Nilesh R. Vasan

Carotid Blowout in Patients with Head and Neck Cancer

Objectives The objective was to review the clinicopathologic features of carotid blowout syndrome (CBS) in patients with head and neck cancer (HNC) and present a management algorithm. Methods We reviewed all HNC patients with a diagnosis of CBS seen at our tertiary cancer hospital from 1994 to 2009 and performed a retrospective review of all English-language studies documenting CBS cases within the past 15 years. Results Eight patients with HNC developed CBS at our institution, and another 132 HNC patients were presented in 21 studies. Patients with CBS typically have a history of radiotherapy (89%), nodal metastasis (69%), and neck dissection (63%). This disease usually occurs proximal to the carotid bifurcation and is commonly associated with soft tissue necrosis in the neck (55%) and mucocutaneous fistulas (40%). Half of CBS patients present with sentinel bleeding, but 60% of patients will develop a life-threatening hemorrhage requiring emergent intervention. Over 90% of patients with CBS were treated with endovascular therapy, and surgical ligation was rarely indicated. The morbidity and mortality rates of patients with CBS are significant; only 23% have survived without evidence of disease. Conclusions Carotid blowout syndrome is uncommon and can be rapidly fatal without prompt diagnosis and intervention. Although endovascular treatment within the carotid system can have a significant risk of mortality and neurologic morbidity, it has become the treatment of choice for CBS.

SINONASAL NEUROENDOCRINE CARCINOMA IN ASSOCIATION WITH SIADH

Background. Neuroendocrine carcinoma (NEC) is a rare malignancy of the nasal cavity or paranasal sinuses. The syndrome of inappropriate ADH secretion (SIADH) has not been previously reported in association with this cancer.

Robotic microlaryngeal surgery: a new retractor that provides improved access to the glottis

Robotic surgery has become the standard of care for many procedures outside of otolaryngology, and now is gaining momentum within our specialty. The robot has several advantages to human hands, including removal of tremor and better access to lesions due to increased degree of movement of the articulated instruments. The glottis has rarely been addressed using robotics because access was previously thought to be difficult. We present a case report using the modular oral retractor system to perform robotic microlaryngeal surgery.

AHNS Series: Do you know your guidelines? Evidence-based management of oral cavity cancers

Oral cavity squamous cell carcinoma (OCSCC) is the most common nonmelanoma head and neck cancer in the world, with an estimated 405 000 new cases expected each year. Subsites of the oral cavity include the alveolar ridge, buccal mucosa, anterior tongue, tonsillar pillar, retromolar trigone, hard palate, gingiva, and floor of the mouth. In this issue of the AHNS “Do you know your guidelines?” series, we review the evidence‐based approach to the management of oral cavity carcinomas based on the framework provided by the National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology.

Improved Early Stage (T1/2) Oral Tongue Cancer MedialPathology Margins Using Horizontal Mattress SutureTechnique

The oral tongue is the most common site for oral cavity cancers. Squamous cell carcinoma (SCCa) is responsible for over 90% of cases with an estimated incidence of 3.0/100,000 in the United States [1,2]. Males with a history of tobacco and alcohol use are at greatest risk and commonly present with early stage lesions. Treatment involves wide local excision, neck dissection if indicated and possibly post-operative radiation therapy depending on pathological features. The 5 year survival is 75-89% for early stage disease [2].

What Can Determine the Length of an Open Nonendoscopic Thyroidectomy Incision

Objectives  Surgeons are now utilizing small incisions when performing thyroidectomy. This study evaluated the association between patient weight, nodule size, and maximum thyroid diameter and the length of an open thyroidectomy incision. Study Design  Retrospective analysis of 32 consecutive patients. Subjects and Methods  Patient demographics, clinical exam, ultrasound findings, operative findings, and pathology were recorded. Results  Of the 32 patients (81% women), 27 underwent a hemithyroidectomy. The mean patient weight was 194 lbs. The mean clinical nodule diameter was 3.46 cm, and the mean maximum thyroid diameter was 5.91 cm. The mean incision size was 5.13 cm. Independently, patient weight, maximum thyroid diameter, and maximum nodule diameter were shown in regression models to be statistically significant predictors of incision size. In stepwise regression analysis that included all three listed variables, maximum thyroid diameter was the most significant predictor of incision size ( p  < 0.0001). Conclusions  Surgeons may determine the length of the incision using clinical and radiologic parameters, but most probably use their subconscious clinical judgment and the challenge of utilizing a very small incision for this operation. This study has shown that maximum thyroid diameter is the most significant determinant for the incision but that nodule size and patient weight are also significant factors. This study is evidence-based medicine level III.

Improving Oral Tongue Cancer Pathology Margins through Surgical Technique

Objectives: Compare pathology margins of oral tongue cancer patients undergoing partial glossectomy between a novel surgical technique and conventional surgical resection. Describe the horizontal mattress surgical technique for partial glossectomy. Methods: Patients with oral tongue cancer underwent partial glossectomy using a new surgical technique by the senior author from February 2011 to July 2013 at a tertiary care medical center. A retrospective comparison cohort was selected from prior patients of the department with age, sex, and tumor stage matching. Anterior, posterior, and medial pathology margins were compared between the groups. Mean values were compared with the Student t test for normally distributed variables, and median values were compared with the Wilcoxon-Mann-Whitney test for variables which were not normally distributed. The horizontal mattress technique for partial glossectomy is described. Results: Ten patients underwent partial glossectomy with the new technique. The mean medial pathology margin was significantly greater in the novel technique group (1.40 cm, 0.88 cm, P < .05; novel technique, conventional technique, P value). There were no significant differences in the median anterior margin (1.10 cm, 1.25 cm, P = .79), mean posterior margin (1.47 cm, 1.13 cm, P = .15), mean tumor size (1.91 cm, 1.71 cm, P = .67), or tumor depth of invasion (0.65 cm, 0.80 cm, P = .73). Conclusions: The new surgical technique using horizontal mattress sutures for dissection guidance and specimen orientation yielded significantly larger medial pathology margins compared to the traditional method. This study is limited by the retrospective nature of the comparison group. A prospective trial should be undertaken to confirm these results.

Analysis of PET for Nodal Metastasis following Radiotherapy

Objective: 1) Determine the ability of PET scan to predict pathologically positive nodes in patients with persistent nodal disease following radiation with or without chemotherapy. 2) Evaluate whether performing a single level neck dissection is feasible in patients with persistent nodal disease. Method: Study design: Retrospective analysis. Setting: Tertiary care center. Patients were evaluated with PET after definitive (chemo) radiation and before neck dissection. The SUV of PET-positive nodes were recorded and compared to pathology reports of subsequent neck dissections. Data regarding follow-up, recurrence rates, and survival of these patients was recorded. Results: When compared to pathology reports, post-radiation PET scans failed to identify positive nodes in 4/11 separate cervical levels (sensitivity of 63.6%, P = .005). It successfully identified 33/40 negative neck levels (specificity of 82.5%, P = .005). This data suggest that PET scan alone may be inadequate for predicting pathologically positive nodal levels for persistent neck disease after (chemo) radiation. It was also shown that 6/13 (46.2%) nodal levels with SUV greater than 3 on PET scan were pathologically positive. Conversely, a PET negative nodal level with SUV less than 3 had a 27.3% chance (3/11) of being found positive upon pathologic evaluation. Conclusion: While the relatively high specificity demonstrated here may help support the case for selective neck dissection when PET shows positive nodes, the low sensitivity makes it difficult to exclude PET negative levels from the planned dissection. Larger prospective studies are needed to confirm these findings.

S156 – What Can Determine the Length of a Thyroidectomy Incision?

Objectives Patient expectations regarding cosmesis following surgical procedures have increased. Subsequently, many surgeons are now utilizing very small incisions when performing thyroidectomy. This study evaluated the association between patient weight, nodule size, and maximum thyroid diameter, and the length of a thyroidectomy incision. Methods Data from a cohort of 28 consecutive patients treated by a single surgeon was analyzed. Patient demographics, clinical exam, ultrasound findings, operative findings, and pathology were recorded. All incisions were measured pre-operatively. Results Of the 28 patients (79% female), 24 underwent a hemithyroidectomy and isthmusectomy. One patient had papillary thyroid cancer and 7 (25%) required operation for compressive symptoms. The mean patient weight was 200.76 lbs (median=188 lbs; IQR 75lbs). The mean clinical nodule diameter was 3.64 cm (median=3.7 cm; IQR=1.7 cm), and the mean maximum thyroid diameter was 6.22 cm (median=5.25 cm; IQR=3.7 cm). The mean incision size was 5.32 cm (median=5.0 cm; IQR=2.0 cm). Independently, patient weight, maximum thyroid diameter, and maximum nodule diameter were shown in regression models to be statistically significant predictors of incision size. In stepwise regression analysis that included all three listed variables, only maximum thyroid diameter remained a significant predictor of incision size (p<0.0001). Conclusions The use of small incisions when performing thyroidectomy is becoming common. To further reduce incision size, video-assisted thyroidectomy is now being advocated. For thyroidectomy, surgeon preference and comfort level are obviously important factors in deciding incision length. This retrospective study has shown that this decision is taken in context of the patients’ weight, maximum nodule diameter, and most importantly, maximum thyroid diameter.