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Objective: The aim of this study was to report the incidence and clinical course of a series of patients who were misdiagnosed with Bell's palsy and were eventually proven to have occult neoplasms., Methods: Two hundred forty patients with unilateral facial paralysis who were assessed at the facial nerve reanimation clinic, Victoria Hospital, London Health Science Centre, from 2008 through 2017 were reviewed. Persistent paralysis without recovery was the presenting complaint., Results: Nine patients (3.8%) who were proven to have occult neoplasms initially presented with a diagnosis of Bell's palsy. The mean diagnostic delay was 43.5 months. Four patients were proven to have skin cancers, 3 patients had parotid cancers, and 2 patients had facial nerve schwannomas as a final diagnosis. Initial magnetic resonance imaging (MRI) was performed in all 9 patients and 8 underwent a follow-up MRI. An occult tumor was identified upon review of the original MRI in one patient and at follow-up MRI in 8 patients. The mean time interval between the initial and follow-up imaging was 30.8 months. The disease status at most recent follow-up were no evidence of disease in 2 patients (22%) and alive with disease in 7 patients (78%). An irreversible, progressive pattern of facial paralysis combined with pain, multiple cranial neuropathies or history of skin cancer were predictable risk factors for occult tumors. Seven out of the 9 patients (77.8%) underwent at least one type of facial reanimation surgery, and the final subjective results by the surgeon were available for 5 patients. Three out of the 5 (60%) patients who were available for final subjective analysis were reported as Grade III according to the modified House-Brackmann scale., Conclusion: Occult facial nerve neoplasm should be suspected in patients with progressive and irreversible facial paralysis but the diagnosis may only become evident with follow-up imaging. Facial reanimation surgery is a satisfactory option for these patients., (© 2022. The Author(s).)

Background: Squamous cell carcinoma is the most common malignancy of the oral cavity. Primary treatment involves surgical resection of the tumour with a surrounding margin. Historically, the most commonly accepted margin clearance is 5 mm. This distance is controversial, with recent publications suggesting closer margins do not impact local recurrence and survival. The objective of this study is to determine the closest surgical margin that does not impact local recurrence and overall survival., Methods: A retrospective review of the London Health Sciences Centre Head and Neck Multidisciplinary Clinic between 2010 and 2018 was performed. Demographic data, subsite, tumour staging, treatment modality, margins, and survival outcomes were analyzed. The primary endpoint was local recurrence free survival. Secondary endpoints included recurrence-free survival and overall survival. Descriptive statistics, as well as univariable and multivariable Cox proportional hazards regression modelling were performed for all patients., Results: Four-hundred and twelve patients were included in the study, with a median follow-up of 3.3 years. On univariable analysis, positive margins and margins < 1 mm were associated with significantly worse local recurrence-free survival, recurrence-free survival, and overall survival (p < 0.05), compared to margins > 5 mm. Patients with surgical margins > 1 mm experienced similar outcomes to those with margins > 5 mm. Multivariable analysis identified age of diagnosis, alcohol consumption, pathological tumour and nodal category as predictors of local recurrence free survival., Conclusions: Although historical margins for head and neck surgery are 5 mm, similar outcomes were observed for margins greater than 1 mm in our cohort. These findings require validation through multi-institutional collaborative efforts., (© 2022. The Author(s).)

Anaplastic thyroid cancer (ATC) is a rare, aggressive form of undifferentiated thyroid cancer, which exhibits rapid progression and is almost universally fatal. At least a subset of ATC is thought to arise from pre-existing well-differentiated thyroid cancer, most frequently papillary thyroid cancer (PTC). While PIK3CA mutations are rare in PTC, they are common in ATC and tend to co-occur with BRAF mutations. This provided the rationale for our study to identify the potential role of PIK3CA mutations in the progression from well-differentiated to undifferentiated thyroid cancer. We introduced PIK3CA E545K into the LAM1 PTC cell line, which carries a BRAF V600E mutation. In culture, the engineered cell line (LAM1:PIK3CA E545K ) proliferated faster and demonstrated increased clonogenic potential relative to the parental line carrying an empty vector (LAM1 EV ). Both the LAM1 EV and LAM1:PIK3CA E545K edited lines were implanted into hind flanks of athymic nude mice for in vivo determination of disease progression. While tumour weights and volumes were not significantly higher in LAM1:PIK3CA E545K mice, there was a decrease in expression of thyroid differentiation markers TTF-1, thyroglobulin, PAX8 and B-catenin, suggesting that introduction of PIK3CA E545K led to dedifferentiation in vivo. Collectively, this study provides evidence of a role for PIK3CA E545K in driving disease progression from a well-differentiated to an undifferentiated thyroid cancer; however, over-expression was not a determinant of an accelerated growth phenotype in ATC., (© 2022. The Author(s).)

Objective: To evaluate the impact of a high efficiency rapid standardized OR (RAPSTOR) for hemithyroid/parathyroid surgery using standardized equipment sets (SES) and consecutive case scheduling (CCS) on turnover times (TOT), average case volumes, patient outcomes, hospital costs and OR efficiency/stress., Methods: Patients requiring hemithyroidectomy (primary or completion) or unilateral parathyroidectomy in a single surgeon's practice were scheduled consecutively with SES. Retrospective control groups were classified as sequential (CS) or non-sequential (CNS). A survey regarding OR efficiency/stress was administered. Phenomenography and descriptive statistics were conducted for time points, cost and patient outcome variables. Hospital cost minimization analysis was performed., Results: The mean TOT of RAPSTOR procedures (16 min; n = 27) was not significantly different than CS (14 min, n = 14) or CNS (17 min, n = 6). Mean case number per hour was significantly increased in RAPSTOR (1.2) compared to both CS (0.9; p < 0.05) and CNS (0.7; p < 0.05). Average operative time was significantly reduced in RAPSTOR (32 min; n = 28) compared to CNS (48 min; p < 0.05) but not CS (33 min; p = 0.06). Time to discharge was reduced in RAPSTOR (595 min) compared to CNS (1210 min, p < 0.05). There was no difference in complication rate between all groups (p = 0.27). Survey responses suggested improved efficiency, teamwork and workflow. Furthermore, there is associated decrease in direct operative costs for RAPSTOR vs. CS., Conclusion: A high efficiency standardized OR for hemithyroid and parathyroid surgery using SES and CCS is associated with improved efficiency and, in this study, led to increased capacity at reduced cost without compromising patient safety., Level of Evidence: Level 2.

Background: Radiotherapy, along with laser surgery, is considered a standard treatment option for patients with early glottic squamous cell cancer (SCC). Historically, patients have received complete larynx radiotherapy (CL-RT) due to fear of swallowing and respiratory laryngeal motion and this remains the standard approach in many academic institutions. Local control (LC) rates with CL-RT have been excellent, however this treatment can carry significant toxicities include adverse voice and swallowing outcomes, along with increased long-term risk of cerebrovascular morbidity. A recent retrospective study reported improved voice quality and similar local control outcomes with focused vocal cord radiotherapy (VC-RT) compared to CL-RT. There is currently no prospective evidence on the safety of VC-RT. The primary objective of this Bayesian Phase II trial is to compare the LC of VC-RT to that of CL-RT in patients with T1N0 glottic SCC., Methods: One hundred and fifty-five patients with T1a-b N0 SCC of the true vocal cords that are n ot candidate or declined laser surgery, will be randomized in a 1:3 ratio the control arm (CL-RT) and the experimental arm (VC-RT). Randomisation will be stratified by tumor stage (T1a/T1b) and by site (each site will be allowed to select one preferred radiation dose regimen, to be used in both arms). CL-RT volumes will correspond to the conventional RT volumes, with the planning target volume extending from the top of thyroid cartilage lamina superiorly to the bottom of the cricoid inferiorly. VC-RT volumes will include the involved vocal cord(s) and a margin accounting for respiration and set-up uncertainty. The primary endpoint will be LC at 2-years, while secondary endpoints will include patient-reported outcomes (voice impairment, dysphagia and symptom burden), acute and late toxicity radiation-induced toxicity, overall survival, progression free survival, as well as an optional component of acoustic and objective measures of voice analysis using the Consensus Auditory-Perceptual Evaluation of Voice., Discussion: This study would constitute the first prospective evidence on the efficacy and safety of VC-RT in early glottic cancer. If positive, this study would result in the adoption of VC-RT as standard approach in early glottic cancer., Trial Registration: ClinicalTrials.gov Identifier: NCT03759431 Registration date: November 30, 2018.

Background: Transoral surgery (TOS), particularly transoral robotic surgery (TORS) has become the preferred modality in the United States for the treatment of early stage oropharyngeal cancer, largely due to assumptions of fewer toxicities and improved quality of life compared to primary radiotherapy (RT). However, these assumptions are based on retrospective analysis, a subset of which utilize primary RT groups not limited to T1-2 stage tumors for which transoral robotic surgery is FDA approved. Thus, there is potential for underestimating survival and overestimating toxicity, including treatment related mortality, in primary RT., Methods: Consecutive cases of early T-stage (T1-T2) oropharyngeal cancer presenting to the London Health Sciences Centre between 2014 and 2018 treated with RT or chemoradiation (CRT) were reviewed. Patient demographics, treatment details, survival outcomes and toxicity were collected. Toxicities were retrospectively graded using the Common Terminology Criteria for Adverse Events criteria., Results: A total of 198 patients were identified, of which 82% were male and 73% were HPV-positive. Sixty-eight percent of patients experienced a grade 2 toxicity, 48% a grade 3 and 4% a grade 4. The most frequent toxicities were dysphagia, neutropenia and ototoxicity. The rates of gastrostomy tube dependence at 1 and 2 years were 2.5% and 1% respectively. There were no grade 5 (fatal) toxicities. HPV-positive patients experienced improved 5-year overall survival (86% vs 64%, p = 0.0026)., Conclusions: Primary RT or CRT provides outstanding survival for early T-stage disease, with low rates of severe toxicity and feeding tube dependence. This study provides a reference for comparison for patients treated with primary transoral surgery.

Background: Aberrant activation of the phosphatidylinositol 3-kinase (PI3K) pathway is common in many malignancies, including head and neck squamous cell carcinoma (HNSCC). Despite pre-clinical and clinical studies, outcomes from targeting the PI3K pathway have been underwhelming and the development of drug resistance poses a significant barrier to patient treatment. In the present study, we examined mechanisms of acquired resistance to the PI3Kα inhibitor alpelisib (formerly BYL719) in HNSCC cell lines and patient-derived xenografts (PDXs)., Methods: Five unique PDX mouse models and three HNSCC cell lines were used. All cell lines and xenografts underwent genomic characterization prior to study. Serial drug treatment was conducted in vitro and in vivo to develop multiple, clinically-significant models of resistance to alpelisib. We then used reverse phase protein arrays (RPPAs) to profile the expression of proteins in parental and drug-resistant models. Top hits were validated by immunoblotting and immunohistochemistry. Flow cytometric analysis and RNA interference studies were then used to interrogate the molecular mechanisms underlying acquired drug resistance., Results: Prolonged treatment with alpelisib led to upregulation of TAM family receptor tyrosine kinases TYRO3 and AXL. Importantly, a significant shift in expression of both TYRO3 and AXL to the cell surface was detected in drug-resistant cells. Targeted knockdown of TYRO3 and AXL effectively re-sensitized resistant cells to PI3Kα inhibition. In vivo, resistance to alpelisib emerged following 20-35 days of treatment in all five PDX models. Elevated TYRO3 expression was detected in drug-resistant PDX tissues. Downstream of TYRO3 and AXL, we identified activation of intracellular MAPK signalling. Inhibition of MAPK signalling also re-sensitized drug-resistant cells to alpelisib., Conclusions: We have identified TYRO3 and AXL receptors to be key mediators of resistance to alpelisib, both in vitro and in vivo. Our findings suggest that pan-TAM inhibition is a promising avenue for combinatorial or second-line therapy alongside PI3Kα inhibition. These findings advance our understanding of the role TAM receptors play in modulating the response of HNSCC to PI3Kα inhibition and suggest a means to prevent, or at least delay, resistance to PI3Kα inhibition in order to improve outcomes for HNSCC patients.

Background: Patients with resected oral cavity squamous cell carcinoma (OCSCC) are often treated with adjuvant radiation (RT) ± concomitant chemotherapy based on pathological findings. Standard RT volumes include all surgically dissected areas, including the tumour bed and dissected neck. RT has significant acute and long-term toxicities including odynophagia, dysphagia, dermatitis and fibrosis. The goal of this study is to assess the rate of regional failure with omission of radiation to the surgically dissected pathologically node negative (pN0) hemi-neck(s) compared to historical control, and to compare oncologic outcomes, toxicity, and quality of life (QoL) profiles between standard RT volumes and omission of RT to the pN0 neck., Methods: This is a multicentre phase II study randomizing 90 patients with T1-4 N0-2 OCSCC with at least one pN0 hemi-neck in a 1:2 ratio between standard RT volumes and omission of RT to the pN0 hemi-neck(s). Patients will be stratified based on overall nodal status (nodal involvement vs. no nodal involvement) and use of concurrent chemotherapy. The primary endpoint is regional failure in the pN0 hemi-neck(s); we hypothesize that a 2-year regional recurrence of 20% or less will be achieved. Secondary endpoints include overall and progression-free survival, local recurrence, rate of salvage therapy, toxicity and QoL., Discussion: This study will provide an assessment of omission of RT to the dissected pN0 hemi-neck(s) on oncologic outcomes, QoL and toxicity. Results will inform the design of future definitive phase III trials., Trial Registration: Clinicaltrials.gov identifier: NCT03997643 . Date of registration: June 25, 2019, Current version: 2.0 on July 11 2020.

Background: Patients with human papillomavirus-positive (HPV+) oropharyngeal squamous cell carcinoma (OPC) have substantially better treatment response and overall survival (OS) than patients with HPV-negative disease. Treatment options for HPV+ OPC can involve either a primary radiotherapy (RT) approach (± concomitant chemotherapy) or a primary surgical approach (± adjuvant radiation) with transoral surgery (TOS). These two treatment paradigms have different spectrums of toxicity. The goals of this study are to assess the OS of two de-escalation approaches (primary radiotherapy and primary TOS) compared to historical control, and to compare survival, toxicity and quality of life (QOL) profiles between the two approaches., Methods: This is a multicenter phase II study randomizing one hundred and forty patients with T1-2 N0-2 HPV+ OPC in a 1:1 ratio between de-escalated primary radiotherapy (60 Gy) ± concomitant chemotherapy and TOS ± de-escalated adjuvant radiotherapy (50-60 Gy based on risk factors). Patients will be stratified based on smoking status (< 10 vs. ≥ 10 pack-years). The primary endpoint is OS of each arm compared to historical control; we hypothesize that a 2-year OS of 85% or greater will be achieved. Secondary endpoints include progression free survival, QOL and toxicity., Discussion: This study will provide an assessment of two de-escalation approaches to the treatment of HPV+ OPC on oncologic outcomes, QOL and toxicity. Results will inform the design of future definitive phase III trials., Trial Registration: Clinicaltrials.gov identifier: NCT03210103. Date of registration: July 6, 2017, Current version: 1.3 on March 15, 2019.

Background: The genomic landscape of head and neck cancer has been reported through The Cancer Genome Atlas project. We attempt to determine if high-risk human papillomavirus (HPV) or frequently mutated genes are correlated with survival in an oral cancer cohort., Methods: Patient demographic data along with data from final pathology was collected. Tumor DNA was analyzed using a custom Illumina targeted sequencing panel. Five high-risk HPV types were tested by qPCR. Statistical analyses were used to identify associations between patient outcome and mutational status., Results: High-risk HPV types were identified in 7% of cases; HPV status was not associated with survival. Mutations were identified in TP53, TERT promoter, & PIK3CA. Mutations in TP53 were significantly associated with poorer overall survival on multi-variate analysis ( p  = 0.03)., Conclusions: Mutations in TP53 were associated with poor patient survival. Expanding our sample size may identify further predictors of outcome to direct customized cancer care., Competing Interests: Competing interestsThe authors declare that they have no competing interests., (© The Author(s) 2019.)

Background: Considerable evidence now indicates that individuals living in underprivileged neighbourhoods have higher rates of mortality and morbidity independent of individual-level characteristics. This study explored the impact of geographical marginalization on smoking cessation in a population of individuals with a diagnosis of head and neck cancer. The aims of this study were twofold: (1) assess the prevalence of smoking cessation in those with a previous diagnosis of head and neck cancer, (2) analyze the determinants of smoking alongside area-based measures of socioeconomic status., Methods: This was a cross-sectional study. We administered a self-reported nicotine dependence package to participants between the ages of 20-90 with a previous mucosal head and neck cancer diagnosis and with a history of tobacco use. Using the Canadian Marginalization (CAN-Marg) Index tool based on 2006 Canada Census data we compared the degree of marginalization to the smoking status. For those individuals who were currently smoking, nicotine dependence and readiness to quit were assessed. A summative score of marginalization was compared to smoking status of individuals., Results: The results from this study indicate that the summative level of marginalization developed from the combined factors of residential instability, material deprivation, ethnic concentration and dependency may be important factors in smoking cessation., Conclusions: This analysis of determinants of smoking alongside area-based measures of socioeconomic status may implicate the need for targeted population-based smoking cessation interventions.

Background: Conservative management of Warthin tumor (WT) may be a viable alternative to surgery, but there are concerns of missed malignancies on fine needle aspiration biopsy (FNAB). The purpose of this study is to measure the sensitivity and positive predictive value of FNAB for WT, and to identify clinical features associated with WT that can aid in this diagnosis., Methods: Retrospective analysis of patients from January 1, 2006 to April 30, 2017 at a tertiary care center in London, Ontario, Canada. All patients with a diagnosis of WT on FNAB or resection were included. Electronic medical records were identified for 177 patients that fit the criteria. Study outcomes included the sensitivity and positive predictive value of FNAB alone for WT, and, when including clinical features associated with WT., Results: The mean age of patients in this study was 63.2 years (SD 10.4); 115 (65%) were male, and 157 (89%) were past or present smokers. The measured sensitivity and positive predictive value of FNAB for WT were 95.8 and 97.2% respectively. Two cases were classified as WT on FNAB but confirmed at resection as mucoepidermoid carcinoma and acinic cell carcinoma. When only patients with multifocal, bilateral or incidental tumors were assessed, sensitivities and positive predictive values for each were 100%. Isolating for inferior pole location also resulted in a positive predictive value of 100%., Conclusions: The sensitivity and positive predictive value of FNAB for WT in this study are high, with two false negatives on FNAB. Multifocal, bilateral, incidentaloma and inferior pole location were identified as potential clinical features that may increase the diagnostic confidence for WT, strengthening the argument for conservative management in these patients. Overall, this study serves as an initial exploration into whether clinical features may be included with FNAB results to improve the sensitivity and positive predictive value of diagnosing WT. Further research is necessary before these findings can be translated into clinical practice.

Objectives: Organ preserving surgery (OPS) and radiotherapy (RT) are both accepted treatment options for early stage supraglottic cancer (SGC). Radiation has supplanted surgery in most cases, because of the perception that surgery results in poorer functional outcomes. However, evidence suggests that OPS with a neck dissection may be associated with improved survival. Our objective was to conduct a systematic review of the literature to compare functional outcomes of OPS and RT for early SGC., Methods: We searched Medline, EMBASE and Cochrane Central Register of Controlled Trials to identify studies. Studies were included if they reported functional outcomes on 10 or more patients with early stage SGC treated with radiation or OPS, including open partial laryngectomy, transoral laser microsurgery (TLM) or transoral robotic surgery (TORS). Two reviewers independently screened articles for relevance using pre-determined criteria., Results: From 7720 references, we included 10 articles (n = 640 patients). 50% (n = 320) of patients were treated with surgery. Three head-to-head RT versus OPS papers were included, however different outcome measures were used for each group. Intractable aspiration management (including total laryngectomy or permanent tracheostomy) following OPS was reported in five papers representing 186 patients; the definitive intractable aspiration management rate was 2.6% (95% CI 1.0-6.8%). Four papers reported permanent G-tube rate for the surgical group (n = 198), calculating a rate of 5.3% (95% CI 2.6-10.5%), this was not reported for the RT group in any papers. One study reported quality of life. Two studies reported objective voice measures., Conclusions: This systematic review revealed a paucity of objective measures and significant data heterogeneity, rendering the comparison of functional outcomes following OPS versus RT for early SGC limited. Future research should include objective measures of functional outcomes including laryngectomy rate, g-tube rate, tracheostomy dependence, quality of life, and voice quality measures.

Objectives: For early stage supraglottic squamous cell carcinoma (SCC), single modality treatment either in the form of primary organ preservation surgery alone or radiation alone is recommended. Thus, a definite treatment strategy for early stage supraglottic SCC remains undefined. The primary objective of this study was to conduct a systematic review and meta-analysis comparing the oncologic outcomes of surgery and radiotherapy in early stage (Stage I and II) T1 N0 and T2 N0 supraglottic SCC., Methods: Systematic methods were used to identify published and unpublished data. Two reviewers independently screened all titles, abstracts and articles for relevance using predefined criteria. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were calculated., Results: Five studies met the inclusion criteria for disease specific mortality with a total of 2864 pooled patients. 5-year disease specific mortality was lower in the surgery group (ORs 0.43, 95% CI 0.31-0.60). Four studies met the inclusion criteria for 5-year overall mortality with a total of 2790 pooled patients. Five-year overall mortality was lower in surgery group (ORs 0.40, 95% CI 0.29-0.55)., Conclusions: This is the first study to examine the management of early stage supraglottic SCC using meta-analytic methodology. Our results suggest that primary surgery may result in decreased disease specific and overall mortality compared to primary radiotherapy.

Background: Learners often utilize online resources to supplement formalized curricula, and to appropriately support learning, these resources should be of high quality. Thus, the objectives of this study are to develop and provide validity evidence supporting an assessment tool designed to assess the quality of educational websites in Otolaryngology- Head & Neck Surgery (ORL-HNS), and identify those that could support effective web-based learning. METHODS: After a literature review, the Modified Education in Otolaryngology Website (MEOW) assessment tool was designed by a panel of experts based on a previously validated website assessment tool. A search strategy using a Google-based search engine was used subsequently to identify websites. Those that were free of charge and in English were included. Websites were coded for whether their content targeted medical students or residents. Using the MEOW assessment tool, two independent raters scored the websites. Inter-rater and intra-rater reliability were evaluated, and scores were compared to recommendations from a content expert., Results: The MEOW assessment tool included a total of 20 items divided in 8 categories related to authorship, frequency of revision, content accuracy, interactivity, visual presentation, navigability, speed and recommended hyperlinks. A total of 43 out of 334 websites identified by the search met inclusion criteria. The scores generated by our tool appeared to differentiate higher quality websites from lower quality ones: websites that the expert "would recommend" scored 38.4 (out of 56; CI [34.4-42.4]) and "would not recommend" 27.0 (CI [23.2-30.9]). Inter-rater and intra-rater intraclass correlation coefficient were greater than 0.7., Conclusions: Using the MEOW assessment tool, high quality ORL-HNS educational websites were identified.

Background: Medialization thyroplasty and injection laryngoplasty are widely accepted treatment options for unilateral vocal fold paralysis. Although both procedures result in similar clinical outcomes, little is known about the corresponding medical care costs. Medialization thyroplasty requires expensive operating room resources while injection laryngoplasty utilizes outpatient resources but may require repeated procedures. The purpose of this study, therefore, is to quantify the cost differences in adult patients with unilateral vocal fold paralysis undergoing medialization thyroplasty versus injection laryngoplasty., Study Design: Cost minimization analysis conducted using a decision tree model., Methods: A decision tree model was constructed to capture clinical scenarios for medialization thyroplasty and injection laryngoplasty. Probabilities for various events were obtained from a retrospective cohort from the London Health Sciences Centre, Canada. Costs were derived from the published literature and the London Health Science Centre. All costs were reported in 2014 Canadian dollars. Time horizon was 5 years. The study was conducted from an academic hospital perspective in Canada. Various sensitivity analyses were conducted to assess differences in procedure-specific costs and probabilities of key events., Results: Sixty-three patients underwent medialization thyroplasty and 41 underwent injection laryngoplasty. Cost of medialization thyroplasty was C$2499.10 per patient whereas those treated with injection laryngoplasty cost C$943.19. Results showed that cost savings with IL were C$1555.91. Deterministic and probabilistic sensitivity analyses suggested cost savings ranged from C$596 to C$3626., Conclusions: Treatment with injection laryngoplasty results in cost savings of C$1555.91 per patient. Our extensive sensitivity analyses suggest that switching from medialization thyroplasty to injection laryngoplasty will lead to a minimum cost savings of C$596 per patient. Considering the significant cost savings and similar effectiveness, injection laryngoplasty should be strongly considered as a preferred treatment option for patients diagnosed with unilateral vocal fold paralysis.

Background: Modern radiation oncology demands a thorough understanding of gross and cross-sectional anatomy for diagnostic and therapeutic applications. Complex anatomic sites present challenges for learners and are not well-addressed in traditional postgraduate curricula. A multidisciplinary team (MDT) based head-and-neck gross and radiologic anatomy program for radiation oncology trainees was developed, piloted, and empirically assessed for efficacy and learning outcomes., Methods: Four site-specific MDT head-and-neck seminars were implemented, each involving a MDT delivering didactic and case-based instruction, supplemented by cadaveric presentations. There was no dedicated contouring instruction. Pre- and post-testing were performed to assess knowledge, and ability to apply knowledge to the clinical setting as defined by accuracy of contouring. Paired analyses of knowledge pretests and posttests were performed by Wilcoxon matched-pair signed-rank test., Results: Fifteen post-graduate trainees participated. A statistically significant (p < 0.001) mean absolute improvement of 4.6 points (17.03%) was observed between knowledge pretest and posttest scores. Contouring accuracy was analyzed quantitatively by comparing spatial overlap of participants' pretest and posttest contours with a gold standard through the dice similarity coefficient. A statistically significant improvement in contouring accuracy was observed for 3 out of 20 anatomical structures. Qualitative and quantitative feedback revealed that participants were more confident at contouring and were enthusiastic towards the seminars., Conclusions: MDT seminars were associated with improved knowledge scores and resident satisfaction; however, increased gross and cross-sectional anatomic knowledge did not translate into improvements in contouring accuracy. Further research should evaluate the impact of hands-on contouring sessions in addition to dedicated instructional sessions to develop competencies.

Background: Increasing focus is being placed on Clerkship curriculum design and implementation in light of new undergraduate medical education research and accreditation standards. Canadian Otolaryngology-Head and Neck Surgery (OTOHNS) Clerkship programs are continually but independently evolving towards a common goal of improving Clerkship curriculum., Methods: An electronic survey was sent to undergraduate OTOHNS directors at all Canadian medical schools (n = 17) examining their Clerkship curricula. Themes included Clerkship format, teaching methods, faculty support and development, program strengths, and barriers., Results: Survey response rate was 76%. All responding schools had OTOHNS Clerkship programs ranging in type (mandatory, selective or elective) and length (<1 to 4 weeks). Learning modalities varied. Electronic learning tools were identified as increasingly important to curriculum delivery. Common strengths included wide clinical exposure and one-on-one mentoring. Multiple challenges were identified in curriculum implementation and evaluation. All schools expressed interest in developing national standards, objectives and e-learning resources., Conclusions: Significant variation exists in OTOHNS Clerkship experiences between Canadian medical schools. Many schools perceive barriers of insufficient time, space and curriculum standardization. Interested Canadian OTOHNS educators are eager to collaborate to improve the collective OTOHNS Clerkship experience.

Background: The incidence of oropharyngeal squamous cell carcinoma (OPSCC) has markedly increased over the last three decades due to newly found associations with human papillomavirus (HPV) infection. Primary radiotherapy (RT) is the treatment of choice for OPSCC at most centers, and over the last decade, the addition of concurrent chemotherapy has led to a significant improvement in survival, but at the cost of increased acute and late toxicity. Transoral robotic surgery (TORS) has emerged as a promising alternative treatment, with preliminary case series demonstrating encouraging oncologic, functional, and quality of life (QOL) outcomes. However, comparisons of TORS and RT in a non-randomized fashion are susceptible to bias. The goal of this randomized phase II study is to compare QOL, functional outcomes, toxicity profiles, and survival following primary RT (± chemotherapy) vs. TORS (± adjuvant [chemo] RT) in patients with OPSCC., Methods/design: The target patient population comprises OPSCC patients who would be unlikely to require chemotherapy post-resection: Tumor stage T1-T2 with likely negative margins at surgery; Nodal stage N0-2, ≤3 cm in size, with no evidence of extranodal extension on imaging. Participants will be randomized in a 1:1 ratio between Arm 1 (RT ± chemotherapy) and Arm 2 (TORS ± adjuvant [chemo] RT). In Arm 1, patients with N0 disease will receive RT alone, whereas N1-2 patients will receive concurrent chemoradiation. In Arm 2, patients will undergo TORS along with selective neck dissections, which may be staged. Pathologic high-risk features will be used to determine the requirement for adjuvant radiotherapy +/- chemotherapy. The primary endpoint is QOL score using the M.D. Anderson Dysphagia Inventory (MDADI), with secondary endpoints including survival, toxicity, other QOL outcomes, and swallowing function. A sample of 68 patients is required., Discussion: This study, if successful, will provide a much-needed randomized comparison of the conventional strategy of primary RT vs. the novel strategy of primary TORS. The trial is designed to provide a definitive QOL comparison between the two arms, and to inform the design of an eventual phase III trial for survival outcomes., Trial Registration: NCT01590355.

Objective: To assess the oncological and functional outcomes of T1b squamous cell carcinoma (SCC) of the glottic larynx treated with laser in comparison with radiation., Design: A Canadian multicenter cohort study., Setting: Three tertiary referral centers for head and neck cancer- Dalhousie University in Halifax, Nova Scotia, Western University in London, Ontario and the University of Manitoba, Winnipeg., Methods: Patients with T1b glottic SCC who underwent transoral laser resection or radiation as the primary modality of treatment., Outcome Measures: Oncological outcomes were evaluated using local control, laryngeal preservation, disease free survival and disease specific survival. Voice outcomes were assessed using the Voice Handicap Index-10 (VHI-10)., Results: 63 patients met study criteria. 21 were treated with laser and 42 with radiation. Oncologic outcomes at 2 years for laser and radiation demonstrated local control of 95% and 85.9%; laryngeal preservation of 100% and 85.9%; disease free survival of 88.7% and 85.9% and overall survival of 94.1% and 94.8% respectively. VHI-10 data was available for 23/63 patients. During the last follow up visit VHI-10 ranged from 0 to 11 (median 6) in the laser group and 0 to 34 (median 7) in the radiation group., Conclusion: T1b SCC of the glottis can be effectively treated with transoral laser microsurgery with oncological outcomes that are at least equivalent to radiation. For patients with VHI scores, voice quality was similar between the two groups. To our knowledge this is the first study directly comparing the oncologic and voice outcomes with laser and radiation for the treatment of glottic cancer involving the anterior commissure.

Due to significant differences in healthcare structure between the United States and Canada, there are unique barriers to adopting new medical technology in Canada. In this article, we describe our experience developing a transoral robotic surgery (TORS) program at Western University. Specifically, we outline the steps that were necessary to obtain institutional and multidisciplinary team approval, financial support, as well as surgeon and allied healthcare personnel training. This experience can potentially be used as a roadmap for other Canadian institutions pursuing a TORS program.

Background: An epidemic of human papillomavirus (HPV)-related oropharyngeal squamous cell cancer (OPSCC) has been reported worldwide largely due to oral infection with HPV type-16, which is responsible for approximately 90% of HPV-positive cases. The purpose of this study was to determine the rate of HPV-positive oropharyngeal cancer in Southwestern Ontario, Canada., Methods: A retrospective search identified ninety-five patients diagnosed with OPSCC. Pre-treatment biopsy specimens were tested for p16 expression using immunohistochemistry and for HPV-16, HPV-18 and other high-risk subtypes, including 31,33,35,39,45,51,52,56,58,59,67,68, by real-time qPCR., Results: Fifty-nine tumours (62%) were positive for p16 expression and fifty (53%) were positive for known high-risk HPV types. Of the latter, 45 tumors (90%) were identified as HPV-16 positive, and five tumors (10%) were positive for other high-risk HPV types (HPV-18 (2), HPV-67 (2), HPV-33 (1)). HPV status by qPCR and p16 expression were extremely tightly correlated (p < 0.001, Fishers exact test). Patients with HPV-positive tumors had improved 3-year overall (OS) and disease-free survival (DFS) compared to patients with HPV-negative tumors (90% vs 65%, p = 0.001; and 85% vs 49%, p = 0.005; respectively). HPV-16 related OPSCC presented with cervical metastases more frequently than other high-risk HPV types (p = 0.005) and poorer disease-free survival was observed, although this was not statistically significant., Conclusion: HPV-16 infection is responsible for a significant proportion of OPSCC in Southwestern Ontario. Other high-risk subtypes are responsible for a smaller subset of OPSCC that present less frequently with cervical metastases and may have a different prognosis.

Objectives: There is no standardized curriculum for laryngology within otolaryngology residency programs despite the fact that laryngology is a significant portion of the Royal College of Physicians and Surgeons of Canada examination. Our objective was to evaluate trainee perceptions of laryngology within otolaryngology residency programs., Design: Cross-sectional survey., Setting: Canadian otolaryngology residency programs., Methods: A Web-based, anonymous survey was conducted among otolaryngology residents. The survey was based on Royal College learning objectives for laryngology. The survey was administered using Dillman's Total Design Method and distributed in English and French., Results: Sixty-four of 150 (42.6%) residents responded to the survey (55.6% male; mean age 29.3 years). About half of the respondents agreed or strongly agreed that the amount of didactic and clinical laryngology instruction was adequate. About 41.0% agreed or strongly agreed that the amount of operative laryngology instruction was adequate. Cited areas for improvement included injection laryngoplasty, botulinum toxin injection, medialization thyroplasty, care of the professional voice, phonosurgery, and videostroboscopy. Areas of strength included flexible nasopharyngoscopy, laryngeal anatomy, hoarseness, stridor, laryngopharyngeal reflux disease, and vocal cord paralysis. Overall, 40.7% felt somewhat comfortable providing laryngology care. The presence of a laryngology fellowship at the training program, respondent interest in pursuing a fellowship, completion of a laryngology elective, and previous laryngology research did not affect the residency experience. Senior residents are more comfortable with providing laryngology care than juniors., Conclusions: Several areas of strengths and areas for improvement in laryngology appear to exist within otolaryngology residency programs as perceived by current trainees.

Objective: To compare the laryngeal preservation rates and voice outcomes after treatment of early glottic cancer between transoral laser microsurgery (TLM) and radiotherapy (RT)., Design: Multicenter, retrospective consecutive cohort of stage 1 and 2 glottic carcinoma treated with TLM or RT., Setting: Three Canadian academic cancer centres., Methods and Main Outcome Measures: The patients were those of the regional cancer registries associated with each of the participating universities between 2002 and 2010. The primary oncologic end point was organ preservation. The primary functional outcome measure was the Voice Handicap Index (VHI-10)., Results: A total of 234 patients were treated for early glottic cancer (143 TLM, 91 RT). At 2 years, the laryngeal preservation rate for stage 1 disease was 100% TLM and 92% RT (p < .004); for stage 2 disease, it was 100% TLM and 88% RT (p  =  not significant). There was only one laryngectomy in the TLM group over 5 years posttreatment. There were functional data on 132 patients (83 TLM, 49 RT). Median VHI-10 scores were inferior for laser patients at all three time intervals (6, 12, and 24-48 months posttreament) despite a stage bias in favour of TLM (range of median VHI score over time intervals: TLM  =  9.5-12, RT  =  3.5-8; p  =  .01-.08). However, theses scores represent mild disability in both groups., Conclusions: TLM patients have poorer voice quality than RT patients. However, the advantages of TLM in most patients outweigh the degree of voice handicap. Organ preservation rates for TLM were better than or equal to those of RT for both stage 1 and 2 glottic cancer.

Objective: Advancements in technology and personal computing afford the development of novel teaching modalities such as online Web-based modules. These modules are currently being incorporated into undergraduate medical curricula and, in some paradigms, have been shown to be superior to traditional methods of instruction. The purpose of this study was to evaluate the ability of a computer-assisted learning (CAL) module to demonstrate content and spatial information in the context of cranial nerve anatomy., Study Population: Undergraduate anatomy students., Methods: A prospective, randomized, controlled trial was conducted comparing a CAL module to traditional text-/image-based learning supplements. Indications of the participants' ability to translate spatial relationships between the trigeminal nerve and the craniofacial skeleton were assessed via a postintervention knowledge quiz., Results: No significant difference was identified between the CAL module and the control group. Students in both groups performed poorly in questions testing spatial relationships., Conclusions: The CAL module used in the present study did not objectively contribute to the understanding of spatial anatomic relationships of the cranial nerves in novice students. Despite this, these modules may help pique student interest and motivation and, as such, may be used in the context of supplemental learning resources in existing university curricula.

Background: Radiotherapy is commonly used to treat neoplasms of the head and neck, and fibrosis is a known side effect. The Cutometer is a device that quantifies properties of the skin. The goal of the study was to validate the Cutometer in normal neck tissues and then quantify fibrosis in radiated necks., Methods: We performed a prospective study of 251 patients. The elasticity and stiffness parameters were recorded. Control patients were compared to determine the correlation between their left and right sides. Next, the treatment groups were compared using a nonparametric test (Kruskal-Wallis)., Results: We found a significant correlation between the left and right sides of the control patients' necks, supporting the view that the Cutometer provides reproducible measurements in the normal neck. Furthermore, the Cutometer demonstrated reduced elasticity in necks treated with radiation, surgery-radiation, and chemoradiation. No significant difference in stiffness was seen., Conclusion: The Cutometer may serve as a valuable and valid tool for the measurement of neck skin elasticity. Radiated patients have a quantifiable decrease in their skin elasticity.

Background: This article considers whether preoperative tracheostomy and primary tracheoesophageal puncture (TEP) contribute as independent risk factors to the development of pharyngocutaneous fistula (PCF), as well as discusses the significant factors related to the perioperative management of these patients., Methods: Retrospective data were collected on 145 patients treated with total laryngectomy/pharyngolaryngectomy between January 2003 and July 2010 at the Victoria Hospital in London, Ontario, including whether preoperative tracheostomy or primary TEP was performed., Results: One in four (25%) patients developed a postoperative PCF. No increase in PCF rates was observed with either preoperative tracheostomy or primary TEP. Salvage surgery PCFs achieved lower rates of spontaneous closure compared to those undergoing primary surgery (p  =  .002)., Conclusions: Neither preoperative tracheostomy nor primary TEP was associated with the development of PCF. Surgical closure of PCF is more likely to be required in the setting of salvage surgery.

Background: Early-stage laryngeal squamous cell carcinoma is managed with radiotherapy or endoscopic surgery. Although cure rates are high, radiation failures often require total laryngectomy for salvage. Biomarkers that can predict tumour radioresistance may be useful in modifying the treatment approach for individual patients., Methods: Retrospective patient chart review yielded 75 patients with T1-T2 glottic squamous cell carcinoma treated with radiation therapy at the London Health Sciences Centre. Pretreatment tumour biopsies were immunostained for B-cell lymphoma 2 (Bcl-2), Ki-67, and epidermal growth factor receptor (EGFR) to correlate biomarker expression with disease-free survival (DFS)., Results: Ki-67 expression was strongly associated with recurrence following radiation and independently predicted poor DFS (hazard ratio 4.86, 95% CI 1.58-15.00; p  =  .006). EGFR and Bcl-2 were not associated with a risk of recurrence., Conclusions: Ki-67 expression identified a subset of patients with increased risk of local recurrence after radiation therapy. Ki-67 expression can potentially guide improved personalized treatments for patients with early-stage glottic squamous cell carcinomas.

Background: The ability to palpate neck masses and lymph nodes and appreciate qualities such as size, location, and consistency is critical for patient care and an important clinical skill for all physicians. Medical students currently learn neck palpation by practicing on healthy, standardized patients; however, studies of similar procedures have shown that educational models with simulated pathology help improve technique and confidence., Objective: Our goal was to create a tissue-mimicking neck model with palpable masses., Methods: Iterative design and development of a high-fidelity neck model using polyvinyl alcohol-cryogel (PVA-C), a nontoxic and biocompatible polymer that exhibits favourable tissue-mimicking elastic properties. Model geometries were digitally reconstructed from high-resolution cadaveric magnetic resonance imaging sections to create physical moulds through stereolithography. PVA-C was formulated to mimic the characteristics of human tissue., Results: A life-like neck model was built and consists of these components: muscle, larynx, spine, soft tissue, pathologic nodes, and skin., Discussion: A final neck model prototype has been completed and will be evaluated by otolaryngology consultants and residents for face and construct validity and assessed in a randomized, controlled trial to evaluate how it impacts students' ability to detect neck masses.

Background: The size of the malignancy in well-differentiated thyroid carcinoma (WDTC) is an important factor in patient risk stratification. Final pathologic measurements are currently used for treatment decisions. Measurements are made by both ultrasonography and on final pathology and should, theoretically, agree with each other., Objective: To evaluate the agreement between ultrasound and final pathologic measurements in thyroid nodules and WDTC., Methods: A retrospective chart review of all total thyroidectomies between 1998 and 2007 was completed by four different surgeons at one centre. Thyroid specimens with a solitary nodule and complete ultrasound and pathologic data were included. A comparison of discrepancy and concordance of the largest dimension of the nodule by ultrasound and pathologic measurement was made., Results: A total of 263 thyroid specimens with a solitary nodule were identified. Of these, 68 were found to harbour WDTC. A median underestimation by pathology of 0.54 cm was present in WDTC, averaging 20% of the nodule size by pathology. This trend was consistent with subgroup analysis for size, pathology, and nodularity. An underestimation by pathology of 0.4 cm was present for papillary carcinoma under 1 cm. Grouping nodules by size, a concordance of 80% was present for nodules under 1 cm. Statistical testing revealed weak correlation and a kappa of approximately 0.3 for agreement. Weighted kappa was approximately 0.5 for agreement., Conclusion: The recent advances in ultrasonography and the constraints of pathology preparation allow an argument to be made for investigation of using ultrasound measurements as an adjunct in making treatment decisions.

Objective: To assess the feasibility of internal transport disk distraction osteogenesis (ITDDO) for the regeneration of segmental mandibular defects and to evaluate the effect of radiation therapy., Design: Prospective case series., Setting: Tertiary care academic medical centre., Methods: Nine patients were accrued (M:F 6:3; mean age 63 years, range 37-77 years) and underwent ITDDO for the regeneration of segmental mandibular defects. The mean follow-up time was 43 months (range 6-87 months). The average bony defect was 6.1 cm (range 3.0-10.0 cm)., Main Outcome Measures: Construct formation (graded as complete, partial, and none based on evidence of calcification on panorex films and palpation), complications, and plate exposure (grouped by those that were thought to be related to distraction and those that were independent of distraction)., Results: Construct formation was "complete" in two of nine patients (22%), "partial" in four of nine (44%), "none" in two of nine (22%), and one of nine patients (11%) died prior to the 6 month assessment point. Four patients did not undergo radiation therapy, and two had stable constructs 6 years after treatment completion. Five patients underwent radiation therapy, and none of these patients formed stable, ossified constructs. All patients experienced a complication, and seven of nine (78%) developed hardware exposure, with six contributing to construct loss., Conclusions: Construct formation with ITDDO is possible for large composite mandibular defects in patients who have not received radiation. The complication rate was unacceptably high but may improve with better patient selection, refinement in surgical technique and distractor design, and tissue engineering for construct support.

Objectives: Adductor spasmodic dysphonia (ADSD) is a voice disorder characterized by considerable intra- and intersubject variability. Although objective, acoustic measures of voice may provide a metric for ADSD, such measures can be inefficient in documenting such characteristics. This project integrated a simple auditory-perceptual measure termed "laryngeal overpressure" (LO) with measures of acoustic variability., Methods: Ten adults diagnosed with ADSD were sequentially followed over a period of 3 to 6 months. Standard voice recordings were obtained at each point, and acoustic measures were gathered. Additionally, three experienced listeners then rated LO using a visual analogue scale, and acoustic variability was assessed relative to the measure of LO., Results: Listener ratings of LO did not differ across the three-sentence stimuli and were highly correlated (r  =  .828 and .909 for naive and experienced listeners, respectively). A strong correlation was identified between the acoustic measure of harmonics to noise ratio and the all-voiced sentence stimuli (r  =  .710)., Conclusion: LO appears to provide an easy clinical method of documenting voice change over time in those with ADSD. Although additional methods of voice monitoring may be used, the use of LO may provide the opportunity for a standard and reliable approach to the clinical monitoring of voice variability in those presenting with ADSD.

Background: The aim of this preliminary study was to determine the prevalence of trismus in head and neck cancer patients treated with radiotherapy with or without concomitant chemotherapy and surgery., Methods and Materials: Patients with malignant lesions in the head and neck treated with curative intent were comprehensively evaluated for trismus using subjective and objective measures., Results: A large proportion of the 70 patients recruited demonstrated moderate to severe subjective trismus (45.7%). Similarly, the vast majority of patients showed slight to severe trismus (91.4%) according to objective secondary outcome measures. Of these patients, 21 (65.6%) were also treated with concurrent chemoradiotherapy. When the radiation field involved the pterygoid muscles, 30 (93.8%) patients reported subjective trismus. Similarly, bilateral pterygoid muscle inclusion resulted in 28 (87.5%) patients with trismus., Conclusions: Trismus is a significantly prevalent consequence of treatment for head and neck cancer. Predictive factors include treatment with concurrent chemoradiotherapy and bilateral inclusion of the structures of mastication in the high-dose radiotherapy volume.

Background: Malignant submandibular gland tumours are rare tumours treated primarily with surgery., Purpose: This retrospective study was done to determine the effectiveness of adjuvant radiation therapy (RT), to document the patterns of failure, and to define the prognostic variables for treatment outcome., Materials and Methods: Between 1960 and 2002, 74 patients diagnosed as having malignant submandibular gland tumours were treated with radical surgery. The surgery included neck dissection in 37 patients and adjuvant RT in 50 patients with high-risk features., Results: Forty-one (54%) patients experienced disease relapse. The local recurrence rates were 35% in those treated only with surgery and 21% in patients who underwent postoperative RT (p  =  .20). The risk of subclinical nodal metastases in the clinical N0 neck was 21%., Conclusions: The American Joint Committee on Cancer stage approached statistical significance for cause-specific survival. Although not statistically significant, RT probably reduced local recurrence. All patients with malignant submandibular tumours except T1 need elective neck treatment.

Objective: Hematoma is a potentially life-threatening complication of thyroid surgery. Ketorolac is a nonsteroidal anti-inflammatory drug with known antiplatelet activity that is used for analgesia. The goal of this study was to determine the risk of hematoma in patients who received ketorolac in thyroid surgery., Design: Retrospective cohort study., Setting: London Health Sciences Centre., Methods: A retrospective cohort study was conducted of patients who underwent thyroid surgery between 2002 and 2007. Data were analyzed using the Fisher exact test., Main Outcome Measures: Incidence of postoperative hematoma and perioperative ketorolac administration., Results: Thirteen hematomas occurred in 799 patients. Of the 799, 183 patients received ketorolac (22.9%) and 616 did not. Five in the ketorolac group (2.73%) and eight in the nonketorolac group (1.30%) developed hematomas. The calculated relative risk was 2.10 (95% CI 0.70-6.35)., Conclusions: Although there was an increased incidence of hematomas in the group receiving ketorolac, the difference was not statistically significant. The lack of significance may be due to the low number of hematomas.

Objective: Radiation therapy (RT) and transoral laser microsurgery (TLM) are established treatments for early glottic squamous cell carcinoma (SCC). Similar oncologic outcomes have been reported with both modalities, leading physicians to consider other factors when making clinical recommendations. One such factor is voice-related quality of life. This investigation sought to characterize differences in self-reported voice outcomes in patients undergoing RT or TLM for the treatment of Tis or T1a glottic SCC., Methods: A retrospective cohort study was conducted of all individuals who received either RT or TLM for the treatment of Tis or T1a glottic SCC between 2004 and 2009 at the London Regional Cancer Program. The primary outcome measure was voice-related quality of life, as assessed by the Voice-Related Quality of Life questionnaire (V-RQOL). Secondary outcomes included local control, overall survival, and laryngectomy-free survival., Results: Fifty-seven patients were eligible for this study; 34 received RT and 23 received TLM. Forty (70.2%) of the 57 patients completed the V-RQOL. No statistically significant difference in total V-RQOL score was observed between the RT and TLM cohorts (p  =  .228). There was, however, a trend toward higher scores (ie, less voice disability) in the physical function domain of the V-RQOL for the RT group (90.0%) compared to the TLM group (80.2%) (p  =  .05). No significant differences were observed in recurrence or overall survival between the two groups., Conclusion: Both oncologic outcomes and self-rated voice-related quality of life are similar in patients treated with RT and TLM for early glottic carcinoma.

Objective: To study the treatment outcomes of N3 neck disease following primary chemoradiotherapy., Design: Retrospective cohort., Setting: Tertiary care centre., Methods: A review was conducted of 25 consecutive patients with N3 neck disease treated with primary platinum-based chemoradiotherapy. A neck dissection (ND) was offered in the event of clinical and/or radiologic evidence of residual disease on follow-up., Main Outcome Measures: Recurrence-free, disease-specific, and overall survival and patterns of failure., Results: A regional complete response (CR) was noted in 48% of the patients. ND was performed in 36% of the cases. The median duration between the end of radiation and ND was 71 days. The recurrence-free survival rates at 1 and 2 years were 73% and 64%, respectively. The 2-, 3-, and 5-year overall survival rates were 66.7%, 52%, and 31.2%, respectively. Disease-specific survival rates were 69.6%, 63.3%, and 50.6%, respectively. Nine patients developed distant recurrence, with one having concurrent local and regional recurrence as well. Patients in the CR group remained free of regional recurrence. Among the initial partial responders, 54% eventually developed distant metastasis compared to 17% in the CR group., Conclusion: Patients with N3 disease may be managed with chemoradiotherapy, with ND reserved for salvage. Distant metastasis accounts for most recurrences and for the reduction in survival.

Background: type I thyroplasty is an effective and safe procedure for unilateral vocal fold paralysis and is shifting toward outpatient postoperative care. However, serious airway complications have been reported., Objectives: the aims of this study were to investigate whether risk stratification into inpatient/outpatient postoperative care reduces outpatient airway complications and to compare the cost-effectiveness and surgical outcomes of risk stratification to a historical inpatient control group (non-risk stratified)., Setting: tertiary, university-based medical centre., Design and Results: Three retrospective groups were examined: historical inpatient control (n = 15), risk-stratified (RS)- inpatient (n = 16), and RS outpatient (n = 17). Laryngeal edema was encountered in two historical controls (13.3%), two RS inpatients (12.5%), and one RS outpatient (5.9%). One case of implant extrusion occurred in the RS outpatient group. There was no difference in maximum phonation time or voice-related quality of life between RS versus historical controls (p > .5). The cost savings of risk stratification versus entirely inpatient care was $CAD 633.12/patient. The average duration in hospital for RS inpatient versus RS outpatient was 29.8 and 8.3 hours, respectively., Conclusions: postoperative RS may reduce potentially serious outpatient airway complications and cost while improving patient satisfaction.

Objective: To review the experience with scapular free tissue transfer at the University of Western Ontario and to describe the various applications of both the fasciocutaneous and osteocutaneous versions., Design: Retrospective review., Setting: Tertiary care centre., Methods: A retrospective review was conducted of patients who underwent a scapular free flap reconstruction between 1997 and 2007. Osteocutaneous and fasciocutaneous flaps were included. Demographic data including gender and age were collected. Defect analysis and complications were also reviewed., Main Outcome Measures: Defect analysis, flap-related complications, and non-flap-related complications., Results: Sixty procedures, including 31 osteocutaneous and 29 fasciocutaneous flaps, were performed. Most fasciocutaneous flaps were used for large lateral skull base and facial defects (70%). The skin paddle dimensions ranged from 4 × 3 to 15 × 10 cm. All osteocutaneous flaps were used for mandibular reconstruction. The length of the bony defect ranged between 4 and 12 cm. Eleven patients required osteotomies. In most cases, the facial or external carotid arteries and internal jugular or facial veins were selected as recipient vessels. A vein graft was required in four cases. The total flap failure rate was 5%. Seven patients who had osteocutaneous flaps suffered medical complications, including one mortality., Conclusions: Scapular free flaps are reliable options. Fasciocutaneous applications are suitable for defects requiring facial contouring or complex skull base defects. Osteocutaneous flaps are acceptable options for patients with comorbidities requiring bony reconstructions. The flap complication rates were acceptable even in medically higher-risk patients.

Introduction: Adductor spasmodic dysphonia (ADSD) is a focal dystonia treated most commonly by chemodenervation of the thyroarytenoid (TA) muscles with botulinum toxin. Currently, there are no consensus guidelines regarding this treatment and the management of ADSD. The objective of this study was to assess current practice patterns among physicians who treat ADSD., Methods: A cross-sectional survey study was conducted regarding treatment choices and specific technical aspects of injection technique and botulinum toxin use. The study population consisted of laryngologists from the Canadian Society of Otolaryngology-Head and Neck Surgery and laryngologists obtained from the American Laryngological Association member database and the American Academy of Otolaryngology-Head and Neck Surgery Neurolaryngology Study Group., Results: An overall response rate of 13% was achieved, with a high absolute number of physicians who manage ADSD responding (n = 37). Most respondents treat ADSD by injecting botulinum toxin type A (Botox) through the cricothyroid membrane submucosally at a mode starting dose of 2.5 units per TA muscle using electromyographic guidance with or without fibre-optic laryngoscopy every 3 to 4 months, with the frequency of reinjection being based on patient symptomatology. There is much variability with regard to starting injection dose, alternate treatments for ADSD, unilateral versus bilateral injections, and guidance technique. Most physicians (36 of 37) share one vial among more than one patient, and some (7 of 37) freeze a reconstituted vial that has remaining toxin for reuse at a later time., Conclusions: There is considerable variability in treatment practices for the management of ADSD. Further study is warranted to define an optimal therapeutic paradigm.

Introduction: Didactic head and neck anatomy teaching has been replaced by a novel self-directed, multimodal, and multidisciplinary approach at the Schulich School of Medicine and Dentistry (SSMD)., Objectives: To describe the use of a novel teaching paradigm at SSMD and to enable readers to determine how this methodology may benefit medical students at other academic institutions and disciplines., Design: Prospective cohort study., Methods: The paradigm consists of multimedia learning modules to guide independent anatomy learning. Students received a case-based assignment based on the content of the learning modules to guide them through cadaveric dissections facilitated by a multidisciplinary team of surgeons and anatomists., Primary Outcome: Postcourse survey and mean scores comparison. The survey collected data, including demographics and previous anatomic and computer-assisted learning (CAL) experiences, and focused on measuring student perception of the proposed paradigm. Secondary outcome: Correlation of demographics., Results: The paradigm was successfully implemented and warmly received, but it still requires further development. Although CAL allows increased individual engagement, students still enjoy and value lectures. In addition, students view instruction by surgeons in laboratories as the most valuable component of their anatomy teaching as it not only deepened the students' understanding of anatomic structures but also provided them with the clinical relevance. Technological innovations were welcomed by the students but have not replaced their appreciation of dissection and lecures.

Objective: The goal of our study was to identify factors in intermediate-risk fine-needle aspiration (FNA) results that are predictive of malignancy., Design: Retrospective chart review., Setting: Head and neck oncology clinic at the London Health Sciences Centre., Methods: A database of 665 patients who had received thyroid surgery between 2001 and 2007 was created. FNA biopsy data were collected for each patient, as well as pathologic, patient, and ultrasound data. Of the 665 patients, 302 FNA biopsies were considered intermediate risk, and these data were analyzed., Main Outcome Measure: Presence of malignancy., Results: Intermediate-risk patients were significantly more likely to have a benign nodule if the width to length (W/L) ratio of their nodule was < 0.6. The relative risk was 5.64 (95% confidence interval [CI] 0.81-39.65) (p < .05). As well, patients who were in the intermediate-risk category were significantly more likely to have a malignancy if they were < 40 years old compared to those patients who were > or = 40 years old., Conclusions: Both age and W/L ratio of a nodule can be used to help predict whether a nodule in an intermediate-risk patient is malignant. An intermediate-risk patient who has a W/L ratio < 0.6 can be treated conservatively based on the extremely low risk of malignancy (2.86%).

Objective: To evaluate a novel method of teaching laryngeal anatomy., Design: Prospective, randomized, controlled trial., Setting: University educational program., Methods: Computer model development: A three-dimensional (3D) educational computer model of the larynx was created from high-resolution computed tomography and magnetic resonance images of cadaveric necks using segmentation software (Amira) (Visage Imaging, Inc., Carlsbad, CA). E-learning authoring software (Articulate, Articulate Global, Inc, New York, NY) then was used to make the model interactive and multimedia. The model was launched on a Web-based platform. Model evaluation: One hundred students (age 23.8 +/- 2.2 years; 55% male) were randomized to either the 3D computer model group (3D group) (n = 50) or the standard written instruction group (SWI group) (n = 50)., Main Outcome Measures: The primary outcome measure was the score on a 20-question laryngeal anatomy test; the secondary outcome measure was a student opinion questionnaire., Results: The mean score on the laryngeal anatomy test was 14.2 +/- 2.8 (72.0 +/- 15.1%). The mean score for the 3D group was 13.6 +/- 3.0 (67.0 +/- 16.1%) versus 14.8 +/- 2.5 (76.0 +/- 12.7%) for the SWI group (t = 2.194, df = 98, p < .031). A majority of students felt that the 3D model was effective, clear, user-friendly, and a preferred supplement to traditional methods of instruction. The 3D group rated the computer model more enjoyable than the SWI group., Conclusions: A 3D educational computer model of the larynx was not shown to be superior to written lecture notes in its efficacy in teaching anatomy; however, it was judged to be a preferred and valuable supplement to traditional teaching methods.

Objectives: Otolaryngologic problems are common in primary care but are underrepresented in undergraduate medical education (UME). A significant portion of the total structured teaching received by physicians in primary care specialties is spent in UME, but teaching of otolaryngology in UME is limited and not standardized across Canadian medical schools. This study assessed the content and structure of otolaryngology UME at Canadian undergraduate medical programs and postgraduate primary care programs and surveyed community otolaryngologists to identify important clinical topics for inclusion in an otolaryngology curriculum., Methods: A survey was created based on previously validated and published curriculum needs assessment instruments for medical education. Surveys were distributed to (1) undergraduate directors of otolaryngology, (2) postgraduate program directors of family and emergency medicine at English-language medical schools, and (3) community otolaryngologists in Canada., Results: There is large variation in the quantity of otolaryngology teaching in UME. Knowledge of otolaryngology is formally evaluated at half of the responding programs, although skills in otolaryngology are rarely tested. Clerkship rotations are not uniformly offered, and the length of these placements is limited. Opportunities in postgraduate training for formal education in otolaryngology are rare. Several important topics that are not uniformly taught include sudden sensorineural hearing loss, sleep apnea, and nasal trauma. Important skills that are not uniformly taught include treatment of benign paroxysmal positional vertigo and epistaxis., Conclusions: There is limited time for teaching otolaryngology in UME; therefore, it is essential to emphasize teaching key topics and skills, which are highlighted in the results of this study.

Objective: Clinical scar assessment lacks standardized methodology and consensus on the most appropriate evaluation instrument. This study empirically evaluated whether area scars could be validly assessed by naive observers with the objective to develop and validate a novel multidimensional visual analogue scale (VAS) for the assessment of area scars., Methods: Standardized digital photographs of radial forearm free flap (RFFF) donor sites were obtained. Naive observers evaluated the images in three sequential psychophysical experiments, which led to the development of the new scar scale. These experiments involved initial evaluation of four dimensions (pigmentation, vascularity, observer comfort, acceptability) using a paired comparison (PC) paradigm and correlation with ratings of overall severity using a VAS, and initial VAS test phase followed by formal debriefing, and, subsequently, evaluation of a VAS for the four dimensions in addition to contour. Validation involved determination of intra- and interrater reliability and correlational analysis., Results: Across all three experiments, 56 observers evaluated 101 images, generating 12 720 observations for analysis. PC data demonstrated that observers could assess scars with high reliability and internal consistency for all dimensions (> 95%). Overall (VAS) severity correlated highly with all dimensions, including contour. The new VAS yielded high levels of correlation (r = .72-.98, p < .01)., Conclusion: Comprehensive VAS analysis demonstrates high reliability in mirroring PC results for multiple dimensions of area scars. These data support our novel multidimensional VAS method as a valid, reliable, simple, and time-efficient instrument for clinical and research use. We introduce the Western Scar Index as a new measurement tool with many potential applications.

Background: Mucositis is one of the most debilitating side effects of head and neck cancer therapy and is currently believed to arise from an inflammatory cascade leading to cellular damage. However, no effective treatment has been identified despite extensive attempts with anti-inflammatory medications., Objective: To compare real-time microvascular inflammatory changes with oral mucositis levels in patients undergoing radiotherapy or chemoradiotherapy for head and neck tumours., Design: Prospective, longitudinal, cohort, observational study., Setting: Regional cancer program., Methods: Twenty patients with head and neck tumours were assessed on a weekly basis throughout the course of radiotherapy. Levels of mucositis were graded objectively using the Oral Mucositis Assessment Scale and subjectively using a patient symptom questionnaire. Video imaging of the sublingual microcirculation was obtained using orthogonal polarized spectral imaging to quantify inflammatory markers such as microcirculatory velocity, white blood cell margination, and extravasation., Results: Despite very high levels of objective and subjective mucositis, inflammatory changes were not present in the microcirculation., Conclusions: Typical microvascular inflammatory changes are not demonstrated in radiation-induced mucositis. These findings contradict the currently proposed mechanism of mucosal damage and may therefore have important implications in the development of novel therapeutic interventions.

Objectives: To investigate the adequacy of otolaryngology teaching in undergraduate medical education (UME) and to determine the general level of comfort of family medicine residents in managing and assessing diseases affecting the ears, nose, and throat., Design: Cross-sectional survey., Methods: A sample of family medicine residents at the University of Western Ontario (N = 68) completed a questionnaire inquiring into their exposure to topics in otolaryngology during their UME. They were also asked to comment on their present comfort with knowledge and skills specific to otolaryngology., Results: Family medicine residents suggest that there is generally little otolaryngology training in UME; 66.7% of respondents who received UME in Canada suggested that they received very little classroom instruction and 75.6% received very little clinical otolaryngology instruction. Residents identified specific otolaryngologic conditions with which they felt particularly uncomfortable., Conclusions: This study demonstrated that students receive very little exposure to otolaryngology in UME and highlighted specific conditions and procedures that family medicine residents lack confidence in managing and performing.

Objectives: Efforts to assess the level of voice-related disability through application of written instruments are gaining wider acceptance in clinical practice. However, based on the questions posed, additional diagnostic information may be obtained. This study evaluated the potential extended utility of the Physical Functioning (PF) subscore of the Voice-Related Quality of Life (V-RQOL) measurement instrument. Specifically, we examined whether the PF subscore could distinguish between the presence or absence of vocal fold lesions in patients who presented with dysphonia secondary to hyperfunctional voice disorders. A normative control database was also used for comparative purposes., Design: Comparative analysis., Setting: Academic tertiary care centre., Methods: Forty adults with a hyperfunctional voice disorder. All had been seen for medical evaluation to confirm laryngeal status., Main Outcome Measures: V-RQOL total and domain scores., Results: Although variability in V-RQOL scores was observed, differential profiles emerged from comparisons of participants who presented with vocal fold pathology and those who did not. Significantly lower PF and total V-RQOL scores were observed for those with benign mass lesions of the vocal folds. Additionally, discriminant analysis of the data permitted the generation of a cutoff value for the PF subscore, which identified 80% of those with mass lesions. These data also permitted calculation of sensitivity, specificity, and positive predictive and negative predictive values., Conclusions: The findings suggest that the PF subscore may exhibit the capacity to distinguish dysphonic patients who present with a mass lesion of the vocal folds from those who do not within the context of a hyperfunctional voice disorder. Clinical implications and applications of the V-RQOL are discussed.