Search

Objectives/hypothesis: Common endpoints in reporting the outcomes for early glottic cancer do not highlight the importance of organ preservation. We evaluated the treatment outcomes among patients with T1aN0 laryngeal cancer with laryngectomy-free disease-specific survival (LFS-DSS), which is defined as time to total laryngectomy or time to death from cancer cause, against all other endpoints., Study Design: Outcome research on an institutional database., Methods: A retrospective review covered all consecutive patients from 2003 to 2013. Patients with T1a laryngeal squamous cell carcinoma (SCC) were offered the options of either radiation treatment (RT) or transoral laser microsurgery (TLM). Tumor control, survival outcomes, standard definition laryngectomy-free survival (LFS), and LFS-DSS were calculated., Results: There were 105 patients, of whom 53 were treated with TLM and 52 were treated with RT. There were 11 recurrences within the TLM group, of which four were successfully salvaged with repeated TLM and two were salvaged with RT. Among the four recurrences within the RT group, all four patients had salvage total laryngectomies. The 5-year overall survival for patients treated with TLM versus RT was 86% versus 85% (P = .887), disease-free survival was 69% versus 78% (P = .151), LFS was 65% versus 77% (P = .198), LFS-DSS was 100% versus 88% (P = .030), and ultimate locoregional control was 100% in both groups., Conclusions: Patients with T1aN0 glottic SCC treated with RT or TLM have similar survival outcomes. Patients with T1a tumor treated with TLM have better organ preservation compared to RT, when measured with LFS-DSS., Level of Evidence: 4. Laryngoscope, 127:1322-1327, 2017., (© 2016 The American Laryngological, Rhinological and Otological Society, Inc.)

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.

Albendazole is an anti-helminthic drug that has been shown to exhibit anti-cancer properties, however its activity in head and neck squamous cell cancer (HNSCC) was unknown. Using a series of in vitro assays, we assessed the ability of albendazole to inhibit proliferation in 20 HNSCC cell lines across a range of albendazole doses (1 nM-10 μM). Cell lines that responded to treatment were further examined for cell death, inhibition of migration and cell cycle arrest. Thirteen of fourteen human papillomavirus-negative HNSCC cell lines responded to albendazole, with an average IC 50 of 152 nM. In contrast, only 3 of 6 human papillomavirus-positive HNSCC cell lines responded. Albendazole treatment resulted in apoptosis, inhibition of cell migration, cell cycle arrest in the G2/M phase and altered tubulin distribution. Normal control cells were not measurably affected by any dose tested. This study indicates that albendazole acts to inhibit the proliferation of human papillomavirus-negative HNSCC cell lines and thus warrants further study as a potential chemotherapeutic agent for patients suffering from head and neck cancer., Competing Interests: CONFLICTS OF INTEREST Authors declare no conflicts of interest.

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.

Objective: To identify which factors influence medical students' decision to choose a career in family medicine and pediatrics, and which factors influence their decision to choose careers in non-front-line specialties., Design: Survey that was created based on a comprehensive literature review to determine which factors are considered important when choosing practice specialty., Setting: Ontario medical school., Participants: An open cohort of medical students in the graduating classes of 2008 to 2011 (inclusive)., Main Outcome Measures: The main factors that influenced participants' decision to choose a career in primary care or pediatrics, and the main factors that influenced participants' decision to choose a career in a non-front-line specialty., Results: A total of 323 participants were included in this study. Factors that significantly influenced participants' career choice in family medicine or pediatrics involved work-life balance (acceptable hours of practice [ P = .005], acceptable on-call demands [ P = .012], and lifestyle flexibility [ P = .006]); a robust physician-patient relationship (ability to promote individual health promotion [ P = .014] and the opportunity to form long-term relationships [ P  < .001], provide comprehensive care [ P = .001], and treat patients and their families [ P = .006]); and duration of residency program ( P = .001). The career-related factors that significantly influenced participants' decision to choose a non-front-line specialty were as follows: becoming an expert ( P  < .001), maintaining a focused scope of practice ( P  < .001), having a procedure-focused practice ( P = .001), seeing immediate results from one's actions ( P  < .001), potentially earning a high income ( P  < .001), and having a perceived status among colleagues ( P  < .001)., Conclusion: In this study, 8 factors were found to positively influence medical students' career choice in family medicine and pediatrics, and 6 factors influenced the decision to choose a career in a non-front-line specialty. Medical students can be encouraged to explore a career in family medicine or pediatrics by addressing misinformation, by encouraging realistic expectations of career outcomes in the various specialties, and by demonstrating the capacity of primary care fields to incorporate specific motivating factors., (Copyright© the College of Family Physicians of Canada.)

Background: The pedicled adipofascial infraclavicular flap (ICF) is based on the anterior perforator of the supraclavicular artery and supplies the fasciocutaneous tissue of the upper chest. This flap may be used to address neck contour defects and vessel coverage after radical and modified radical neck dissections (MRNDs)., Methods: We described the pedicled adipofascial ICF elevation technique and its use immediately after neck dissections in order to maintain soft tissue volume and vessel coverage. A video of the operation is provided., Results: Our results demonstrated satisfactory neck contours with adequate volume replacement, great vessel coverage, and little donor-site morbidity., Conclusion: The pedicled adipofascial ICF is a technically straightforward operation with broad possible applications in head and neck surgery. It may be useful to provide vascularized soft-tissue coverage and maintain neck contour after neck dissections. © 2016 Wiley Periodicals, Inc. Head Neck 38: First-1582, 2016., (© 2016 Wiley Periodicals, Inc.)

Objectives/hypothesis: Computer-aided instruction (CAI) is defined as instruction in which computers play a central role as the means of information delivery and direct interaction with learners. Computer-aided instruction has become mainstream in medical school curricula. For example, a three-dimensional (3D) computer module of the larynx has been created to teach laryngeal anatomy. Although the novelty and educational potential of CAI has garnered much attention, these new technologies have been plagued with low utilization rates. Several experts attribute this problem to lack of motivation in students. Motivation is defined as the desire and action toward goal-oriented behavior. Psychologist Dr. John Keller developed the ARCS theory of motivational learning, which proposed four components: attention (A), relevance (R), concentration (C), and satisfaction (S). Keller believed that motivation is not only an innate characteristic of the pupil; it can also be influenced by external factors, such as the instructional design of the curriculum. Thus, understanding motivation is an important step to designing CAI appropriately. Keller also developed a 36-item validated instrument called the Instructional Materials Motivation Survey (IMMS) to measure motivation. The objective of this study was to study motivation in CAI. Medical students learning anatomy with the 3D computer module will have higher laryngeal anatomy test scores and higher IMMS motivation scores. Higher anatomy test scores will be positively associated with higher IMMS scores., Study Design: Prospective, randomized, controlled trial., Methods: After obtaining institutional review board approval, 100 medical students (mean age 25.5 ± 2.5, 49% male) were randomized to either the 3D computer module (n = 49) or written text (n = 51). Information content was identical in both arms. Students were given 30 minutes to study laryngeal anatomy and then completed the laryngeal anatomy test and IMMS. Students were categorized as either junior (year 1 and 2) or senior (year 3 and 4)., Results: There were no significant differences in anatomy scores based on educational modality. There was significant interaction of educational modality by year [F(1,96) = 4.12, P = 0.045, ω(2)  = 0.031]. For the total score, there was a significant effect of year [F(1,96) = 22.28, P < 0.001, ω(2)  = 0.178], with seniors (15.4 ± 2.6) scoring significantly higher than juniors (12.8 ± 3.1). For the motivational score, the total IMMS score had two significant effects. With educational modality [F(1,96) = 5.18, P = 0.025, ω(2)  = 0.041], the 3D group (12.4 ± 2.8) scored significantly higher than the written text group (11.7 ± 3.2). With year [F(1,96) = 25.31, P < 0.001, ω(2)  = 0.198], seniors (13.4 ± 3.0) scored significantly higher than juniors (10.8 ± 2.5). Pearson's correlation showed positive associations (r = 0.22-0.91) between anatomy scores and IMMS motivation scores (P < 0.05)., Conclusion: Computer-aided instruction conferred no measurable educational benefit over traditional written text in medical students; however, CAI was associated with higher motivational levels. Computer-aided instruction was found to have a greater positive impact on senior medical students with higher anatomy and motivational scores. Higher anatomy scores were positively associated with higher motivational scores. Computer-aided instruction may be better targeted toward senior students., Level of Evidence: N/A. Laryngoscope, 126:S5-S13, 2016., (© 2016 The American Laryngological, Rhinological and Otological Society, Inc.)

Introduction: Spontaneous thyroid hemorrhage is a rare occurrence that results in pain, discomfort, and occasionally compressive symptoms. Infrequently, extensive thyroid hemorrhage can result in a rapidly expanding hematoma resulting in airway compromise. This is a case of an otherwise healthy young woman, 3 months postpartum, with a slowly expanding spontaneous thyroid hemorrhage that measured at 7 × 5.5 × 5 cm by computed tomography. She ultimately required intubation to manage respiratory distress and subsequently a hemithyroidectomy for definitive treatment. The case presentation is followed by a literature review where known etiologies of thyroid hematoma including traumatic and nontraumatic causes, precipitating anticoagulation, and spontaneous rupture of branches of the external carotid artery are outlined. The potential links to pregnancy are explored. The roles of bedside thyroid ultrasound in the emergency department and lateral neck roentgenogram in diagnosis are explored. The importance of airway management and indications for conservative versus surgical treatments are discussed., Conclusions: This is a case of a spontaneous intrathyroidal hemorrhage, which progressed over days to ultimately cause airway compromise. It is imperative that physicians are educated on the appropriate detection and management of the potentially life-threatening spontaneous thyroid hematoma., Competing Interests: The authors report no conflicts of interest.

Objectives/hypothesis: To assess the efficacy of a novel high-fidelity epistaxis simulator in teaching epistaxis management to junior otolaryngology head and neck surgery residents., Study Design: Prospective cohort study., Methods: A novel high-fidelity epistaxis task trainer was developed using a cadaver head, intravenous tubing, and a food coloring-filled saline bag to emulate blood. Learners were instructed on two techniques of nasal packing (formal nasal pack and nasal tampon) for the management of epistaxis using the task trainer. Learners were videotaped attempting to pack the nose of the task trainer pre- and postintervention (verbal instruction, and practice time with task trainer). Five board-certified otolaryngologists (blinded to pre- and postintervention status) evaluated the packing technique using standardized subjective outcome measures., Results: There were 13 junior otolaryngology residents enrolled in the study. This cohort showed a statistically significant increase in global rating scores (P < 0.05) in all items measured for both packing methods., Conclusion: This novel cadaveric epistaxis simulator has been successful in teaching and the practical application of various skills in epistaxis management. This task trainer appears to confer an educational benefit in technical skills acquisition in novice learners. Further studies are needed to determine long-term skill retention. Simulation is a promising educational adjunct that effectively enhances epistaxis management skills acquisition while maximizing patient safety., Level of Evidence: NA. Laryngoscope, 126:1501-1503, 2016., (© 2015 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: To critically review current literature comparing interventional approaches for unilateral vocal fold paralysis., Study Design: Systematic review of the literature., Methods: All English-language literature published in the PubMed database was eligible for inclusion. Inclusion criteria were: 1) the major topic must be a direct comparison of outcomes in interventions for unilateral vocal fold paralysis, 2) the subjects were 18 years or older, and 3) it was original research. Studies involving treatment of bilateral vocal fold paralysis and nonprocedural interventions were excluded. Included studies were categorized according to level of evidence. Outcomes analyzed were acoustic and aerodynamic measures, auditory perceptive evaluation, laryngoscopic findings, and complications., Results: Of the 504 studies retrieved from the search strategy, 17 studies met inclusion and exclusion criteria. Overall, four interventional approaches were used for treatment of unilateral vocal fold paralysis: medialization thyroplasty, injection laryngoplasty, arytenoid adduction, and laryngeal reinnervation. Aside from some select improvements in single outcome parameters, overall, the majority of studies show no difference in improvement of outcomes between techniques., Conclusions: Four surgical interventions for unilateral vocal fold paralysis are available for treatment of unilateral vocal cord paralysis. Multiple studies show favorable outcomes, but no significant differences between treatment arms based on perceptual, acoustic, quality of life, and laryngoscopic outcomes., Level of Evidence: NA Laryngoscope, 126:1616-1624, 2016., (© 2015 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: To create and assess a novel high-fidelity peritonsillar abscess simulation task trainer with junior otolaryngology-head and neck surgery residents., Study Design: Prospective cohort study., Setting: Third annual Emergencies in Otolaryngology Head & Neck Surgery Bootcamp course at the Canadian Surgical Technologies & Advanced Robotics in London, Canada., Subjects and Methods: Fresh cadaveric material was obtained consisting of a head and neck. Abscess pockets were simulated with a finger of a latex glove containing vanilla pudding to represent pus, tied off with a silk suture. These abscess pockets were inserted into the peritonsillar space from the transected neck inferiorly, passing medial to the great vessels into the parapharyngeal space. Faculty members evaluated the models to test content validity. The primary outcome measure was a postbootcamp survey evaluation assessing specific domains: learning objectives, effectiveness of faculty, and the quality and realism of models., Results: When working with this model, learners were able to locate, visualize, and manipulate the abscess. The materials and positioning of the pockets created high-fidelity models that were realistic in appearance and haptics feedback., Conclusions: A novel high-fidelity task trainer has been successfully developed to teach the technique of peritonsillar abscess incision and drainage. This task trainer is currently the highest-fidelity model reported in the literature. This model allows learners to practice a high-stakes emergency skill in a controlled environment, affording the opportunity to practice localization, visualization, and drainage of the abscess with a high level of realism., (© American Academy of Otolaryngology—Head and Neck Surgery Foundation 2016.)

PIK3CA is the only frequently-mutated, directly druggable oncogene in head and neck squamous cell carcinoma (HNSCC). However, it is unclear if a molecularly-driven intervention trial can be launched successfully, particularly within a single-institution setting secondary to the infrastructure necessary for mutation detection, mutation prevalence, and patient willingness to participate. This study aimed to evaluate 1) local frequency of PIK3CA activating mutations in HNSCC, 2) timeliness of our mutation-profiling clinical pathway, and 3) patients' willingness to enroll in a novel neoadjuvant drug trial. Tissue biopsies of 25 consecutive cases of HNSCC were tested for activating PIK3CA mutations at three mutational hotspots by real-time polymerase chain reaction. Mutations prevalence and number of working days accrued in determining PIK3CA mutational status were calculated. In addition, 30 HNSCC patients were surveyed prospectively regarding their willingness to participate in a hypothetical drug trial. Survey data were summarized descriptively. 4 of 25 (16 %) tumors harbored a PIK3CA activating mutation, including one at codon E542K, two at codon E545K/D, and one at codon H1047R. On average, this result was obtained in approximately 15 working days (range, 9-24 working days). The majority of patients surveyed (70 %) indicated their willingness to participate in a targeted PIK3CA trial. This study provides evidence that within a single institution, PIK3CA activating mutations can be detected with expected frequency, with sufficient timeliness and sufficient patient interest to mount a targeted intervention trial that may lead to improved tumor response in selected HNSCC patients.

Eagle syndrome occurs when an elongated styloid process causes otolaryngological or neurological symptoms or signs. We report a patient who had an isolated asymptomatic Horner syndrome that resulted from a pinned internal carotid artery being dynamically injured by an elongated styloid process during chiropractic neck manipulation. There was no evidence of arterial dissection.

Background: Osteoradionecrosis (ORN) of the temporal bone is a complication of radiation therapy that is extremely challenging to manage., Methods: We report the case of a patient treated at our institution and present a review of the literature., Results: A 52-year-old woman presented with ORN of the temporal bone 20 years after radiation therapy for an ipsilateral parotid tumor. She failed conservative management, including serial debridements, oral and topical antibiotics/antifungals, and aural lavage. As an alternative to hyperbaric oxygen (HBO) and/or temporal bone resection, treatment with pentoxifylline-tocopherol-clodronate combination (PENTOCLO) was pursued and her condition improved dramatically., Conclusion: This is the first document use of PENTOCLO to treat ORN of the temporal bone. PENTOCLO may represent an effective nonsurgical management option for ORN of the temporal bone., (© 2015 Wiley Periodicals, Inc.)

The objective of this study was to determine the 30-day incidence of ischemic stroke following neck dissection compared to matched patients undergoing non-head and neck surgeries.A surgical dissection of the neck is a common procedure performed for many types of cancer. Whether such dissections increase the risk of ischemic stroke is uncertain.A retrospective cohort study using data from linked administrative and registry databases (1995-2012) in the province of Ontario, Canada was performed. Patients were matched 1-to-1 on age, sex, date of surgery, and comorbidities to patients undergoing non-head and neck surgeries. The primary outcome was ischemic stroke assessed in hospitalized patients using validated database codes.A total of 14,837 patients underwent surgical neck dissection. The 30-day incidence of ischemic stroke following the dissection was 0.7%. This incidence decreased in recent years (1.1% in 1995 to 2000; 0.8% in 2001 to 2006; 0.3% in 2007 to 2012; P for trend <0.0001). The 30-day incidence of ischemic stroke in patients undergoing neck dissection is similar to matched patients undergoing thoracic surgery (0.5%, P = 0.26) and colectomy (0.5%, P = 0.1). Factors independently associated with a higher risk of stroke in 30 days following neck dissection surgery were of age ≥75 years (odds ratio (OR) 1.63, 95% confidence interval (CI) 1.05-2.53), and a history of diabetes (OR 1.60, 95% CI 1.02-2.49), hypertension (OR 2.64, 95% CI 1.64-4.25), or prior stroke (OR 4.06, 95% CI 2.29-7.18).Less than 1% of patients undergoing surgical neck dissection will experience an ischemic stroke in the following 30 days. This incidence of stroke is similar to thoracic surgery and colectomy.

Objectives: To study the current selection of mobile applications (apps) relating to otolaryngology-head and neck surgery (OtoHNS). To conduct a review of the apps available in OtoHNS., Data Sources: App Store, Google Play, BlackBerry World, Windows Store., Methods: The Apple, Google, Windows, and Blackberry mobile app stores were searched for apps relating to OtoHNS. App information was analyzed based on in-store descriptions, and apps were downloaded and reviewed., Conclusions and Implications for Practice: There is a rapidly expanding collection of apps with a wide variety of functions available in OtoHNS. There are several high-quality apps for education and clinical use, which have been highlighted in our review. Mobile apps have the potential to become widely incorporated into OtoHNS, although there is a need for appropriate guidance from the specialty to ensure app quality and accuracy of content., (© American Academy of Otolaryngology—Head and Neck Surgery Foundation 2015.)

Background: Radiation therapy treatment planning has advanced over the past 2 decades, with increased emphasis on 3-dimensional imaging for target and organ-at-risk (OAR) delineation. Recent studies suggest a need for improved resident instruction in this area. We developed and evaluated an intensive national educational course ("boot camp") designed to provide dedicated instruction in site-specific anatomy, radiology, and contouring using a multidisciplinary (MDT) approach., Methods: The anatomy and radiology contouring (ARC) boot camp was modeled after prior single-institution pilot studies and a needs-assessment survey. The boot camp incorporated joint lectures from radiation oncologists, anatomists, radiologists, and surgeons, with hands-on contouring instruction and small group interactive seminars using cadaveric prosections and correlative axial radiographs. Outcomes were evaluated using pretesting and posttesting, including anatomy/radiology multiple-choice questions (MCQ), timed contouring sessions (evaluated relative to a gold standard using Dice similarity metrics), and qualitative questions on satisfaction and perceived effectiveness. Analyses of pretest versus posttest scores were performed using nonparametric paired testing., Results: Twenty-nine radiation oncology residents from 10 Canadian universities participated. As part of their current training, 29%, 75%, and 21% receive anatomy, radiology, and contouring instruction, respectively. On posttest scores, the MCQ knowledge scores improved significantly (pretest mean 60% vs posttest mean 80%, P<.001). Across all contoured structures, there was a 0.20 median improvement in students' average Dice score (P<.001). For individual structures, significant Dice improvements occurred in 10 structures. Residents self-reported an improved ability to contour OARs and interpret radiographs in all anatomic sites, 92% of students found the MDT format effective for their learning, and 93% found the boot camp more effective than educational sessions at their own institutions. All of the residents (100%) would recommend this course to others., Conclusions: The ARC boot camp is an effective intervention for improving radiation oncology residents' knowledge and understanding of anatomy and radiology in addition to enhancing their confidence and accuracy in contouring., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objectives/hypothesis: Adductor spasmodic dysphonia (AdSD) is a voice disorder characterized by variable symptom severity and voice disability. Those with the disorder experience a wide spectrum of symptom severity over time, resulting in varied degrees of perceived voice disability. This study investigated the longitudinal variability of AdSD, with a focus on auditory-perceptual judgments of a dimension termed laryngeal overpressure (LO) and patient self-assessments of voice-related quality of life (V-RQOL)., Study Design: Longitudinal, correlational study., Methods: Ten adults with AdSD were followed over three time periods. At each, both voice samples and self-ratings of V-RQOL were gathered prior to their scheduled Botox injection. Voice recordings subsequently were perceptually evaluated by eight listeners for LO using a visual analog scale., Results: LO ratings for all-voiced and Rainbow Passage sentence stimuli were found to be highly correlated. However, only the LO ratings obtained from judgments of AV stimuli were found to correlate moderately with self-ratings of voice disability for both the physical functioning and social-emotional subscores, as well as the total V-RQOL score. Based on perceptual judgments, LO appears to provide a reliable means of quantifying the severity of voice abnormalities in AdSD., Conclusions: Variability in self-ratings of the V-RQOL suggest that perceived disability related to AdSD should be actively monitored. Further, auditory-perceptual judgments may provide an accurate index of the potential impact of the disorder on the speaker. Similarly, LO was supported as a simple clinical measure that serves as a reliable index of voice change over time., (© 2014 The American Laryngological, Rhinological and Otological Society, Inc.)

Background: The threshold size required to detect lymphadenopathy via palpation has never been formally determined. The purpose of this study was to determine the threshold, sensitivity, and error of node palpation and how this changes with experience., Methods: Lymphadenopathy models were created using polyvinyl alcohol cryogel (PVA-C) to mimic tissue tactility. Node diameter ranged from 0.5 to 4 cm. Study subjects were medical students, otolaryngology residents, and otolaryngology consultants. Each subject provided 22 estimates of size. Primary outcomes were the sensitivity, error (true vs estimated size), and threshold of palpation., Results: Thirty subjects completed the study. Sensitivity was 60%, 74%, and 86% for students, residents, and consultants, respectively (p < .01). Error was 0.88 cm, 0.61 cm, and 0.57 cm, respectively (p < .05). Palpation threshold was 1.32 cm, 0.83 cm, and 0.75 cm, respectively (p < .05). All participants detected nodes ≥2 cm, whereas consultants detected nodes ≥1 cm., Conclusion: Experience is associated with decreased palpation threshold and error, and increased sensitivity. Educational interventions should target nodes <2 cm., (© 2014 Wiley Periodicals, Inc.)

Objectives/hypothesis: Medical students graduate with the knowledge and skills to be undifferentiated general physicians. Otolaryngology-head and neck surgery (OtoHNS) is an essential component of primary healthcare, but is disproportionately under-represented in undergraduate medical education (UME). Advances and innovations in educational technology may represent an exciting and creative solution to this important problem. Failure to meet this educational need will result in substantial downstream effects in primary healthcare delivery. The objectives of this study were to 1) demonstrate current deficits in OtoHNS teaching at the UME level; 2) develop, validate, and critically appraise educational innovations that may enrich OtoHNS teaching in medical school curricula; and 3) propose a process for standardization of learning objectives for OtoHNS in UME as it relates to development and deployment of such educational tools., Study Design: A white paper, prepared as a Triological Society thesis, which consolidates a prospective 10-year investigation of the problem of and potential solutions for under-representation of OtoHNS in UME. Cited datasets include multicenter surveys, cohort studies, and prospective, randomized controlled trials., Methods: A series of published and unpublished data were synthesized that addresses the following: 1) the current state of OtoHNS teaching at the UME level with respect to content, volume, structure, and methods; and 2) educational innovations including e-learning and simulation with emphasis on validity and learning effectiveness. Educational innovations specific to postgraduate (residency) training were excluded., Results: Data support the observation that there is uniformly disproportionate under-representation of OtoHNS within UME curricula. Medical school graduates, especially those pursuing primary care specialties, report poor overall comfort levels in managing OtoHNS problems. A series of novel teaching methods were developed and validated using e-learning and simulation. Selected technologies may have a role in medical student teaching. It has been shown that e-learning has limited value in teaching complex spatial anatomy to novice learners, but good value in teaching basic clinical knowledge and selected technical skills. The role of simulation as it pertains to the novice learner is evolving. Important factors to consider during development of these tools include: 1) knowledge base and learning style of the learner, 2) complexity and nature of the learning objectives, 3) understanding the features and limitations of different technological genres, and 4) a team approach to module development. There remains a role for traditional teaching paradigms such as lectures, labs, and standardized patients; however, the choice of instructional genre should be fundamentally tailored to the nature of the learning outcomes., Conclusions: Enriching OtoHNS teaching in medical school is essential optimize primary care delivered to patients. Although e-learning and simulation are broadly accepted and desirable by today's medical students, these technologies should be woven into the fabric of UME pedagogical principles judiciously, and only after empiric assessment. Foundational to the development and implementation of these technologies is the framework of standardized competency-based learning objectives, common to all graduating medical students., Level of Evidence: NA, (© 2014 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives: Our objective was to systematically identify and evaluate prospective studies providing evidence for and against the use of prokinetic agents in the treatment of laryngopharyngeal reflux (LPR) disease., Data Sources: Our data sources were PubMed, Embase, BIOSIS, and Web of Science databases., Review Methods: A systematic literature review was conducted to identify studies prospectively evaluating the effectiveness of prokinetic agents in the treatment of LPR. Data from eligible studies were independently extracted from each study by two authors. The primary outcome of interest was the improvement of LPR symptoms among study participants. Secondary outcomes included resolution of LPR physical signs and the development of side effects from therapy., Results: Among 724 unique articles identified, four studies met inclusion criteria. These four investigations provided mixed evidence about the effectiveness of prokinetic agents in the treatment of LPR. The studies included in the review were deemed to be at high risk of bias. Three of the four investigations demonstrated a statistically significant difference in patient symptoms that favored the use of prokinetics in the management of LPR. The investigations were mixed in their report of improvement in physical examination findings among patients receiving and those not receiving prokinetic medical therapy. No significant adverse effects were described in any of these trials., Conclusions: Prokinetic agents may be a viable treatment option for LPR. The current body of literature is inadequate to make a recommendation for their use in this disease process. Further research should be conducted to assess the use of prokinetic medications in the management of LPR., (© 2014 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: A 1-day intensive course (bootcamp) was developed, to teach junior otolaryngology-head and neck surgery (OTO-HNS) residents emergency procedural skills, clinical reasoning, and communication skills. This learning paradigm utilized a number of novel task trainers, panel discussions, and emergency simulations. The study objective was to assess the educational value of this bootcamp., Study Design: Prospective cohort survey., Methods: Residents were recruited from regional teaching centers within a 2000-km radius of the simulation center. Preceptors fluent in English and in French were in attendance. Pre-bootcamp outcome measures included the Kolb Learning Style Inventory and a self-administered survey measuring confidence levels in performing specific OTO-HNS tasks. Post-bootcamp outcome measures included a survey evaluating the bootcamp experience and a structured follow-up telephone interview., Results: Twenty-eight residents participated in the bootcamp from across the United States and Canada. When asked if they felt that "overall, the educational day was an effective learning process," the average score was 4.75/5.0. The vast majority of participants (92.9%) felt they would recommend the bootcamp to a future junior resident. Kolb learning styles that prefer active experimentation (acting, initiating, and deciding) were more common than those that utilize reflective observation (imagining, analyzing, reflecting), which favors a hands-on model of learning., Conclusion: This first Canadian OTO-HNS bootcamp demonstrated the feasibility and effectiveness of conducting a centralized bootcamp for regional training centers spanning multiple states/provinces and languages. Future bootcamps will be held annually and will ideally continue the natural evolution of surgical, hands-on training., (© 2014 The American Laryngological, Rhinological and Otological Society, Inc.)

Background and Significance: Anaplastic thyroid cancer (ATC) is rare, but its clinical presentation is often dramatic and aggressive and is nearly uniformly fatal. Oncolytic viral therapy is a potential strategy to improve outcomes for patients suffering with this disease., Methods: Seven established ATC cell lines were infected with a panel of poxviruses to identify which virus had the most potential as an oncolytic agent. These included myxoma, vaccinia, and tanapox viruses, all modified to express green fluorescence protein (GFP). Viral proliferation was assessed by fluorescence and viral amplification. The effect on cell line growth was assessed by the Presto Blue metabolic assay and a live-dead assay. A replication assay was performed to assess the production of infectious progeny. An additional five ATC cell lines were tested using the assays described above for susceptibility to vaccinia virus., Results: ATC cell lines were differentially susceptible to each virus. Vaccinia virus was superior to myxoma and tanapox viruses for the control of anaplastic thyroid cancer in vitro. Although subsequent investigation using an expanded panel of cell lines revealed differential susceptibility to vaccinia virus, effective control of cell proliferation was still achieved using higher titers., Conclusions: Vaccinia virus was the most potent of the tested poxviruses and was highly effective in controlling proliferation and inducing cell death in ATC cell lines. The efficacy of these viruses offers hope for improving outcomes for patients suffering with ATC., (Copyright © 2014 Elsevier B.V. All rights reserved.)

Background: The role of the HPV E6/E7 oncogenes in head and neck squamous cell cancer (HNSCC) has been studied extensively, but the role of the viral E5 protein remains poorly understood. Studies in cervical cancer indicate that E5 increases epidermal growth factor receptor (EGFR) recycling to the cell surface and enhances growth factor signal transduction., Objective: This study was designed to examine the relationship between HPV E5, EGFR, and survival in HPV-positive HNSCC., Study Design: A retrospective search of the London Health Sciences Centre pathology database was performed to identify oropharyngeal cancer samples. HPV E5 and EGFR expression was measured by reverse transcriptase real-time PCR., Results: The majority of oropharyngeal tumor samples (59/82, 72%) were HPV-16 positive. Among the HPV-positive tumors, highly variable E5 expression was detected from early polycistronic transcripts. Tumors with high E5 expression levels had significantly higher EGFR levels (p=0.03). High E5 levels were correlated with improved recurrence-free survival, but not overall survival (p=0.02 and 0.71, respectively), whereas high EGFR was strongly associated with decreased recurrence-free and overall survival (p<0.001 and 0.006 respectively). Multivariate analysis revealed E5 and EGFR to be the strongest predictors of recurrence-free survival (p<0.01)., Conclusions: HPV E5-encoded transcripts are variably expressed in HPV-positive HNSCC and this is correlated with EGFR expression in HPV-positive OPC. However, E5 and EGFR independently predict recurrence-free survival in opposing manners. These findings require further validation to determine if E5 and EGFR are useful biomarkers to stratify treatment intensity for patients with HPV-positive HNSCC., (Copyright © 2014. Published by Elsevier B.V.)

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.

Objectives/hypothesis: To evaluate the feasibility and efficacy of transtympanic L-N-Acetylcysteine (L-NAC) administration in patients receiving cisplatin chemotherapy for head and neck cancer., Study Design: Prospective randomized nonblinded open-label clinical trial., Methods: Transtympanic 2% L-NAC was administered to one randomly selected ear with the other ear as control in each patient. Primary outcome parameter was the difference in the loss of pure tone averages (PTA) at 2, 4, and 8 kHz between the L-NAC and control ear at 1 to 2 months following chemotherapy., Results: Eleven patients completed the study, with two patients demonstrating significantly better hearing in the L-NAC treated ear (18.2%). However, for the overall group, the difference in hearing preservation did not reach significance. Two percent L-NAC administration was well tolerated in this patient population. There were no adverse effects associated with L-NAC., Conclusion: Although the study did not demonstrate a significant benefit overall, transtympanic L-NAC was associated with significantly better hearing in two patients. Better delivery methods may improve the efficacy of this treatment. L-NAC remains a promising drug in preventing cisplatin-induced ototoxicity., (© 2013 The American Laryngological, Rhinological and Otological Society, Inc.)

Background: Head and neck squamous cell carcinoma (HNSCC) is the fifth most common cancer worldwide. Existing therapies for advanced tumors have high failure rates and can have severe consequences in terms of pain, disfigurement, and poor speech and swallowing function. New treatment strategies are needed to improve outcomes for patients suffering with this disease and oncolytic viruses represent a promising approach., Methods: We infected six well-characterized HNSCC cell lines (Cal27, Detroit562, FaDu, SCC4, SCC15, SCC25), with increasing doses of a panel of poxviruses (including myxoma, vaccinia, raccoonpox and tanapox viruses) modified to express green fluorescence protein to determine which virus was the most effective oncolytic agent in cell-based assays., Results: While myxoma, raccoonpox and tanapox displayed differing efficacy in the panel of cell lines, vaccinia virus was the most potent of the tested poxviruses and was highly effective in controlling cell growth in all cell lines., Conclusion: Oncolytic poxviruses, particularly vaccinia virus, were effective in killing HNSCC in vitro and hold promise as potential treatments for patients with HNSCC., (Copyright © 2013 S. Karger AG, Basel.)

Background: Because of the significant toxicity of chemoradiation regimens, there has been a resurgence of interest in the primary surgical management of head and neck cancer and, in particular, the use of minimally invasive surgery. One such technique is transoral robotic surgery (TORS). We aim to discuss the potential role of TORS in patients requiring total laryngectomy (TL)., Methods and Results: Three patients underwent TORS-assisted narrow-field TL. Relative data on preoperative, intraoperative, and postoperative management were collated including postoperative complications., Conclusions: We present 3 cases of transoral robotic surgery (TORS)-assisted TL in patients requiring narrow field laryngectomy without requirement for neck dissection. In reviewing these cases we provide a discussion of pertinent preoperative and intraoperative considerations that can assist in facilitating successful completion of the procedure. In particular, appropriate assessment at the pinsertlinePOLA&#95;Del&#95;Blank&#95;PgPOLA&#95;Shift&#95;FramePORT&#95;rem&#95;fpg&#95;underremovelinetabminilanning endoscopy in addition to a methodical surgical approach are vital to the successful use of the robot in TORS-assisted TL., (Copyright © 2012 Wiley Periodicals, Inc.)

Background: The purpose of this study was to review our experience with the scapular tip free flap for mandibular reconstruction, describe the surgical approach, and highlight specific clinical applications., Methods: A retrospective review of all patients undergoing oromandibular reconstruction using a scapular tip free flap at the London Health Sciences Centre was undertaken. Patient demographics, surgical data, and early outcomes were collated., Results: Twenty patients were identified. The majority involved mandibular angle and short segment defects (16 of 20). Average length of the segmental defect was 6.2 cm with the longest measuring 8 cm. A single patient required an osteotomy. Six were revision cases. No vein grafts were required. One complete flap failure occurred., Conclusions: The natural scapular angle makes the scapular tip flap ideal for mandibular angle reconstruction. Short bone segments can be harvested with little donor-site morbidity. The long pedicle length may obviate vein grafts., (Copyright © 2012 Wiley Periodicals, Inc.)

Importance: Large-scale whole-exome sequencing studies of head and neck squamous cell carcinoma (HNSCC) have established that the disease is dominated by frequent mutations in tumor suppressor genes with rare activating mutations in oncogenes that would be easily targetable with molecular agents. There was evidence in these reports, however, that activating mutations in phosphoinositide 3-kinase catalytic subunit p110α (PIK3CA) were common in patients with human papillomavirus (HPV)-positive tumors. We set out to test this prediction in oropharyngeal patient samples from our institution., Objective: To confirm whether activating mutations in PIK3CA are frequent in HPV-positive HNSCC because this mutated oncogene represents a potential therapeutic target., Design, Setting, and Participants: A retrospective search of the London Health Sciences Centre pathology database was performed to identify oropharyngeal cancer samples. DNA from pretreatment primary site biopsy samples from 87 patients were tested for high-risk HPV types 16 and 18 by real-time polymerase chain reaction., Main Outcomes and Measures: Samples were tested for activating mutations at the 3 mutational hot spots (codons 542, 545, and 1047) by polymerase chain reaction followed by Sanger sequencing using forward and reverse primers., Results: Only 4 of 41 HPV-negative tumors (10%) demonstrated PIK3CA hot spot mutations, including 3 at codon 1047 and 1 at codon 542. Of 46 HPV-positive tumors, 13 (28%) demonstrated activating PIK3CA mutations, including 7 at codon 542, 5 at codon 545, and 1 at codon 1047. The difference in PIK3CA mutation frequency was significantly different between HPV-positive and HPV-negative cancers (P = .03)., Conclusions and Relevance: Although there has been a suggestion that activating PIK3CA mutations are common in HPV-positive HNSCC, to our knowledge, this is the first study to clearly identify this phenomenon. Targeting PIK3CA with molecular agents in HPV-positive patients may be a mechanism to improve cure rates and decrease treatment toxic effects in this rapidly growing cohort of patients.

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.

Importance: Provides an approach to osseous free flap selection for reconstruction of segmental mandible defects that takes into consideration general medical status of the patient and reconstruction requirements; demonstrates the complementary qualities of fibular and subscapular system free flaps; and describes the different surgical indications for lateral border scapular and scapular tip free flaps., Objectives: To review our experience with osseous mandible reconstruction comparing the fibular and subscapular system free flaps, determine reconstruction-specific and general health variables that may differ between these patient groups, and present our approach to oromandibular reconstruction., Design: Retrospective study., Setting: Academic tertiary care medical center., Participants: A total of 110 patients (68 male, 42 female) undergoing single-stage oromandibular reconstructions with free-tissue transfers between May 1, 2006, and May 30, 2012., Intervention: Single-stage oromandibular reconstruction with free-tissue transfer., Main Outcome Measures: Differences in patient demographics, bone and soft-tissue aspects of the reconstruction, operative time, flap outcomes, and major postoperative complications between fibular, lateral scapular border, and scapular tip free flaps., Results: A total of 110 patients underwent 113 reconstructions, including 58 fibular free flaps (FFFs) (51.3%) and 55 subscapular system flaps (48.7%). Of the subscapular system free flaps, 27 flaps (49%) were scapular tip free flaps (STFFs) based on the angular artery branch of the thoracodorsal pedicle; the remaining 28 cases were lateral scapular border flaps (LSBFs). Patients undergoing reconstruction with FFFs were significantly younger than their subscapular system flap counterparts (56 vs 70 years, P < .001). Mean mandible defect lengths were similar for patients undergoing FFF and LSBF reconstruction (7.8 and 7.7 cm, respectively); STFFs were used to reconstruct significantly shorter defects (mean, 6.0 cm, P < .001). The FFFs were more commonly used for anterior mandible defects in which multiple osteotomies and limited soft tissue were required, while subscapular flaps were more commonly used for linear mandible defects with complex soft-tissue requirements. A single complete flap loss occurred in a patient who underwent reconstruction with an STFF; other complication rates were similar between groups., Conclusions and Relevance: The FFFs and subscapular flaps are complementary options for oromandibular reconstruction. The FFF is ideal for younger patients, extended defects, multiple osteotomies, and limited soft-tissue requirements. The subscapular system free flaps (LSBF and STFF) are excellent options for (1) elderly patients; (2) those with significant comorbidities, such as peripheral vascular disease; and (3) mandible defects associated with complex soft-tissue requirements. Furthermore, the STFF offers a reliable option to reconstruct short-segment defects, in particular, defects involving the angle of the mandible.

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.

We describe the presentation, management, and clinical outcome of a massive acinic cell carcinoma of the parotid gland. The primary tumor and blood underwent exome sequencing which revealed deletions in CDKN2A as well as PPP1R13B, which induces p53. A damaging nonsynonymous mutation was noted in EP300, a histone acetylase which plays a role in cellular proliferation. This study provides the first insights into the genetic underpinnings of this cancer. Future large-scale efforts will be necessary to define the mutational landscape of salivary gland malignancies to identify therapeutic targets and biomarkers of treatment failure.

Objectives: Kallikrein-related peptidase 10 (KLK10) has been implicated in the development of several types of cancer. The purpose of this study was to analyze the expression of KLK10 in 3 types of salivary gland tumour and normal salivary glands., Materials and Methods: A standard immunoperoxidase staining technique was used to assess the immunoexpression profile of KLK10 in normal salivary glands and 3 types of salivary gland tumour: pleomorphic adenoma, adenoid cystic carcinoma and mucoepidermoid carcinoma., Results: Pleomorphic adenomas showed significantly lower KLK10 levels than control tissues. Neither of the malignant tumours (adenoid cystic carcinoma and mucoepidermoid carcinoma) showed a significant alteration in the immunoreactive scores of KLK10 in comparison with the normal salivary gland tissues. KLK10 immunoreactive scores were comparable in adenoid cystic carcinoma and mucoepidermoid carcinoma. Pleomorphic adenoma had significantly lower levels of KLK10 than mucoepidermoid carcinoma., Conclusions: The finding of lower KLK10 levels in pleomorphic adenoma suggests aberrant expression in a tumour that develops primarily from myoepithelial cells. A kallikrein cascade may play a role in the development and/or outcome of some salivary gland tumours.

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: Early detection of circulating tumor cells (CTCs) offers the possibility of improved outcome for patients with head and neck squamous cell cancer (HNSCC)., Methods: Patients with advanced-stage HNSCC (stage III/IV) were tested for CTCs using the CellSearch system (a registered trade name), which has been approved by the U.S. Food and Drug Administration (FDA) for monitoring CTCs in other cancers., Results: CTCs were detected in 6 of 15 patients with advanced-stage HNSCC (range, 1-2 cells/7.5 mL of blood). CTCs were significantly associated with patients with lung nodules >1 cm (p = .04). There was also a suggestion of improved survival in the CTC-negative versus the CTC-positive patients (p = .11)., Conclusions: CTCs can be successfully isolated in patients with advanced-stage HNSCC using the CellSearch system. CTC detection may be important for prognosis, evaluating treatment outcome, and for determining efficacy of adjuvant treatments., (Copyright © 2011 Wiley Periodicals, Inc.)

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.

Purpose: Both short- and long-term outcomes for individuals with head and neck cancer (HNCa) may be influenced by multiple factors. Identification of distress in those with HNCa may provide a critical dimension that influences quality of life (QoL). Consequently, this investigation assessed distress and QoL in those with HNCa., Methods: This study utilized a cross-sectional, self-report survey design. Participants included 49 adults diagnosed with HNCa. Upon assessment, post-diagnosis time ranged between 3-12 months. All participants completed a validated distress screening measure, the Brief Symptom Inventory 18 (BSI-18), and the EORTC general QoL assessment tool (EORTC-QLQ-C30) and HNCa module (EORTC-QLQ-H&N35)., Results: Approximately 22% of participants demonstrated clinically significant distress. Additionally, distress was significantly related to QoL status and specific symptoms., Conclusions: Screening for distress in those with HNCa may permit early identification of problems that influence QoL outcomes. The ability to identify distress early may also facilitate timely intervention to reduce distress and optimize QoL.

Objective: Patients considering surgery face many uncertainties and concerns. This investigation sought to develop an objective assessment tool for characterizing the areas of greatest concern among those considering thyroidectomy., Study Design: Prospective cohort design., Setting: Tertiary-care otolaryngology practice., Subjects: Participants included individuals presenting with a thyroid nodule found to be of intermediate risk (15%-20%) of cancer based on fine-needle aspiration (FNA) biopsy and amendable to hemithyroidectomy., Methods: As part of validating a clinical measure concerning perioperative concerns, patients presenting with thyroid nodules amendable to hemithyroidectomy were voluntarily recruited. Thirty individuals (6 men, 24 women) completed a novel 18-item questionnaire during their initial clinical visit and again 3 days later. Outcome measures included descriptive statistics and test-retest reliability., Results: Individual patients have both general and specific preoperative concerns. A wide range of responses was obtained across the entire spectrum of the survey. The questionnaire demonstrated fair-to-excellent test-retest reliability, with correlation values from 0.467 to 0.954. Between-rater reliability was consistent with intraclass correlation coefficient values of 0.52 to 0.86. No relationship between question order and patient response was identified. Women were found to be more concerned about scar appearance (P = .028), and men were conversely more concerned about resuming daily activities (P = .026)., Conclusions: Patients considering thyroidectomy have concerns that remain stable in the early preoperative period. This is the first study to evaluate preoperative patient concerns and preliminarily establishes the Western Surgical Concern Inventory-Thyroid as a means of ensuring adequate patient counseling and a method of evaluating preoperative patient education.

Objective: To conduct high-throughput mutational analysis in 6 commonly used head and neck cancer cell lines. Comprehensive mutation analysis of primary head and neck squamous cell carcinoma (HNSCC) tumors has recently been reported, and mutations in the NOTCH receptors, TP53 and CDKN2A, were key findings. Established cell lines are valuable tools to study cancer in vitro. Similar high-throughput mutational analysis of head and neck cancer cell lines is necessary to confirm their mutational profile., Design: DNA was extracted from American Type Culture Collection (ATCC) cell lines Cal27, Detroit562, FaDu, SCC4, SCC15, and SCC25. Cell line identity was confirmed by short tandem repeat (STR) analysis, and human papillomavirus (HPV) infection status was assessed by real-time polymerase chain reaction. A total of 535 cancer-associated genes were sequenced through a limited exome capture on the Illumina HiSeq system., Setting: London Regional Cancer Program., Results: The identity of the 6 cell lines was confirmed by STR analysis, and all lines tested negative for HPV infection. We achieved an average of 129-fold coverage with paired-end 100 base-pair reads. Sequencing revealed an average of 38 damaging mutations in each cell line (range, 30-45). The TP53 mutations, predicted to confer loss of function, were noted in all cell lines, and damaging CDKN2A mutations were found in all lines except SCC15., Conclusions: High-throughput sequencing of head and neck cancer cell lines revealed similar mutations to those observed in primary tumors. Thus, these lines reflect the tumor biology of HNSCC and can serve as valuable models to study HNSCC in vitro.

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.

Tissues infected with highly pathogenic avian influenza viruses such as H5N1 and H7N7 are normally required to be fixed in formalin or paraformaldehyde before examination in order to inactivate the virus. In this study commercially available monoclonal antibodies to the influenza nucleoprotein (NP) were evaluated in order to determine which antibodies would identify positive cells in tissues fixed in formalin or paraformaldehyde. An assessment of which antigen retrieval process would unmask antigens blocked by formalin fixation was also made. Of six commercially available monoclonal antibodies tested, only one (HB65, European Veterinary Laboratories) was able to identify all formalin fixed avian, swine and human influenza virus infected tissues, and this was after pronase induced epitope retrieval. This monoclonal antibody is recommended for routine diagnostic use for the detection of influenza A infected tissues that have been fixed in formalin or paraformaldehyde., (Copyright © 2011 Elsevier B.V. All rights reserved.)