative care (PC). Our objective was to examine factors that shape PC utilization and implications for overall survival in stage IVc head and neck cancer patients.

Methods: A retrospective study of patients with stage IVc head and neck cancer in the National Cancer Database from 2004 and 2015 was conducted.

Results: 7794 cases met inclusion criteria, of which 19.3% received PC. PC use was associated with more recent years of diagnosis, Northeast facility geography, and non-private insurances (p < 0.05). Compared to no PC, "interventional" PC, defined as palliative surgery, radiation, and/or chemotherapy, and "pain management only" PC were associated with lower overall survival (p < 0.05).

Conclusions: PC use increased over time and was associated with demographic and clinical factors. There remains opportunity for improvement in optimal implementation of palliative care.
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http://dx.doi.org/10.1002/hed.26761DOI Listing
September 2021

What is the Right Treatment for Adults With Unilateral Deafness?

Laryngoscope 2021 Mar 5. Epub 2021 Mar 5.

Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A.

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http://dx.doi.org/10.1002/lary.29481DOI Listing
March 2021

Predictors of Postoperative Electrode Deactivation Among Adult Cochlear Implantees.

Otol Neurotol 2021 07;42(6):e675-e683

Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.

Objective: To characterize postoperative electrode functionality after adult cochlear implantation; to identify rationale and risk factors for electrode deactivation.

Study Design: Retrospective Chart Review.

Setting: Academic Cochlear Implant Center.

Subject Population: Five hundred nineteen cochlear implants in 433 adult patients over 5 years.

Interventions: Unilateral or bilateral cochlear implantation.

Main Outcome Measures: Rate of electrode deactivation after adult cochlear implantation.

Results: One hundred twenty (27.7%) patients experienced electrode deactivation postoperatively, involving a total of 447 electrodes. The most common reasons for deactivation were bothersome nonauditory symptoms (n = 170, 38.0%), perceived benefit by patients (n = 64, 14.3%), and bothersome auditory symptoms (n = 60, 13.4%). Four hundred nineteen (93.7%) of involved electrodes remained deactivated at most recent follow-up, whereas 28 (6.3%) were able to be reactivated. Deactivation was most likely to occur within the first 4 weeks after activation (n = 90 patients,75.0%; p < 0.01). Among affected patients, the average number of electrodes deactivated was 3.44 (range 1-13; SD 2.50). Age was not associated with electrode deactivation.

Conclusions: While 98% of cochlear implants had full insertions, more than a quarter of implantees may experience electrode deactivation postoperatively for a multitude of reasons, with bothersome nonauditory symptoms most prevalent. Deactivation of five or more electrodes and simultaneous deactivation of two or three electrodes seems to increase the odds of subsequent device failure. However, deactivation encompasses a wide range of issues that likely include patient factors, surgical technique, and device-specific issues. Prognosis varies greatly at the individual level and further evaluation is required to better identify the issues underlying deactivation and identify true predictors of failure.
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http://dx.doi.org/10.1097/MAO.0000000000003093DOI Listing
July 2021

Primary Orbital Melanoma: An Investigation of a Rare Malignancy Using the National Cancer Database.

Laryngoscope 2021 08 11;131(8):1790-1797. Epub 2021 Feb 11.

Department of Otorhinolaryngology - Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A.

Objectives: Primary orbital melanoma (POM) is a rare disease with limited data on survival and best treatment practices. Here we utilize the National Cancer Database (NCDB) to determine the overall survival (OS) and covariates that influence mortality.

Study Design: Retrospective cohort study.

Methods: All patients diagnosed with POM from 2004 to 2016 were identified in the NCDB. Patient and oncologic data were analyzed using the Kaplan-Meier method and multivariate models for the primary outcome of OS.

Results: A total of 129 patients were identified. Median OS was 36.9 months (95% confidence interval [CI] 24.1-78.7 months) with mean 5-year survival of 42.0% (CI 33.2%-53.2%). Treatments received included surgery alone (43.4%), radiation alone (23.3%), and surgery followed by radiation (20.2%). The multivariate model demonstrated an increased risk of death associated with age over 80 years (hazard ratio [HR] 3.41, CI 1.31-8.86, P = .012), a Charlson-Deyo comorbidity score of 2 or greater (HR 5.30, CI 1.87-15.03, P = .002), and no treatment (HR 2.28, CI 1.03-5.06, P = .042). For every 1 cm increase in tumor size, there was an increased risk of death (HR 1.06, CI 1.00-1.13, P = .039). When compared to surgery alone, no other treatment modality had an effect on OS.

Conclusions: This study leveraged multiyear data from the NCDB to provide prognostic and demographic information on the largest known cohort of POM cases. Increased age, increased comorbidities, not receiving treatment, and larger tumor size were associated with increased mortality. There was no clear survival advantage for specific treatments.

Level Of Evidence: 4 Laryngoscope, 131:1790-1797, 2021.
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http://dx.doi.org/10.1002/lary.29428DOI Listing
August 2021

Streamlining the Cochlear Implant Evaluation: Utility of Community Audiometry in Cochlear Implant Candidacy Assessment.

Otol Neurotol 2021 03;42(3):402-407

Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.

Objective: To identify redundancy in the cochlear implant candidacy evaluation and assess its financial impact.

Study Design: Retrospective chart review.

Setting: Tertiary care academic cochlear implant center.

Patients: One hundred thirty-five patients referred for cochlear implant candidacy evaluation from 2004 through 2019.

Intervention: Community and academic audiometry were compared in a matched-pair analysis.

Main Outcome Measures: Pure-tone audiometry and word recognition scores (WRS) were compared using the Wilcoxon signed-rank test. Cost of repeated audiometry was estimated using the Medicare Provider Utilization and Payment data.

Results: The majority of pure-tone thresholds (PTT) and pure-tone averages (PTA) had no statistically significant differences between community and academic centers. Only air PTT at 2000 Hz on the right and air PTA on the right demonstrated differences with α = 0.05 after Bonferroni correction. Despite statistical differences, mean differences in PTT and PTA were all under 3.5 dB. WRS were on average lower at the academic center, by 14.7% on the right (p < 0.001) and 10.6% on the left (p = 0.003). Repeating initial audiometry costs patients up to $60.58 and costs the healthcare system up to $42.94 per patient.

Conclusions: Pure-tone audiometry between community and academic centers did not demonstrate clinically significant differences. Lower academic WRS implies that patients identified as potential cochlear implant candidates based on community WRS are likely suitable to proceed to sentence testing without repeating audiometry, saving patients and the healthcare system time and resources.
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http://dx.doi.org/10.1097/MAO.0000000000002942DOI Listing
March 2021

The Impact of COVID-19 on Otolaryngology Community Practice in Massachusetts.

Otolaryngol Head Neck Surg 2021 09 2;165(3):424-430. Epub 2021 Feb 2.

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

Objectives: Coronavirus disease 2019 (COVID-19) significantly affected many health care specialties, including otolaryngology. In response to governmental policy changes, many hospitals and private practices in Massachusetts canceled or postponed nonurgent office visits and elective surgeries. The objective of this study was to quantify the impact of COVID-19 on the provision and practice trends of otolaryngology services for 10 private practices in Massachusetts.

Study Design: Retrospective review.

Setting: Multipractice study for community practices in Massachusetts.

Methods: Electronic billing records from 10 private otolaryngology practices in Massachusetts were obtained for the first 4 months of 2019 and 2020. Questionnaires from these otolaryngology practices were collected to assess financial and staffing impact of COVID-19.

Results: The local onset of the COVID-19 pandemic had a significant decrease of 63% of visits in comparison to equivalent weeks in 2019. Virtual visits overtook in-person visits over time. A greater decline in operating room (OR) procedures than for office procedures was recorded. Ninety percent of practices reduced working hours, and 80% furloughed personnel. Seventy percent of practices applied for the Paycheck Protection Program (PPP).

Conclusion: COVID-19 has had a multifaceted impact on private otolaryngology practices in Massachusetts. A significant decline in provision of otolaryngology services aligned with the Massachusetts government's public health policy changes. The combination of limited personnel and personal protective equipment, as well as suspension of nonessential office visits and surgeries, led to decrease in total office visits and even higher decrease in OR procedures.
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http://dx.doi.org/10.1177/0194599820983732DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7862921PMC
September 2021

Innovations in otorhinolaryngology in the age of COVID-19: a systematic literature review.

World J Otorhinolaryngol Head Neck Surg 2021 Jan 22. Epub 2021 Jan 22.

Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania, PA, USA.

Objective: Otolaryngologists are at increased occupational risk of Coronavirus Disease 2019 (COVID-19) infection due to exposure from respiratory droplets and aerosols generated during otologic, nasal, and oropharyngeal examinations and procedures. There have been a variety of guidelines and precautions developed to help mitigate this risk. While many reviews have focused on the personal protective equipment (PPE) and preparation guidelines for surgery in the COVID-19 era, none have focused on the more creative and unusual solutions designed to limit viral transmission. This review aims to fill that need.

Data Sources: PubMed, Ovid/Medline, and Scopus.

Methods: A comprehensive review of literature was performed on September 28, 2020 using PubMed, Ovid/Medline, and Scopus databases. All English-language studies were included if they proposed or assessed novel interventions developed for Otolaryngology practice during the COVID-19 pandemic. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed.

Results: A total of 41 papers met inclusion criteria and were organized into 5 categories ('General Recommendations for Otolaryngologic Surgery', 'Equipment Shortage Solutions', 'Airway Procedures', 'Nasal Endoscopy and Skull Base Procedures', and 'Otologic Procedures'). Articles were summarized, highlighting the innovations created and evaluated during the COVID-19 pandemic. Creative solutions such as application of topical viricidal agents, make-shift mask filters, three-dimensional (3-D) printable adapters for headlights, aerosol containing separation boxes, and a variety of new draping techniques have been developed to limit the risk of COVID-19 transmission.

Conclusions: Persistent risk of COVID-19 exposure remains high. Thus, there is an increased need for solutions that mitigate the risk of viral transmission during office procedures and surgeries, especially given that most COVID-19 positive patients present asymptomatically. This review examines and organizes creative solutions that have been proposed and utilized in the otolaryngology. These solutions have a potential to minimize the risk of viral transmission in the current clinical environment and to create safer outpatient and operating room conditions for patients and healthcare staff.
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http://dx.doi.org/10.1016/j.wjorl.2021.01.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7825952PMC
January 2021

Jugular Bulb Anomalies Involving the Internal Auditory Canal: A Case Series.

Ann Otol Rhinol Laryngol 2021 Aug 29;130(8):970-975. Epub 2021 Jan 29.

Department of Otolaryngology-Head and Neck Surgery, Columbia University Medical Center, New York, NY, USA.

Objective: Jugular bulb abnormalities (JBA) such as high riding jugular bulb and jugular bulb diverticulum can extend or erode into the middle and inner ear. In this report, we report on a series of 6 patients with jugular bulb anomalies involving the internal auditory canal (IAC).

Methods: A retrospective case series.

Results: Six females, ages 6 to 63 presenting with myriad of otologic symptoms including hearing loss, tinnitus, balance disturbance, fullness, and otalgia were discovered to have JB eroding into IAC. Computerized tomography, but not Magnetic Resonance Imaging, was able to identify IAC erosion by a significantly enlarged JB.

Conclusion: A significantly enlarged JB eroding into the IAC maybe congenital or acquired. It can present with a variety of common otologic symptoms. Long term follow-up is needed to determine the natural history of JB anomalies involving the IAC and need for intervention.
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http://dx.doi.org/10.1177/0003489421990153DOI Listing
August 2021

Impact of Reconstruction With Hydroxyapatite Bone Cement on CSF Leak Rate in Retrosigmoid Approach to Vestibular Schwannoma Resection: A Review of 196 Cases.

Otol Neurotol 2021 07;42(6):918-922

Division of Otology & Neurotology, Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania.

Objective: To assess the impact of reconstructive technique on the incidence of cerebrospinal fluid (CSF) leak following retrosigmoid approach to acoustic neuroma resection.

Study Design: Retrospective case series.

Setting: Academic medical center.

Patients: A total of 1,200 patients with acoustic neuromas presented to our institution from 2005 to 2018. Of these, 196 patients underwent surgical resection via a retrosigmoid approach.

Intervention: At our institution, internal auditory canal (IAC) reconstruction following a retrosigmoid approach was performed with bone wax and muscle plug or Norian hydroxyapatite bone cement from 2005 to 2013. Starting in 2014, a newer model of bone cement, Cranios hydroxyapatite, was used exclusively for reconstruction.

Main Outcome Measures: Rates of CSF leak were evaluated across different methods of IAC reconstruction and types of bone cement. Patients whose leaks were attributable to the craniectomy site were excluded from analysis.

Results: The postoperative CSF leak rate among patients who did not receive bone cement for IAC reconstruction was 15.6% (n.5). The leak rate amongst patients who received Norian bone cement was 6.3% (n.4). After introduction of Cranios bone cement, the total leak rate decreased to 1% (n.1). Compared with all other types of closure, Cranios had a significantly reduced rate of postoperative CSF leak (p < 0.005). The leak rate following Cranios versus Norian was also significantly reduced (p < 0.05). Leak rate was not affected by tumor size (p.0.30) or age (p.0.43).

Conclusion: CSF leak rate following acoustic neuroma resection was significantly reduced by introduction of Cranios hydroxyapatite bone cement.
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http://dx.doi.org/10.1097/MAO.0000000000003072DOI Listing
July 2021

Role of elective neck dissection and adjuvant radiation therapy in patients with polymorphous adenocarcinoma.

Eur Arch Otorhinolaryngol 2021 Sep 3;278(9):3459-3466. Epub 2021 Jan 3.

Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, 800 Walnut Street, 18th Floor, Philadelphia, PA, 19107, USA.

Purpose: To evaluate the role of elective neck dissection (END) and of adjuvant radiation (aRT) in polymorphous adenocarcinoma (PAC), previously known as polymorphous low-grade adenocarcinoma (PLGA).

Methods: Retrospective cohort study of patients in the National Cancer Database with a histology of PAC (coded as PLGA) at a head and neck site diagnosed between 2004 and 2015. Multivariable Cox proportional hazard modeling was used to assess overall survival in the overall population, and in sub-analyses of clinically N0 disease, positive resection margins, and late stage disease.

Results: A total of 922 patients [66.8% female; mean (SD) age, 60.9 (13.9) years] met inclusion criteria. 74.7% of patients received surgery alone, and 18.0% received surgery and aRT. Only 7.6% of patients with clinically N0 disease received an END, with 10.6% of these having at least one positive node. END did not have a survival benefit compared to no END [HR 1.28 (0.61-2.68)]. Compared to surgery alone, aRT did not have significantly increased survival in the overall population or in late stage [HR 0.68 (0.39-1.19) and HR 0.46 (0.18-1.22), respectively]. On sub-analysis of patients with positive resection margins, aRT had a significant survival benefit compared to surgery alone [HR 0.37 (0.14-0.99)].

Conclusion: PAC is a rare, slow-growing malignant tumor typically treated with surgical excision, with undefined indications for END or aRT. Our findings show END to not have a benefit to overall survival. In patients with positive resection margins, there was a survival benefit for aRT.
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http://dx.doi.org/10.1007/s00405-020-06539-xDOI Listing
September 2021

Adenocarcinoma of the Sinonasal Tract: A Review of the National Cancer Database.

J Neurol Surg B Skull Base 2020 Dec 12;81(6):701-708. Epub 2019 Sep 12.

Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, United States.

 Sinonasal adenocarcinoma (SNAC) is a rare malignancy arising from mucus-secreting glandular tissue. Limited large-scale studies are available due to its rarity. We evaluated SNAC in the National Cancer Database (NCDB), a source that affords multi-institutional, population studies of rare cancers and their outcomes.  The NCDB was queried for adenocarcinoma in the sinonasal tract. Multivariate analyses were performed to evaluate for factors contributing to overall survival (OS).  A total of 553 patients were identified. The cohort was composed of 59.3% males. The nasal cavity was the most common primary site, representing 44.1% of cases. About 5.7% of patients presented with nodal disease, while 3.3% had distant metastases. About 40.6% of cases presented with stage IV disease. About 73.5% of patients underwent surgery, 54.2% received radiation therapy, and 27.7% had chemotherapy. Median OS was 71.7 months, while OS at 1, 2, and 5 years was 82, 73.0, and 52%, respectively. On multivariate analysis, advanced age (hazard ratio [HR]: 1.04; 95% confidence interval [CI]: 1.02-1.05), Charlson-Deyo score of 1 (HR: 1.99; 95% CI: 1.20-3.30), advanced tumor grade (HR: 2.73; 95% CI: 1.39-5.34), and advanced tumor stage (HR: 2.71; 95% CI: 1.33-5.50) were associated with worse OS, whereas surgery (HR: 0.34; 95% CI: 0.20-0.60) and radiation therapy (HR: 0.55; 95% CI: 0.33-0.91), but not chemotherapy (HR: 1.16; 95% CI: 0.66-2.05), predicted improved OS.  SNAC is a rare malignancy with 5-year survival approximating 50%. Surgery and radiation therapy, but not chemotherapy, are associated with improved survival, and likely play a critical role in the interdisciplinary management of SNAC.
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http://dx.doi.org/10.1055/s-0039-1696707DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7755511PMC
December 2020

Real-time feedback control of voice in cochlear implant recipients.

Laryngoscope Investig Otolaryngol 2020 Dec 21;5(6):1156-1162. Epub 2020 Nov 21.

Department of Otorhinolaryngology: Head and Neck Surgery Hospital of the University of Pennsylvania Philadelphia Pennsylvania USA.

Objectives: To evaluate feedback-dependent vocal control in cochlear implant patients using pitch-shifted auditory feedback.

Methods: Twenty-three CI recipients with at least 6 months of implant experience were enrolled. Vocal recordings were performed while subjects repeated the vowel /e/ and vocal signals were altered in real-time using a digital effects processor to introduce a pitch-shift, presented back to subjects using headphones. Recordings were analyzed to determine pitch changes following the pitch-shifted feedback, and results compared to the magnitude of the shift as well as patient demographics.

Results: Consistent with previous results, CI patients' voices had higher pitches with their implant turned off, a change explainable by increases in vocal loudness without the CI. CI patients rapidly compensated for pitch-shifted feedback by changing their vocal pitch, but only for larger shifts. Considerable inter-subject variability was present, and weakly correlated with the duration of implant experience and implant sound thresholds.

Conclusions: CI patients, like normal hearing individuals, are capable of real-time feedback-dependent control of their vocal pitch. However, CI patients are less sensitive to small feedback changes, possibly a result of courser CI frequency precision, and may explain poorer than normal vocal control in these patients.

Level Of Evidence: Level 3b.
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http://dx.doi.org/10.1002/lio2.481DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7752050PMC
December 2020

Failure and Revision Surgery After Cochlear Implantation in the Adult Population: A 10-year Single-institution Retrospective and Systematic Review of the Literature.

Otol Neurotol 2021 03;42(3):408-413

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

Objective: To characterize failure rate and etiology after cochlear implantation; to identify predictors and describe outcomes after implant failure.

Study Design: Retrospective chart review and systematic review of the literature using PubMed and Embase.

Setting: Academic Cochlear Implant Center.

Subject Population: Four hundred ninety-eight devices in 439 distinct adult patients.

Interventions: Unilateral or bilateral cochlear implantation.

Main Outcome Measures: Implant failure rate and etiology.

Results: A total of 32 devices (5.9%) failed in 31 patients encompassing the following failure types in accordance with the European Consensus Statement of Cochlear Implants: 17 device failures (53.1%), 11 failures due to performance decrement/adverse reactions (34.4%), and 4 medical reasons (12.9%). There was no significant difference in age, sex, or manufacturer between patients with and without failures. Twenty-five percent of patients with failure leading to explantation had childhood onset of deafness compared to 12.1% of patients with adult-onset hearing loss (OR = 2.42; p = 0.04). Performance decrement/adverse reaction patients had an older average age at implantation compared to device failure patients (mean 68.5 yr 95% CI: 59.9-77.1 vs mean 47.6 yr, CI: 39.9-55.3, p < 0.01). There was no significant difference in time to failure, sex, or device manufacturer between the different types of failures. Twenty-nine patients who experienced CI failure underwent a revision surgery, while the remaining two opted for explantation without reimplantation. One patient who underwent revision surgery subsequently presented with a second failure and underwent a second revision, which was successful.In our systematic review, 815 citations were reviewed, and 9 studies were selected for inclusion. Overall failure rate across all studies was 5.5%. Device failure was the leading cause of failure in the majority (6/9) of studies, accounting for 40.8% of all failures. Medical reasons were the second leading cause at 33.6%, followed by performance decrement/adverse reaction (20.9%) and other (4.8%).

Conclusions: Cochlear implant failure is a rare phenomenon. Childhood-onset of hearing loss appears to be associated with an increased risk of overall failure. Older patients are at increased risk for performance decrement/adverse reaction. Revision surgery success rates remain very high and patients with failure of any cause should be offered explantation with concurrent reimplantation.
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http://dx.doi.org/10.1097/MAO.0000000000002940DOI Listing
March 2021

Endoscopic sinus surgery and aspirin desensitization improve otologic-specific SNOT-22 scores.

World J Otorhinolaryngol Head Neck Surg 2020 Dec 17;6(4):248-254. Epub 2020 Oct 17.

University of Pennsylvania Health System, Department of Otorhinolaryngology-Head and Neck Surgery, Otology/Neurotology, 3400 Spruce St, 5 Silverstein, Philadelphia, PA 19104, USA.

Objective: There are few studies evaluating the impact of Aspirin-exacerbated respiratory disease (AERD) treatment on otologic symptoms. The aim of this study is to evaluate the effects of endoscopic sinus surgery (ESS) and aspirin desensitization (AD) on otologic symptoms in subjects with AERD.

Methods: Retrospective chart review of adult patients diagnosed with AERD at our tertiary Care Academic Medical Center - Otorhinolaryngology Department. Charts of adult patients diagnosed with AERD who underwent ESS and ASA desensitization at our institution's AERD Center from 2016 to 2019 were reviewed. Sino-Nasal Outcomes Test 22-item survey (SNOT-22) scores were evaluated for patients at various time points including: pre-surgery, post-surgery/pre-aspirin desensitization, and various times post-desensitization up to >12 months. Within the SNOT-22, otologic-specific subdomain scores were evaluated at similar time points. Patients on immunomodulatory medications other than corticosteroids were excluded from analysis.

Results: SNOT-22 scores were analyzed for 121 patients. There was a significant improvement in overall SNOT scores from pre-surgery (44.62) to post surgery/pre-desensitization (23.34) ( < 0.0005). Similarly, SNOT-22 otologic-specific scores also improved after surgery prior to desensitization (3.19-2.04) ( = 0.005). Following AD, the improvement in the overall SNOT-22 continued to improve for up to 12 months ( < 0.005). While the otologic-specific SNOT-22 scores remained stable after surgery and ASA desensitization.

Conclusion: ESS and AD reduce otologic-specific SNOT-22 scores and parallel trends in overall SNOT-22 scores. The effect of treatment is durable over the course of 12 months. Future work should aim to correlate otologic SNOT-22 scores with objective otologic data.
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http://dx.doi.org/10.1016/j.wjorl.2020.07.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7729217PMC
December 2020

An Analysis of the Methodology for Attribution of Specialty Care in Otolaryngology and Urology.

Otolaryngol Head Neck Surg 2021 02 21;164(2):336-338. Epub 2020 Jul 21.

Division of Urology, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.

() rankings can assist patients with choosing where to receive their specialty care. methodology assumes that the specialty caring for hospitalized patients is equivalent to the specialty assigned by administrative coding. We examined the frequency of discordance between methodology-assigned specialty and the actual specialty care received for 2 surgical specialties, otolaryngology (ENT) and urology (GU). Our analysis included inpatient deaths identified by coding for these specialties from 2013 to 2017 at a single academic tertiary care center. We found that a minority of patients with deaths attributed by to these 2 specialties were actually cared for by ENT (6/14; 43%) or GU (3/19; 16%). Only 5 of 14 (36%) and 2 of 19 (11%) deaths were potentially associated with ENT and GU care, respectively. We identified a significant discordance between -assigned specialty and the actual specialty care received.
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http://dx.doi.org/10.1177/0194599820941016DOI Listing
February 2021

Impact of Lymph Node Yield on Survival in Surgically Treated Oropharyngeal Squamous Cell Carcinoma.

Otolaryngol Head Neck Surg 2021 01 21;164(1):146-156. Epub 2020 Jul 21.

University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA.

Objectives: (1) To estimate the association between neck dissection lymph node yield (LNY) and survival among patients with surgically treated human papilloma virus (HPV)-associated oropharyngeal squamous cell carcinoma (OPSCC). (2) To identify a clinically relevant quality metric for surgical treatment of HPV-related OPSCC.

Study Design: Retrospective cohort study.

Setting: National Cancer Database.

Subjects And Methods: From the National Cancer Database, 4130 patients were identified with HPV-associated OPSCC treated with primary surgery from 2010 to 2016. Based on prior literature, an adequate neck dissection LNY was defined as ≥18 lymph nodes. To determine whether LNY is associated with survival, univariable and multivariable Cox proportional hazards regression was performed. Analysis was stratified by adjuvant therapy regimen.

Results: A total of 2113 patients (51.2%) underwent surgery with or without adjuvant radiation (S ± RT), and 2017 patients (48.8%) underwent surgery with adjuvant chemoradiation. LNY ≥18 was associated with a 5-year survival benefit of 7.15% (91.7% for LNY ≥18, 84.5% for LNY <18, = .004) for the S ± RT cohort on unadjusted survival analysis. For the S ± RT group, LNY ≥18 was associated with decreased hazard of death (hazard ratio, 0.45; 95% CI, 0.29-0.70; < .001) after adjustment for patient characteristics, TNM staging, surgical margins, extranodal extension, and treating facility characteristics. For surgery with adjuvant chemoradiation, the adjusted hazard ratio estimate for LNY ≥18 was 0.64 (95% CI, 0.41-1.00), but the result was not statistically significant ( = .052).

Conclusion: An adequate LNY from a neck dissection may affect survival when HPV-related OPSCC is treated with up-front surgery.
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http://dx.doi.org/10.1177/0194599820936637DOI Listing
January 2021

Predictors of nodal metastasis in sinonasal squamous cell carcinoma: A national cancer database analysis.

World J Otorhinolaryngol Head Neck Surg 2020 Jun 25;6(2):137-141. Epub 2020 Mar 25.

Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, United States.

Objective: We present the largest population based study of sinonasal squamous cell carcinoma (SCC) to identify risk factors for presentation with nodal metastasis.

Methods: The National Cancer Database (NCDB) was used for this study. Location codes corresponding to the nasal cavity and paranasal sinuses and histology codes representing SCC malignancy were queried. regression analysis was performed to identify factors associated with presentation with nodal metastasis.

Results: 6448 cases met inclusion criteria. Nodal metastasis at presentation was seen in 13.2% of patients, with the sinus subsite (19.3%) being a significant risk factor for nodal metastasis at presentation when compared to the nasal cavity (7.9%). regression analysis showed black, uninsured and Medicaid patients were more likely than white and privately insured patients, respectively, to present with nodal metastasis.

Conclusions: In sinonasal SCC, the sinus subsite has a significantly increased risk of nodal metastasis compared to the nasal cavity. Black race, uninsured and Medicaid patients are more likely to have nodal metastasis at presentation.
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http://dx.doi.org/10.1016/j.wjorl.2020.01.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7296471PMC
June 2020

Predicting salvage laryngectomy in patients treated with primary nonsurgical therapy for laryngeal squamous cell carcinoma using machine learning.

Head Neck 2020 09 8;42(9):2330-2339. Epub 2020 May 8.

Department of Otolaryngology-Head and Neck Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA.

Background: Machine learning (ML) algorithms may predict patients who will require salvage total laryngectomy (STL) after primary radiotherapy with or without chemotherapy for laryngeal squamous cell carcinoma (SCC).

Methods: Patients treated for T1-T3a laryngeal SCC were identified from the National Cancer Database. Multiple ML algorithms were trained to predict which patients would go on to require STL after primary nonsurgical treatment.

Results: A total of 16 440 cases were included. The best classification performance was achieved with a gradient boosting algorithm, which achieved accuracy of 76.0% (95% CI 74.5-77.5) and area under the curve = 0.762. The most important variables used to construct the model were distance from residence to treating facility and days from diagnosis to start of treatment.

Conclusion: We can identify patients likely to fail primary radiotherapy with or without chemotherapy and who will go on to require STL by applying ML techniques and argue for high-quality, multidisciplinary regionalized care.
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http://dx.doi.org/10.1002/hed.26246DOI Listing
September 2020

A Population-Level Analysis of Pituitary Carcinoma from the National Cancer Database.

J Neurol Surg B Skull Base 2020 Apr 15;81(2):180-186. Epub 2019 Mar 15.

Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, United States.

 Pituitary carcinoma is a rare entity with fewer than 200 total cases reported in the English literature. Analysis of the population-level data from the National Cancer Database (NCDB) affords the opportunity to study this poorly understood tumor type.  The NCDB was queried for site, histology, and metastasis codes corresponding to pituitary carcinoma. Statistical analyses were performed to determine factors associated with overall survival (OS).  A total of 92 patients with pituitary carcinoma met inclusion criteria. The 1 and 5 years of OS for all patients was 93.3% (95% confidence interval [CI]: 88.2-98.6%) and 80.0% (95% CI: 71.6-89.4%), respectively. Patients with invasive primary tumor behavior had 1 and 5 years of OS of 69.2% (95% CI: 48.2-99.5%) and 52.7% (95% CI: 31.2-89.2%), respectively. Multivariate analysis demonstrated that compared with benign primary behavior, invasive behavior had increased all-cause mortality (hazard ratio [HR], 1,296, 95% CI: 15.1- > 2,000). Surgery without adjuvant radiation or chemotherapy was the most common therapy (48.9%), followed by no treatment (40.2%). Compared with surgery alone, no treatment had worse OS (HR, 11.83, 95% CI: 1.41-99.56). Increasing age and female sex were both associated with increased mortality.  The most common treatment for pituitary carcinoma is surgery alone followed by no surgery. Surgery alone has significantly better OS compared with no treatment. The efficacy of radiation, chemotherapy, and neurohormonal treatments needs to be examined with prospective studies.
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http://dx.doi.org/10.1055/s-0039-1683435DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7082172PMC
April 2020

Lateral Wall Electrodes Increase the Rate of Postactivation Nonauditory Percepts.

Otol Neurotol 2020 06;41(5):e575-e579

Department of Otorhinolaryngology - Head and Neck Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania.

Objective: To evaluate factors influencing the development of nonauditory percepts and facial nerve stimulation after cochlear implant (CI) activation.

Study: Retrospective cohort study.

Setting: Tertiary referral center.

Patients: Over the course of 5 years, 433 consecutive patients were evaluated for CI and 518 ears were implanted. Of those, 497 ears had information regarding CI activation.

Interventions: Lateral wall electrodes (LWE) or perimodiolar/mid-scalar electrodes (PME) were used during implantation.

Primary Outcome Measure: Nonauditory percepts and facial nerve stimulation after activation of CI.

Results: Among the 497 devices, which were activated at our institution, 357 (72%) had LWE while 140 (28%) patients had a PME. Of the patients with LWE, 49 (13.7%) patients experienced some form of nonauditory percept. In comparison, 11 (9.2%) patients with a PME had some form of nonauditory percept (p < 0.05). Among the patients who had an LWE, 33 (9.2%) patients had facial nerve stimulation compared with 6 (4.3%) patients with PME (p < 0.05). Additionally, there were 11 (2.2%) patients with incomplete insertion of the electrode who had a significant increase (p < 0.05) in facial nerve stimulation. The mean number of electrodes requiring programming modification to control symptoms was 2.9.

Conclusions: The use of LWE and incomplete insertions significantly increase the rate of nonauditory percepts and FNS after activation of CIs. Otic capsule anomalies are an independent risk factor for both.
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http://dx.doi.org/10.1097/MAO.0000000000002610DOI Listing
June 2020

Recurrent glomangioma ("true" glomus tumor) of the middle ear and mastoid.

World J Otorhinolaryngol Head Neck Surg 2019 Dec 13;5(4):175-179. Epub 2019 Dec 13.

Department of Otorhinolaryngology Head and Neck Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.

Objective: To review current literature and experience with glomangiomas, or true glomus tumors of the middle ear and mastoid as well asto report on the exceptionally rare case of a glomangiomastemming from the middle ear space with multiple recurrences.

Methods: Review of existing world literature and description of personal experience with rare cases of a glomangioma of the middle ear and mastoid.

Results: Review of existing literature revealed two cases of patients presenting with tinnitus and hearing loss refractory to medical management. Both patients were ultimately diagnosed with glomangioma on histopathology. Complete surgical excision is thought to be curative.

Patient: A 36-year-old woman presented with a rare case of a glomangioma of the middle ear presenting with unilateral hearing loss. She was noted to have a mass behind the tympanic membrane. Imaging revealed a diffuse mass filling the mastoid air cells. Imaging characteristics and histology were consistent with a glomangioma.

Intervention: Initial resection via mastoidectomy using a postauricular approach. The tympanic membrane was reconstructed with temporalis tissue. Follow-up revision tympanomastoidectomy was performed upon recurrence of disease. The chorda tympani were sacrificed due to tumor involvement. The incus and head of the malleus were removed to gain better access to the tumor. The ossicular chain was reconstructed with a Goldenberg Total Ossicular Prosthesis.

Main Outcome Measure: Recurrence of disease.

Follow-up: In the 67 months since her most recent surgery, there has been no evidence of recurrence by CT or physical exam.

Conclusion: Glomangioma of the middle ear represents an exceptionally rare entity that can present in a similar fashion to a paraganglioma.
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http://dx.doi.org/10.1016/j.wjorl.2019.01.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7015857PMC
December 2019

Association of Type of Treatment Facility With Overall Survival After a Diagnosis of Head and Neck Cancer.

JAMA Netw Open 2020 01 3;3(1):e1919697. Epub 2020 Jan 3.

Department of Otorhinolaryngology-Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia.

Importance: Patients with head and neck cancer receive care at academic comprehensive cancer programs (ACCPs), integrated network cancer programs (INCPs), comprehensive community cancer programs (CCCPs), and community cancer programs (CCPs). The type of treatment facility may be associated with overall survival.

Objective: To examine whether type of treatment facility is associated with overall survival after a diagnosis of head and neck cancer.

Design, Setting, And Participants: This population-based retrospective cohort study included patients from the National Cancer Database, a prospectively maintained, hospital-based cancer registry of patients treated at more than 1500 US hospitals. Participants were diagnosed with malignant tumors of the head and neck from January 1, 2004, through December 31, 2016. Data were analyzed from May 1 through November 30, 2019.

Exposures: Treatment at facilities classified as ACCPs, INCPs, CCCPs, or CCPs.

Main Outcomes And Measures: Overall survival after diagnosis and treatment of head and neck cancer was the primary outcome. The secondary outcome was the odds of receiving treatment at ACCPs and INCPs vs CCCPs and CCPs. Multivariable Cox proportional hazards regression and univariable and multivariable logistic regression models were used for analysis.

Results: A total of 525 740 patients (368 821 men [70.2%]; mean [SD] age, 63.3 [14.0] years) were diagnosed with malignant tumors of the head and neck during the study period. Among them, 36 595 patients (7.0%) were treated at CCPs; 174 658 (33.2%), at CCCPs; 232 867 (44.3%), at ACCPs; and 57 857 (11.0%), at INCPs. The median survival for patients with aerodigestive cancers was 69.2 (95% CI, 68.6-69.8) months; salivary gland cancers, 107.2 (95% CI, 103.9-110.2) months; and skin cancers, 113.2 (95% CI, 111.4-114.6) months. Improved overall survival was associated with treatment at ACCPs (hazard ratio [HR], 0.89; 95% CI, 0.88-0.91), INCPs (HR, 0.94; 95% CI, 0.92-0.96), and CCCPs (HR, 0.94; 95% CI, 0.92-0.95) compared with CCPs. Compared with patients with private insurance, those with government insurance (odds ratio [OR], 1.35; 95% CI, 1.29-1.41), no insurance (OR, 1.12; 95% CI, 1.09-1.16), or Medicaid (OR, 1.17; 95% CI, 1.14-1.20) were more likely to receive treatment at ACCPs and INCPs, whereas patients with Medicare were less likely to receive treatment at ACCPs and INCPs (OR, 0.95; 95% CI, 0.94-0.97). Compared with white patients, black (OR, 1.55; 95% CI, 1.52-1.59) and Asian (OR, 1.56; 95% CI, 1.49-1.63) patients were more likely to receive care at ACCPs and INCPs. Compared with patients from lower-income areas, patients from high-income areas were more likely to receive treatment at ACCPs and INCPs (OR, 1.25; 95% CI, 1.22-1.28).

Conclusions And Relevance: These findings suggest that treatment at ACCPs and INCPs was associated with a better overall survival rate in patients with head and neck cancer. Key social determinants of health such as race/ethnicity, socioeconomic status, and type of insurance were associated with receiving treatment at ACCPs and INCPs.
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http://dx.doi.org/10.1001/jamanetworkopen.2019.19697DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6991286PMC
January 2020

Factors Associated With Facial Nerve Paresis Following Gamma Knife for Vestibular Schwannoma.

Otol Neurotol 2020 01;41(1):e83-e88

Department of Otorhinolaryngology-Head and Neck Surgery.

Objective: Evaluate the incidence of and potential contributory factors to facial nerve paresis and other cranial neuropathies (CN) following stereotactic radiosurgery with Gamma Knife (GK) for primary treatment of vestibular schwannoma (VS).

Study Design: Retrospective chart review.

Setting: Tertiary referral center.

Patients: Charts were reviewed for all adult patients receiving primary GK treatment for unilateral VS between 2005 and 2013. Patients with NF2 or previous surgery were excluded from analysis.

Intervention: GK radiosurgery.

Main Outcome Measures: The incidence of new-onset facial nerve paresis after primary GK treatment of VS was evaluated. Secondary endpoints included other cranial neuropathies.

Results: One hundred thirty-three patients with VS received primary GK therapy. Posttreatment CN developed in 33 patients (24.8%). Twelve patients (9.0%) experienced trigeminal paresthesia, 11 (8.3%) developed sudden sensorineural hearing loss (SSNHL) requiring steroids, and seven (5.3%) demonstrated facial paresis. The mean maximum cochlear dose was 15.49 Gy in patients with facial paresis compared with 12.42 Gy in subjects without facial paresis (p = 0.032). Subjects with facial paresis were more likely to have a lateral tumor without fundal fluid on magnetic resonance imaging (MRI) (71%) compared with subjects without facial paresis (43%).

Conclusions: In the treatment of VS with primary GK, maximum cochlear dose was significantly associated with facial paresis. Laterally extending tumors without fundal fluid on MRI experienced higher rates of facial paresis. These factors should be considered during GK treatment planning for VS.
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http://dx.doi.org/10.1097/MAO.0000000000002401DOI Listing
January 2020

Social determinants of health and survivorship in parotid cancer: An analysis of the National Cancer Database.

Am J Otolaryngol 2020 Jan - Feb;41(1):102307. Epub 2019 Oct 18.

Department of Otorhinolaryngology: Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA 19104, United States of America.

Background: Given the rarity of parotid cancer, there is relatively few data published regarding outcomes. Utilizing the large sample population of the National Cancer Database (NCDB), we aim to examine the relationship between two key social determinants of health, demographics and socioeconomic status (SES), and parotid malignancy survival rates.

Methods: Our analytic sample consists of patients with a diagnosis of primary malignancy of the parotid gland between 2004 and 2012 in the NCDB. We used univariable and multivariable Cox proportional hazard models to evaluate the relationship between overall survival rate and two key social determinants of health: demographics and SES.

Results: 15,815 cases met inclusion criteria. Average age was 60.1 years and 8255 were male (52.2%). Median overall survival was 121 months with 5-year overall survival of 67.4%. Male sex and older age at diagnosis were associated with poorer overall survival (p < 0.0001). We found that Asian Americans compared to whites had better overall survival (HR 0.75; 95% CI [0.58-0.95]). Black patients had improved survival compared to whites on univariate (HR 0.71; 95% CI [0.64-0.79]); but not multivariate analysis. Hispanic ethnicity and higher education level were protective (HR 0.76 95% CI [0.63-0.91] and HR 0.84 95% CI [0.74-0.96], respectively). We found no significant survival association based on income level.

Conclusion: In this national sample of patients with parotid malignancy, a rare form of cancer, we found a significant correlation between important social determinants of health and overall survival rate. Females, Asian-Americans, Hispanics, and patients with higher education level have better overall survival.
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http://dx.doi.org/10.1016/j.amjoto.2019.102307DOI Listing
April 2020
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