Faculty Bibliography

AIM: To investigate the impact of definitive radiation therapy (RT) in the management of early glottic cancer on clinical RT-induced dysphagia (RID) and carotid vasculopathy (RICV). PATIENTS AND METHODS: This is a single-institution retrospective study. From January 1997 to 2010, 253 patients, with early glottic cancer, underwent RT with (60)Co or LINAC-6 MV photons. RT fields with wedge pair and daily 5-mm bolus were applied in all patients treated with 6-MV photons to avoid under-dose of the anterior laryngeal structures. The whole larynx (LX), pharyngeal constrictors (PCs), and carotid arteries (CA) were contoured and dose-volume histograms (DVHs) were generated to assess the delivered dose. The median age of patients was 65 years (range; 28-93), Caucasians were 80%, males were 87%, and 23% had T2 lesions. RESULTS: After a median follow-up of seven years (range; 1.5-12), the median dose and fraction size delivered to the LX were 63 and 2.25 Gy, respectively. The mean doses to the LX, PC, and CA were 57 Gy delivered to 34 cm(3), 54 Gy to 15 cm(3), and 60 Gy to 4 cm(3), respectively. The LX, PC and CA V60 and V65 were (77 and 71), (70 and 52) and (84 and 51), respectively. Patients with acute dysphagia grades 1, 2, and 3 or more were 81, 19%, and zero, respectively; none had clinically RID or RICV. CONCLUSION: Small-volume RT up to 67.5 Gy at 2.25 Gy per fraction, is not a predictor of RID or RICV. Separate delineation of the aforementioned critical structures, as well as others, may better identify dose tolerances to maintain function and further prioritize the importance of structures in RID and RICV.

Interleaved masking in cochlear implants is analogous to acoustic simultaneous masking and is relevant to speech processing strategies that interleave pulses on concurrently activated electrodes. In this study, spatial decay of masking as the distance between masker and probe increases was compared between forward and interleaved masking in the same group of cochlear implant users. Spatial masking patterns and the measures of place specificity were similar between forward and interleaved masking. Unlike acoustic hearing where broader tuning curves are obtained in simultaneous masking, the type of masking experiment did not influence the measure of place specificity in cochlear implants.

Background/Purpose: Rheumatoid arthritis (RA) patients are at increased risk of infection due to both RA itself and immunomodulating treatments. Infection rates are often difficult to compare across studies, since the rates may vary across the world, and due to methodological and demographic differences between studied populations or cohorts. We investigated rates of hospitalized infection in 5 RA registries from 4 continents, employing a standard set of analyses and standardizing rates to a common population. Methods: Participating registries were CORRONA (USA), SRR (Sweden), NOAR (UK), CORRONA International (East Europe, Latin America, India) and IORRA (Japan). The definition of hospitalized infections was harmonized as much as possible across registries. Within each registry, we analyzed a primary cohort of all RA patients from January 2000 to last available data of each registry (2010-2013), and several subcohorts for sensitivity analyses, defined by disease activity, treatment status, calendar time, duration of follow-up and prior comorbidity. Rates were standardized for age, sex and, in 1 sensitivity analysis, also for HAQ, using the distributions from a typical RA trial program population. Results: There was relatively high consistency in rates across registries, and sex/age standardization increased consistency further (Table 1). Generally, the primary cohorts provided the lowest or close to lowest rate (Table 2). In most registries, the highest rates were seen in subcohorts (either biologic naive or with prior biologic treatment) with only 18 months follow-up after treatment change (Table 2). Additional standardization for HAQ score according to a trial patient distribution led to increased rates in all registries (Table 2). Conclusion: This study constitutes the first attempt to compare the incidence of hospitalized infections internationally using existing RA cohorts. Consistent methodology, outcome definitions and analysis with standardization of rates facilitated comparison across !

IMPORTANCE/OBJECTIVE:Since technologic advances allow the use of robotic assistance in various surgical interventions performed to treat pediatric otolaryngology patients, the feasibility and outcomes of potential procedures must be assessed. OBJECTIVE:To assess the feasibility and outcomes of robotic-assisted lingual tonsillectomy in the pediatric population. DESIGN, SETTING, AND PARTICIPANTS/METHODS:Retrospective medical record review in a tertiary care children's hospital of 16 pediatric patients who underwent robotic-assisted lingual tonsillectomy from March 1, 2011, through December 31, 2012. INTERVENTION/METHODS:All patients underwent robotic-assisted lingual tonsillectomy using the da Vinci Surgical System (Intuitive Surgical, Inc) at the Children's Hospital of Pittsburgh of the University of Pittsburgh Medical Center. MAIN OUTCOMES AND MEASURES/METHODS:Demographic data, comorbidities, robot docking time, operative time, estimated blood loss, and postoperative course, including complications in the immediate and longer-term postoperative period, were collected and analyzed. RESULTS:All patients successfully underwent lingual tonsillectomy using the da Vinci Surgical System. Endotracheal intubation was performed in all patients and did not interfere with visualization of the oropharynx. Optimal retraction allowed visualization of pertinent structures and maximized transoral access. A significant learning curve from the first 5 surgical cases to subsequent cases with respect to robot docking time was observed (9 vs 3 minutes, respectively; P < .05). Operative time, estimated blood loss, and postoperative complication profiles are within the expected and acceptable limitations for performing lingual tonsillectomy in the pediatric population. CONCLUSIONS AND RELEVANCE/CONCLUSIONS:Technologic advances have allowed miniaturization of robotic instrumentation and have expanded the scope of surgical options for the pediatric airway. Robotic-assisted lingual tonsillectomy is well tolerated and can be performed in the pediatric population with excellent success. It should be considered a feasible option for implementation at an institution-based level.

BACKGROUND: The purpose of this study was to analyze the oncologic and functional outcomes of the preserved eye in malignant sinonasal tumors with orbital involvement. METHODS: In a retrospective study of 19 consecutive patients who underwent craniofacial resection or maxillectomy with preservation of orbital contents and adjuvant radiotherapy, the oncological outcome in terms of local recurrence and survival was analyzed. The functional outcome in the preserved eye was analyzed for the cases that did not recur in the orbit. RESULTS: Nineteen patients were analyzed for their oncologic and functional outcomes. Fifteen patients underwent immediate reconstruction of the orbital support. Eight patients had local recurrences; 11 patients were disease free at the end of the follow-up. Squamous cell carcinoma has a high propensity for local recurrences (ie, 5 of 8 local recurrences were squamous cell carcinoma). Sixteen patients, in whom a satisfactory orbital tumor clearance was obtained, remained recurrence free in the orbit. All the preserved eyes retained adequate function after adjuvant radiotherapy. CONCLUSIONS: Adequate local control with preserved visual function can be obtained with surgery and adjuvant radiation in appropriately selected malignant sinonasal tumors with orbital involvement. The preserved eye, if reconstructed appropriately, maintains good overall function with acceptable morbidity.

Patients in a US public hospital were recently found to present with more advanced differentiated thyroid carcinoma (DTC) than those in an adjacent university hospital. 37% of public hospital patients with DTC were primarily Spanish-speaking. We used focus groups and key informant interviews to examine access to care and knowledge of diagnosis/treatment among Spanish-speaking patients with DTC. All adult patients treated for DTC between 2000-2011 and who indicated Spanish as their preferred language met inclusion criteria. Focus groups and key informant interviews were conducted in Spanish by trained facilitators, utilizing a phenomenology approach. Discussions focused on diagnosis and treatment of DTC. 16/50 eligible patients participated. While all expressed a preference for Spanish when discussing medical care, no patient found language to be a barrier due to ready availability of interpreting services. All reported unimpeded access to primary care, with community networks serving as an important information source of public health services. The majority of patients presented with a selfreported nodule or symptoms associated with hypo/hyperthyroidism, which prompted furtherwork-up. DTCwas discovered incidentally on imaging in a small minority of patients. The majority of patients reported limited to no knowledge of thyroid cancer prior to diagnosis. Although only one patient used alternativemedicine as a treatment for thyroid cancer,many expressed a belief in its value as a complementary modality. Access to care proved unhindered among this patient population, though was contingent on strong community networks and availability of interpreter services. Despite limited patient knowledge, DTC was most commonly diagnosed following presentation with a self-discovered nodule or symptoms of hypo/hyperthyroidism. Beliefs in alternative medicine did not affect timely treatment. These data emphasize the importance of patient education and a culturally sensitive approach to optimize care in this demogr!

OBJECTIVES/HYPOTHESIS: Hard palate and maxillary alveolus are two commonly grouped oral cavity subsites due to their anatomic contiguity and oncologic disease behavior. Few studies have been conducted investigating clinical presentation, staging, prevalence of cervical metastases, and outcomes in this population. The primary objective of this study was to analyze predictors of disease-free survival (DFS) in surgically treated patients, particularly as it relates to the role of neck dissection. STUDY DESIGN: Cohort study with planned data collection. METHODS: This cohort study used planned data collection over 15 years (1994-2008) at a large tertiary care cancer center to study all patients presenting with squamous cell carcinoma of the maxillary alveolus and hard palate treated surgically. Univariate and multivariate Cox regression analyses were used to identify predictors of DFS. RESULTS: Ninety-seven patients met the inclusion criteria (54 male, 56%). The majority of patients (54, 56%) presented with locally advanced disease (cT3, cT4). Occult nodal metastases were noted in 26% (17 of 65) of patients clinically staged as N0. The 3-year DFS was 70% (95% confidence interval = 59%-78%) with a median time to failure of 1.1 years (range = 0.3-9.7 years). Cox regression multivariate model demonstrated that advanced pathologic T stage, hard palate tumor site, and poorly differentiated tumor grade were each independent predictors of DFS. CONCLUSIONS: A significant portion of the patients with hard palate and maxillary alveolus tumors harbor occult cervical metastases. Elective neck dissection in the high-risk patients may potentially be beneficial in providing more accurate staging and improving DFS. LEVEL OF EVIDENCE: 2b.

In this Review, we summarise recent published work on the use of intraoperative radiotherapy to treat common tumour sites in the primary or recurrent setting. Techniques, radiobiology, and the physics of intraoperative radiotherapy are also explored. Disease sites discussed in this Review include head and neck cancer, breast cancer, sarcoma, gastrointestinal cancer, genitourinary cancer, gynaecological cancer, thoracic cancer, and palliative applications.

Sinusitis is a common patient complaint that carries with it a large economic burden. It is one of the most common reasons patients visit their primary care physician. Acute bacterial rhinosinusitis (ABRS) can be distinguished from other forms of rhinosinusitis based on symptom duration of <4 weeks in a patient with purulent rhinorrhea associated with facial pain or pressure. Native upper aerodigestive tract bacteria are the most common etiologic agents. Treatment of ABRS is targeted primarily at symptom improvement. Amoxicillin can be used based on the clinical scenario and patient comorbidities. Computed tomographic scans are reserved for complicated presentations or when there is concern for intracranial extension or other complications. A systematic approach to ABRS will allow for improved patient quality of life and a decreased overall economic burden of this common entity.