Impact of Race, Ethnicity, and Socioeconomic Status on Nasopharyngeal Carcinoma Disease-Specific and Conditional Survival

Introduction  Race, ethnicity, and socioeconomic status (SES) are complex, interconnected social determinants of health outcomes. This study uses multivariable analysis on a combination of large national datasets to examine the effects of these factors on 5-year disease-specific survival (DSS) and conditional DSS (CDSS) for nasopharyngeal carcinoma (NPC). Methods  A retrospective study of adults with NPC between 2000 and 2017 from the Surveillance, Epidemiology, End Results (SEER) registry was performed, using the National Cancer Institute Yost Index, a census tract-level composite score of SES to categorize patients. Kaplan-Meier analysis and Cox's regression for DSS and CDSS were stratified by SES. Logistic regression was conducted to identify risk factors for advanced cancer stage at time of diagnosis and receiving multimodal therapy. Results  Our analysis included 5,632 patients. DSS was significantly associated with race and SES ( p  < 0.01). Asian/Pacific Islander patients exhibited increased survival when controlling for other variables (hazard ratio [HR] = 0.73, p  < 0.01). Although Black patients were more likely to be diagnosed with advanced disease (Black odds ratio [OR] = 1.47, p  < 0.01), Black patients were also less likely to receive multimodal therapy; however, this relationship lost statistical significance once SES was incorporated into the multivariable analysis. DSS was decreased among the lowest (first) and middle (second) tertiles of SES (first HR = 1.34, p  < 0.01; second HR = 1.20, p  < 0.01) compared with the highest (third). Conclusion  Our results indicate that race, ethnicity, and SES significantly affect survival, stage at diagnosis, and treatment of NPC. An interplay of tumor biology and inequalities in access to care likely drives these disparities.

International consensus statement on allergy and rhinology: rhinosinusitis 2021

I.

EXECUTIVE SUMMARY

BACKGROUND: The 5 years since the publication of the first International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR-RS) has witnessed foundational progress in our understanding and treatment of rhinologic disease. These advances are reflected within the more than 40 new topics covered within the ICAR-RS-2021 as well as updates to the original 140 topics. This executive summary consolidates the evidence-based findings of the document.

METHODS

ICAR-RS presents over 180 topics in the forms of evidence-based reviews with recommendations (EBRRs), evidence-based reviews, and literature reviews. The highest grade structured recommendations of the EBRR sections are summarized in this executive summary.

RESULTS

ICAR-RS-2021 covers 22 topics regarding the medical management of RS, which are grade A/B and are presented in the executive summary. Additionally, 4 topics regarding the surgical management of RS are grade A/B and are presented in the executive summary. Finally, a comprehensive evidence-based management algorithm is provided.

CONCLUSION

This ICAR-RS-2021 executive summary provides a compilation of the evidence-based recommendations for medical and surgical treatment of the most common forms of RS.

Pediatric Nasal Chondromesenchymal Tumors: Case Report and Review of the Literature

INTRODUCTION

Nasal chondromesenchymal tumors (NCMT) are rare benign neoplasms that usually present in children <1 year of age. They can display rapid growth and significant local bony remodeling that can mimic a malignant process. Of the ∼50 published cases to date, few have documented the need for neurosurgical intervention. We herein report a NCMT in an infant treated with a staged cranial and transnasal approach, as well as summarize the available literature on this pathology.

CASE REPORT

A newborn male with a compromised airway was noted to have a large sinonasal lesion. After stabilization, MRI demonstrated a 4-cm enhancing mass with diffuse sinus involvement and significant extension into the anterior cranial fossa, with displacement of the optic apparatus and hypothalamic pituitary axis. After an initial biopsy, the patient underwent a bifrontal craniofacial approach at 2 months of age, followed by a second-stage transnasal endoscopic approach at 15 months which resulted in a complete resection. There were no neurosurgical complications. Pathology was consistent with a NCMT.

DISCUSSION

Although rare, neurosurgical involvement is critical for the treatment of NCMTs with intracranial extension. Staged cranial and endonasal endoscopic approaches may be needed for complete resection of such lesions.

Budget Impact of a Steroid-Eluting Sinus Implant Versus Sinus Surgery for Adult Chronic Sinusitis Patients with Nasal Polyps

BACKGROUND

A corticosteroid-eluting sinus implant was recently approved by the FDA as a drug to treat adult patients with nasal polyps who have undergone previous endoscopic sinus surgery (ESS) of the ethmoid sinuses. ESS is performed in an operating room under general anesthesia, whereby diseased tissue and bone are removed to provide improved drainage. ESS typically involves dissection of 1 or more of the 4 paired sinus cavities (maxillary, ethmoid, sphenoid, or frontal). The implant, containing 1,350 mcg of mometasone furoate, is inserted by a physician in an office setting and offers controlled localized release of corticosteroid to the polypoid sinus tissue. The implant has demonstrated significant improvements in clinical testing; however, little research has been conducted on its economic impact.

OBJECTIVE

To evaluate and quantify the budget impact to a commercial payer of using this implant instead of ESS in patients with nasal polyps after a previous ESS. Since essentially all patients with recurrent nasal polyps after ESS are patients with chronic sinusitis (CS) diagnosis, this study also identified patients with CS with nasal polyposis (CSwNP) for consistency with the patient population studied in clinical trials evaluating the implant.

METHODS

A budget impact analysis was conducted from a U.S. commercial payer perspective over a 1-year time horizon with patients who received the implant or revision ESS. Primary outcomes of interest were annual total and per-member per-month (PMPM) direct health care costs. Costs were estimated using a decision analysis model, assuming 50% implant utilization as an alternative to revision ESS in eligible patients, with other levels (25%, 75%) also considered. The model utilized the results of a recently published analysis of 86,052 patients in the Blue Health Intelligence database, results from published clinical trials evaluating the implant, a literature review, and published Medicare national payment amounts.

RESULTS

A commercial health plan with 1 million members could anticipate 1,000 CSwNP patients as candidates for receiving the implant or revision ESS. Estimated direct treatment costs for refractory CSwNP using only revision ESS are $11.03 million ($0.92 PMPM). If the implant replaced surgery in 50% of cases and if 63% those patients received a second treatment with the implant during the year, the estimated total cost savings would be $2.56 million ($0.21 PMPM). Cost savings associated with using the implant changed to $0.11 PMPM and $0.32 PMPM with implant adoption of 25% and 75%, respectively.

CONCLUSIONS

In a large commercially insured U.S. population, annual revision ESS costs are substantial. Using the implant instead of revision ESS could result in considerable cost savings for payers at various levels of adoption.

DISCLOSURES

This study was sponsored by Intersect ENT, which was involved in study design and manuscript review. Ernst and Imhoff are employed by CTI Clinical Trial and Consulting Services, which contracted with Intersect ENT to conduct this study. Ernst and Imhoff also report other financial support from Intersect ENT during the conduct of the study. DeConde reports personal fees from Intersect ENT during the conduct of the study, as well as personal fees from Optinose, Stryker Endoscopy, and Olympus, outside the submitted work. Manes reports grants from Intersect ENT during the conduct of the study, as well as grants from Optinose and Sanofi outside the submitted work.

Inpatient Mortality After Endoscopic Sinus Surgery for Invasive Fungal Rhinosinusitis

OBJECTIVES:

Invasive fungal rhinosinusitis is a rare, life-threatening condition that affects the paranasal sinuses. The standard of care after diagnosis includes surgical debridement and aggressive medical management. Despite treatment, mortality remains unacceptably high. Most data are derived from small cohort experiences, with limited identification of mortality risk factors in the acute setting. The authors used a large national database to better understand clinical factors associated with inpatient mortality for this challenging condition.

METHODS:

Using the 2000-2014 National (Nationwide) Inpatient Sample database, the authors identified 979 adult patients with an International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code of mucormycosis or aspergillosis and a procedure code of sinus surgery. Multivariate imputation by chained equation was performed to account for missing data, followed by multivariate logistic regression to identify predictors of inpatient mortality.

RESULTS:

In total, 979 adult patients were identified, with a median age of 57 years. The inpatient mortality rate was 15.8%. The most prevalent comorbidity was hematologic disorders (42.9%). Mucormycosis versus aspergillosis was associated with increased odds of inpatient mortality (odds ratio, 2.95; 95% confidence interval, 2.00-4.34; P < .001). The odds of inpatient mortality were significantly increased between patients with hematologic disorders and those without (odds ratio, 1.92; 95% confidence interval, 1.08-3.39; P = .024). Diabetes (odds ratio, 0.53; 95% confidence interval, 0.34 - 0.80; P = .003) was associated with the lowest odds of inpatient mortality.

CONCLUSIONS:

This represents the first population-based study evaluating the factors associated with inpatient mortality. These findings support prior observations demonstrating that the underlying immune dysfunction and type of fungal infection are important predictors of early mortality.

International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis

BACKGROUND

Critical examination of the quality and validity of available allergic rhinitis (AR) literature is necessary to improve understanding and to appropriately translate this knowledge to clinical care of the AR patient. To evaluate the existing AR literature, international multidisciplinary experts with an interest in AR have produced the International Consensus statement on Allergy and Rhinology: Allergic Rhinitis (ICAR:AR).

METHODS

Using previously described methodology, specific topics were developed relating to AR. Each topic was assigned a literature review, evidence-based review (EBR), or evidence-based review with recommendations (EBRR) format as dictated by available evidence and purpose within the ICAR:AR document. Following iterative reviews of each topic, the ICAR:AR document was synthesized and reviewed by all authors for consensus.

RESULTS

The ICAR:AR document addresses over 100 individual topics related to AR, including diagnosis, pathophysiology, epidemiology, disease burden, risk factors for the development of AR, allergy testing modalities, treatment, and other conditions/comorbidities associated with AR.

CONCLUSION

This critical review of the AR literature has identified several strengths; providers can be confident that treatment decisions are supported by rigorous studies. However, there are also substantial gaps in the AR literature. These knowledge gaps should be viewed as opportunities for improvement, as often the things that we teach and the medicine that we practice are not based on the best quality evidence. This document aims to highlight the strengths and weaknesses of the AR literature to identify areas for future AR research and improved understanding.

Isolated sphenoid sinus opacifications: a systematic review and meta-analysis

BACKGROUND

Isolated sphenoid sinus opacifications (ISSOs) represent a relatively uncommon disease with the potential for serious complications. To better understand this disease, we performed a systematic review to further characterize the underlying pathologies, associated symptoms, and treatment outcomes of patients with ISSOs.

METHODS

A systematic review of ISSO case series was performed utilizing the Medline, Embase, Web of Science, and Cochrane databases in accordance with guidelines established by PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). Data of interest included disease pathology, associated symptoms, and treatment outcomes.

RESULTS

Of the initial 1051 hits from the 4 databases, 17 articles, with a combined 1133 ISSO patients, were ultimately included in the review. On a weighted analysis, the underlying pathologies were classified as chronic rhinosinusitis without nasal polyps (CRSsNP) (28.3%), mucoceles (20.3%), fungal sinusitis (12.5%), malignant neoplasms (7.7%), intracranial lesions (7.0%), benign neoplasms (5.7%), chronic rhinosinusitis with nasal polyps (CRSwNP) (3.4%), and other lesions (4.7%). Cranial neuropathies were present in 16.3% (95% confidence interval [CI], 10.1-22.5%) of ISSO patients. A favorable surgical complication rate of 1.5% (95% CI, -0.1% to 3.2%) was found in patients undergoing surgery for an ISSO.

CONCLUSION

ISSOs are caused by diverse pathologies. Given the considerable rates of neoplastic disease and cranial neuropathies, patients affected by an ISSO should be monitored closely and treated aggressively. Prompt surgical intervention, with either diagnostic or therapeutic intent, is often indicated.

Squamous cell carcinoma of buccal mucosa: a 40-year review

PURPOSE

The aim of this study was to analyze the outcome of surgical therapy for buccal squamous cell carcinoma (SCCA) at a single tertiary care institution during a 40-year period.

MATERIALS AND METHODS

A retrospective review was performed by examining the records and pathology of 48 patients with buccal SCCA treated at a single tertiary care institution from 1970 to 2009.

RESULTS

Treatment entailed surgery alone in 18 patients (37.5%) and surgery followed by radiation therapy in 30 patients (62.5%). Composite resection was performed in 17 patients (35.4%), and ipsilateral neck dissections were performed in 37 patients (77.1%). One-year observed actuarial disease-free survival rates were 60%, 46%, 0%, and 40% for T1 through T4, respectively. Univariate analysis revealed increased age as a risk factor for disease recurrence (P = .062), with skin taken and neck dissection not achieving significance (P = .24 and .20, respectively). Multivariate analysis demonstrated age as increasing risk and neck dissection as decreasing risk of recurrence (P = .029 and .023, respectively).

CONCLUSIONS

We report relatively high disease-free survival rates in patients who underwent aggressive resection and neck dissection. Performance of neck dissection and younger age were associated with a favorable prognosis. Performance of neck dissection may decrease the risk of recurrence in primary SCCA of the buccal mucosa. Although through-and-through resection of skin decreased risk of disease recurrence, this difference is not statistically significant (P = .24).

Composite mandibulectomy: a novel animal model

OBJECTIVES

Segmental mandibular defects can result after the treatment of various pathologic processes, including osteoradionecrosis, tumor resection, or fracture nonunion with sequestration. The variety of etiologies and the frequency of occurrence make the reconstruction of segmental mandibular defects a topic of significant interest. Despite these incentives, a well-established small-animal model of the segmental mandibulectomy, including composite resection, does not exist. The objective of this study is the creation of a reliable animal model that can be used to study the reconstruction of en bloc mandibular defects. Surgical techniques and an array of reconstructive options are described.

STUDY DESIGN

Description of an animal model.

SETTING

Animal laboratory at a quaternary care university medical center.

METHODS

We present an Animal Research Oversight Committee-approved prospective analysis of survival operations in the rat model. A detailed, stepwise description of surgical technique and relevant intraoperative anatomy is presented. Postoperative management, early pitfalls, surgical complications, and future applications are discussed.

RESULTS

A total of 72 operations were performed by a single individual between July and October 2010. Two intraoperative and 9 postoperative complications were recognized. There were 6 orocutaneous fistulas, 2 abscesses, and 1 seroma. There were 4 fatalities, which were attributed to anesthetic complications (2, intraoperative), hematoma formation (1, postoperative), and foreign-body aspiration (1, postoperative).

CONCLUSION

This novel animal model reliably replicates the en bloc segmental mandibular defects seen in our patient population and can be manipulated to achieve a wide variety of research objectives.

Spasmodic Dysphonia Translocated via Reinnervated Ansa Cervicalis

Objective: Illustrate the first reported case of recurrent adductor spasmodic dysphonia (ADSD) after bilateral selective laryngeal adductor denervation-reinnervation (SLAD-R) surgery presenting with dystonia of the strap muscles and adductors of the larynx.

Method: A 40-year-old man presented with ADSD. The patient underwent a bilateral SLAD-R surgery 10 years ago after botulinum toxin failure. The laryngeal dystonia was quiescent until 2 years ago when the patient noted worsening tension in his voice temporally associated with muscle spasm of his anterior neck.

Results: The patient elected to undergo re-exploration of his neck with lysis of his ansa cervicalis reinnervation. The operation revealed bilaterally intact neurorrhaphies between the superior root of the ansa cervicalis and the distal recurrent laryngeal nerves. Electrical stimulation of the superior roots of the ansa cervicalis produced laryngeal adductor activity as evidenced by an electromyography nerve monitor and by palpation of the arytenoids cartilage. The neurorrhaphies were sectioned and postoperatively the patient’s dystonias immediately resolved.

Conclusion: We present a case of demonstrated functional activity of nerves used for reinnervation in SLAD-R surgery for spasmodic dysphonia. Unfortunately in this case, the disease recurred through aberrant activity mediated via the translocated ansa cervicalis nerves.

Squamous Cell Carcinoma of the Buccal Mucosa: A 40-Year Review

Objective: Evaluate the treatment results of buccal squamous cell carcinoma at a single institution during a 40-year period.

Method: A retrospective review was performed by examining the records and reviewing the pathology of 48 patients with buccal squamous cell carcinoma treated at UCLA Medical Center from 1970 to 2009. Forty-eight patients were identified that received first-time surgical therapy for squamous cell carcinoma of the buccal mucosa and had adequate follow-up.

Results: Treatment entailed surgery alone in 18 out of 48 patients (37.5%) and surgery followed by radiation therapy in 30 out of 48 patients (62.5%). Composite resection of the tumor was performed in 17 out of 48 patients (35.4%) and ipsilateral neck dissections were performed in 37 out of 48 patients (77.1%). One-year observed actuarial disease-free survival rates were 60%, 46%, 0%, and 40% for T1 through T4, respectively. Univariate analysis revealed increased age as a risk factor ( P = .062), and multivariate analysis demonstrated age as a risk factor and performance of neck dissection having a decreased risk of recurrence ( P = .029 and .023, respectively).

Conclusion: We report fairly high disease-free survival rates in this patient population. Performance of neck dissection and younger age were associated with a favorable prognosis. Performance of neck dissection may decrease the risk of recurrences in primary squamous cell carcinoma of the buccal mucosa.

Endoscopic Management of Supraglottic Stenosis

Objective: 1) Understand traditional techniques for the management of supraglottic stenosis. 2) Learn minimally invasive endoscopic technique using CO2 laser pharyngoplasty, balloon dilation, and Mitomycin-C application in the management of supraglottic stenosis.

Method: Case series in a tertiary academic medical center of patients with isolated symptomatic supraglottic stenosis who underwent endoscopic management.

Results: Four patients with symptomatic supraglottic stenosis were initially managed with CO2 laser endoscopic pharyngoplasty, balloon dilation, and topical Mitomycin-C application under general anesthesia. Subsequent management in 3 patients included office-based balloon dilations. Voice, swallowing, and airway outcomes are reviewed with minimum twelve month follow-up. Results were satisfactory in all patients and all were decannulated.

Conclusion: Supraglottic stenosis is a rare entity that has been traditionally managed with supraglottic laryngectomy. However, using minimally invasive endoscopic techniques, long-term success with minimal morbidity can be achieved and should be considered as a first-line management option for this condition.

Oncologic Validity of Cervical Recipient Vessel Preservation

Objective: Determine whether preservation of cervical recipient vessels affects surgical resection margins in patients who undergo microvascular free flap procedures for defects of reconstruction of the head and neck after the treatment of neoplasms.

Method: Consecutive patients with adventitial biopsies of recipient neck vessels were identified over the previous 6-month period, and pathology was reviewed. Patient clinical information (age, sex, diagnosis, tumor site, tumor stage, prior treatment with surgery, radiation therapy, chemotherapy) was reviewed as potential risk factors for tumor involvement of recipient vessels.

Results: A total of 57 patients with recipient vessel biopsies were identified between June 2010 and January 2011. Tumor sites included oral-oropharnygeal (n = 38), laryngopharyngeal (n = 8), scalp (n = 7), skull base-midface (n = 3), and neck (n = 1). Tumor pathology included squamous cell carcinoma (n = 45), osteoradionecrosis with a history of squamous cell carcinoma (n = 4), adenocarcinoma (n = 2), ossifying fibroma (n = 2), as well as a case each of ameloblastma and melanoma. One (1.7%) recipient vessel biopsy was positive for squamous cell carcinoma. This vessel looked grossly abnormal and was sent for frozen section analysis.

Conclusion: Microvascular free flap reconstruction uses recipient vessels in the neck, which can potentially adversely affect resection margins by requiring preservation of recipient vessels in proximity to tumors. However, our results show that frozen section biopsy is necessary only when intra-operative findings are concerning for tumor involvement of the recipient vessels.