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Genetic, symptomatic, and biochemical heterogeneity of patients with primary hyperparathyroidism (PHPT) has become apparent in recent years. An in-depth, evidence-based review of the phenotypes of PHPT was conducted. This review was intended to provide the resulting information to surgeons who operate on patients with hyperparathyroidism. This review revealed that the once relatively clear distinction between familial and sporadic PHPT has become more challenging by the finding of various germline mutations in patients with seemingly sporadic PHPT. On the one hand, the genetic and clinical characteristics of some syndromes in which PHPT is an important component are now better understood. On the other hand, knowledge is emerging about novel syndromes, such as the rare multiple endocrine neoplasia type IV (MEN4), in which PHPT occurs frequently. It also revealed that, currently, the classical array of symptoms of PHPT is seen rarely upon initial presentation for evaluation. More common are nonspecific, nonclassical symptoms and signs of PHPT. In areas of the world where serum calcium levels are checked routinely, most patients today are "asymptomatic" and they are diagnosed after an incidental finding of hypercalcemia; however, some of them have subclinical involvement of bones and kidneys, which is demonstrated on radiographs, ultrasound, and modern imaging techniques. Last, the review points out that there are three distinct biochemical phenotypes of PHPT. The classical phenotype in which calcium and parathyroid hormone levels are both elevated, and other disease presentations in which the serum levels of calcium or intact parathyroid hormone are normal. Today several, distinct phenotypes of the disease can be identified, and they have implications in the diagnostic evaluation and treatment of patients, as well as possible screening of relatives.

Objective Standard techniques for primary dural repair following lateral skull base surgery are both technically challenging and time consuming without the potential for primary dural repair. Inadequate closure may result in postoperative cerebrospinal fluid (CSF) leak infectious sequalae. Traditional methods of dural repair rely on secondary obliteration of the CSF fistula. We hypothesized that the use of nonpenetrating titanium microclips may serve as a useful adjunct in primary dural repair or the establishment of an immobile repair layer following lateral skull base surgery. Methods Here, we report a novel technique for primary dural repair using nonpenetrating titanium microclips as an adjunct to standard techniques in a series of six patients with lateral skull base pathologies. Results A total of six consecutive lateral skull base tumor patients with titanium microclip dural reconstruction were included in our case series. Lateral skull base pathologies represented in this group included two jugular foramen schwannomas, one vestibular schwannoma, one petroclival meningioma, one glomus jugulare paraganglioma, and one jugular foramen chordoid meningioma. Conclusion To our knowledge, this is the first report on the use of microclips in repairing dural defects following lateral skull base surgery. Surgical outcomes for this small case series suggest that dural repair of the later skull base with nonpenetrating titanium microclips is a useful adjunct in dural repair following lateral skull base surgery.

Anterior cervical discectomy and fusion (ACDF) is the most common surgical procedure utilized for degenerative diseases of the cervical spine. The authors present the case of a 64-year-old man who underwent an ACDF for degenerative changes causing cervical stenosis with myelopathy. The patient’s symptoms consisted of pain and weakness of the bilateral upper extremities that slowly progressed over 1.5 years. During the procedure, the superior horn of the thyroid cartilage impeded proper retraction, preventing adequate visualization due to its prominent size. At this point, otorhinolaryngology was consulted, which allowed for safe resection of this portion of the thyroid cartilage while preserving nearby critical structures. With the frequent usage of this surgical approach for various etiologies, the importance of proper recognition and consultation is paramount. Encountering prominent thyroid cartilage resulting in surgical obstruction has not been described in the literature and this report represents a paradigm for the proper course of action.

Background Cancer cachexia affects up to over 50% of advanced head and neck cancer (HNC) patients. To date, the potential utility of anabolic steroids in perioperative cachectic HNC patients has not been determined. Methods Retrospective review of pre- and post-oxandrolone administration prealbumin levels in 18 perioperative HNC patients between October 2007 and October 2014 at a tertiary academic medical center. Results The median pretreatment prealbumin was 88.5 mg/L. The median post-treatment prealbumin was 227 mg/L. The median interval improvement of the prealbumin level was 131.5 mg/L. The median differences between the pretreatment and post-treatment prealbumin levels were found to be statistically significant (P

OBJECTIVES To evaluate the diagnostic performance of ultrasound (US)-guided fine-needle aspiration with optional core needle biopsy of head and neck lymph nodes and masses, with attention to differences between biopsy of treated squamous cell carcinoma (SCC) and biopsy of other lesions. METHODS Institutional Review Board approval was obtained, and the need for consent was waived for this retrospective study. All 861 US-guided biopsies of head and neck lymph nodes and masses performed between March 1, 2012, and May 16, 2016, were reviewed. RESULTS Of the 861 biopsies, 53 targeted SCC with residual masses after treatment. The biopsy procedures yielded benign or malignant pathologic results in 71.7% (38 of 53) of treated SCC and 90.7% (733 of 808) of all other lesions (P

BACKGROUND Merkel cell carcinoma (MCC) is a rare, highly aggressive malignancy which lacks high-level evidence-based treatment guidelines. METHODS To determine outcomes of MCC patients and assess the role of radiation in treatment, we performed a retrospective chart review of patients treated for MCC between 2006 and 2016 at a single high-volume academic medical center. The primary outcome was overall survival (OS) for the entire population and for those populations receiving specific therapies. RESULTS Forty-two patients were evaluable. OS for all patients was not reached since most remain alive at time of analysis. OS for the American Joint Committee on Cancer (AJCC) stage I was not reached. OS for stages II, III, and IV was 37.3 months (6.8, -), 49.5 months (14.2, 49.5), and 14.5 months (10.8, -), respectively. OS could not be reached in the high radiotherapy (RT) dose group (biologically equivalent dose [BED] ≥ 60) and was 49.5 months (10.8, -) in the low-dose group (BED < 60). For surgical margin status, OS was 14.9158 months (6.8008, -) for positive margins and 37.3 months (10.8, -) for negative margins. CONCLUSIONS No conclusive findings for OS were identified; however, trends for improved OS were associated with lower AJCC staging, negative surgical margins, and high RT doses.

The coronavirus disease‐2019 (COVID‐19) pandemic has rapidly spread across the world, placing unprecedented strain on the health care system. Health care resources including hospital beds, ICUs, as well as personal protective equipment are becoming increasingly rationed and scare commodities. In this environment, the laryngectomee (patient having previously undergone a total laryngectomy) continues to represent a unique patient with unique needs. Given their surgically altered airway, they pose a challenge to manage for the otolaryngologist within the current COVID‐19 pandemic. In this brief report, we present special considerations and best practice recommendations in the management of total laryngectomy patients. We also discuss recommendations for laryngectomy patients and minimizing community exposures.

Background: The prevention of cancer and the development of more effective strategies to detect cancer precursor lesions and early-stage cancers remain critical goals. It has been estimated that 50% - 60% of cancers could be prevented if known strategies were optimally used. Cancer risk is not uniform, but varies based on age, genetic susceptibility, exposures, existence of preneoplastic conditions across the population. The DNA is constantly damaged by exogenous and endogenous sources. DNA repair mechanisms maintain the integrity of the genome. DNA damage has emerged as a major culprit in tumorigenesis and progression. There are numerous strategies with inherent advantages and disadvantages that may be used for the evaluation of DNA damage and repair. We have developed a novel and highly sensitive primer-anchored DNA damage detection assay (PADDA) to map and quantify DNA damage in p53, the most frequently mutated gene in human cancer. Here, we have extended this assay to HPRT (hypoxanthine-guanine phosphoribosyltransferase), the gene most frequently analyzed in DNA damage studies. Aim: (1) To quantify the amount of DNA damage in HPRT in peripheral blood cells of never-smokers, smokers, and secondhand smokers. (2) To determine whether cancer patients have higher levels of DNA damage in HPRT than non-cancer patients. Methods: The assay, PADDA was used on a high-throughput setting to quantify DNA damage (q-PADDA) on the HPRT gene. DNA was extracted and damage was quantified by q-PADDA in peripheral blood cells collected from non-cancer patients [never-smokers (n=28), tobacco smokers (n=25), secondhand smokers (n=18)], and cancer patients (n=66). Pairwise comparisons in DNA damage among the diverse groups were performed using the Tukey's adjustment in a one-way ANOVA model. Linear regression models were also used to test difference in DNA damage between cancer and non-cancer groups. Results: Never-smokers, tobacco smokers, and secondhand smokers had similar age distribution. In non-cancer patients, the amount of DNA damage in the HPRT gene in smokers was significantly higher than in non-smokers (p=0.01). Secondhand smokers also showed higher levels of DNA damage than never-smokers but this difference did not reach significance. Among cancer patients (n=64), smokers (n=29) showed significantly higher levels of DNA damage (p=0.03) than non-smokers (n=16). Conclusion: Our preliminary data document PADDA's ability to quantify DNA damage on HPRT gene. Damage was significantly higher in smokers than never-smokers, both in cancer and non-cancer patients. Application of this assay to a larger population sample has a major potential to establish biomarkers of susceptibility to tobacco-induced cancer, which can guide preventive and diagnostic strategies. Funding: This work was supported by the NIH, NCI (1R33 CA202898-01, LQ). Dr. Queimado holds a Presbyterian Health Foundation Endowed Chair in Otorhinolaryngology. Citation Format: Mayilvanan Chinnaiyan, Daniel Brobst, Balaji Sadhasivam, Vengatesh Ganapathy, Sarah E. Johnston, Daniel Zhao, Greg A. Krempl, Lurdes Queimado. DNA damage on HPRT as a biomarker of susceptibility to tobacco-induced cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 2075.

Objectives/Hypothesis This study compares the overall durability, phonation effort, and speech quality achieved by the Blom-Singer Dual Valve prosthesis to the same characteristics achieved by the single-valve prosthesis used in a select population of total laryngectomy patients who have demonstrated single-valve prosthesis failure within 3 months of placement. Study Design Prospective phase IV study. Methods Fourteen patients who had previously experienced early valve failure using a single-valve prosthesis had a Dual Valve placed by a speech language pathologist. A total of seventeen Dual Valves were inserted during routine clinical visits for valve replacement. Time intervals from insertion to replacement of the Dual Valve, as well as the average lifespan of patients’ three previous single valves were collected. Subjective, categorical responses to speech quality and phonation effort for the Dual Valve compared to the single valve were collected on a questionnaire upon failure of the device. Results The mean duration of the single valve was 60 days, with a median of 51 days, whereas the mean duration of the Dual Valve was 164 days, with a median duration of 84 days. Both sets of data were statistically significant, with a P value of .0131. Valve life was increased in 86% of patients, with 43% experiencing greater than 150 days improvement in valve duration when using the Dual Valve. Phonation effort was increased in 14% of patients, and speech quality was not significantly affected in any patients. Conclusions In this select population, the Dual Valve offers improved durability over the single valve without sacrificing speech quality, making it a preferred prosthesis option for patients experiencing single-valve failure in less than 3 months. Level of Evidence 4. Laryngoscope, 128:422–426, 2018

Objectives Preferential use of fine-needle aspiration (FNA) versus core needle biopsy (CNB) for distinguishing benign from malignant major salivary gland tumors is highly debated. The main disadvantage of FNA is lower sensitivity, whereas arguments against CNB include use of a larger bore needle and greater risk of complications. The aim of this study is to evaluate our experience performing ultrasound-guided (UG) FNA with selective use of CNB based on preliminary cytopathology, and to determine whether our preoperative diagnostic approach is more sensitive and specific than FNA alone—and at least as sensitive and specific as CNB alone. Study Design Retrospective review of UG needle biopsy sampling of lesions arising in or around parotid and submandibular glands. Methods Ultrasounds of 141 needle biopsies were identified. Patient/lesion/needle biopsy characteristics, preliminary cytopathology, final pathology, imaging studies, and subsequent clinical course and treatment were documented. Results Needle biopsies performed according to our protocol provided results that guided clinical decision making in 125 of 135 cases, 92.6% (95% confidence interval [CI], 86.8%–96.4%) of the time. Using 41 cases that had histologic verification, sensitivity was 100% (95% CI, 79.6%–100%), and specificity was 92.3% (95% CI, 75.9%–97.9%) for detecting malignancy. We definitively characterized 120 lesions as benign (84) or malignant (36). Conclusion Preoperative needle biopsy diagnoses allowed clinical management to progress 92.6% of the time. The protocol of FNA with selective use of CNB may potentially reduce patient exposure to risks associated with CNB without the tradeoff of lower sensitivity seen with FNA. Level of Evidence 4. Laryngoscope, 2017

Objectives IRX-2 is a primary-cell-derived immune-restorative consisting of multiple human cytokines that act to overcome tumor-mediated immunosuppression and provide an in vivo tumor vaccination to increase tumor infiltrating lymphocytes (TILs). A randomized phase II trial was conducted of the IRX regimen 3 weeks prior to surgery consisting of an initial dose of cyclophosphamide followed by 10 days of regional perilymphatic IRX-2 cytokine injections and daily oral indomethacin, zinc and omeprazole (Regimen 1) compared to the identical regimen without IRX-2 cytokines (Regimen 2). Methods A total of 96 patients with previously untreated, stage II-IV oral cavity SCC were randomized 2:1 to experimental (1) or control (2) regimens (64:32). Paired biopsy and resection specimens from 62 patients were available for creation of tissue microarray (n = 39), and multiplex immunohistology (n = 54). Increases in CD8+ TIL infiltrate scores of at least 10 cells/mm2 were used to characterize immune responders (IR). Results Regimen 1 was associated with significant increases in CD8+ infiltrates (p = 0.01) compared to Regimen 2. In p16 negative cancers (n = 26), significant increases in CD8+ and overall TILs were evident in Regimen 1 (p = 0.004, and 0.04 respectively). IRs were more frequent in Regimen 1 (74% vs 31%, p = 0.01). Multiplex immunohistology for PD-L1 expression confirmed an increase in PD-L1 H score for Regimen 1 compared to Regimen 2 (p = 0.11). Conclusions The findings demonstrate significant increases in TILs after perilymphatic IRX-2 injections. Three quarters of patients showed significant immune responses to IRX-2. (NCT 02609386).

Here we present the case of a 36-year-old man who was found to have a symptomatic malignant neural sheath tumor growing from the C2 nerve root following a period of progressively worsening headaches. The patient was successfully treated with surgical resection resulting in resolution of cranial nerve deficits. Though uncommon, malignant peripheral nerve sheath tumor must be considered in the differential diagnosis of tumors involving the cervical nerve roots and carotid space.

To evaluate the diagnostic performance of ultrasound (US)-guided fine-needle aspiration with optional core needle biopsy of head and neck lymph nodes and masses, with attention to differences between biopsy of treated squamous cell carcinoma (SCC) and biopsy of other lesions.Institutional Review Board approval was obtained, and the need for consent was waived for this retrospective study. All 861 US-guided biopsies of head and neck lymph nodes and masses performed between March 1, 2012, and May 16, 2016, were reviewed.Of the 861 biopsies, 53 targeted SCC with residual masses after treatment. The biopsy procedures yielded benign or malignant pathologic results in 71.7% (38 of 53) of treated SCC and 90.7% (733 of 808) of all other lesions (P .001). A reference standard based on subsequent pathologic results or clinical and imaging follow-up was established in 68.4% of procedures. In cases with benign or malignant biopsy results and a subsequent reference standard, the sensitivity values for malignancy were 87.5% (95% confidence interval, 64.0%-96.5%) in treated SCC and 98.3% (95% confidence interval, 96.0%-99.3%) in all other cases (P = .047), and the specificity values were 63.6% (95% confidence interval, 35.4%-84.8%) in treated SCC and 99.5% (95% confidence interval, 97.3%-99.9%) in all other cases (P .001). There were no major complications related to the biopsy procedures.Excluding treated SCC, US-guided fine-needle aspiration with optional core needle biopsy of head and neck lymph nodes and masses has excellent diagnostic performance. Needle biopsy of head and neck SCC with a residual mass after therapy has a high rate of nondiagnostic samples, suboptimal sensitivity, and poor specificity.

ContextThe 15-item University of Washington Quality of Life questionnaire-Radiation Therapy Oncology Group (RTOG) modification (UW-QOL-RTOG modification) has been used in several trials of head and neck cancer conducted by NRG Oncology such as RTOG 9709, RTOG 9901, RTOG 0244, and RTOG0537.ObjectivesThis study is an exploratory factor analysis (EFA) to establish validity and reliability of the instrument subscales.MethodsEFA on the UW-QOL-RTOG modification was conducted using baseline data from NRG Oncology's RTOG 0537, a trial of acupuncture-like transcutaneous electrical nerve stimulation in treating radiation-induced xerostomia. Cronbach α coefficient was calculated to measure reliability; correlation with the University of Michigan Xerostomia Related Quality of Life Scale was used to evaluate concurrent validity; and correlations between consecutive time points were used to assess test-retest reliability.ResultsThe 15-item EFA of the modified tool resulted in 11 items split into four factors: mucus, eating, pain, and activities. Cronbach α ranged from 0.71 to 0.93 for the factors and total score, consisting of all 11 items. There were strong correlations (ρ≥0.60) between consecutive time points and between total score and the Xerostomia Related Quality of Life Scale total score (ρ>0.65).ConclusionThe UW-QOL-RTOG modification is a valid tool that can be used to assess symptom burden of head and neck cancer patients receiving radiation therapy or those who have recently completed radiation. The modified tool has acceptable reliability, concurrent validity, and test-retest reliability in this patient population, as well as the advantage of having being shortened from 15 to 11 items.

Preferential use of fine-needle aspiration (FNA) versus core needle biopsy (CNB) for distinguishing benign from malignant major salivary gland tumors is highly debated. The main disadvantage of FNA is lower sensitivity, whereas arguments against CNB include use of a larger bore needle and greater risk of complications. The aim of this study is to evaluate our experience performing ultrasound-guided (UG) FNA with selective use of CNB based on preliminary cytopathology, and to determine whether our preoperative diagnostic approach is more sensitive and specific than FNA alone-and at least as sensitive and specific as CNB alone.Retrospective review of UG needle biopsy sampling of lesions arising in or around parotid and submandibular glands.Ultrasounds of 141 needle biopsies were identified. Patient/lesion/needle biopsy characteristics, preliminary cytopathology, final pathology, imaging studies, and subsequent clinical course and treatment were documented.Needle biopsies performed according to our protocol provided results that guided clinical decision making in 125 of 135 cases, 92.6% (95% confidence interval [CI], 86.8%-96.4%) of the time. Using 41 cases that had histologic verification, sensitivity was 100% (95% CI, 79.6%-100%), and specificity was 92.3% (95% CI, 75.9%-97.9%) for detecting malignancy. We definitively characterized 120 lesions as benign (84) or malignant (36).Preoperative needle biopsy diagnoses allowed clinical management to progress 92.6% of the time. The protocol of FNA with selective use of CNB may potentially reduce patient exposure to risks associated with CNB without the tradeoff of lower sensitivity seen with FNA.4. Laryngoscope, 127:2522-2527, 2017.

The purpose of this secondary analysis was to determine change in overall health-related quality of life (HRQOL) based on patient data obtained from NRG Oncology RTOG 0537 as measured by the RTOG-modified University of Washington Head and Neck Symptom Score (RM-UWHNSS).A multi-site prospective randomized clinical trial design stratified 137 patients with post-radiation therapy xerostomia according to prior pilocarpine (PC) treatment and time after radiation therapy and/or chemotherapy and randomized patients into two groups. Patients were assigned to acupuncture or PC. Twenty-four sessions of acupuncture-like transcutaneous electrical nerve stimulation (ALTENS) were administered over 12 weeks, or oral PC (5 mg) three times daily over the same 12 weeks. The RM-UWHNSS was administered at baseline and at 4, 6, 9, and 15 months after the date of randomization.There were no between-arm differences in change scores on the RM-UWHNSS in the individual items, total score, or factor scores. For statistical modeling, race and time were significant for all outcomes (total and factor scores), while treatment arm was not significant. The ALTENS arm showed greater yet nonsignificant improvement in outcomes compared to the PC arm.Although no significant treatment differences were seen in this trial, patients receiving ALTENS consistently had lower scores, indicating better function, as compared to those receiving PC. Radiation-induced xerostomia improved over time for all patients.

When managing a patient with nasopharyngeal carcinoma there are a number of clinical and imaging factors a clinician will use to make the appropriate staging evaluation and treatment recommendations. In this chapter a sample case of a patient with a poorly differentiated non-keratinizing carcinoma of the lateral wall of the nasopharynx with palpable lymphadenopathy, clinically staged T2N1M0, is used to assist the reader in formulating decisions about the best methods for assessing skull base involvement, the role of PET imaging, the role of viruses in tumorigenesis, and pertinent decisions regarding the treatment of the primary tumor in both untreated and recurrent disease. The unique decisions pertaining to managing the neck nodes and the role of adjuvant chemotherapy are reviewed as well.

Objectives/Hypothesis Salvage laryngectomy after failed organ preservation often has a high complication rate, pharyngocutaneous fistulas being the most common. These fistulas increase morbidity, prolong hospitalization, and potentially delay adjuvant treatment. Fistula rates in the literature range from 3% to 65%. Use of the pectoralis flap to prevent fistula formation has been adopted as a common practice at our institution. A review of our experience using the overlay myofascial showed a higher than desired complication rate. The aim of this study is to assess whether the use of integrated myocutaneous flap results in a lower fistula rate. Study Design A retrospective review of 30 patients followed by a pilot study of 10 patients. All underwent salvage laryngectomy after failed organ preservation. Methods The operation notes of 40 laryngectomy patients were analyzed. The patient/tumor characteristics, pretreatment, neck dissection, flap type, and fistula rate were documented. Results The patient sample was 25% female. All patients received prior radiotherapy, but only 37.5% received prior chemoradiation. Neck dissections were performed in 80% of these patients, 76% of the myocutaneous group, and 84% of the myofascial group. Advanced tumor stage was found in 42% of the myofascial group and 52% of the myocutaneous group. Five of the 19 myofascial patients developed a fistula, whereas seven of the 21 myocutaneous patients developed a fistula. Conclusions The use of the pectoralis myocutaneous flap (PMCF) in this pilot series did not show a lower rate of fistula; other alternatives should be pursued to decrease this complication. Evidence Level 4. Laryngoscope, 124:1615–1617, 2014

Background: The use of intratympanic (IT) steroids for the treatment of inner ear disorders is promising, but the clinical challenges of prolonged middle ear drug application have proven burdensome, and a sustainable delivery system is yet to be developed. Method: In this study, a guinea pig model was used to determine if dexamethasone in combination with a hyaluronic-acid (HA)-based hydrogel is an efficient, stable and sustainable dexamethasone delivery system to the inner ear. For each animal, right and left middle ear bullae were randomly selected to be filled with dexamethasone alone or dexamethasone-HA (Dex-HA) gel. Perilymph samples were collected at different time points and dexamethasone levels were determined using an ELISA. Results: Dexamethasone was measurable in the perilymph samples up to 72 h after treatment. At 24 h after treatment, the perilymph dexamethasone concentrations were significantly higher (p = 0.01) in the ears treated with Dex-HA gel than in those treated with dexamethasone alone. While the perilymph dexamethasone concentration had decreased at 48 h after treatment with Dex-HA gel, the levels were still higher than those observed at 24 h in ears treated with dexamethasone alone. A high variability in dexamethasone concentration was observed between the samples, and the variability between matched ears receiving different treatments was remarkably lower than the variability within each treatment group, suggesting that individual parameters might play a major role in perilymph dexamethasone concentration. There was no statistically significant correlation between dexamethasone concentration and sex, weight or laterality. Conclusions: Our results show that the Dex-HA gel used in this study provides an effective and sustained dexamethasone release mechanism that might be utilized to treat conditions such as sudden sensorineural hearing loss. This could potentially reduce the morbidity and costs associated with IT treatment.

Background. Our aim was to determine the feasibility and safety of initiating early oral feeding in patients who underwent salvage laryngectomy on postoperative day 5 and to review the rate of pharyngocutaneous fistula formation. Methods. A retrospective review of 29 patients who underwent salvage laryngectomy was completed. Patients included in the study had radiation therapy ± chemotherapy for laryngeal squamous cell carcinoma with subsequent total laryngectomy. Patients were excluded from analysis if they were reliant on a gastrostomy tube preoperatively, had a concurrent complete glossectomy, or developed a fistula before beginning oral feedings. Early oral feeding was initiated on postoperative day 5. Results. Twenty patients met complete inclusion criteria. Pharyngocutaneous fistula occurred in 10% (2/20) of the patients. Patients without postoperative complications on an average remained in the hospital for 7 days. Conclusions. The risk of fistula formation is not increased and the duration of hospital stay may be shortened in patients who were given early postoperative feeds. © 2009 Wiley Periodicals, Inc. Head Neck, 2009

Objectives/Hypothesis: To assess the efficacy of paclitaxel, ifosfamide, and cisplatinum induction chemotherapy plus concurrent chemoradiation in the treatment of stage III and IV base of tongue cancer. Study Design: Subgroup analysis of patients with base of tongue cancer enrolled in a single-institution prospective phase II trial, evaluating an organ-preservation approach in the treatment of locally advanced head and neck cancer. Methods: Eighteen patients with tumors ranging from stage T2–T4, any N, or M0 were treated with a protocol of induction chemotherapy, with Taxol, ifosfamide, cisplatin every 21 days for up to three cycles. If the primary tumor exhibited a complete or partial response, patients were treated with radiation and weekly taxol and carboplatin for 7 weeks. Surgery was used for those with less than partial response or disease progression. Neck dissection was performed in cases with clinical or radiological evidence of persistent disease in the neck 6 to 8 weeks after completion of treatment. Results: Sixteen patients were male and two were female; the average age was 55 years (range, 43–65). Fifteen patients had stage IV disease and three had stage III disease. Of the 18 patients initially enrolled, 17 patients had a complete response. All 17 patients had no evidence of loco-regional disease at a median follow-up of 29.6 months. Only 1 of them developed distant metastases 30 months after completion of treatment. Three patients required permanent percutaneous endoscopic gastrostomy tubes because of severe dysphagia associated with concurrent chemoradiation. Conclusions: The treatment regimen studied is remarkably effective in stage III and IV base of tongue cancer with 100% of patients completing the protocol alive to date. Although some patients required persistent percutaneous endoscopic gastrostomy use, no patient experienced significant enough toxicity during the protocol to delay or withdraw from treatment.

Objective The aim of this study was to determine the accuracy of the fluorine 18 (18F)–labeled fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) scan in the evaluation of thyroid nodules in which the cytopathology of fine-needle aspiration (FNA) biopsies are classified as “indeterminate,” ie, either follicular or Hurthle cell lesion. Methods At an academic medical center, we conducted a prospective pilot study of 15 patients with thyroid nodules in whom adequate FNA was diagnosed as indeterminate. All patients underwent a whole-body FDG-PET/CT scan followed by thyroidectomy. Preoperative FDG-PET/CT results and the histopathology of the surgical specimen were compared and statistically analyzed. Results The FNA demonstrated follicular cells in 11 (73%) patients, Hurthle cells in 3 (20%) patients, and both types of cells in 1 (7%) patient. The histopathology of the surgical specimen revealed thyroid cancer in 7 (47%) patients. The FDG-PET/CT scan was positive in 8 patients; 4 (50%) patients were found to have cancer. The FDG-PET/CT scan was negative in 7 patients. Four of these patients had benign lesions and 3 had thyroid carcinoma. Thus, 4 (27%) patients had false-positive FDG-PET/CT scans and 3 (20%) patients had false-negative studies. The sensitivity of FDG-PET/CT to detect a malignant focus was 57% with a specificity of 50%. The positive predictive value was 50% and the negative predictive value was 57%. Conclusions In this pilot study of patients with cytologically indeterminate thyroid nodules, FDG-PET/CT was not a predictable indicator of benign or malignant disease. Although a larger series may elucidate a role for FDG-PET/CT, the relatively low predictability shown in this study should caution clinicians about using FDG-PET/CT to consider foregoing thyroidectomy for cytologically indeterminate nodules.

Objective: The objective of this study was to report the long-term efficacy of radiofrequency volumetric tissue reduction (RFVTR) and to compare this with other accepted surgical treatments of inferior turbinate hypertrophy. Study Design and Setting: Prospective, 2-year follow-up of 19 patients originally enrolled in a prospective, randomized, single blinded, placebo controlled trial for treatment of inferior turbinate hypertrophy with RFVTR. Patients evaluated their severity of obstruction, frequency of obstruction, and overall ability to breathe by way of a 10 cm visual analogue scale. Results: RFVTR for inferior turbinate hypertrophy showed continued benefit at 2 years posttreatment, with no indication of increasing symptomatology. The benefit demonstrated in frequency of obstruction, severity of obstruction, and overall ability to breathe (P < .05) was maintained at 2 years. No complications occurred. Review of the literature shows lower short- and long-term complications for RFVTR compared with other surgical methods Conclusion: RFVTR is effective in treating inferior turbinate hypertrophy with sustained benefit at 2 years follow-up while resulting in fewer complications than other surgical methods. Significance: RFVTR is a relatively new procedure, and therefore there are few long-term evaluations of its effectiveness; this is the first prospective study to document successful outcomes at 2 years follow-up.

The goal of this study was to identify clinical characteristics and concurrent medications associated with an increased or decreased incidence of cisplatin-induced nephrotoxicity. The medical records for 62 subjects with head and neck cancer who received cisplatin 100 mg/m2 (day 1) plus fluorouracil 1000 mg/m2 (days 1-5) with or without radiation therapy were reviewed from three medical centers. The demographics, concurrent medication therapy, co-existing illnesses and clinical laboratory values were extracted from the medical records. Nephrotoxicity was defined as a minimum rise in serum creatinine of 0.5 mg/dl or above. The concurrent use of hydrochlorothiazide or multivitamins was associated with a higher incidence of nephrotoxicity after cycle 1. Use of albuterol, atenolol or hydrochlorothiazide was also associated with a higher incidence of nephrotoxicity after cycle 1 or 2. In contrast, subjects prescribed dexamethasone or ondansetron were less likely to experience nephrotoxicity. None of these medications affected treatment response. Race/ethnicity was independently correlated with the incidence of nephrotoxicity; African-American subjects were more likely to develop nephrotoxicity independent of the influence of these concurrent medications. Medications may modulate cisplatin-induced nephrotoxicity by altering the metabolic activation of cisplatin to a nephrotoxin. Genetic differences in the drug-metabolizing enzymes may contribute to the correlation with race. The results from this retrospective study provide data to support a larger prospective study to further investigate the associations between these concurrent medications and cisplatin-induced nephrotoxicity.

The role of the surgeon in the management of hyperparathyroidism has changed substantially over the last several decades. Previously, most referrals to surgeons came from endocrinologists. These patients were generally thoroughly evaluated and usually were ready to be scheduled for surgical exploration. In recent years, the addition of serum calcium measurement during routine blood chemistries for adults has led to the identification of numerous patients with asymptomatic hypercalcemia. These patients are being referred in increasing numbers to surgeons. This change in referral patterns requires the appropriate preoperative evaluation by the surgeon to identify those patients who would be best treated by parathyroidectomy. There have been numerous technological advances in preoperative and intraoperative identification of parathyroid adenomas. These, combined with the availability of rapid intraoperative parathyroid hormone measurements have allowed the introduction of minimally invasive techniques for parathyroid exploration. This article reviews the appropriate preoperative assessment of patients with hypercalcemia, and the indications for surgical management of hyperparathyroidism.

Introduction: IRX-2 is a primary-cell-derived immune-restorative biologic consisting of a well-defined set of human cytokines that act on multiple immune system cell types to overcome tumor-mediated immunosuppression. The IRX-2 biologic stimulates T cells and natural killer cells and turns immature or defective dendritic cells into mature antigen-presenting cells. The IRX-2 biologic is provided as part of the IRX-2 regimen, which contains cyclophosphamide, indomethacin, and zinc to support an anticancer immune response. In a phase 2a clinical trial in 27 patients with therapy-naïve head and neck squamous cell carcinoma (HNSCC), treatment with the IRX-2 regimen was well tolerated and associated with immunologically mediated antitumor effects. The new multicenter randomized IRX-2 Neoadjuvant Therapy in Head and Neck SCC to Provide Immune Response Enhancement (INSPIRE) trial (NCT02609386) is designed to evaluate the safety and effectiveness of combined neoadjuvant and adjuvant therapy with the IRX-2 regimen in patients with oral cavity HNSCC, a disease known to have a disordered immune function. Study Design: Patients enrolled in INSPIRE must be at least 18 years of age; have previously untreated Stage II, III, or IVa SCC of the oral cavity that is surgically resectable with curative intent; and have a Karnofsky Performance status ≥70%. Up to 200 patients will be randomized 2:1 to either the IRX-2 biologic regimen arm or the IRX-2 regimen control arm (the IRX regimen minus the IRX-2 biologic). The neoadjuvant stage of INSPIRE begins 21 days before resection, when patients in both treatment arms will receive the IRX-2 regimen each day until resection. This regimen consists of the immunomodulatory chemotherapeutic agent cyclophosphamide, provided as a low-dose intravenous infusion, as well as two oral drugs, a zinc-containing multivitamin and indomethacin, a nonselective COX-1/COX-2 inhibitor. During this period, patients in the IRX-2 biologic regimen arm will also receive 10 days of the IRX-2 biologic subcutaneously injected into their bilateral sternocleidomastoid insertion regions. After resection, patients receive standard adjuvant radiation or chemoradiation therapy followed by adjuvant IRX-2 booster regimens at 3, 6, 9, and 12 months. During each 10-day booster period, patients in the IRX-2 biologic regimen arm also receive, for 5 consecutive days, the IRX-2 biologic subcutaneously injected into their bilateral deltoid regions. Study Endpoints: INSPIRE is now enrolling patients at 12 selected institutions in the United States. The primary endpoint of INSPIRE is event-free survival (EFS). Secondary endpoints include overall survival (OS) and safety as assessed by the incidence and severity of adverse events. Exploratory endpoints include changes in tumor size and histologic differences between pre- and post-treatment specimens in lymphocytic infiltration, assessed by both cell-surface marker expression (Perkin Elmer multiplex IHC) and immune cell gene signatures (NanoString). Conclusion: With enrollment of up to 200 patients, the randomized INSPIRE trial provides the opportunity to assess the ability of the IRX-2 regimen to improve EFS and OS by inhibiting tumor-mediated immunosuppression. Analysis of the exploratory endpoints will generate data to better describe the mechanism of action of the IRX-2 regimen and provide insight into the differences between inflammatory and non-inflammatory responses to SCCs of the oral cavity. Citation Format: Gregory T. Wolf, Mihir Patel, Audrey Erman, Jason G. Newman, Greg Krempl, Jorge Nieva, R. Bryan Bell, Michael Kaplan, Dennis Kraus, Jeffrey Moyer, Aru Panwar, Joseph Valentino. The INSPIRE trial: A randomized trial of neoadjuvant and adjuvant therapy with the IRX-2 regimen in patients with newly diagnosed stage II, III, or IVa squamous cell carcinoma of the oral cavity [abstract]. In: Proceedings of the AACR-AHNS Head and Neck Cancer Conference: Optimizing Survival and Quality of Life through Basic, Clinical, and Translational Research; April 23-25, 2017; San Diego, CA. Philadelphia (PA): AACR; Clin Cancer Res 2017;23(23_Suppl):Abstract nr 31.

Osteonecrosis of the jaw is an uncommon consequence of biphosphonate therapy. This has most commonly been a bone complication with little if any soft tissue involvement. An unusual case of necrotizing fasciitis with extensive soft tissue infection stemming from a prolonged case of osteonecrosis of the jaw presented. The management of this patient (aggressive surgical debridement and prolonged wound care) is reviewed as well as the review of the underlying processes.

Background Giant cell granuloma is rare in the head and neck region and most commonly affects the maxilla and mandible. Although it is a benign disease process, it may be locally destructive. Surgery is the treatment currently recommended. Because of the location of the disease, surgery may be disfiguring. Because it is a benign process, less radical nonsurgical treatment alternatives are desirable. Methods A case report of a giant cell granuloma treated with steroid injections. Results After six weekly intralesional steroid injections, a giant cell granuloma of the maxilla became calcified and smaller. After a follow-up period of 2 years, there was no evidence of regrowth, and the bony osteolytic lesion had filled with bone. A review of the literature revealed two case reports of successful steroid injections with similar response. Conclusions Steroid injections are a viable alternative in the treatment of giant cell granuloma, which may avoid surgery. © 2000 John Wiley & Sons, Inc. Head Neck 22: 822–825, 2000.

Salvage laryngectomy after failed organ preservation often has a high complication rate, pharyngocutaneous fistulas being the most common. These fistulas increase morbidity, prolong hospitalization, and potentially delay adjuvant treatment. Fistula rates in the literature range from 3% to 65%. Use of the pectoralis flap to prevent fistula formation has been adopted as a common practice at our institution. A review of our experience using the overlay myofascial showed a higher than desired complication rate. The aim of this study is to assess whether the use of integrated myocutaneous flap results in a lower fistula rate.A retrospective review of 30 patients followed by a pilot study of 10 patients. All underwent salvage laryngectomy after failed organ preservation.The operation notes of 40 laryngectomy patients were analyzed. The patient/tumor characteristics, pretreatment, neck dissection, flap type, and fistula rate were documented.The patient sample was 25% female. All patients received prior radiotherapy, but only 37.5% received prior chemoradiation. Neck dissections were performed in 80% of these patients, 76% of the myocutaneous group, and 84% of the myofascial group. Advanced tumor stage was found in 42% of the myofascial group and 52% of the myocutaneous group. Five of the 19 myofascial patients developed a fistula, whereas seven of the 21 myocutaneous patients developed a fistula.The use of the pectoralis myocutaneous flap (PMCF) in this pilot series did not show a lower rate of fistula; other alternatives should be pursued to decrease this complication.4.

Objective We report a series of patients treated for carcinoma of the tonsil who either presented with bilateral carcinomas or later developed a second primary carcinoma of the contralateral tonsil. This report raises awareness of this occurrence. Study design Case series. Methods Four cases have been identified of either concomitant or subsequent carcinoma of the contralateral tonsil inpatients treated for tonsillar carcinoma from the practices of 3 head and neck surgeons in a single demographic area over a 35 year span. Results Four patients were identified who were treated for tonsillar carcinoma with concomitant or subsequent carcinoma of the contralateral tonsil: One patient with bilateral metastatic carcinoma in cervical lymph nodes was found to have bilateral occult tonsillar primaries.Three patients who were treated for tonsillar primary carcinomas subsequently developed carcinoma of the contralateral tonsil. Conclusions A small population of patients with unilateral tonsil carcinoma will developed a second in the contralateral tonsil. This raises the question of whether removal of the contralateral tonsil at the time of initial treatment might have spared the morbidity/mortality of the subsequent contralateral tonsil cancer.

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

To determine the rate of use and non-use of prophylactic percutaneous endoscopic gastrostomy (PEG) tubes among patients with head and neck cancer (HNC) patients.All patients with HNC undergoing PEG between January 1, 2004 and June 30, 2006 were identified. Patients (or their next-of-kin) were surveyed by phone and all available medical records and cancer registry data were reviewed. Prophylactic PEG was defined as placement in the absence of dysphagia and prior to radiation or chemoradiation. Each patient with a prophylactic PEG was assessed for cancer diagnosis, type of therapy, PEG use, and complications related to PEG.One hundred and three patients had PEG tubes placed for HNC. Thirty four patients (33%) could not be contacted for follow-up. Of the 23 (22.3%) patients with prophylactic PEG tubes, 11/23 (47.8%) either never used the PEG or used it for less than 2 wk. No association with PEG use vs non-use was observed for cancer diagnosis, stage, or specific cancer treatment. Non-use or limited use was observed in 3/6 (50%) treated with radiation alone vs 8/17 (47.1%) treated with chemoradiation (P = 1.0), and 3 of 10 (30%) treated with surgery vs 8 of 13 (62%) not treated with surgery (P = 0.21). Minor complications were reported in 5/23 (21.7%). One (4.3%) major complication was reported.There is a high rate of unnecessary PEG placement when done prophylactically in patients with head and neck cancer.

Tracheostomy tube fracture resulting in airway obstruction is a relatively rare but serious complication. We report the case of a 48-year-old man whose tracheostomy tube fractured and became lodged in the right primary bronchus. Recommendations are made for tracheostomy care to help prevent similar complications in patients with an indwelling tracheostomy tube.

Objectives1) To describe a case of ectopic intratracheal thyroid cancer. 2) To review the literature describing ectopic intratracheal thyroid tissue.MethodsEctopic thyroid tissue is periodically encountered and can sometimes be malignant. The most common locations for ectopic thyroid tissue to be found are the tongue and along the tract of descent of the thyroid gland into the neck. We describe a case of ectopic intratracheal thyroid cancer and review the literature for similar cases. We also discuss possible explanations for this phenomenon.ResultsA total thyroidectomy with tracheal resection was performed. The patient received postoperative I131 therapy and has no detectable serum thyroglobulin to date. There is a small number of cases that report ectopic thyroid tissue found in the trachea. 3 of these were malignant. Including the current case, 26% of ectopic intratracheal tissue is malignant.ConclusionsEctopic intratracheal thyroid tissue is rare. Since 26% of reported cases have been malignant, we su...

Objective To analyze patients with “normal” baseline quick intraoperative parathyroid hormone (QPTH) levels during parathyroidectomy and to determine the prevalence of this finding, the usefulness of the assay in this situation, and to explain the possible causes for this phenomenon. Study design and setting Patients who underwent parathyroidectomy using QPTH in a tertiary hospital. Methods Retrospective analysis of 39 patients treated surgically for primary hyperparathyroidism using QPTH. Results Of the patients, 14 (36%) had normal baseline QPTH. 8 patients with localizing sestamibi scans had a single adenoma, and excision resulted in a mean decrease of 85.4% in QPTH. Six patients had nonlocalizing sestamibi scans, 1 patient had an 84% drop in QPTH level after removal of a single adenoma, and 5 patients had hyperplasia requiring ≥3 glands excision. At 11.36 months' mean follow-up, 13 patients (93%) were normocalcemic. Conclusions A “normal” baseline QPTH level was found in 36% of patients. A 50% decrease in QPTH remains predictive of biochemical cures in patients with localizing sestamibi scans. The likely explanation for this variability in “normal” levels between different assays is the variability in detection of the 7-84 PTH fragment, which results in an overestimation of the PTH level. Assays such as the QPTH, which are more sensitive for the biologically active PTH molecule [(1-84) PTH] than other laboratory PTH assays will tend to have lower PTH levels that can be within the normal range. EBM rating: B-3.

We sought to evaluate the short-term efficacy of radiofrequency volumetric tissue reduction (RFVTR) in treating nasal obstruction in subjects with inferior turbinate hypertrophy.We conducted a prospective, randomized, single-blinded, placebo-controlled trial with crossover option, involving 32 patients and performed in a clinical office setting at the University of Oklahoma Medical Center.The outcomes were measured using 10-cm visual analog scales (VASs) before treatment and at 8 weeks and 6 months posttreatment. Improvement was shown in frequency of obstruction, severity of obstruction, and overall ability to breathe for both the placebo and RFVTR treatment arms at 8 weeks (P0.05). The amount of improvement, however, was significantly better in the treatment arm compared with placebo for the severity of obstruction and overall ability-to-breathe categories. At 6 months, the mean improvement scores were significantly better than the pretreatment scores for all 3 categories.RFVTR is an effective alternative for the treatment of patients with nasal obstruction due to inferior turbinate hypertrophy.This is the first randomized trial that demonstrates that RFVTR is significantly better than placebo in treating nasal obstruction due to inferior turbinate hypertrophy.

The recent advance of intraoperative PTH monitoring combined with preoperative localization techniques allow for minimally invasive parathyroid surgery in 75% to 85% of cases. In cases where a single adenoma is identified, minimally invasive techniques should result in a need for repeat surgery in only 2% of cases. The cost of intraoperative PTH assays of localization and gamma probes limits their availability. Complications of parathyroidectomy are uncommon, but appropriate management is important, particularly for patients with hypocalcemia.

Background: Tobacco use is the primary risk factor for head and neck squamous cell carcinoma (HNSCC), the sixth most common malignancy worldwide. Aberrant activation of the Wnt pathway is a key event in tumorigenesis, but the precise mechanisms leading to up-regulation of Wnt signaling in HNSCC have not been defined. Wnt inhibitory factor 1 (WIF1) is significantly down-regulated in many tumors but its expression status in oropharyngeal HNSCC is unknown. Aims: To characterize WIF1 expression in oropharyngeal normal and tumor samples and delineate the mechanisms leading to alterations in WIF1 expression. Methods: Paraffin-embedded tissue samples from fifty patients with HNSCC identified from the annotated tumor registry at the University of Oklahoma were obtained. Additionally, fifty paraffin-embedded tissues were obtained from smoker and non-smoker individuals undergoing tonsillectomy at the University of Oklahoma for non-cancerous diagnosis. Histological diagnoses were reviewed and samples from non-cancer individuals were matched for age and sex. Smoking habits were registered in pack-years. WIF1 protein expression was determined by immunohistochemistry. Genomic DNA isolated from normal and tumor samples were treated with bisulfite, and methylation-specific PCR and bisulfite sequence analysis were performed. Results: WIF1 expression was very high in normal tonsil epithelium obtained from non-smokers. However, WIF1 expression was reduced in smokers compared to non-smokers (p=0.01). WIF1 expression was frequently and significantly reduced in tumors compared to normal adjacent epithelium (p Conclusions: WIF1 promoter hypermethylation is frequent in oropharyngeal cancer and contributes to WIF1 down-regulation. Importantly, by studying samples obtained from non-cancer patients, we show clearly and for the first time that WIF1 promoter methylation is an early event associated with tobacco-use. Taken together, this study establishes an important role for WIF1 in oropharyngeal HNSCC and suggests that WIF1 promoter methylation in normal epithelium is a biomarker of risk for tobacco-associated cancer. Grant support: This work was supported by the Oklahoma Center for the Advancement of Science & Technology. LQ holds a Presbyterian Health Foundation Endowed Chair in Otorhinolaryngology. Citation Format: Lurdes VF Queimado, Ryan Raju, Liu Cheng, Ilangovan Ramachandran, Eva Brabcova, Matt Naifeh, Greg Krempl. Down-regulation of Wnt inhibitory factor 1 is an early event in oropharyngeal cancer associated with tobacco-use. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 4299. doi:10.1158/1538-7445.AM2013-4299

The purpose of this study was to determine if use of an intranasal vasoconstrictor (oxymetazoline) could be used to effectively treat epistaxis, avoiding nasal packing. The charts of 60 patients who presented to the emergency room with the diagnosis of epistaxis and who required medical management were reviewed. Sixty-five percent of these patients were successfully managed with oxymetazoline as their sole therapy. An additional 18% were managed successfully with silver nitrate cautery in combination with oxymetazoline. In only 17% of patients was it necessary to use nasal packing as treatment for epistaxis after an initial attempt with oxymetazoline alone or in combination with silver nitrate failed. These data suggest that pharmacologic management may be adequate in the majority of patients with epistaxis, thus avoiding the need for nasal packing with its associated complications.

Objective: The objective of this study is to determine the incidence, risk factors, and management of sialoceles and salivary fistula after parotidectomy. Methods: Single institution, multiple surgeon retrospective review of patients undergoing parotid surgery r over a three year period (2006-2009). Results: The incidence of sialocele and/or fistula in 65 patients was 21.4%. A salivary fistula was seen in 28% of patients that had a complete superficial parotidectomy, and 5% of patients that had a partial parotidectomy (p 1week) and/or is amylase positive. Factors that were examined included tumor pathology, type of parotidectomy performed (partial lobectomy, complete superficial parotidectomy, total parotidectomy, and radical parotidectomy), the type of drain placed, the duration of drain placement, the volume of the specimen, and the duration of the sialocele or fistula. Patients that required neck dissection, skin resection, regional or microvascular flap reconstruction, or temporal bone resection were excluded. Surgeries were classified as a partial lobectomy (dissection and removal of tissue over either the upper or lower division of the facial nerve), complete lateral lobectomy (dissection and removal of tissue over both the upper and lower division), deep lobe parotidectomy, radical parotidectomy. A students t-test and Fisher exact test were used to determine significance. The incidence of sialocele in this study was found to be 21%, which is consistent with what is reported in other studies. A myriad of factors were examined to determine if a correlation existed with sialocele formation, but the only factor that achieved statistical significance was the type of parotid surgery performed. Patients undergoing a complete dissection of the superficial lobe of the parotid had a significantly higher rate if salivary fistula formation. This finding is contrary to what has been reported in previous studies which showed a higher rate of sialocele with a partial lobectomy.4 Though the reason for the association with extent surgery is unclear, it is possible that as a larger surface area of the gland is exposed, there is a greater accumulation of saliva, leading to a higher propensity of sialocele formation. The higher rate of of sialocele formation in patients undergoing a deep lobe parotidectomy is also suggestive of this reasoning, but this did not approach statistical significance given the low number of patients undergoing this procedure. The type of treatment did not seem to hasten resolution of the sialocele, though the power of this portion of the study was low. A prosepctive study or larger sample size would be necessary to answer this question. Other limitations of this study are primarily due to its retrospective nature. In conclusion, sialoceles and salivary fistulas are a relatively common occurrence after parotid surgery. They appear to occur more frequently with removal of the entire superficial lobe of the parotid compared . Resolution tends occur in approximately one month. At present, no therapy has been shown to prevent their occurrence. Introduction Material and Methods Results Discussion/Conclusion Type of Surgery Sialocele Partial Lobectomy 5% Complete Lateral Lobectomy* 28% Deep Lobe Parotidectomy 50% Treatment Frequency Used Average Days to Resolution Aspiration 64% 26.3 Packing 7.1% 26 Pressure Dressing 35% 26.4 Scopolamine 42% 29.5 Drain 14% 27 TABLE 1 Incidence of Sialocele/Salivary Fistula Based on the type of Surgery Performed