David C. Shonka

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

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

Outcomes of Patients With Head-and-Neck Cancer of Unknown Primary Origin Treated With Intensity-Modulated Radiotherapy

PURPOSEnTo analyze survival, failure patterns, and toxicity in patients with head-and-neck carcinoma of unknown primary origin (HNCUP) treated with intensity-modulated radiotherapy (IMRT).nnnMETHODS AND MATERIALSnRecords from 27 patients with HNCUP treated during the period 2002-2008 with IMRT were reviewed retrospectively. Nodal staging ranged from N1 to N3. The mean preoperative dose to gross or suspected disease, Waldeyers ring, and uninvolved bilateral cervical nodes was 59.4, 53.5, and 51.0 Gy, respectively. Sixteen patients underwent neck dissection after radiation and 4 patients before radiation. Eight patients with advanced nodal disease (N2b-c, N3) or extracapsular extension received chemotherapy.nnnRESULTSnWith a median follow-up of 41.9 months (range, 25.3-93.9 months) for non deceased patients, the 5-year actuarial overall survival, disease-free survival, and nodal control rates were 70.9%, 85.2%, and 88.5%, respectively. Actuarial disease-free survival rates for N1, N2, and N3 disease were 100%, 94.1%, and 50.0%, respectively, at 5 years. When stratified by non advanced (N1, N2a nodal disease without extracapsular spread) vs. advanced nodal disease (N2b, N2c, N3), the 5-year actuarial disease-free survival rate for the non advanced nodal disease group was 100%, whereas for the advanced nodal disease group it was significantly lower at 66.7% (p = 0.017). Three nodal recurrences were observed: in 1 patient with bulky N2b disease and 2 in patients with N3 disease. No nodal failures occurred in patients with N1 or N2a disease who received only radiation and surgery.nnnCONCLUSIONnDefinitive IMRT to 50-56 Gy followed by neck dissection results in excellent nodal control and overall and disease-free survival, with acceptable toxicity for patients with T0N1 or non bulky T0N2a disease without extracapsular spread. Patients with extracapsular spread, advanced N2 disease, or N3 disease may benefit from concurrent chemotherapy, targeted therapeutic agents, or accelerated radiation regimens in addition to surgery.

Immediate postoperative extubation in patients undergoing free tissue transfer

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

p16 Not a Prognostic Marker for Hypopharyngeal Squamous Cell Carcinoma

OBJECTIVEnTo investigate the prognostic significance of p16 in patients with hypopharyngeal squamous cell carcinoma (HPSCC) and to evaluate the relationship between p16 and human papillomavirus (HPV). Unlike in oropharyngeal SCC (OPSCC), the prognostic significance of p16 in HPSCC and its association with HPV is unclear.nnnDESIGNnRetrospective medical chart review.nnnSETTINGnUniversity tertiary referral center.nnnPATIENTSnA total of 27 patients with HPSCC treated with definitive radiation therapy between 2002 and 2011 whose tissue was available for immunohistochemical analysis.nnnINTERVENTIONSnTwenty-two patients were treated with chemoradiation, and 5 with radiation alone. All tumor biopsy specimens were analyzed for p16 and, when sufficient tissue was available, for HPV DNA.nnnMAIN OUTCOME MEASURESnOverall survival (OS), locoregional control (LRC), disease-free survival (DFS), and laryngoesophageal dysfunction-free survival (LEDFS) were analyzed according to p16 status.nnnRESULTSnFindings for p16 were positive in 9 tumors and negative in 18 tumors. Median follow-up was 29.3 months. There was no significant difference in OS, LRC, DFS, or LEDFS for patients with p16-positive vs p16-negative tumors. Only 1 of the 19 tumors tested for HPV was found to be HPV positive. When used as a test for HPV, p16 had a positive predictive value of 17%.nnnCONCLUSIONSnIn contrast to OPSCC, p16 expression in patients with HPSCC had a low positive predictive value for HPV and did not predict improved OS, LRC, DFS, or LEDFS. Thus, for HPSCC, p16 is not a prognostic biomarker. Caution must be taken when extrapolating the prognostic significance of p16 in patients with OPSCC to patients with head and neck SCC of other subsites.

Prognostic Significance of p16 and Its Relationship With Human Papillomavirus in Pharyngeal Squamous Cell Carcinomas

IMPORTANCEnThe prognostic significance of p16 in squamous cell carcinoma (SCC) of the hypopharynx (HP) and nasopharynx (NP) and relationship between human papillomavirus (HPV) and p16 is unclear.nnnOBJECTIVESnTo evaluate the prognostic significance of p16 in pharyngeal subsites (oropharynx [OP], HP, and NP) and assess the relationship between HPV and p16 in the HP and NP.nnnDESIGN, SETTING, AND PARTICIPANTSnRetrospective medical record review of 172 patients with SCC of the pharynx treated with definitive radiation therapy from 2002 to 2013 at a university tertiary referral center, with tissue available for immunohistochemical analysis. The median follow-up was 30.1 months.nnnINTERVENTIONSnA total of 118 patients were treated with chemoradiation, and 54 patients were treated with radiation alone. Immunohistochemical analysis for p16 was performed for all tumors. Hypopharynx and NP tumors were tested for HPV using in situ hybridization, and NP tumors were tested for Epstein-Barr virus.nnnMAIN OUTCOMES AND MEASURESnOverall survival, locoregional control, and disease-free survival were analyzed according to p16, HPV, and Epstein-Barr virus status.nnnRESULTSnThirty-two patients had HP SCC, 127 had OP SCC, and 13 had NP SCC. p16 Was positive in the HP (34%), OP (66%), and NP (46%). Prevalence of HPV was 14% in the HP and 50% in the NP. As a test for HPV, p16 had a positive predictive value of 38% (HP) and 67% (NP) and a negative predictive value of 100% in HP and NP tumors. p16 Status was a significant predictor of all clinical outcomes for patients with OP SCC (P<.001), but not for patients with HP or NP SCC. Patients with Epstein-Barr virus- or HPV-associated NP SCC had improved clinical outcomes.nnnCONCLUSIONS AND RELEVANCEnp16 Was not associated with improved outcomes in patients with HP or NP SCC. The positive predictive value of p16 as a test for HPV is too low for p16 testing alone in the HP and NP. However, p16 negativity is sufficient to rule out HPV. As a research approach, we recommend p16 immunohistochemistry as a screening test for HPV in NP SCC and HP SCC followed by confirmatory HPV in situ hybridization when p16 positive.

Septal hematoma after balloon dilation of the sphenoid

When medical management of chronic rhinosinusitis fails to achieve benefit, surgery is often recommended. Functional endoscopic sinus surgery (FESS) has become the method of choice for addressing this disease, and advances in instrumentation to facilitate FESS have led to significant advances and outcome improvements. More recently, balloon dilation of the sinus ostia (BDSO) using balloon sinuplasty instruments (Acclarent, Menlo Park, CA) has been introduced in an attempt to enhance mucosal preservation, decrease local trauma, and provide an effective means of relieving disease without the risks of more aggressive measures. Initial cadaveric studies revealed this method, which is successful in remodeling bone and tissue in the area of the sinus transition spaces. Thus far there have been no reported cases of significant postoperative complications directly attributable to the use of the balloon. This case report was approved by the Institutional Review Board for Health Science Research at the University of Virginia. A 51-year-old female was referred to the University of Virginia with complaints of chronic headache and recurrent episodes of rhinosinusitis. Multiple courses of antibiotics, saline irrigations, and intranasal steroids failed to improve her symptoms. Computed tomography of the sinuses demonstrated isolated, near-total opacification of bilateral sphenoid sinuses with adjacent osteitis. Her past medical history was notable for coronary artery disease with prior bypass grafting and Factor V Leiden disorder requiring warfarin therapy. Given the patient’s anticoagulation, the decision was made to pursue BDSO of the sphenoid. This was expected to minimize the risk of blood loss. At surgery, the patient’s INR was normal and 12 hours had passed since her last dose of Lovenox. Intraoperatively, the left sphenoid ostium was identified and BDSO performed (Fig 1). This was then repeated on the right side. Reexamination of the left side was then notable

A Painless Right Facial Mass

A healthy nonsmokingwoman in her 30s presented with a 6-year history of a nontender mass on the right side of the inferior face, overlying the mandible. She first noticed the mass following an uncomplicated dental procedure. It grew slowly for a few years but then stabilized. She stated that it was sensitive to cold liquids but was otherwise asymptomatic. Results from routine laboratory tests and hematologic markers were normal. Examination revealed a roughly 4 × 2.5-cm, nontender, firmmass anterior to the right mandibular parasymphysis. The mass was fully mobile relative to the underlying mandible and could be seen bulging into the gingivolabial sulcus. There were no overlying skin or mucosal changes, and the skin and mucosa moved freely over the mass. Computed tomographic (CT) imaging demonstrated a well-defined, hyperdense, mildly heterogeneous mass with few focal areas of fat attenuation along the inferior aspect of the lesion (Figure, A-C). The mass was separate from the right mandibular parasymphysis without evidence of periosteal reaction or erosion into the underlying bone. The surrounding soft tissues appeared unremarkable. No additional lesions were noted. The patient was taken to the operating theater, where a firm, multilobulated, yellowmass was excised through a gingivolabial incision (Figure, D). Themass was not fixed to any adjacent structures. A B