Publications by authors named "Maie A St John"

99 Publications

Cancer of the Larynx and Hypopharynx.

Hematol Oncol Clin North Am 2021 Jul 13. Epub 2021 Jul 13.

Department of Head & Neck Surgery, David Geffen School of Medicine at UCLA, UCLA Head and Neck Cancer Program, 10833 Le Conte Avenue, CHS 62-235, Los Angeles, CA 90095, USA. Electronic address:

The Radiation Therapy Oncology Group 91-11 trial and US Veterans Affairs trial revolutionized the way locally advanced laryngeal cancers are treated. Adjuvant therapies exist aimed toward laryngeal preservation using docetaxel, cisplatin, and fluorouracil. Cetuximab is a cornerstone of treatment due to the large role of epidermal growth factor receptor in laryngeal and hypopharyngeal carcinomas. In addition, the immune system is vital in the prevention of recurrence, and various immunomodulators against programmed cell death receptor 1 are being investigated. Multidisciplinary management of the patient with laryngeal and hypopharyngeal is key, as many vital functions are affected by this devastating disease.
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http://dx.doi.org/10.1016/j.hoc.2021.05.005DOI Listing
July 2021

Surgical approach is associated with complication rate in sinonasal malignancy: A multicenter study.

Int Forum Allergy Rhinol 2021 Jun 27. Epub 2021 Jun 27.

Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh, Pittsburgh, PA.

Background: Management of sinonasal malignancy (SNM) often includes surgical resection as part of the multimodality treatment. Treatment-related surgical morbidity can occur, yet risk factors associated with complications in this population have not been sufficiently investigated.

Methods: Adult patients with histologically confirmed SNM whose primary treatment included surgical resection were prospectively enrolled into an observational, multi-institutional cohort study from 2015 to 2020. Sociodemographic, disease, and treatment data were collected. Complications assessed included cerebrospinal fluid leak, orbital injury, intracranial injury, diplopia, meningitis, osteoradionecrosis, hospitalization for neutropenia, and subsequent chronic rhinosinusitis. The surgical approach was categorized as endoscopic resection (ER) or open/combined resection (O/CR). Associations between factors and complications were analyzed using Student's t test, Fisher's exact test, and logistic regression modeling.

Results: Overall, 142 patients met the inclusion criteria. Twenty-three subjects had at least 1 complication (16.2%). On unadjusted analysis, adjuvant radiation therapy was associated with developing a complication (91.3% vs 65.5%, p = 0.013). Compared with the ER group (n = 98), the O/CR group (n = 44) had a greater percentage of higher T-stage lesions (p = 0.004) and more frequently received adjuvant radiation (84.1% vs 64.4%, p = 0.017) and chemotherapy (50.0% vs 30.6%, p = 0.038). Complication rates were similar between the ER and O/CR groups without controlling for other factors. Regression analysis that retained certain factors showed O/CR was associated with increased odds of experiencing a complication (odds ratio, 3.34; 95% confidence interval, 1.06-11.19).

Conclusions: Prospective, multicenter evaluation of SNM treatment outcomes is feasible. Undergoing O/CR was associated with increased odds of developing a complication after accounting for radiation therapy. Further studies are warranted to build upon these findings.
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http://dx.doi.org/10.1002/alr.22833DOI Listing
June 2021

A Tool to Locate Parathyroid Glands Using Dynamic Optical Contrast Imaging.

Laryngoscope 2021 May 27. Epub 2021 May 27.

Department of Head and Neck Surgery, University of California Los Angeles (UCLA), Los Angeles, California, U.S.A.

Objectives/hypothesis: Identification of parathyroid glands and adjacent tissues intraoperatively can be quite challenging because of their small size, variable locations, and indistinct external features. The objective of this study is to test the efficacy of the dynamic optical contrast imaging (DOCI) technique as a tool in specifically differentiating parathyroid tissue and adjacent structures, facilitating efficient and reliable tissue differentiation.

Study Design: Prospective study.

Methods: Both animal and human tissues were included in this study. Fresh specimens were imaged with DOCI and subsequently processed for hematoxylin and eosin (H&E) stain. The DOCI images were analyzed and compared to the H&E results as ground truth.

Results: In both animal and human experiments, significant DOCI contrast was observed between parathyroid glands and adjacent tissue of all types. Region of interest analysis revealed most distinct DOCI values for each tissue when using 494 and 572 nm-specific band pass filter for signal detection (P < .005 for porcine tissues, and P = .02 for human specimens). Linear discriminant classifier for tissue type prediction based on DOCI also matched the underlying histology.

Conclusions: We demonstrate that the DOCI technique reliably facilitates specific parathyroid gland localization. The DOCI technique constitutes important groundwork for in vivo precision endocrine surgery.

Level Of Evidence: 4 Laryngoscope, 2021.
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http://dx.doi.org/10.1002/lary.29633DOI Listing
May 2021

Imaging in Cutaneous Melanoma: Which Test to Order and When?

Laryngoscope 2021 Feb 19. Epub 2021 Feb 19.

Department of Head and Neck Surgery, UCLA David Geffen School of Medicine, Los Angeles, California, U.S.A.

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http://dx.doi.org/10.1002/lary.29460DOI Listing
February 2021

Tracheostomy During the COVID-19 Pandemic: Comparison of International Perioperative Care Protocols and Practices in 26 Countries.

Otolaryngol Head Neck Surg 2021 06 3;164(6):1136-1147. Epub 2020 Nov 3.

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

Objective: The coronavirus disease 2019 (COVID-19) pandemic has led to a global surge in critically ill patients requiring invasive mechanical ventilation, some of whom may benefit from tracheostomy. Decisions on if, when, and how to perform tracheostomy in patients with COVID-19 have major implications for patients, clinicians, and hospitals. We investigated the tracheostomy protocols and practices that institutions around the world have put into place in response to the COVID-19 pandemic.

Data Sources: Protocols for tracheostomy in patients with severe acute respiratory syndrome coronavirus 2 infection from individual institutions (n = 59) were obtained from the United States and 25 other countries, including data from several low- and middle-income countries, 23 published or society-endorsed protocols, and 36 institutional protocols.

Review Methods: The comparative document analysis involved cross-sectional review of institutional protocols and practices. Data sources were analyzed for timing of tracheostomy, contraindications, preoperative testing, personal protective equipment (PPE), surgical technique, and postoperative management.

Conclusions: Timing of tracheostomy varied from 3 to >21 days, with over 90% of protocols recommending 14 days of intubation prior to tracheostomy. Most protocols advocate delaying tracheostomy until COVID-19 testing was negative. All protocols involved use of N95 or higher PPE. Both open and percutaneous techniques were reported. Timing of tracheostomy changes ranged from 5 to >30 days postoperatively, sometimes contingent on negative COVID-19 test results.

Implications For Practice: Wide variation exists in tracheostomy protocols, reflecting geographical variation, different resource constraints, and limited data to drive evidence-based care standards. Findings presented herein may provide reference points and a framework for evolving care standards.
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http://dx.doi.org/10.1177/0194599820961985DOI Listing
June 2021

Safety of laser-generated shockwave treatment for bacterial biofilms in a cutaneous rodent model.

Lasers Med Sci 2020 Oct 27. Epub 2020 Oct 27.

Department of Head and Neck Surgery, UCLA Medical Center, Los Angeles, CA, USA.

Bacterial biofilms are often found in chronically infected wounds. Biofilms protect bacteria from antibiotics and impair wound healing. Surgical debridement is often needed to remove the biofilm from an infected wound. Laser-generated shockwave (LGS) treatment is a novel tissue-sparing treatment for biofilm disruption. Previous studies have demonstrated that LGS is effective in disrupting biofilms in vitro. In this study, we aim to determine the safety threshold of the LGS technology in an in vivo rodent model. To understand the in vivo effects of LGS on healthy cutaneous tissue, the de-haired dorsal skin of Sprague-Dawley rats were treated with LGS at three different peak pressures (118, 296, 227 MPa). These pressures were generated using a 1064 nm Nd/YAG laser (pulse duration 5 ns and laser fluence of 777.9 mJ) with laser spot size diameters of 2.2, 3.0, and 4.2 mm, respectively. Following treatment, the animals were observed for 72 h, and a small subset was euthanized at 1-h, 24-h, and 72-h post-treatment and assessed for tissue injury or inflammation under histology. Each treatment group consisted of 9 rats (n = 3/time point for 1-h, 24-h, 72-h post-treatment). An additional 4 control (untreated) rats were included in the analysis, for a total of 31 animals. Gross injuries occurred in 21 (77%) animals and consisted of minor erythema, with prevalence positively correlated with peak pressure (p < 0.05). Of injuries under gross observation, 94% resolved within 24 h. Under histological analysis, the injuries and tissue inflammation were found to be localized to the epidermis and superficial dermis. LGS appears to be well tolerated by cutaneous tissue for the laser energy settings shown to be effective against bacterial biofilm in vitro. All injuries incurred, at even the highest peak pressures, were clinically mild and resolved within 1 day. This lends further support to the overall safety of LGS and serves to translate LGS towards in vivo efficacy studies.
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http://dx.doi.org/10.1007/s10103-020-03171-3DOI Listing
October 2020

Decontamination Methods for Reuse of Filtering Facepiece Respirators.

JAMA Otolaryngol Head Neck Surg 2020 08;146(8):734-740

Department of Head and Neck Surgery, David Geffen School of Medicine at University of California, Los Angeles.

Importance: The novel coronavirus disease 2019 (COVID-19) has proven to be highly infectious, putting health care professionals around the world at increased risk. Furthermore, there are widespread shortages of necessary personal protective equipment (PPE) for these individuals. Filtering facepiece respirators, such as the N95 respirator, intended for single use, can be reused in times of need. We explore the evidence for decontamination or sterilization of N95 respirators for health care systems seeking to conserve PPE while maintaining the health of their workforce.

Observations: The filtration properties and fit of N95 respirators must be preserved to function adequately over multiple uses. Studies have shown that chemical sterilization using soap and water, alcohols, and bleach render the respirator nonfunctional. Decontamination with microwave heat and high dry heat also result in degradation of respirator material. UV light, steam, low-dry heat, and commercial sterilization methods with ethylene oxide or vaporized hydrogen peroxide appear to be viable options for successful decontamination. Furthermore, since the surface viability of the novel coronavirus is presumed to be 72 hours, rotating N95 respirator use and allowing time decontamination of the respirators is also a reasonable option. We describe a protocol and best practice recommendations for redoffing decontaminated N95 and rotating N95 respirator use.

Conclusions And Relevance: COVID-19 presents a high risk for health care professionals, particularly otolaryngologists, owing to the nature of viral transmission, including possible airborne transmission and high viral load in the upper respiratory tract. Proper PPE is effective when used correctly, but in times of scarce resources, institutions may turn to alternative methods of preserving and reusing filtering facepiece respirators. Based on studies conducted on the decontamination of N95 respirators after prior outbreaks, there are several options for institutions to consider for both immediate and large-scale implementation.
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http://dx.doi.org/10.1001/jamaoto.2020.1423DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7775871PMC
August 2020

Time for a Paradigm Shift in Head and Neck Cancer Management During the COVID-19 Pandemic.

Otolaryngol Head Neck Surg 2020 09 2;163(3):447-454. Epub 2020 Jun 2.

Department of Head and Neck Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA.

Objective: The coronavirus disease 2019 (COVID-19) pandemic has caused physicians and surgeons to consider restructuring traditional cancer management paradigms. We aim to review the current evidence regarding the diagnosis and management of head and neck cancer, with an emphasis on the role of the multidisciplinary team (MDT) during a pandemic.

Data Sources: COVID-19 resources from PubMed, Google Scholar, the American Academy of Otolaryngology-Head and Neck Surgery, and the American Head and Neck Society were examined.

Review Methods: Studies and guidelines related to the multidisciplinary management of head and neck cancer in the COVID-19 setting were reviewed. A total of 54 studies were included. Given the continuously evolving body of literature, the sources cited include the latest statements from medical and dental societies.

Results: The unpredictable fluctuation of hospital resources and the risk of the nosocomial spread of SARS-CoV-2 have direct effects on head and neck cancer management. Using an MDT approach to help define "essential surgery" for immediately life- or function-threatening disease processes in the context of available hospital resources will help to maximize outcomes. Early enrollment in an MDT is often critical for considering nonsurgical options to protect patients and health care workers. The role of the MDT continues after cancer treatment, if delivered, and the MDT plays an essential role in surveillance and survivorship programs in these challenging times.

Conclusion: Head and neck cancer management during the COVID-19 pandemic poses a unique challenge for all specialists involved. Early MDT involvement is important to maximize patient outcomes and satisfaction in the context of public and community safety.
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http://dx.doi.org/10.1177/0194599820931789DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7484111PMC
September 2020

The promise of immunotherapy in the treatment of young adults with oral tongue cancer.

Laryngoscope Investig Otolaryngol 2020 Apr 21;5(2):235-242. Epub 2020 Feb 21.

UCLA Head and Neck Cancer Program Ronald Reagan Medical Center Los Angeles California.

Historically considered a disease of the older male resulting from cumulative tobacco and alcohol use, more recently we have witnessed a rise in the global incidence of oral tongue squamous cell carcinoma in younger adults, particularly those without any identifiable risk factor exposure. These patients appear to be at higher overall risk for locoregional treatment failure and often experience a more heterogeneous clinical course, with some afflicted with particularly aggressive, rapidly progressive disease. Recent research efforts have supported the idea that although this disease may be genomically similar in these groups, and molecular differences in the tumor immune microenvironment may account for biological differences between young and older patients, as well as patients with and without exposure to alcohol or tobacco. In this review, we seek to summarize current knowledge regarding pathogenesis of oral tongue carcinoma in the young adult patient and examine the potential role of the immune response in disease progression and as a target for novel immunotherapies.
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http://dx.doi.org/10.1002/lio2.366DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7178456PMC
April 2020

To Vaccinate or Not to Vaccinate: Should Adults Aged 26 to 45 Years Receive the Human Papillomavirus Vaccine?

Laryngoscope 2021 01 17;131(1):1-2. Epub 2020 Apr 17.

Department of Head and Neck Surgery, David Geffen School of Medicine at the University of California, Los Angeles (UCLA), Los Angeles, California, U.S.A.

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http://dx.doi.org/10.1002/lary.28666DOI Listing
January 2021

What Is the Appropriate Duration of Antibiotic Use After Septorhinoplasty?

Laryngoscope 2020 09 7;130(9):2093-2095. Epub 2020 Feb 7.

Department of Head and Neck Surgery, Los Angeles Medical Center, Los Angeles, California.

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http://dx.doi.org/10.1002/lary.28522DOI Listing
September 2020

Primary Clear Cell Adenocarcinoma of the Head and Neck: A Population-Based Analysis.

Otolaryngol Head Neck Surg 2020 Apr 4;162(4):498-503. Epub 2020 Feb 4.

UCLA Department of Head and Neck Surgery, Los Angeles, California, USA.

Objective: To characterize the epidemiology and clinicopathologic determinants of survival following the diagnosis of clear cell adenocarcinoma in the head and neck region.

Study Design: Retrospective cohort study.

Setting: The Surveillance, Epidemiology, and End Results registry (1994 to 2014).

Subjects And Methods: A total of 173 cases were identified. Study variables included age, sex, race, tumor subsite, tumor stage, tumor grade, surgical excision, and regional and distant metastases. Survival measures included overall survival (OS) and disease-specific survival (DSS).

Results: Median age at diagnosis was 63 years, 48% were female, and 80.2% were white. Fourteen percent of patients presented with regional lymph node metastases, while 3.3% of patients presented with distant metastases. Most of the tumors presented in the oral cavity, salivary glands, and pharynx. Kaplan-Meier analysis demonstrated OS and DSS of 77.2% and 83.7% at 5 years, respectively. Median OS after diagnosis was 153 months. Bivariate analysis showed that surgical excision was associated with 5-fold increased OS and DSS, whereas advanced age, high tumor grade, advanced stage, larger tumor size, nodal disease, and distant metastases were all significant predictors of decreased OS and DSS.

Conclusions: Clear cell adenocarcinoma is a rare neoplasm that typically affects white individuals in their early 60s, with a generally favorable prognosis. It most commonly arises in the oral cavity, major salivary glands, and pharynx. Surgical excision is associated with 5-fold survival benefit, whereas advanced age, high tumor grade, advanced stage, nodal disease, and distant metastases are independently associated with worse OS and DSS.
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http://dx.doi.org/10.1177/0194599820903028DOI Listing
April 2020

An Update on Epidemiology and Management Trends of Vestibular Schwannomas.

Otol Neurotol 2020 03;41(3):411-417

Department of Head and Neck Surgery, University of California, Los Angeles.

Objective: To determine the current epidemiology and management trends for patients with vestibular schwannomas (VS).

Study Design: Retrospective cohort study.

Setting: The Surveillance, Epidemiology, and End Results (SEER) tumor registry.

Patients: The SEER database was queried to identify patients diagnosed with VS from 1973 to 2015. Demographics, patient and tumor characteristics, and treatment methods were analyzed.

Results: A total of 14,507 patients with VS were identified. The mean age at diagnosis was 55 ± 14.9 years. Age-adjusted incidence from 2006 to 2015 was 1.4 per 100,000 per year and remained relatively stable. Incidence across age varied with sex, as younger women and older men had increased incidences comparatively. A higher percentage of patients underwent surgery alone (43%), followed by observation (32%), radiation alone (23%), and combined radiation and surgery (2%). Age 65 and older was associated with observation (odds ratio [OR] 1.417; p = 0.029) whereas age 20 to 39 and 40 to 49 were associated with surgery (OR 2.013 and 1.935; p < 0.001). Older age was associated with radiation. Larger tumor size was associated with surgery and combined treatment. African American patients and American Indian or Alaskan Native patients were more likely to undergo observation than surgery.

Conclusions: The overall incidence of VS is 1.4 per 100,000 per year and has remained relatively stable. There is a trend toward more conservative management with observation, which may be secondary to earlier diagnosis given widespread use of magnetic resonance imaging. Further studies are necessary to investigate differences in disease patterns and disparities in management.
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http://dx.doi.org/10.1097/MAO.0000000000002542DOI Listing
March 2020

Rapid Diagnostic Test Kit for Point-of-Care Cerebrospinal Fluid Leak Detection.

SLAS Technol 2020 02 22;25(1):67-74. Epub 2019 Sep 22.

Department of Bioengineering, Henry Samueli School of Engineering and Applied Sciences, University of California Los Angeles, Los Angeles, CA, USA.

Cerebrospinal fluid (CSF) leaks can occur when there is communication between the intracranial cavities and the external environment. They are a common and serious complication of numerous procedures in otolaryngology, and if not treated, persistent leaks can increase a patient's risk of developing life-threatening complications such as meningitis. As it is not uncommon for patients to exhibit increased secretions postoperatively, distinguishing normal secretions from those containing CSF can be difficult. Currently, there are no proven, available tests that allow a medical provider concerned about a CSF leak to inexpensively, rapidly, and noninvasively rule out the presence of a leak. The gold standard laboratory-based test requires that a sample be sent to a tertiary site for analysis, where days to weeks may pass before results return. To address this, our group recently developed a semiquantitative, barcode-style lateral-flow immunoassay (LFA) for the quantification of the beta-trace protein, which has been reported to be an indicator of the presence of CSF leaks. In the work presented here, we created a rapid diagnostic test kit composed of our LFA, a collection swab, dilution buffers, disposable pipettes, and instructions. Validation studies demonstrated excellent predictive capabilities of this kit in distinguishing between clinical specimens containing CSF and those that did not. Our diagnostic kit for CSF leak detection can be operated by an untrained user, does not require any external equipment, and can be performed in approximately 20 min, making it well suited for use at the point of care. This kit has the potential to transform patient outcomes.
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http://dx.doi.org/10.1177/2472630319877377DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6980299PMC
February 2020

Should an elective neck dissection be performed for maxillary sinus squamous cell carcinoma?

Laryngoscope 2019 11 16;129(11):2445-2446. Epub 2019 Aug 16.

Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Orange, California, U.S.A.

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http://dx.doi.org/10.1002/lary.28242DOI Listing
November 2019

Understanding nationwide readmissions after parotidectomy.

Laryngoscope 2020 05 18;130(5):1212-1217. Epub 2019 Jul 18.

Department of Head and Neck Surgery, University of California, Los Angeles.

Objectives: To evaluate the incidence, causes, risk factors, and costs associated with 30-day readmissions in parotidectomy patients utilizing the Nationwide Readmissions Database (NRD).

Study Design: Retrospective cohort study.

Methods: We examined the NRD for patients who underwent parotidectomy between 2010 and 2014. Rates, causes, and costs of 30-day readmissions were determined. Multivariate logistic regression was used to identify risk factors for readmission.

Results: Among 15,102 included patients, 594 (3.9%) were readmitted within 30 days. The average cost per readmission was $12,502. Infectious (22.7%) and wound (11.2%) complications were the two most common causes of readmission. After controlling for other covariates, significant predictors of readmission included advanced comorbidity (odds ratio [OR], 1.61; 95% confidence interval [CI], 1.09-2.37), a malignant parotid tumor (OR, 2.37; 95% CI, 1.63-3.43), length of stay ≥2 days (OR, 1.54; 95% CI, 1.09-2.18), and nonroutine discharge destinations (home with care [OR, 1.88; 95% CI, 1.27-2.78] and nursing facility [OR, 2.69; 95% CI, 1.55-4.67]).

Conclusion: In this nationwide database analysis, we found that nearly 4% of all patients undergoing parotidectomy are readmitted within 30 days. Readmissions are commonly due to infections and wound complications. Quality improvement proposals targeting avoidable readmissions should focus on early recognition and prevention of infection and wound complications. Risk factors contributing to readmission include advanced comorbidity, malignant parotid tumor, prolonged index hospitalization, and nonroutine discharge destinations.

Level Of Evidence: NA Laryngoscope, 130:1212-1217, 2020.
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http://dx.doi.org/10.1002/lary.28187DOI Listing
May 2020

Patterns of care and survival impact of adjuvant chemoradiotherapy for oropharyngeal cancer with intermediate-risk features.

Head Neck 2019 09 20;41(9):3177-3186. Epub 2019 May 20.

Department of Head and Neck Surgery, David Geffen School of Medicine at University of California, Los Angeles, California.

Background: Survival outcomes for adjuvant chemoradiotherapy (aCRT) and adjuvant radiotherapy (aRT) were compared in patients with oropharyngeal squamous cell carcinoma (OPSCC) with intermediate-risk features.

Methods: We identified 2164 patients with OPSCC in the National Cancer Database without positive margins or extracapsular extension and with at least one intermediate-risk feature: pT3-T4 disease, ≥two positive lymph nodes, level IV/V nodal disease, and/or lymphovascular invasion. We assessed predictors of aCRT use and covariables impacting overall survival.

Results: aCRT was commonly used for both human papillomavirus (HPV)-positive (62.0%) and HPV-negative (64.3%) patients with OPSCC. Higher N stage, level IV/V neck disease, and younger age strongly predicted aCRT utilization. There was no significant survival benefit associated with aCRT vs aRT in HPV-positive (hazard ratio [HR], 0.93; 95% confidence interval [CI], 0.62-1.38; P = .71) or HPV-negative (HR, 0.75; 95% CI, 0.51-1.10; P = .15) disease.

Conclusions: Despite high rates of utilization, aCRT is not associated with better survival vs aRT for OPSCC with intermediate-risk features, including HPV-negative tumors.
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http://dx.doi.org/10.1002/hed.25808DOI Listing
September 2019

In Response to Should the Contralateral Tonsil Be Removed in Cases of HPV-Positive Squamous Cell Carcinoma of the Tonsil?

Authors:
Maie A St John

Laryngoscope 2019 06 5;129(6):E195. Epub 2019 Mar 5.

Professor and Chair, Department of Head & Neck Surgery Thomas C. Calcaterra Chair in Head and Neck Surgery, Co-Director, UCLA Head and Neck Cancer Program Jonsson Comprehensive Cancer Center David Geffen School of Medicine at UCLA, Los Angeles, California.

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http://dx.doi.org/10.1002/lary.27875DOI Listing
June 2019

Total Glossectomy With Free Flap Reconstruction: Twenty-Year Experience at a Tertiary Medical Center.

Laryngoscope 2019 05 22;129(5):1087-1092. Epub 2019 Jan 22.

Department of Head and Neck Surgery, Los Angeles, California.

Objectives/hypothesis: To characterize the demographics, clinicopathologic characteristics, and treatment and reconstructive outcomes of patients who underwent total glossectomy STUDY DESIGN: Retrospective chart review at an academic tertiary-care medical center.

Methods: All patients who had undergone total glossectomy (as an individual procedure or as part of a more extensive resection) between January 1, 1995 and December 31, 2014 were included in the analysis. Patient characteristics and clinical outcomes were reviewed.

Results: Forty-eight patients underwent total glossectomy for oral tongue and base of tongue cancer. The mean age of the patients was 56 (range, 29-92 years). History of tobacco and heavy alcohol use was found in 76% and 11% of patients, respectively. The majority of patients had advanced cancer (91.7% at stage IV), and 60.4% had salvage therapy for recurrent disease. T4 disease comprised 81% of patients. Sixty percent had clinical or radiographic evidence of nodal metastasis. Reconstruction of the defect was performed with free flaps from the rectus abdominus (40%), fibula (25%), anterolateral thigh (23%), and other donor tissues. One- and 5-year survival rates were 42% and 26%, with locoregional and distant recurrence reported at 36% and 25%, respectively.

Conclusions: Total glossectomy for oncologic control is most commonly performed in patients who have stage IV cancers. Despite high reconstructive success rates, the likelihood of locoregional and distance recurrence was high. Most patients can communicate intelligibly and achieve decannulation, but swallowing outcomes remain guarded, especially considering previous irradiation and resection of the base of tongue.

Level Of Evidence: 4 Laryngoscope, 129:1087-1092, 2019.
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http://dx.doi.org/10.1002/lary.27579DOI Listing
May 2019

The impact of treatment package time on survival in surgically managed head and neck cancer in the United States.

Oral Oncol 2019 01 20;88:39-48. Epub 2018 Nov 20.

Department of Head and Neck Surgery, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, CA, USA; Jonsson Comprehensive Cancer Center, UCLA Medical Center, Los Angeles, CA, USA; UCLA Head and Neck Cancer Program, UCLA Medical Center, Los Angeles, CA, USA.

Objectives: Delays in the initiation of postoperative radiation have been associated with worse outcomes; however, the effect of the overall treatment package time (interval from surgery through the completion of radiation) remains undefined. The purpose of this study was to determine the impact of package time on survival and to evaluate this effect among different subgroups of head and neck cancer patients.

Patients And Methods: In this observational cohort study, the National Cancer Database was used to identify 35,167 patients with resected nonmetastatic head and neck cancer who underwent adjuvant radiation from 2004 to 2014. Kaplan-Meier survival estimates and multivariate Cox regression analyses were performed to determine the effect of treatment package time on overall survival.

Results: Median package time was 96 days (interquartile range, 85-112 days). After adjusting for covariates, package times of 11 weeks or less were associated with improved survival (adjusted hazard ratio (aHR), 0.90; 95% confidence interval, 0.83-0.97) compared to an interval of 12-13 weeks, whereas package times of more than 14 weeks were associated with worse survival (aHR, 1.14, 1.14, and 1.22 for 14-15, 15-17, and >17 weeks, respectively). A significant interaction was identified between package time and disease site, nodal status, and stage. Specifically, patients with oropharyngeal tumors, advanced stage (III or IV) disease, or nodal involvement experienced more pronounced increases in mortality risk with delays in treatment time.

Conclusions: Treatment package time independently impacts survival. This effect may be strongest for patients with oropharyngeal tumors or advanced stage disease.
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http://dx.doi.org/10.1016/j.oraloncology.2018.11.021DOI Listing
January 2019

Survival impact of treatment delays in surgically managed oropharyngeal cancer and the role of human papillomavirus status.

Head Neck 2019 06 7;41(6):1756-1769. Epub 2019 Jan 7.

Department of Head and Neck Surgery, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California.

Background: The impact of treatment delays on survival in oropharyngeal cancer and whether the effect varies by human papillomavirus (HPV) status have yet to be defined.

Methods: Retrospective analysis of the survival impact of time from diagnosis to surgery (DTS), surgery to radiation (SRT), and duration of radiation (RTD) for patients in the National Cancer Database with resected oropharyngeal cancer who underwent adjuvant radiation from 2010 to 2014.

Results: We identified optimal thresholds of 30, 40, and 51 days for DTS, SRT, and RTD, respectively, with treatment times exceeding these thresholds associated with significantly worse overall survival. Prolonged SRT and RTD were associated with mortality regardless of HPV status, although rising DTS was only predictive among patients with HPV-negative tumors.

Conclusions: Treatment delays significantly impact survival in oropharyngeal cancer. The consequences of prolonged DTS may be stronger in HPV-negative than HPV-positive disease. These data serve as a foundation for future research and clinical management.
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http://dx.doi.org/10.1002/hed.25643DOI Listing
June 2019

Oral tongue squamous cell carcinoma survival as stratified by age and sex: A surveillance, epidemiology, and end results analysis.

Laryngoscope 2019 09 21;129(9):2076-2081. Epub 2018 Dec 21.

Department of Head and Neck Surgery, University of California Los Angeles, California, Los Angeles.

Objectives/hypothesis: To utilize the Surveillance, Epidemiology, and End Results (SEER) database to elucidate differences in predictors of survival in oral tongue squamous cell carcinoma (OTSCC) as stratified by age and sex.

Study Design: Retrospective, population-based database analysis.

Methods: The SEER registry was utilized to calculate survival trends for patients with OTSCC between 1973 and 2012. Patient data were then stratified by age (≤40 years vs. >40 years) and sex, then analyzed with respect to race, stage, grade, and treatment modalities. Overall survival (OS) and disease-specific survival (DSS) were calculated and compared.

Results: There were 16,423 cases of OTSCC identified, with 526 and 706 young female and male patients, respectively. Young female patients had improved OS and DSS as compared to young male patients (75% vs. 67% at 5 years), which is better than older patients (P < .001). Younger patients were more likely to receive surgery (P < .001) and combination surgery and radiation (P < .001) as compared to older patients. On multivariate analysis, tumor stage was uniformly associated with worse OS and DSS (P < .05), with surgery predicting improved OS and DSS in all groups except young females (P < .05). Higher tumor grade predicted worse OS and DSS in older patients, but not younger patients (P < .05).

Conclusions: OTSCC appears to present with relatively heterogeneous characteristics across different age groups and sexes. Despite the rising incidence of OTSCC in young individuals, our study demonstrates that young patients have improved survival rates compared to older patients.

Level Of Evidence: NA Laryngoscope, 129:2076-2081, 2019.
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http://dx.doi.org/10.1002/lary.27720DOI Listing
September 2019

Should the Contralateral Tonsil Be Removed in Cases of HPV-Positive Squamous Cell Carcinoma of the Tonsil?

Laryngoscope 2019 06 22;129(6):1257-1258. Epub 2018 Nov 22.

Department of Head and Neck Surgery, David Geffen School of Medicine at University of California, Los Angeles (UCLA).

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http://dx.doi.org/10.1002/lary.27563DOI Listing
June 2019

Risk Factors, Causes, and Costs of Hospital Readmission After Head and Neck Cancer Surgery Reconstruction.

JAMA Facial Plast Surg 2019 Mar;21(2):137-145

Department of Head and Neck Surgery, David Geffen School of Medicine at University of California, Los Angeles (UCLA).

Importance: Thirty-day hospital readmissions have substantial direct costs and are increasingly used as a measure of quality care. However, data regarding the risk factors and reasons for readmissions in head and neck cancer surgery reconstruction are lacking.

Objective: To describe the rate, risk factors, and causes of 30-day readmission in patients with head and neck cancer following free or pedicled flap reconstruction.

Design, Setting, And Participants: This retrospective, population-based cohort study analyzed medical records from the Nationwide Readmissions Database of 9487 patients undergoing pedicled or free flap reconstruction of head and neck oncologic defects between January 1, 2010, and December 31, 2014. Data analysis was performed in October 2017.

Exposures: Pedicled or free flap reconstruction of an oncologic head and neck defect.

Main Outcomes And Measures: The primary outcome was 30-day all-cause readmissions. Secondary outcomes included risk factors, causes, and costs of readmission. Multivariate regression analyses were conducted to determine factors independently associated with 30-day readmissions.

Results: Among 9487 patients included in the study (6798 male; 71.7%), the median age was 63 years (interquartile range, 55-71 years), and the 30-day readmission rate was 19.4% (n = 1839), with a mean cost per readmission of $15 916 (standard error of the mean, $785). The most common indication for readmission was wound complication (26.5%, n = 487). On multivariate regression, significant risk factors for 30-day readmission were median household income in the lowest quartile (vs highest quartile: odds ratio [OR], 1.58; 95% CI, 1.18-2.11), congestive heart failure (OR, 1.68; 95% CI, 1.14-2.47), liver disease (OR, 2.02; 95% CI, 1.22- 3.33), total laryngectomy (OR, 1.40; 95% CI, 1.12-1.75), pharyngectomy (OR, 1.47; 95% CI, 1.08-2.01), blood transfusion (OR, 1.30; 95% CI, 1.04-1.64), discharge to home with home health care (vs routine: OR, 1.32; 95% CI, 1.04-1.67), and discharge to a nursing facility (vs routine: OR, 1.77; 95% CI, 1.30-2.40).

Conclusions And Relevance: Using the Nationwide Readmissions Database, we demonstrate that approximately 1 in 5 patients undergoing head and neck cancer surgery reconstruction is readmitted within 30 days of surgery. Readmissions are most commonly associated with wound complications. Socioeconomic status, complex ablative procedures, and patient comorbidities are independent risk factors for readmission. These findings may be useful to clinicians in developing perioperative interventions aimed to reduce hospital readmissions and improve quality of patient care.
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http://dx.doi.org/10.1001/jamafacial.2018.1197DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6439803PMC
March 2019

Optimal resection margin for head and neck cutaneous melanoma.

Laryngoscope 2019 06 8;129(6):1386-1394. Epub 2018 Nov 8.

Department of Head and Neck Surgery, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California.

Objectives/hypothesis: The objective of this study was to examine the difference between a narrow (between 1 and 2 cm) and a wide (>2 cm) margin in the surgical resection of head and neck cutaneous melanoma.

Study Design: Population-based cohort analysis.

Methods: The Surveillance, Epidemiology, and End Results database was employed to identify patients who had cutaneous melanoma of the head and neck from 2004 to 2014. Outcome measures were overall survival (OS) and disease-specific survival (DSS).

Results: Among the total of 3,583 cases of cutaneous melanoma of the head and neck with known resection margins, 2,641 individuals had narrow resection margins, and 942 patients had wide margins. Most of the tumors presented in the skin of the scalp and neck, followed by the face, external ear, and other areas. The 5-year and 10-year Kaplan-Meier OS probabilities for narrow and wide margins were 65% and 66%, respectively, compared with 49% and 48%, respectively. The DSS probabilities exhibited similar trends between the two groups at these time points. In the Cox regression model, the patients who received narrow margins had similar OS (95% confidence interval [CI]: 0.918-1.217) and DSS (95% CI: 0.856-1.352) compared with the wide resection margin group, even when controlled for age, sex, T stage, and histology.

Conclusions: The survival of patients with cutaneous melanoma of the head and neck depends on age, depth of tumor invasion, and histology. Within the head and neck, a wider resection margin of >2 cm does not confer any additional survival benefit compared with a narrower margin. Future studies should examine whether wider surgical margins would confer survival benefit in local or recurrent melanoma.

Level Of Evidence: 4 Laryngoscope, 129:1386-1394, 2019.
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http://dx.doi.org/10.1002/lary.27465DOI Listing
June 2019

Predictors of Short-term Morbidity and Mortality in Open Anterior Skull Base Surgery.

Laryngoscope 2019 06 16;129(6):1407-1412. Epub 2018 Oct 16.

Department of Head and Neck Surgery, University of California, Los Angeles Medical Center, Los Angeles, California, U.S.A.

Objectives/hypothesis: To describe rates of complications and mortality within 30 days of open anterior skull base surgery using a large, multi-institutional outcomes database.

Study Design: Retrospective cohort study.

Methods: The study included patients who underwent open anterior skull base surgery as listed in the American College of Surgeons National Surgical Quality Improvement Project database from 2007 through 2014.

Results: A total of 336 open anterior skull base surgeries were identified. One hundred nine (32.4%) patients experienced a complication, reoperation, or mortality. The most common events were postoperative transfusion (15.8%), reoperation (10.1%), and readmission (8.0%). Significant independent predictors of any adverse event included higher American Society of Anesthesiologists (ASA) score and increased total operative time (both P < .05). The only predictor of mortality was higher ASA score (P = .02). Predictors of increased hospital stay included impaired sensorium (P = .04), coma >24 hours (P < .001), lower preoperative hematocrit (P = .02), higher ASA score (P = .04), and increased total operative time (P < .001).

Conclusions: Open anterior skull base surgery is understandably complex, and is thus associated with a relatively high adverse event rate. Knowledge of factors associated with adverse events has the potential to improve preoperative optimization of controllable variables and translate into improved surgical outcomes for patients.

Level Of Evidence: NA Laryngoscope, 129:1407-1412, 2019.
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http://dx.doi.org/10.1002/lary.27494DOI Listing
June 2019

Distribution of metastatic regional lymph nodes in squamous cell carcinoma of the oral commissure and its implications for treatment in the neck.

Br J Oral Maxillofac Surg 2018 11 5;56(9):898-900. Epub 2018 Oct 5.

UCLA Department of Head & Neck Surgery, Los Angeles, CA; UCLA Head and Neck Cancer Program; UCLA Jonsson Comprehensive Cancer Center, Los Angeles, CA; David Geffen School of Medicine, UCLA. Electronic address:

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http://dx.doi.org/10.1016/j.bjoms.2018.08.018DOI Listing
November 2018

Vibroacoustographic System for Tumor Identification.

Yale J Biol Med 2018 09 21;91(3):215-223. Epub 2018 Sep 21.

Department of Bioengineering, Henry Samueli School of Engineering and Applied Sciences, UCLA, Los Angeles, CA.

Oral and head and neck squamous cell carcinoma (OSCC) is the sixth most common cancer worldwide. The primary management of OSCC relies on complete surgical resection of the tumor. Margin-free resection, however, is difficult given the devastating effects of aggressive surgery. Currently, surgeons determine where cuts are made by palpating edges of the tumor. Accuracy varies based on the surgeon's experience, the location and type of tumor, and the risk of damage to adjacent structures limiting resection margins. To fulfill this surgical need, we contrast tissue regions by identifying disparities in viscoelasticity by mixing two ultrasonic beams to produce a beat frequency, a technique termed vibroacoustography (VA). In our system, an extended focal length of the acoustic stress field yields surgeons' high resolution to detect focal lesions in deep tissue. VA offers 3D imaging by focusing its imaging plane at multiple axial cross-sections within tissue. Our efforts culminate in production of a mobile VA system generating image contrast between normal and abnormal tissue in minutes. We model the spatial direction of the generated acoustic field and generate images from tissue-mimicking phantoms and specimens with squamous cell carcinoma of the tongue to qualitatively demonstrate the functionality of our system. These preliminary results warrant additional validation as we continue clinical trials of tissue. This tool may prove especially useful for finding tumors that are deep within tissue and often missed by surgeons. The complete primary resection of tumors may reduce recurrence and ultimately improve patient outcomes.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6153624PMC
September 2018

Readmission after surgery for oropharyngeal cancer: An analysis of rates, causes, and risk factors.

Laryngoscope 2019 04 19;129(4):910-918. Epub 2018 Sep 19.

Department of Head and Neck Surgery, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California.

Objectives/hypothesis: Determine the rate, diagnoses, and risk factors associated with 30-day nonelective readmissions for patients undergoing surgery for oropharyngeal cancer.

Study Design: Retrospective cohort study.

Methods: We analyzed the Nationwide Readmissions Database for patients who underwent oropharyngeal cancer surgery between 2010 and 2014. Rates and causes of 30-day readmissions were determined. Multivariate logistic regression was used to identify risk factors for readmission.

Results: Among 16,902 identified cases, the 30-day, nonelective readmission rate was 10.2%, with an average cost per readmission of $14,170. The most common readmission diagnoses were postoperative bleeding (14.1%) and wound complications (12.6%) (surgical site infection [8.6%], dehiscence [2.3%], and fistula [1.7%]). On multivariate regression, significant risk factors for readmission were major ablative surgery (which included total glossectomy, pharyngectomy, and mandibulectomy) (odds ratio [OR]: 1.29, 95% confidence interval [CI]: 1.06-1.60), advanced Charlson/Deyo comorbidity (OR: 2.00, 95% CI: 1.43-2.79), history of radiation (OR: 1.58, 95% CI: 1.15-2.17), Medicare (OR: 1.34, 95% CI: 1.06-1.69) or Medicaid (OR: 1.82, 95% CI: 1.32-2.50) payer status, index admission from the emergency department (OR: 1.19, 95% CI: 1.02-1.40), and length of stay ≥6 days (OR: 1.57, 95% CI: 1.19-2.08).

Conclusions: In this large database analysis, we found that approximately one in 10 patients undergoing surgery for oropharyngeal cancer is readmitted within 30 days. Procedural complexity, insurance status, and advanced comorbidity are independent risk factors, whereas postoperative bleeding and wound complications are the most common reasons for readmission.

Level Of Evidence: 4. Laryngoscope, 129:910-918, 2019.
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http://dx.doi.org/10.1002/lary.27461DOI Listing
April 2019

A Population-Based Analysis of Nodal Metastases in Esthesioneuroblastomas of the Sinonasal Tract.

Laryngoscope 2019 05 8;129(5):1025-1029. Epub 2018 Sep 8.

Department of Otolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A.

Objective: Esthesioneuroblastoma is an uncommon malignancy of the sinonasal tract arising from the olfactory epithelium. Surgical management of the primary site, often via an endoscopic approach, with or without adjuvant radiation, is often curative. There is growing but ultimately limited data regarding management of the neck and the risk of nodal metastases. In this study, we examine the incidence and patterns of esthesioneuroblastoma-related cervical nodal metastases using the Surveillance, Epidemiology, and End Results (SEER) database.

Methods: The SEER registry was queried for all patients with esthesioneuroblastomas diagnosed between 1973 and 2012. Patient data was then analyzed with respect to age, sex, race, modified Kadish stage, grade, survival functions, and nodal disease including specific nodal basins.

Results: Three hundred and eighty-one cases of esthesioneuroblastoma with information on nodal metastases were identified. The overall cervical nodal metastasis rate was 8.7%. Level II metastases were most common (6.6%). A total of 4.5% of cases presented with multiple positive nodal basins. Male sex (P = 0.009) and higher tumor grade (P = 0.009) correlated with the presence of level II metastases. There was no association of primary tumor site to the presence of nodal metastases (P > 0.05). The presence of nodal disease significantly predicted poorer overall (P = 0.001) and disease-specific survival (P = 0.017).

Conclusion: The incidence of nodal metastases in esthesioneuroblastoma at diagnosis is rare, and elective management of the neck remains controversial. Primary tumor site does not appear to predict metastases at specific nodal basins. Higher tumor grade may be a harbinger of eventual nodal metastases.

Level Of Evidence: NA Laryngoscope, 129:1025-1029, 2019.
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http://dx.doi.org/10.1002/lary.27301DOI Listing
May 2019
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