Perioperative opioids and survival outcomes in resectable head and neck cancer: A systematic review.

BACKGROUND: Opioids are a mainstay in pain control for oncologic surgery. The objective of this systematic review is to evaluate the associations of perioperative opioid use with overall survival (OS) and disease-free survival (DFS) in patients with resectable head and neck cancer (HNC). METHODS: A systematic review of PubMed, SCOPUS, and CINAHL between 2000 and 2022 was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies investigating perioperative opioid use for patients with HNC undergoing surgical resection and its association with OS and DFS were included. RESULTS: Three thousand three hundred seventy-eight studies met initial inclusion criteria, and three studies representing 562 patients (intraoperative opioids, n = 463; postoperative opioids, n = 99) met final exclusion criteria. One study identified that high intraoperative opioid requirement in oral cancer surgery was associated with decreased OS (HR = 1.77, 95% CI 0.995-3.149) but was not an independent predictor of decreased DFS. Another study found that increased intraoperative opioid requirements in treating laryngeal cancer was demonstrated to have a weak but statistically significant inverse relationship with DFS (HR = 1.001, p = 0.02) and OS (HR = 1.001, p = 0.02). The last study identified that patients with chronic opioid after resection of oral cavity cancer had decreased DFS (HR = 2.7, 95% CI 1.1-6.6) compared to those who were not chronically using opioids postoperatively. CONCLUSION: An association may exist between perioperative opioid use and OS and DFS in patients with resectable HNC. Additional investigation is required to further delineate this relationship and promote appropriate stewardship of opioid use with adjunctive nonopioid analgesic regimens

Minimally invasive retroauricular approach parotidectomy: A pictorial essay.

The surgical approach to a parotid neoplasm has traditionally been taught through a modified-Blair incision. This approach results in a visible scar in the preauricular, retromandibular, and upper neck skin. Various modifications have been undertaken which aim to improve cosmesis either by decreasing overall incision length and/or relocation of the incision to the hairline via what is commonly described as a facelift approach . We describe a novel minimally invasive parotidectomy approach which utilizes a single retroauricular incision. This approach eliminates both the preauricular scar as well as the extended incision in the hairline and additional skin flap elevation which accompanies it. Sixteen patients underwent parotidectomy using this minimally invasive incision and the excellent clinical outcomes are reviewed. The minimally invasive retroauricular approach to parotidectomy provides excellent exposure with no visible incision/scar in appropriately selected patients

The Snare Technique: A Novel Atraumatic Method for the Removal of Difficult Nasal Foreign Bodies

Nasal foreign bodies (NFBs) are a common occurrence, particularly in children between 2 and 4 years old. Many techniques have been developed to remove NFBs, though intranasal batteries, in particular, possess characteristics such as round shape, smooth surface, and limited visibility that make attempts at removal significantly more difficult. In the context of intranasal batteries, a considerable local soft tissue reaction and potential necrosis may exist to further complicate removal. To present a technique for removal of difficult intranasal foreign bodies that may be utilized by health care practitioners, particularly in the Emergency Department setting. We present a case of a 4-year-old child presenting with intranasal battery with mucosal necrosis. After conventional techniques failed, we utilized a novel wire snare technique to dissect the NFB free from the nasal mucosa safely and in an atraumatic fashion. This technique is noted to be a rapid, atraumatic, and effective means for the removal of difficult NFBs

Middle ear carcinoid with distant osseous metastasis

Middle ear carcinoid is a rare entity with an indolent clinical course. Numerous reports have described local recurrence and metastasis to the cervical lymph nodes, although only one report of distant visceral metastasis exists in the literature. We describe the potential for osseous metastasis. A 52-year-old male with previous middle ear carcinoid (resected 10 years prior) presented with a neck mass. Subsequent workup revealed a suspicious lytic lesion of the iliac crest. Selective neck dissection and core biopsy of the iliac lesion were performed, which revealed concurrent histologically identical metastasis to both the cervical lymph nodes and iliac crest, morphologically indistinguishable from the previous middle ear carcinoid. This case presents the novel description of distant osseous metastasis of middle ear carcinoid

Disfigurement and Mental Health in Head and Neck Cancer

Objective: Evaluate the relationship between physician-rated patient disfigurement and mental health status and quality of life variables in a 1-year posttreatment head and neck cancer population. Method: Cross-sectional study, academic, tertiary referral center. One hundred fifty patients with a diagnosis of head and neck cancer at least 1 year status posttreatment completed a series of mental health and quality of life intake questionnaires. A single physician completed an observer-rated disfigurement scale for all patients. Results: Racial stratification included: 61% Caucasian, 33% Hispanic, 4% African American, and 2% other. Gender stratification included: 69% male and 31% female. Mean age: 63 (range 20-89). Thirteen percent of the patient population was noted to have untreated depression/anxiety, 100% of which had undergone some type of surgical intervention. No anxiety/depression was noted in patients who had only undergone chemo and/or radiotherapy and no surgery. Physician rated disfigurement was higher in the surgical treatment group, though the highest physician-rated disfigurement scores did not correlate to the highest anxiety/depression scores, nor the lowest quality of life scores. Conclusion: While physician-rated disfigurement is higher in surgically treated patients, the most disfigured patients did not report the worst quality of life. Therefore all head and neck patients should be assessed for adverse mental health and quality of life outcomes posttreatment, not only the most disfigured

Sentinel lymph node biopsy for head and neck malignancies utilizing simultaneous radioisotope gamma probe and indocyanine green fluorescence navigation.

We depict an innovative surgical approach for sentinel lymph node biopsy (SLNB) in head and neck malignancies that utilizes both near-infrared (NIR) imaging with indocyanine green (ICG) dye and hand-held gamma probe intraoperatively to isolate and excise SLNs. Twenty-one patients presented to our institution with cutaneous melanoma, cutaneous squamous cell carcinoma (SCC), and oral cavity SCC tumors that met criteria for SLNB based on tumor depth and histology. The video offers a step-by-step approach for this technique along with descriptions of recommended equipment. Among 21 patients, two patients had positive SLNs on final pathology. One patient developed a local recurrence over an average of 16.2 months of follow-up (SD = 15.6). SLNB with ICG and radionucleotide co-localization may enhance the identification of sentinel nodes without compromising outcomes in the hands of surgeons well-versed in the technique

The Role of Fine-Needle Aspiration in Parotid Pleomorphic Adenoma

Objective: Fine-needle aspiration (FNA) biopsy is often used as a well-accepted and both sensitive and specific diagnostic adjunct in the workup of parotid masses. In the case of pleomorphic adenoma, the most common benign tumor of the parotid gland, we examine cytopathologic reports to assess the performance of FNA for this particular histologic diagnosis. Method: A total of 317 patients who underwent parotidectomy over the past 5 years and met eligibility criteria of 1) primary parotid tumor, 2) age greater than 18 years, and 3) availability of pathology (FNA, intraoperative frozen section, final pathology) were reviewed. Clinical history and demographics, physical exam findings, and intraoperative findings were noted. Results: Pleomorphic adenoma was noted on final pathology in 136 patients (42.9%). Interestingly 24 (17.6%) of these patients had initially undergone FNA and been given a incorrect diagnosis, despite the FNA being “diagnostic.” One patient received false positive diagnosis of malignancy by FNA. Of the 24 patients with incorrect diagnosis on FNA, 15 (62.5%) received the correct diagnosis of pleomorphic adenoma with intraoperative frozen section, though one patient received a false positive for malignancy and underwent surgical upstage unnecessarily. For pleomorphic adenoma, it appears that diagnostic sensitivity increases from 82% for FNA to 92% with frozen section. Conclusion: While FNA is commonly used as preoperative diagnostic adjunct for parotid masses, one must exercise caution, even in the context of a diagnostic sample, as nearly 18% of pleomorphic adenomas were not identified. Fortunately, misdiagnosis was benign 95% of time, and subsequently had no surgical implications

Examination of care processes and treatment optimization for head and neck cancer patients in a community setting “hub and hub” model

Objective To examine referral pattern, the timing of diagnostic/staging processes, and treatment initiation for new head and neck cancer patients in a community setting. Methods Patients with a newly diagnosed previously untreated diagnosis of head neck cancer managed at Asplundh Cancer Pavilion/Abington Memorial Hospital from October 2018 to March 2020. Source of referral and preceding workup were examined as well as intervals between initial head and neck consult and various timepoints of treatment initiation. Results One hundred and five patients were included in the study. The primary referral sources were external general otolaryngology (56.3%). Oral surgery and dermatology obtained tissue biopsy approximately 80% of the time before referral. The average time from the ordering of initial staging positron emission tomography/computed tomography to finalized results was 14 days (range: 10–25 days). Patients referred from dermatology and oral surgery were more likely to require single modality care, namely definitive surgical management. Time to treatment initiation average was 37 days (range: 29–41 days). Patients with longer treatment times noted significantly higher times to both radiation and medical oncology consults (48.42 vs. 18.13 days; P \u3c 0.001). Conclusions No notable differences in treatment initiation times were identified based on referral source or extent of workup performed before head/neck surgery consult. It appears the largest opportunities for improvement in terms of reducing overall treatment length exist in the optimization of radiation initiation time