Laurence J. DiNardo

Factors affecting smoking cessation in patients with head and neck cancer.

The role of tobacco in the etiology of upper aerodigestive tract carcinomas is well established. Smoking decreases the effectiveness of cancer therapy and increases the risk of all treatment modalities. Smoking adversely affects the general health of the cancer survivor and places the patient at risk of developing additional primary tumors. The smoking habits of head and neck cancer patients were evaluated using a questionnaire administered at two tertiary head and neck cancer centers. Demographic factors, level of exposure, tumor stage and location, treatment modalities, concomitant alcohol use, and cessation methods were examined. Results demonstrate a high rate of smoking cessation at the time of cancer diagnosis. Significant demographic factors were not identified. Physical barriers to continued smoking because of cancer treatment as well as counseling at the time of tumor diagnosis were the most effective deterrents to continued tobacco use. Heavy alcohol use was a negative predictor of smoking cessation. Pharmacologic aids alone were found to be of no value. This study demonstrates the difficulties with smoking cessation in head and neck cancer patients, and emphasizes the importance of intervention by the otolaryngologist‐head and neck surgeon.

Accuracy, Utility, and Cost of Frozen Section Margins in Head and Neck Cancer Surgery

Objectives Intraoperative frozen section analysis of surgical margins is widely used in head and neck cancer surgery. This study evaluates frozen section accuracy relative to permanent controls and final margins from the entire specimen, the rate at which frozen sections impact intraoperative management, and the resultant cost.

Lymphatics of the submandibular space : An anatomic, clinical, and pathologic study with applications to floor-of-mouth carcinoma

The detection and management of submandibular metastases are fundamental to the treatment of oral carcinoma. Detailed investigation of submandibular lymphatic anatomy and subsite predilection for metastases, as well as a comprehensive method for submandibular space dissection, have been lacking. This thesis explores submandibular lymphatic anatomy through a review of the literature and cadaver dissections. A standardized lymph node nomenclature and submandibular dissection technique are proposed. Also presented is a report on 41 consecutive patients with floor‐of‐mouth squamous cell carcinoma who were prospectively evaluated and treated. Pretreatment clinical and computed tomography (CT) examinations revealed the detection of submandibular metastases to be more difficult than for the remainder of the neck and not improved by the routine use of CT scanning. Management of the neck was either with surgery, which included complete bilateral level I dissections, or at least 2‐year follow‐up when left untreated. Overall, 39% of patients manifested submandibular disease. The majority of submandibular metastases in this study measured 1 cm or less and most commonly involved the perivascular (primarily prevascular) nodes followed by the preglandular and, previously ill‐defined, deep nodes. These findings are discussed with regard to the rationale for currently used neck dissections.

CURRENT TREATMENT PRACTICES FOR EARLY LARYNGEAL CARCINOMA

OBJECTIVE : Controversy regarding the management of early laryngeal carcinoma persists in the absence of a definitive comparison of treatment modalities. This study examines the basic management practices for early laryngeal cancer among the American Academy of Otolaryngology–Head and Neck Surgery membership with an emphasis on the role of conservation surgery. METHODS : Questionnaires were randomly distributed to 3000 members with 1000 responses. The results were collated and statistically evaluated with multivariable frequency analysis. RESULTS : For operable supraglottic tumors, supraglottic laryngectomy was advocated by 41.6% of those responding. Definitive radiation therapy was suggested by 5.3% of participants and total laryngectomy by 1.4%. Explanation of treatment options with the patient deciding the therapy was selected by 48.3% of responders. For suitable glottic tumors, hemilaryngectomy was recommended by 37.1%, definitive radiation therapy by 8.1%, total laryngectomy by 1.9%, and patient choice by 50.4% of members completing the survey. When patients were left to weigh the treatment options, surgery was much less likely to be chosen than if it was advocated by the physician. Trends were evident according to practice region and setting, but these variables did not correlate strongly with physician recommendations. However, date of residency completion and rating of available radiation oncology services were significant factors. The evaluation of postoperative considerations in laryngeal conservation surgery demonstrated large variability in the definition of a close margin and the perceived need for additional therapy. CONCLUSIONS : The varied practice patterns among the American Academy of Otolaryngology–Head and Neck Surgery membership reflect the lack of a comparative outcome analysis for the treatment of early laryngeal carcinoma. Consequently, the full reliance on patient choice, which is more pronounced among young physicians, and cost considerations may have the greatest impact on the future treatment of this disease.

Performance of the Internal Jugular Vein after Functional Neck Dissection

The objective of this study was to assess internal jugular vein performance after functional neck dissection in routine and extended head and neck surgical procedures, including bilateral neck dissections, treatment of radiation failures, and those combined with microvascular free grafts. Because the indications for functional neck dissection in our practice have increased, it is important to assess the use of the procedure in these circumstances. Although previous work has suggested the patency of the internal jugular vein after functional neck dissection, actual flow rates have not been investigated. The function of the dissected internal jugular vein was analyzed with duplex ultrasound at least 4 weeks after treatment. Maximal venous flow rates were evaluated. The results of this study will be presented and discussed.

Accelerated superfractionated radiotherapy with concomitant boost for locally advanced head-and-neck squamous cell carcinomas

PURPOSE A growing body of evidence supports the efficacy of accelerated superfractionated radiotherapy with concomitant boost for advanced head-and-neck carcinomas. This study represents a single-institution experience, performed to identify the factors influencing tumor control, survival, and toxicity. MATERIALS AND METHODS Between 1988 and 1999, 133 patients with primary squamous cell head-and-neck carcinoma underwent accelerated superfractionated radiotherapy using a concomitant boost. The concomitant boost in this regimen was delivered using reduced fields delivered 3 times weekly in a twice-daily schedule during the final phase. The total radiation dose ranged from 64.8 Gy to 76.5 Gy (mean 71.1). Patients were evaluated in follow-up for local control and late toxicity. Multivariate analysis of treatment and patient parameters was performed to evaluate their influence on toxicity, local control, and overall survival. RESULTS With a mean follow-up of 37 months, the actuarial overall survival rate for the entire group at 5 years was 24% and the local control rate was 57%. The tumor volume was the most significant predictor of local control, such that each 1-cm(3) increase in volume was associated with a 1% decrease in local control. For patients with tumor volumes </=30 cm(3) vs. >30 cm(3), the 5-year disease-specific survival rate was 52% and 27% (p = 0.004) and locoregional control rate was 76% and 26% (p <0.001), respectively. Seventy-six patients with a minimum of 12 months and median of 39 months toxicity follow-up were studied for late effects. None of these patients experienced Grade 4 or 5 toxicity. The actuarial rate of significant toxicity (Grade III or greater) was 32% at 5 years. Of the toxicities observed, xerostomia (19%) was the most common. Multivariate analysis revealed N stage and dose as independent predictors of Grade 3 effects. CONCLUSION The locoregional control and survival for patients in this institutional experience compare favorably to other published reports. Tumors of the larynx had the best prognosis. Larger volume tumors were associated with significantly lower local control and survival. Significant late effects were related to dose and nodal status.

Toxic Effects on Gustatory Function

A large number of substances and disease processes may impact the sense of taste. Toxic substances may cause taste dysfunction from their effects on the gustatory system from the salivary gland, to the taste bud, to the central neural pathways. A number of external toxins, including industrial compounds, tobacco, and alcohol, may adversely affect taste, most commonly through local effects in the oral cavity. Blood-borne toxins, such as medications and those present in autoimmune and other systemic disorders (e.g. renal or liver failure), have access to all parts of the gustatory system, and thus may exhibit varied effects on taste function. An understanding of these potential toxins and their impact on gustation will help physicians better recognize, and potentially limit the impact of such taste alterations on their patients.

Olfactory Epithelium Grafts in the Cerebral Cortex: An Immunohistochemical Analysis

Objective To develop an alternative model for studying the regenerative capacity of olfactory neurons.

The Infectious and Hematologic Otolaryngic Complications of Myelosuppressive Cancer Chemotherapy

The otolaryngologist–head and neck surgeon is frequently consulted to evaluate patients before the administration of myelosuppressive cancer chemotherapy. Fifty consecutive patients treated at the University of Pennsylvania Oncology Center were studied before and during chemotherapy for adult leukemia or bone marrow transplantation. Otolaryngic history, physical examination, radiographic studies, and hematologic surveys were analyzed for the duration of therapy in an attempt to identify risk factors for infectious and hematologic otolaryngic complications. Two-thirds of the patients studied experienced untoward effects that required the further attention of an otolaryngologist–head and neck surgeon. The various complications and associated correlations with the study parameters before and during chemotherapy are discussed.

DuraSeal™ in Endoscopic Repair of Cerebrospinal Fluid Leak:

Objective: 1) Review use of DuraSeal (Confluent Surgical, Waltham, MA) as sealant in the primary repair of spontaneous cerebrospinal fluid (CSF) leaks and in secondary repair following transspehnoidal pituitary surgery for persistent leak. 2) Compare success and postoperative course of DuraSeal to fibrin glues in our patients and in the literature. Method: A database of endoscopic cerebrospinal fluid leak repairs was created by retrospective review of the operative log from 1999 to 2012 at a tertiary care hospital. Operative reports and postoperative hospital records were collected and analyzed for type of repair and CSF leak recurrence. Results: Nine cases were identified in which DuraSeal was used as a dural sealant during endoscopic CSF leak repair for spontaneous leak or in secondary repair of CSF leaks following previous transsphenoidal pituitary surgery. There was no recurrence of CSF leak in any patients in which DuraSeal was used in the repair. The average follow-up was 21 months (range 1 to 53 months). There were no complications from the use of DuraSeal. A similar group of 7 patients in whom fibrin glue was used noted 1 repair failure (14.3%) with a 32-month average follow-up. Conclusion: The use of DuraSeal to strengthen CSF leak repair and form a watertight seal was successful in 100% of reported cases and had no adverse events related to its use. This report of 9 patients would be the largest to date where DuraSeal was used in this manner.