Publications by authors named "Swar Vimawala"

15 Publications

  • Page 1 of 1

Surgery with Post-Operative Endoscopy Improves Recurrence Detection in Sinonasal Malignancies.

Ann Otol Rhinol Laryngol 2021 May 6:34894211011449. Epub 2021 May 6.

Department of Otolaryngology and Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA.

Objective: The mainstay of treatment in sinonasal malignancy (SNM) is surgery, and when combined with chemoradiation therapy, often leads to the best overall prognosis. Nasal endoscopy is essential for post-treatment surveillance along with physical exam and radiologic evaluation. The ability to directly visualize the sinus cavities after surgery may also improve early detection of tumor recurrence and is another reason to potentially advocate for surgery in these patients.

Methods: A retrospective chart review of medical records of patients with pathologically proven SNM was conducted from 2005 to 2019.

Results: The nasal cavity and maxillary sinus were the most common primary tumor sub-sites. The most common pathology was squamous cell carcinoma (42%). The median time to recurrence was 9.8 months. Recurrence was initially detected endoscopically in 34.3% patients, by imaging in 62.7% patients, and by physical exam in 3.0% patients. 67 (29%) total recurrences were detected on follow-up, of which 46 (68.7%) were local. Twenty-three of the local recurrences were identified via nasal endoscopy. Thirteen recurrences were identified via endoscopic surveillance within the surgically patent paranasal sinuses while 13 were identified within the nasal cavity; 5 patients had multiple sites of recurrence.

Conclusion: Local recurrence of SNM is the most common site for recurrent disease and nasal endoscopy identified half of these cases. 50% of these recurrences were within the paranasal sinuses and would not have been easily identified if the sinuses were not open for inspection. Thus, open sinus cavities aid in the detection of tumor recurrence and is another advantage of surgery in the management of SNM.
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http://dx.doi.org/10.1177/00034894211011449DOI Listing
May 2021

An Oropharyngeal Obstructive Lesion in a Neonate.

Ear Nose Throat J 2021 Mar 15:145561321995014. Epub 2021 Mar 15.

Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, 2202Cooper University Health Care, Camden, NJ, USA.

Neonatal HNT in the pharynx is a rare cause of respiratory distress and poor feeding in the newborn, but must be differentiated from teratoma, encephalocele, and nasal glioma. While surgical resection is the preferred treatment modality, we posit there is a role for sclerosis of the glial heterotopic cyst if complete surgical excision is not possible or carries risk of high morbidity. Here, we present a case of a 7-day-old neonate presenting with acute respiratory distress found to have a nasopharyngeal/oropharyngeal mass ultimately treated with sclerotherapy at 9 months of age.
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http://dx.doi.org/10.1177/0145561321995014DOI Listing
March 2021

Tolerance of Continuous Positive Airway Pressure After Sinonasal Surgery.

Laryngoscope 2021 03 16;131(3):E1013-E1018. Epub 2020 Sep 16.

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

Objectives/hypothesis: For patients with obstructive sleep apnea (OSA) undergoing sinonasal surgery, there is a lack of consensus on the risk and appropriate postoperative use of continuous positive airway pressure (CPAP). The aim of this study was to assess the tolerability of restarting CPAP on postoperative day one.

Study Design: Prospective cohort study.

Methods: A prospective study on patients with OSA on CPAP who required a septoplasty/turbinectomy and/or functional endoscopic sinus surgery (FESS) was performed. Data from the memory card of a patient's CPAP machine and subjective information were obtained on the day of surgery and at scheduled follow-up visits. All subjects were instructed to restart CPAP on the first postoperative night.

Results: A total of 14 patients were analyzed; nine underwent FESS and five had a septoplasty/turbinectomy. There were no postoperative complications encountered. The only significant change in the first postoperative week was a reduction in the percentage of nights used over 4 hours (P < .05). By the third postoperative visit, average 22-item Sino-Nasal Outcome Test, Nasal Obstruction Symptom Evaluation, and CPAP tolerance scores improved from preoperative values. CPAP pressures, residual apnea-hypopnea index, and number of hours and mean percentage of nights used remained stable throughout the study period.

Conclusions: Both quality-of-life and CPAP outcomes improved or remained the same when restarting CPAP immediately postoperatively. Combined with a lack of significant complications, this study suggests that CPAP is well-tolerated when restarted the day after a septoplasty/turbinectomy or FESS.

Level Of Evidence: 4 Laryngoscope, 131:E1013-E1018, 2021.
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http://dx.doi.org/10.1002/lary.28968DOI Listing
March 2021

Initial Experience Using 3-Dimensional Printed Models for Head and Neck Reconstruction in Haiti.

Ear Nose Throat J 2020 Aug 10:145561320938920. Epub 2020 Aug 10.

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

This report describes the first use of a novel workflow for in-house computer-aided design (CAD) for application in a resource-limited surgical outreach setting. Preoperative computed tomography imaging obtained locally in Haiti was used to produce rapid-prototyped 3-dimensional (3D) mandibular models for 2 patients with large ameloblastomas. Models were used for patient consent, surgical education, and surgical planning. Computer-aided design and 3D models have the potential to significantly aid the process of complex surgery in the outreach setting by aiding in surgical consent and education, in addition to expected surgical applications of improved anatomic reconstruction.
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http://dx.doi.org/10.1177/0145561320938920DOI Listing
August 2020

Predicting prolonged length of stay after endoscopic transsphenoidal surgery for pituitary adenoma.

Int Forum Allergy Rhinol 2020 06 3;10(6):785-790. Epub 2020 May 3.

Department of Otolaryngology-Head & Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, PA.

Background: Endoscopic transsphenoidal surgery (ETS) for the resection of pituitary adenoma has become more common throughout the past decade. Although most patients have a short postoperative hospitalization, others require a more prolonged stay. We aimed to identify predictors for prolonged hospitalization in the setting of ETS for pituitary adenomas.

Methods: A retrospective chart review as performed on 658 patients undergoing ETS for pituitary adenoma at a single tertiary care academic center from 2005 to 2019. Length of stay (LoS) was defined as date of surgery to date of discharge. Patients with LoS in the top 10th percentile (prolonged LoS [PLS] >4 days, N = 72) were compared with the remainder (standard LoS [SLS], N = 586).

Results: The average age was 54 years and 52.5% were male. The mean LoS was 2.1 days vs 7.5 days (SLS vs PLS). On univariate analysis, atrial fibrillation (p = 0.002), hypertension (p = 0.033), partial tumor resection (p < 0.001), apoplexy (p = 0.020), intraoperative cerebrospinal fluid (ioCSF) leak (p = 0.001), nasoseptal flap (p = 0.049), postoperative diabetes insipidus (DI) (p = 0.010), and readmission within 30 days (p = 0.025) were significantly associated with PLS. Preoperative continuous positive airway pressure (CPAP) (odds ratio, 15.144; 95% confidence interval, 2.596-88.346; p = 0.003) and presence of an ioCSF leak (OR, 10.362; 95% CI, 2.143-50.104; p = 0.004) remained significant on multivariable analysis.

Conclusion: For patients undergoing ETS for pituitary adenomas, an ioCSF leak or preoperative use of CPAP predicted PLS. Additional common reasons for PLS included postoperative CSF leak (10 of 72), management of DI or hypopituitarism (15 of 72), or reoperation due to surgical or medical complications (14 of 72).
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http://dx.doi.org/10.1002/alr.22540DOI Listing
June 2020

Platelet-Rich Plasma Enhances Distal Flap Viability and Underlying Vascularity in a Radiated Rotational Flap Rodent Model.

Facial Plast Surg Aesthet Med 2020 May/Jun;22(3):181-187. Epub 2020 Apr 15.

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

Autologous platelet-rich plasma (PRP) has received widespread attention due to its physiologic healing properties, augmenting the body's natural healing process through platelet activation and release of growth factors. The effects of PRP on radiated tissue have been inadequately studied in vivo. To determine whether PRP can be used to improve viability of radiated tissue subjected to a clinically meaningful stressor, in this case a rotational skin flap. This is a prospective trial using a radiated rat abdominal rotational flap model in the laboratory. Male Sprague-Daley rats were used in this study. Harvested PRP or saline control was injected into rotational flaps immediately after surgery. Progression of necrosis was documented with photo analysis. After 1 week, animals were sacrificed and flap tissue was stained and analyzed for presence of vascular tissue. PRP versus control injection into radiated skin tissue. Percentage necrosis of rotational flap and number of vascular channels stained with CD31 present in flap tissue. PRP administration helped rescue the distal flap from necrosis, achieving viability similar to nonradiated controls. Superficial vascularity was similarly increased fivefold in radiated tissue if PRP was given postoperatively, mirroring the vascular density of nonradiated tissue. PRP may enhance distal rotational flap viability after radiation, possibly by protecting superficial vessels from tissue necrosis when administered at the time of surgery.
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http://dx.doi.org/10.1089/fpsam.2019.0018DOI Listing
November 2020

Qualitative Assessment of the Effect of Continuous Positive Airway Pressure on the Nasal Cavity.

Am J Rhinol Allergy 2020 Jul 26;34(4):487-493. Epub 2020 Feb 26.

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

Background: For patients with obstructive sleep apnea (OSA), there is a lack of knowledge regarding the impact of continuous positive airway pressure (CPAP) on the nasal cavity. There is a significant need for evidence-based recommendations regarding the appropriate use of CPAP following endoscopic sinus and skull base surgery.

Objective: The goal of this study is to translate a previously developed cadaveric model for evaluating CPAP pressures in the sinonasal cavity by showing safety in vivo and quantifying the effect of positive pressurized air flow on the nasal cavity of healthy individuals where physiologic effects are at play.

Methods: A previously validated cadaveric model using intracranial sensor catheters has proved to be a reliable technique for measuring sinonasal pressures. These sensors were placed in the nasal cavity of 18 healthy individuals. Pressure within the nose was recorded at increasing levels of CPAP.

Results: Overall, nasal cavity pressure was on average 85% of delivered CPAP. The amount of pressure delivered to the nasal cavity increased as the CPAP increased. The percentage of CPAP delivered was 77% for 5 cmHO and increased to 89% at 20 cmHO. There was a significant difference in mean intranasal pressures between all the levels of CPAP except 5 cmHO and 8 cmHO ( < .001).

Conclusion: On average, only 85% of the pressure delivered by CPAP is transmitted to the nasal cavity. Higher CPAP pressures delivered a greater percentage of pressurized air to the nasal cavity floor. Our results are comparable to the cadaver model, which demonstrated similar pressure delivery even in the absence of anatomic factors such as lung compliance, nasal secretions, and edema. This study demonstrates the safety of using sensors in the human nasal cavity. This technology can also be utilized to evaluate the resiliency of various repair techniques for endoscopic skull base surgery with CPAP administration.
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http://dx.doi.org/10.1177/1945892420908749DOI Listing
July 2020

Evaluating the impact of smoking on disease-specific survival outcomes in patients with human papillomavirus-associated oropharyngeal cancer treated with transoral robotic surgery.

Cancer 2020 01 7;126(9):1873-1887. Epub 2020 Feb 7.

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

Background: When treated nonsurgically with definitive chemoradiation, smokers with human papillomavirus (HPV)-positive oropharyngeal squamous cell carcinoma (OPSCC) have a worse prognosis compared with their nonsmoking counterparts. To the authors' knowledge, the prognostic significance of smoking in surgically treated patients is unknown.

Methods: The current study is a retrospective case series of patients with HPV-positive OPSCC who underwent upfront transoral robotic surgery at a single institution from 2010 through 2017. Exclusion criteria were nonoropharyngeal primary tumors, histology other than SCC, HPV-negative tumors, previous history of head and neck cancer, and/or previous head and neck radiotherapy. Recurrence-free survival (RFS), overall survival, and disease-specific survival were compared using the Kaplan-Meier method and the log-rank test. Smoking history was categorized as never smokers (<1 pack-year), current smokers (smoking at the time of the cancer diagnosis), and former smokers.

Results: A total of 258 patients met the study criteria. The average age was 60 years, and approximately 87% of patients were male. A total of 148 patients (57.4%) were smokers whereas 110 (42.6%) reported never smoking. There were 44 active smokers (17.1%) and 104 former smokers (40.3%). The median follow-up was 3.23 years. There were 17 patients of disease recurrence. Smoking pack-year history was not found to be significant for RFS (hazard ratio, 1.01; 95% CI, 0.99-1.03 [P = .45]). There was no significant difference in RFS noted between never and ever smokers (92% vs 89.8%; P = .85) nor was there a difference observed between never, former, and current smokers (92% vs 91.5% vs 86.1%, respectively; P = .69).

Conclusions: A smoking history is common in patients with HPV-positive OPSCC. In the current study, HPV-positive smokers were found to have excellent survival and locoregional control, similar to their nonsmoking counterparts. The results of the current study do not support the exclusion of smokers with early-stage, HPV-positive OPSCC from transoral robotic surgery-based deintensification trials.
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http://dx.doi.org/10.1002/cncr.32739DOI Listing
January 2020

Treatment-related morbidity in patients treated for sinonasal malignancy.

Int Forum Allergy Rhinol 2020 04 12;10(4):526-532. Epub 2020 Jan 12.

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

Background: Sinonasal malignancies are a rare, heterogeneous group of tumors that often present at an advanced stage and require multimodal therapy. The presence of high-grade toxicity and sinonasal complications after treatment can negatively impact quality of life. In this study we aim to describe posttreatment morbidity in patients with sinonasal malignancy.

Methods: A retrospective analysis of all patients treated for sinonasal malignancy was conducted from 2005 to 2018 at a tertiary referral institution. A total of 129 patients met the inclusion criteria. Primary outcomes were treatment details, pathology, posttreatment complications, and radiation toxicity. Fisher's exact test, chi-square test, and Student t test were used for statistical analysis.

Results: Mean age was 58.4 (median, 61; range, 19-94) years. After diagnosis, 24 patients had surgery alone, 46 had surgery with radiation alone, 47 had surgery with chemoradiation, and 14 received definitive chemoradiation. Overall, 10.4% (n = 12) of patients had postoperative complications, and 21.0% (n = 22) had high-grade (grade 3-5) radiation toxicity. After radiation, 20% (n = 21) of patients had chronic sinusitis requiring functional endoscopic sinus surgery and 20% (n = 21) had symptomatic nasal obstruction requiring operative debridement.

Conclusion: Sinonasal complications, including nasal obstruction and chronic sinusitis, occur frequently after definitive treatment of sinonasal malignancy and should be addressed when considering quality of life in survivors. These complications occur more frequently in patients who undergo chemoradiation as opposed to surgery alone.
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http://dx.doi.org/10.1002/alr.22509DOI Listing
April 2020

Virtual Surgical Planning in Subscapular System Free Flap Reconstruction of Midface Defects.

Oral Oncol 2020 02 19;101:104508. Epub 2019 Dec 19.

Thomas Jefferson University, Department of Otolaryngology - Head & Neck Surgery, Philadelphia, PA, USA.

Objectives: Reconstruction of the midface has many inherent challenges, including orbital support, skull base reconstruction, optimizing midface projection, separation of the nasal cavity and dental rehabilitation. Subscapular system free flaps (SF) have sufficient bone stock to support complex reconstruction and the option of separate soft tissue components. This study analyzes the effect of virtual surgical planning (VSP) in SF for midface on subsite reconstruction, bone segment contact and anatomic position.

Materials And Methods: Retrospective cohort of patients with midface defects that underwent SF reconstruction at a single tertiary care institution.

Results: Nine cases with VSP were compared to fourteen cases without VSP. VSP was associated with a higher number of successfully reconstructed subunits (5.9 vs 4.2, 95% CI of mean difference 0.31-3.04, p = 0.018), a higher number of successful bony contact between segments (2.2 vs 1.4, 95% CI of mean difference 0.0-1.6, p = 0.050), and a higher percent of segments in anatomic position (100% vs 71%, 95% CI of mean difference 2-55%, p = 0.035). When postoperative bone position after VSP reconstruction was compared to preoperative scans, the difference in anteroposterior, vertical and lateral projection compared to the preoperative 'ideal' bone position was <1 cm in 82% of measurements. There were no flap losses.

Conclusion: VSP may augment SF reconstruction of the midface by allowing for improved subunit reconstruction, bony segment contact and anatomically correct bone segment positioning. VSP can be a useful adjunct for complex midface reconstruction and the benefits should be weighed against cost.
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http://dx.doi.org/10.1016/j.oraloncology.2019.104508DOI Listing
February 2020

Rate of rhinosinusitis and sinus surgery following a minimally destructive approach to endoscopic transsphenoidal hypophysectomy.

Int Forum Allergy Rhinol 2020 03 25;10(3):405-411. Epub 2019 Nov 25.

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

Background: There remains considerable variation in the extent of sinonasal preservation during the approach for endoscopic transsphenoidal hypophysectomy (TSH). We advocate for a minimally destructive approach utilizing turbinate lateralization, small posterior septectomy, no ethmoidectomy, and preservation of nasoseptal flap (NSF) pedicles bilaterally. Due to these factors, this approach may affect the rates of postoperative rhinosinusitis. The objective of this study is to define the rates of postoperative rhinosinusitis in patients undergoing this approach.

Methods: Single institution, retrospective chart review of patients undergoing TSH from 2005 to 2018.

Results: A total of 415 patients were identified and 14% developed an episode of postoperative rhinosinusitis within 3 months. These patients were significantly more likely to have had a history of recurrent acute or chronic rhinosinusitis. Most cases were sphenoethmoidal sinusitis managed with 1 to 2 courses of antibiotics. Of patients with postoperative rhinosinusitis, most did not undergo NSF. Average follow-up was 38 months. Six patients (1.4%) underwent post-TSH functional endoscopic sinus surgery (FESS). Average time from TSH to FESS was 26.3 months. Two of these patients had a history of prior chronic rhinosinusitis without polyposis. Two patients underwent revision TSH for recurrent tumor as the primary indication for surgery at time of FESS. Twenty-two-item Sino-Nasal Outcome Test (SNOT-22) scores generally increased immediately postoperatively, but frequently decreased below preoperative level by the time of last follow-up, regardless of whether patients developed rhinosinusitis.

Conclusion: Sinonasal preservation during TSH is associated with a low rate of postoperative rhinosinusitis requiring FESS and excellent long-term patient reported outcomes. We continue to advocate for sinonasal preservation during pituitary surgery.
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http://dx.doi.org/10.1002/alr.22482DOI Listing
March 2020

Complications, Mortality, and Functional Decline in Patients 80 Years or Older Undergoing Major Head and Neck Ablation and Reconstruction.

JAMA Otolaryngol Head Neck Surg 2019 12;145(12):1150-1157

Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri.

Importance: Data regarding outcomes after major head and neck ablation and reconstruction in the growing geriatric population (specifically ≥80 years of age) are limited. Such information would be extremely valuable in preoperative discussions with elderly patients about their surgical risks and expected functional outcomes.

Objectives: To identify patient and surgical factors associated with 30-day postoperative complications, 90-day mortality, and 90-day functional decline; to explore whether an association exists between the type of reconstructive procedure and outcome; and to create a preoperative risk stratification system for these outcomes.

Design, Setting, And Participants: This retrospective, multi-institutional cohort study included patients 80 years or older undergoing pedicle or free-flap reconstruction after an ablative head and neck surgery from January 1, 2015, to December 31, 2017, at 17 academic centers. Data were analyzed from February 1 through April 20, 2019.

Main Outcomes And Measures: Thirty-day serious complication rate, 90-day mortality, and 90-day decline in functional status. Preoperative comorbidity and frailty were assessed using the American Society of Anesthesiologists classification, Adult Comorbidity Evaluation-27 score, and Modified Frailty Index. Multivariable clustered logistic regressions were performed. Conjunctive consolidation was used to create a risk stratification system.

Results: Among 376 patients included in the analysis (253 [67.3%] men), 281 (74.7%) underwent free-flap reconstruction. The median age was 83 years (range, 80-98 years). A total of 193 patients (51.3%) had 30-day serious complications, 30 (8.0%) died within 90 days, and 36 of those not dependent at baseline declined to dependent status (11.0%). Type of flap (free vs pedicle, bone vs no bone) was not associated with these outcomes. Variables associated with worse outcomes were age of at least 85 years (odds ratio [OR] for 90-day mortality, 1.19 [95% CI 1.14-1.26]), moderate or severe comorbidities (OR for 30-day complications, 1.80 [95% CI, 1.34-2.41]; OR for 90-day mortality, 3.33 [95% CI, 1.29-8.60]), body mass index (BMI) of less than 25 (OR for 30-day complications, 0.95 [95% CI, 0.91-0.99]), high frailty (OR for 30-day complications, 1.72 [95% CI, 1.10-2.67]), duration of surgery (OR for 90-day functional decline, 2.94 [95% CI, 1.81-4.79]), flap failure (OR for 90-day mortality, 3.56 [95% CI, 1.47-8.62]), additional operations (OR for 30-day complications, 5.40 [95% CI, 3.09-9.43]; OR for 90-day functional decline, 2.94 [95% CI, 1.81-4.79]), and surgery of the maxilla, oral cavity, or oropharynx (OR for 90-day functional decline, 2.51 [95% CI, 1.30-4.85]). Age, BMI, comorbidity, and frailty were consolidated into a novel 3-tier risk classification system.

Conclusions And Relevance: Important demographic, clinical, and surgical characteristics were found to be associated with postoperative complications, mortality, and functional decline in patients 80 years or older undergoing major head and neck surgery. Free flap and bony reconstruction were not independently associated with worse outcomes. A novel risk stratification system is presented.
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http://dx.doi.org/10.1001/jamaoto.2019.2768DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6802247PMC
December 2019

Risk factors for unplanned readmission in total laryngectomy patients.

Laryngoscope 2020 07 26;130(7):1725-1732. Epub 2019 Aug 26.

Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, U.S.A.

Objective: To determine which patient or surgical factors affect the likelihood of unplanned readmission (within 30 days) after total laryngectomy (TL).

Methods: Retrospective chart review of all patients who underwent TL at a single institution from April 2007 through August 2016. Primary outcome was unplanned readmission to the hospital within 30 days of discharge. Univariable and multivariable logistic regression were performed to identify risk factors for unplanned readmission.

Results: Two hundred seventy-eight patients met inclusion criteria. Twenty-nine patients (10.4%) had unplanned readmissions within 30 days. The most common reasons for readmission were pharyngocutaneous fistula (n = 15), neck abscess (n = 3), and wound breakdown (n = 4). Average time to unplanned readmission was 11.2 days (range 0-27 days). Fistula (OR 30.259; 95% CI, 9.186, 118.147; P ≤ .001), postoperative pneumonia (OR 9.491; 95% CI, 1.783, 53.015; P = .008), and history of cardiac disease (OR 7.074; 95% CI, 2.324, 25.088, P = .001) were independently associated with an increased risk of 30-day unplanned readmission on multivariate analysis. However, return to OR on initial admission was associated with a lower risk of unplanned readmission (OR 0.075; 95% CI, 0.009, 0.402; P = .007). Unplanned readmission was associated with a delay in initiation of adjuvant radiation (OR 1.494; 95% CI, 1.397, 1.599; P < .001).

Conclusion: Unplanned readmission occurs in a small but significant number of TL patients. Patients who have a 30-day unplanned readmission may be at risk for a delay in initiation of adjuvant therapy.

Level Of Evidence: 4 Laryngoscope, 130:1725-1732, 2020.
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http://dx.doi.org/10.1002/lary.28255DOI Listing
July 2020

Review of inbound medical tourism and legal details of obtaining a visa for treatment of head and neck cancer.

Head Neck 2019 08 25;41(8):E125-E132. Epub 2019 Mar 25.

Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, Cooper University Hospital, Camden, New Jersey.

Background: We aim to provide a review of inbound medical tourism and the legal process of obtaining a visa for medical/surgical treatment for the patients with head and neck cancer.

Methods: We reviewed current statistics and the medical and legal literature regarding inbound medical tourism and the process of obtaining a visa for patients traveling to the United States for medical treatment. To illustrate this process, we present a case of an advanced-staged and disfiguring facial polymorphous high-grade adenocarcinoma in a previously healthy 29-year-old woman from Liberia.

Results: This report provides a synopsis of available statistical data on inbound medical tourism and the legal aspects of obtaining a visa for patients seeking medical care from abroad.

Conclusions: Medical tourists traveling to the United States for treatment of head and neck pathologies face considerable barriers in obtaining prompt care, leading to a possible increased disease burden and difficulty in rendering oncologic treatment.
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http://dx.doi.org/10.1002/hed.25743DOI Listing
August 2019

Loss of CD169 Subcapsular Macrophages during Metastatic Spread of Head and Neck Squamous Cell Carcinoma.

Otolaryngol Head Neck Surg 2019 07 12;161(1):67-73. Epub 2019 Feb 12.

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

Objective: The purpose of this study is to assess CD169 expression in metastatic and nearby tumor-free lymph nodes of patients with head and neck squamous cell carcinoma (SCC).

Study Design: Retrospective analysis based on immunohistochemistry.

Setting: Tertiary care center.

Subjects And Methods: The abundance of CD169 cells in the subcapsular sinuses (SCSs) of lymph nodes was assessed immunohistochemically in paraffin-embedded tissue samples derived from 22 patients with oral cavity and oropharyngeal SCC.

Results: SCSs of lymph nodes harboring metastatic SCC contained significantly fewer CD169 macrophages (106.5 ± 113.6 cells/mm) compared to nearby tumor-free lymph nodes (321.3 ± 173.4 cells/mm, < .001). This observation extended to 21 of the 22 cases investigated. In addition, 6 patients who later developed recurrent disease contained lower numbers of CD169 cells (268.6 ± 169.5 cells/mm) in nearby tumor-free lymph nodes compared to 341.0 ± 176.1 cells/mm in those who remained disease free ( = .399). Human papillomavirus (HPV)-positive patients (n = 4) had a 6-fold lower number of CD169 cells in metastatic nodes (61.2 ± 85.5 cells/mm) compared to nearby tumor-free lymph nodes (369.5 ± 175.5 cells/mm, = .028). In comparison, HPV-negative patients had only a 3-fold reduction (116.6 ± 118.5 cells/mm vs 310.6 ± 176.2 cells/mm, < .001).

Conclusion: Metastatic spread of SCC to regional lymph nodes is associated with lower abundance of CD169 macrophages in the SCSs of draining lymph nodes. These results set the stage for an in-depth investigation into the mechanism(s) by which metastatic SCC controls CD169 macrophage abundance and its significance as it relates to prognosis and treatment response.
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http://dx.doi.org/10.1177/0194599819829741DOI Listing
July 2019