Who Is Performing Stapedectomy Surgery? Implications for Residency and Fellowship Training

Objectives: To demonstrate that 1) recent graduates of training programs in otorhinolaryngology–head and neck surgery are less likely to recommend/perform stapedectomy than more senior otolaryngologists; and 2) when surgery is recommended, referral is most commonly made to an otologist/neurotologist. Study Design: Survey of 500 regional otolaryngologists pertaining to their treatment of patients with hearing loss secondary to otosclerosis. Methods: Otolaryngologists in community practice were provided with written surveys pertaining to their treatment of otosclerosis. Results: Data were obtained from 179 general otolaryngologists treating adults and children in solo or group private practices in our geographic region. The majority (66%) diagnosed one to five new cases per year. Ten percent of surgeons graduating in the 1970s, 25% graduating in the 1980s, 50% graduating in the 1990s, and 90% of graduates in the 2000s never performed stapedectomy as part of their practices (P < .001). Similarly, a significant number of surgeons who formerly performed stapedectomies no longer do this surgery. A trend toward greater use of hearing aids for the treatment of otosclerosis was seen in more recent graduates (P < .08). When surgery was recommended, otologists/neurotologists received the majority of referrals (75%) from the practitioners surveyed. Conclusions: Stapedectomy is performed and recommended less often by more recent graduates of otolaryngology training programs. Training requirements for both general otolaryngologists and neurotologists may need modification given current practice patterns for stapes surgery.     

Practice of pediatric otolaryngology: results of the future of pediatric education II project

OBJECTIVES: To define the practice of pediatric otolaryngology compared with general otolaryngology and to estimate pediatric otolaryngology workforce utilization and needs. METHODS: Survey of members of the American Academy of Pediatrics Section on Otolaryngology and Bronchoesophagology and the American Society of Pediatric Otolaryngology and of a random sample of the membership of the American Academy of Otolaryngology-Head and Neck Surgery. RESULTS: Pediatric otolaryngologists were more likely to practice in urban and/or academic settings than were general otolaryngologists. Children (age <18 years) comprised over 88% of the patients of pediatric otolaryngologists and 30% to 35% of the patients of general otolaryngologists. Pediatric otolaryngologists were more likely to see children with complicated diseases such as airway disorders or congenital anomalies than were general otolaryngologists. Pediatric otolaryngologists, unlike general otolaryngologists, reported an increasing volume of pediatric referrals, as well as increased complexity in the patients referred. The surveyed physicians estimated the present number of pediatric otolaryngologists in their communities as approximately 0.2 to 0.3 per 100 000 people. CONCLUSIONS: Most children receiving otolaryngologic care in the United States receive such care from general otolaryngologists. The patient profile and practice setting of the subspecialty of pediatric otolaryngology differ from those of general otolaryngology. The demand for pediatric otolaryngologists appears to be increasing, but many general otolaryngologists do not believe there is an increased need.     

Disability in patients with head and neck cancer

BACKGROUND: Patients with head and neck cancer often experience debilitating speech, eating, and respiratory problems as well as the psychological effects of loss of function and change in body image. These patients often become unemployed as a result of their disease process, which adds financial burden to their already stressful lives. Yet the specific factors associated with unemployment have not been systematically studied. METHODS: This multisite study used survey and chart data to determine the predictors of work-related disability. RESULTS: Of the 384 patients who were working prior to their diagnosis of head and neck cancer, 52% (n = 201) were disabled by their cancer treatment. Multivariate analysis demonstrated significant links between disability and chemotherapy (odds ratio [OR], 3.4; P <.001), neck dissection status (OR, 2.3; P =.01), pain scores (OR, 1.2; P =.01), and time since diagnosis (OR, 0.9; P =.04). CONCLUSIONS: More than half of the patients in this study were disabled by their head and neck cancer or treatment. Patients with head and neck cancer who have undergone chemotherapy or neck dissection or have high pain scores are at increased risk for disability from their cancer or their treatment. Efforts to prevent (if possible), better assess, and treat pain and other adverse effects of head and neck cancer treatments may also have the potential to reduce patient disability.     

Examination of care processes and treatment optimization for head and neck cancer patients in a community setting “hub and hub” model

ObjectiveTo examine referral pattern, the timing of diagnostic/staging processes, and treatment initiation for new head and neck cancer patients in a community setting.MethodsPatients with a newly diagnosed previously untreated diagnosis of head neck cancer managed at Asplundh Cancer Pavilion/Abington Memorial Hospital from October 2018 to March 2020. Source of referral and preceding workup were examined as well as intervals between initial head and neck consult and various timepoints of treatment initiation.ResultsOne hundred and five patients were included in the study. The primary referral sources were external general otolaryngology (56.3%). Oral surgery and dermatology obtained tissue biopsy approximately 80% of the time before referral. The average time from the ordering of initial staging positron emission tomography/computed tomography to finalized results was 14 days (range: 10–25 days). Patients referred from dermatology and oral surgery were more likely to require single modality care, namely definitive surgical management. Time to treatment initiation average was 37 days (range: 29–41 days). Patients with longer treatment times noted significantly higher times to both radiation and medical oncology consults (48.42 vs. 18.13 days; P < 0.001).ConclusionsNo notable differences in treatment initiation times were identified based on referral source or extent of workup performed before head/neck surgery consult. It appears the largest opportunities for improvement in terms of reducing overall treatment length exist in the optimization of radiation initiation time.     

颈Ⅱ和Ⅲ区清扫术治疗cNO声门上型喉鳞状细胞癌

目的 研究择区性即ⅡA、ⅡB和Ⅲ区颈淋巴结清扫术(selective neck dissection,SND)治疗临床颈淋巴结阴性(clinical node negative,cN0)的声门上荆喉鳞癌隐匿性颈转移的可行性.方法 回顾性分析2002年10月至2006年3月在哈尔滨医科大学肿瘤医院头颈外科行SND(ⅡA、ⅡB和Ⅲ区)治疗52例cN0声门上型喉癌的治疗结果.结果 52例cNO声门上型喉癌中32例同期行单侧(ⅡA、ⅡB和Ⅲ区),20例行双侧SND.52例颈清扫标本病理检查发现,颈转移阳性者15例(28.9%).3例首次病理检查阴性者在随访中发生未手术侧颈部转移,总的颈隐匿性转移率为34.6%(18/52),单侧、双侧隐匿性颈转移率分别为28.8%和5.8%.72侧颈清标本共获淋巴结1190枚,其中病理阳性30枚,分布于ⅡA区25枚(83.3%)、Ⅲ区5枚(16.7%).术侧颈部复发率为5.8%(3/52).Kaplan-Meier法统计3年累积生存率为84.6%.淋巴结病理阴性和阳性的颈部复发率分别为0(0/34)和16.7%(3/18),差异有统计学意义(Fisher精确检验,P=0.021),有无包膜外侵犯的颈部复发率分别为50%(2/4)和2.1%(1/48),差异有统计学意义(Fisher精确检验,户=0.002).结论 颈SND(ⅡA、ⅡB和Ⅲ区)治疗cNO声门上型喉癌颈隐匿性转移是可行的,该术式能缩短手术时间、减少并发症且不影响肿瘤治疗效果.     

Analysis of risk factors predictive of distant failure after targeted chemoradiation for advanced head and neck cancer.

BACKGROUND: Distant metastasis (DM) is the most common mode of recurrence among patients with advanced head and neck carcinoma treated with intra-arterial cisplatin and radiotherapy (RADPLAT). OBJECTIVE: To identify which patients are at greatest risk for DM and would benefit the most from new strategies designed to treat occult metastases. METHODS: Between 1993 and 1999, 250 patients with advanced head and neck cancer were treated by RADPLAT. Excluded from the analysis were 10 patients who either did not complete the protocol or were unavailable for follow-up and 39 patients with persistent disease or local recurrence. The incidence and the risk factors for DM in these patients were evaluated in a model that included the following factors: age, T and N classification, site of tumor, histologic grade, number (0, 1, or >1) and position (high vs low) of neck levels involved, and bilateral nodal disease. Multiple stepwise logistic regression was used for the analysis. RESULTS: In a univariate analysis, the following variables correlated to DM: N classification (P =.02), site of tumor (P =.01), lower neck nodes (P =.002), number of neck levels involved (P =.001), and bilateral nodal disease (P =.02). In a multivariate analysis, the most significant risk factors for DM were the number of neck levels involved and the site of the primary tumor (P<.001). The highest odds ratios for DM were among patients with multiple levels of nodal involvement (3.17) and patients with hypopharyngeal carcinoma (2.8). CONCLUSIONS: Patients with more than 1 level of clinical nodal involvement and patients with hypopharyngeal carcinoma have the highest risk of developing DM as the initial site of failure and would benefit most from treatment strategies that address occult distant disease.     

Physician specialty is associated with differences in the evaluation and management of acute bacterial rhinosinusitis

BACKGROUND: Acute bacterial rhinosinusitis (ABRS) is a common illness that is routinely managed by physicians from several different specialties. However, the actual diagnostic and treatment preferences of physicians from these different specialties are not known. OBJECTIVE: To determine whether the radiographic evaluation and management of community-acquired ABRS differs according to medical specialty. DESIGN, SETTING, AND PARTICIPANTS: Randomized survey of 450 board-certified physicians in the United States from family medicine, general internal medicine, and otolaryngology. MAIN OUTCOME MEASURES: Responding physicians' use of diagnostic radiography as well as choice and duration of antimicrobial and adjunctive treatments of ABRS. RESULTS: Otolaryngologists were more likely to use supportive diagnostic radiography (P =.04). They were also more likely to treat patients with adjunctive therapy, such as topical decongestants (P =.01), guaifenesin (P =.01), and saline nasal irrigation (P =.01), in addition to antibiotics. Otolaryngologists prescribed more medications to treat patients with ABRS than primary care physicians (P =.01). There were no significant differences in diagnosis and management by family physicians and general internists. CONCLUSIONS: Otolaryngologists use more health care resources to diagnose and treat ABRS than primary care physicians despite an absence of evidence that such tests and treatments lead to better outcomes. Otolaryngologists typically treat a patient population with a higher prevalence of ABRS and frequently see referred patients with recurrent acute sinusitis and chronic rhinosinusitis, which may explain their tendency to treat patients more aggressively. Nevertheless, these survey results illustrate a lack of consensus within the medical community regarding the evaluation and management of community-acquired ABRS, suggesting that widely accepted evidence-based practice guidelines need to be developed.     

Tumor volume predicts outcome for advanced head and neck cancer treated with targeted chemoradiotherapy

OBJECTIVES/HYPOTHESIS: Just as tumor volume is a prognostic indicator for local disease control among patients with head and neck cancer of intermediate size treated with radiation therapy, we hypothesized a similar association for patients with advanced disease treated with chemoradiation therapy. STUDY DESIGN: Retrospective analysis of primary and nodal tumor volume was correlated with prospectively collected treatment outcome measures. METHODS: Sixty-four patients with stage III-IV disease who were treated with targeted intra-arterial chemotherapy and radiation therapy (RADPLAT) were studied. Tumor volume was correlated with local disease control and survival.RESULTS Primary tumor volume correlated with local disease control and survival. The greatest risk for local failure was found among patients with primary tumor volume greater than 19.6 cc (93.8% vs. 57% [P =.001]). A nominal logistic regression analysis demonstrated primary tumor volume as being the only significant parameter related to local failure. Survival was only 14.1% among patients with primary tumor volume greater than 19.6 cc compared with 41.5% for patients with volumes less than 19.6 cc ( P=.0018). A proportional hazard model indicated that the most significant and independent parameters associated with survival were primary tumor volume ( P=.0007) and the site of the tumor ( P=.05). CONCLUSION: Tumor volume is the most important factor predictive of treatment outcome among patients with advanced head and neck cancer and should be used to stratify favorable versus unfavorable patient subsets.     

变应性鼻炎诊疗现状调查

目的 变应性鼻炎(allergic rhinitis,AR)是鼻科常见病之一,但患者的就诊率不高,部分患者对疗效不满意,表明临床诊疗过程中存在亟待改进的问题.本研究针对中国部分大中城市的耳鼻咽喉头颈外科医师进行AR诊疗现状调查,通过剖析存在的问题,为提高临床诊疗水平提供参考.方法 采用问卷调查方式在全国13个省或自治区(63个市)和4个直辖市,针对508名耳鼻咽喉头颈外科医师,调查AR患者门诊状况、诊断状况和治疗状况.结果 AR患者占全部耳鼻咽喉头颈外科门诊患者的比例平均为19%±14%,占全部鼻腔鼻窦疾病门诊患者的35%±17%.既往使用过鼻用糖皮质激素或H1受体拮抗剂等抗过敏药物的患者为42%±26%.可进行皮肤点刺试验和血清特异性IgE检查的医师比例分别为74%和20%.仅依据患者症状和体征诊断,不进行皮肤点刺试验和血清特异性IgE检查等临床检测的比例为6l%±29%,而综合病史和皮肤点刺试验或血清学检测的诊断比例为35%±28%.从医师治疗成人AR患者的药物处方比例来看,鼻用糖皮质激素平均为70%4-27%,口服和鼻用H1受体拮抗剂分别为49%±32%和36%±28%.过敏原特异性皮下免疫治疗占23%4±26%,口服白三烯受体拮抗剂和鼻用色甘酸钠分别为18%±22%和16%±22%.重视复诊随访患者所占比例平均为24%±17%,对复诊和随访重视程度一般的患者所占比例为35%4±19%,而几乎不复诊随访的患者所占比例为39%±24%.结论 AR已成为我国耳鼻咽喉头颈外科门诊患者求诊的主要疾病,但无论是患者对疾病的整体认识,还是专科医师的整体诊治水平,均需要在现有基础上尽快提高.     

Clinical predictors of quality of life in patients with head and neck cancer

OBJECTIVE: To identify clinical predictors of quality of life (QoL) in a head and neck cancer patient population. DESIGN, PATIENTS, AND SETTING: A convenience sample of 570 patients with upper aerodigestive tract cancers were surveyed at a tertiary care oncology clinic and Veterans Affairs otolaryngology clinic. INTERVENTIONS: A self-administered health survey was constructed to collect demographic, health, smoking, alcohol, depression symptom, and QoL information. Tumor site and tumor stage, clinical, and treatment data were abstracted from the patient medical records. MAIN OUTCOME MEASURES: Quality of life was assessed using the Medical Outcomes Study Short-Form 36-Item Health Survey (SF-36) and the Head and Neck QoL (HNQoL) instrument. RESULTS: Of the 570 eligible respondents, the presence of a feeding tube had the most negative impact on QoL, with significant decrements in 6 of the 8 SF-36 scales and all 4 HNQoL scales (P<.01). In descending order of severity, medical comorbid conditions, presence of a tracheotomy tube, chemotherapy, and neck dissection were also associated with significant (P<.05) decrements in QoL domains. Patients who took the survey more than 1 year after diagnosis had improved QoL in 7 of 12 domains. Hospital site, age, education level, sex, race, and marital status were also significant predictors of QoL. CONCLUSION: There are at least 13 demographic and clinical characteristics that are significant predictors of QoL in patients with head and neck cancer, which should be considered when treating patients and conducting QoL studies in the future.     

Changes in quality of life over 1 year in patients with head and neck cancer

OBJECTIVES: To characterize and compare quality of life (QOL) in patients with head and neck cancer shortly before initial treatment and 1 year later and to study the predictors of changes in QOL over 1 year. DESIGN: Prospective cohort study. SETTING: Three otolaryngology clinics. PATIENTS: Three hundred sixteen patients having newly diagnosed squamous cell head and neck cancer. MAIN OUTCOME MEASURE: Health-related QOL was assessed using the 36-item Short-Form Health Survey and a head and neck cancer-specific QOL scale. RESULTS: Over 1 year, QOL decreased for physical functioning measures and eating but improved for mental health QOL. Depression and smoking were major predictors of poor QOL at baseline. Major predictors of change in QOL from baseline to 1 year were treatment factors, especially feeding tube placement (9 scales), chemotherapy (3 scales), and radiation therapy (3 scales). Baseline smoking and depressive symptoms also remained significant predictors of several QOL scales at 1 year. CONCLUSIONS: Health-related physical QOL tended to decline over 1 year and mental health QOL improved. The major predictors of change in QOL were treatment factors, smoking, and depressive symptoms. Physicians should alert patients to the relative effects on QOL one may experience with different treatments.     

Workforce Issues for the Academic Otolaryngologist

Background The current medico‐economic environment has led to profound changes in our health care system and questions of physician surplus. These issues have particularly affected the academic health care system, as research funding and departmental support have decreased, and many young otolaryngologists are questioning academic careers because of these uncertainties. The current study was undertaken to assess the workforce environment for the academic otolaryngologist, particularly the young physician. Methods Surveys were sent to the academic chairmen of all accredited otolaryngology residency programs in the United States, requesting information on faculty appointments—actual and projected—as well as subspecialty appointments and expectations of young faculty. Results The response rate was 60% (59/98). Faculty additions have been relatively stable from 1994 to 1998, with approximately 37 assistant professor and 5 associate professor positions filled yearly. Faculty additions were the result of departmental expansion in 83% of cases and spanned many subspecialties. The subspecialty positions most frequently added from 1994 to 1998 were generalists (57), head and neck oncologists (53), pediatric otolaryngologists (48), and otologists (39), with generalists filling 15 positions in 1998. Ninety‐three percent of programs anticipate faculty additions in the next 5 years; most will be at the assistant professor level (77%), with 30% of positions for generalists, 20% for head and neck oncologists, and 18% for pediatric otolaryngologists. Faculty expectations are primarily clinical, with research being least important. Conclusions Academic positions are available for the young otolaryngologist, particularly in the fields of general otolaryngology, head and neck oncology, and pediatric otolaryngology.     

Proportion of heritable paraganglioma cases and associated clinical characteristics.

OBJECTIVE/HYPOTHESIS: To determine the heritable proportion of paraganglioma (PGL) and identify clinical features associated with heritable PGL. STUDY DESIGN: Patients diagnosed with head and neck PGLs, identified retrospectively through clinical otolaryngology practices and/or participation in previous PGL research studies, were given a medical and family history questionnaire. METHODS: Questionnaire information was used to classify participants as having "heritable" or "non-heritable" cases of PGL. Classification of the participants identified through otolaryngology clinics was used to estimate the heritable proportion of PGL. Statistical analysis was performed to identify significant differences in the clinical characteristics of the heritable versus non-heritable groups. RESULTS: Among the otolaryngology clinic population, 35% were classified as having heritable PGL. Individuals with heritable PGL were younger on average than those with non-heritable PGL. The majority of non-heritable participants were female, but there was an equal gender ratio among the heritable participants. Individuals diagnosed with a carotid body tumor (CBT) were 5.8 times more likely to be classified as heritable than those diagnosed with PGL at other anatomic locations. CONCLUSIONS: Approximately 35% of individuals who present to an otolaryngologist with a head and neck PGL have inherited a predisposition for this growth. Among individuals diagnosed with head and neck PGL, those diagnosed with CBT are 5.8 times more likely to have an inherited predisposition than those diagnosed with PGL at other anatomic locations.     

Predictive factors for diagnosis of advanced-stage squamous cell carcinoma of the head and neck

OBJECTIVE: To identify the predictive factors (with emphasis on diagnostic delay) associated with the diagnosis of an advanced-clinical stage head and neck cancer. DESIGN: Cross-sectional study of patients with head and neck cancer originally recruited for a case-control study. SETTING: Three referral oncological centers in metropolitan areas in southern Brazil: S?o Paulo, Curitiba, and Goiania. PATIENTS: The study population comprised 679 patients recently diagnosed as having a previously untreated head and neck squamous cell carcinoma. MAIN OUTCOME MEASURE: Diagnosis of advanced disease (clinical stage III-IV) head and neck cancer. RESULTS: Patients with laryngeal and hypopharyngeal cancers were more likely to be diagnosed as having advanced disease than those with lip, oral, and oropharyngeal cancers (88.0% vs 74.6%) (P<.001). Patient delay was inversely associated with clinical stage at diagnosis in patients with the same cancers, while professional delay was directly associated with a higher risk of advanced clinical stage at diagnosis (P =.001 and P =.006, respectively). In the analysis of laryngeal and hypopharyngeal cancer, both patient and professional delays were associated with advanced disease, with patient delay being a stronger predictive factor than professional delay. CONCLUSIONS: Clinical stage at diagnosis was associated with sociodemographic characteristics, patient delay, and professional delay. Our results indicate that continued educational programs for the population and health care professionals regarding the identification of early symptoms of head and neck cancers are warranted.     

Prevalence of complementary and alternative medicine use among a population of head and neck cancer patients: a survey-based study

We sought to determine the prevalence and patterns of complementary and alternative medicine (CAM) use among head and neck cancer patients who were being treated at an academic otolaryngology practice in the northeastern United States from January 2005 through December 2006. During a 3-month period, we conducted an anonymous survey of 213 new and established patients regarding their use of CAM during their cancer treatment. According to the responses, only 13 of these patients (6.1%) were currently using CAM during treatment. With respect to the various products being taken, 9 patients (69.2% of all CAM users) were taking herbs or supplements. Only 7 patients (53.8%) who used CAM disclosed this fact to their physician during in-office encounters. The most common sources for obtaining CAM were health-food stores, where most patients spent approximately $25 per week. The most frequently cited reason for using CAM was that a particular product had been recommended by family or friends as being potentially helpful. No adverse effects of CAM were reported. We conclude that while CAM use was not very prevalent in this study, patients who did use it were employing modalities with biologic activity that may potentially interact with conventional therapies. Because patients' disclosure of CAM use is frequently not volunteered, otolaryngologists should routinely elicit this information in a highly specific fashion so that we may better serve our unique patient population.     

Multicentric prospective study on the prevalence of sublevel IIb metastases in head and neck cancer

OBJECTIVE: To evaluate the prevalence of sublevel IIB lymph node (LN) metastases for head and neck primary tumors in a large cohort of patients. DESIGN: Prospective study. SETTING: One referral university hospital and 2 national institutes of oncology. PATIENTS: Between 2003 and 2005, 297 patients (male to female ratio, 3.5:1; mean age, 58.8 years [range, 18-89 years]) affected by head and neck cancer were treated by surgery on the primary tumor and/or the neck. Primary site distribution included the following: oral cavity in 111 patients, larynx in 92, oropharynx in 32, thyroid gland in 22, skin of the lateral face or scalp in 16, hypopharynx in 11, unknown primary in 7, and parotid gland in 6. Sublevel IIB was evaluated for the number of LNs and pathologic N (pN) status. INTERVENTIONS: All patients underwent unilateral or bilateral neck dissection (ND) with therapeutic or elective intent according to the primary site and clinical T (cT) and clinical N (cN) status. Sublevel IIB was selectively dissected at the beginning of ND, labeled, and processed independently. MAIN OUTCOME MEASURES: The distribution of metastases among the different levels was analyzed. The influence of several factors (institution in which the surgical procedure was performed, sex of the patient, site of primary, histotype, pathologic T [pT] status, cN status, lower level involved in the neck together with sublevel IIB, association with sublevel IIA metastasis, ipsilateral number of involved levels, and previous surgical treatment limited on the primary site) on the prevalence of sublevel IIB metastasis was statistically evaluated by the Pearson chi(2) test or Fisher exact test. RESULTS: A total of 443 NDs were performed (unilateral in 151 patients and bilateral in 146). Among the patients, the tumors were staged cN0/pN0 in 27%, cN+/pN+ in 50%, cN+/pN0 in 7%, and cN0/pN+ in 16%. The mean number of LNs collected at sublevel IIB was 5.4 (range, 0-24). The overall prevalence of sublevel IIB metastases was 5.6% (26 neck sides). Tumor histologic type in the sublevel IIB+ population was squamous cell carcinoma in 80%, papillary carcinoma in 8%, melanoma in 8%, and adenocarcinoma in 4%. The chi(2) test showed a significantly higher risk for LN metastases at sublevel IIB in patients affected by parotid gland primary tumors (33%), tumors of the skin or scalp (25%), unknown primary tumors (14%), and cancers of the oral cavity (10%) (P = .02) and in those clinically staged as cN+ (P < .001). CONCLUSIONS: Sublevel IIB dissection is strongly recommended for all patients with cN+ tumors and in those affected by tumor of the parotid gland, skin, and scalp scheduled for elective ND. Patients affected by laryngeal cancer scheduled for elective ND can be considered the ideal candidates for preservation of sublevel IIB. However, whether this policy could be associated with a better functional outcome remains to be demonstrated by prospective studies on a large series of patients.     

'Push' versus 'pull' percutaneous endoscopic gastrostomy tube placement in patients with advanced head and neck cancer

OBJECTIVES/HYPOTHESIS: Percutaneous endoscopic gastrostomy tube (PEG) placement by means of the "pull" method has been reported to result in a significantly higher complication rate when compared with "push" PEG placement. These findings have led to a renewed interest in the push, or Russell introducer, method of PEG placement at the authors' institution when PEG is required before definitive treatment of advanced head and neck cancer. The authors sought to determine whether the push method of PEG placement is associated with a lower incidence of complications in this patient population. STUDY DESIGN: Nonrandomized, retrospective patient analysis. METHODS: The medical records of all patients presenting to the Medical College of Georgia (Augusta, GA) who received a diagnosis of squamous cell carcinoma of the head and neck between 1999 to 2001 were retrospectively reviewed. Patients who required PEG placement as part of their treatment comprised the study population. RESULTS: The push PEG technique was used in 29 patients, and the pull technique was used in 50 patients. There was a statistically significant difference in the complication rate between the two techniques. Patients who underwent placement by means of the pull technique had an overall complication rate of 30% (15 of 50) versus a 0% (0 of 29) complication rate in patients undergoing the push technique (P =.0006, Fisher's Exact test). CONCLUSION: The push PEG technique appears to have a significantly lower risk of complications compared with the pull technique in patients with advanced head and neck cancer. The authors recommend considering the use of the push method when PEG placement is required.     

Variables associated with feeding tube placement in head and neck cancer

OBJECTIVE: To identify clinical factors associated with enteral feeding tube placement in a head and neck cancer population. DESIGN: A self-administered survey was given to patients being treated for head and neck cancer while they were waiting to be seen in 1 of 4 otolaryngology clinics. The post hoc analysis presented here combines survey and chart review data to determine clinical and demographic variables associated with feeding tube placement. SETTING: Four otolaryngology clinics. PATIENTS: Otolaryngology clinic patients being treated for head and neck cancer. MAIN OUTCOME MEASURE: Enteral feeding tube placement. RESULTS: Of the 724 patients eligible for this study, 14% (n = 98) required enteral feeding tube placement. Multivariate analysis found the following variables to be independently associated with feeding tube placement: oropharynx/hypopharynx tumor site (odds ratio [OR], 2.4; P = .01), tumor stage III/IV (OR, 2.1; P = .03), flap reconstruction (OR, 2.2; P = .004), current tracheotomy (OR, 8.0; P<.001), chemotherapy (OR, 2.6; P<.001), and increased age (OR, 1.3; P = .02). In addition, there was a curvilinear relationship between time since treatment and feeding tube placement, with about 30% having a feeding tube at 1 month posttreatment, tapering down during the first 3 years to about 8% and leveling off thereafter. CONCLUSIONS: Identification of factors associated with an increased risk of feeding tube placement may allow physicians to better counsel patients regarding the possibility of feeding tube placement during treatment. Since feeding tube placement has been linked to decreased quality of life in head and neck cancer, such counseling is an integral part of the clinical management of these patients.     

Transverse myelitis

Transverse myelitis is a known complication of radiation treatment for carcinoma of the head and neck. Otolaryngologists treat patients who receive radiotherapy and should be familiar with this complication. During the past ten years there has been little or no mention made of this problem in the ENT literature. In a five year period, 1970 to 1975, 120 patients with head and neck cancer received radiation as part of their treatment in this hospital. A review of the records of these patients showed only two cases of myelitis, an incidence of about 2%. This paper reviews the clinical syndrome; treatment and preventive measures are discussed and a survey of the literature is presented.     

Trismus in patients with head and neck cancer and 5-year overall survival

Abstract

Background: Trismus is a common complication of radiotherapy for head and neck cancer but its impact on survival is unknown.

Aims/Objectives: This prospective study evaluates the incidence of trismus in patients with head and neck cancer receiving radiotherapy and the impact of trismus on 5-year overall survival.

Material and methods: Two hundred forty-four patients with head and neck cancer were included. All patients received instructions on jaw exercises and were evaluated before initiation of radiotherapy and at 2, 6, and 12 months after termination of radiotherapy.

Results: One year after treatment 25% had a reduced maximum interincisal opening (MIO) of 13?mm or more as compared to the pretreatment MIO. Trismus was most prevalent in patients with oral and oropharyngeal cancer. A trend towards worse 5-year overall survival was seen among patients with trismus.

Conclusions: The trismus rate was approximately 30% at 12 months. Jaw exercises should primarily be offered to patients with oral and oropharyngeal cancer who are most likely to benefit. Further studies are required to investigate the effect of trismus on survival.

Significance: This study identifies patients likely to benefit from jaw exercises and provides basis for further research on trismus and survival.