Incidence, predictors and impact of positive bony margins in surgically treated T4 stage cancers of the oral cavity

Publication date: March 2019

Source: Oral Oncology, Volume 90

Author(s): Arjun Singh, Manish Mair, Hitesh Singhvi, Ankit Mahuvakar, Deepa Nair, Sudhir Nair, Pankaj Chaturvedi

Abstract

Objectives

A sea of literature addressing the adequacy of mucosal/soft tissue surgical margins in oral cavity cancers is available, but no mention exists regarding bony margins. We aim to study the predictors and impact on survival of positive bony margins and propose a safe margin distance.

Methods

This is a retrospective study of 400 consecutive surgically treated pT4 oral cavity squamous cell carcinoma patients between January 2012 and December 2015. The factors predicting positive bony margins were determined using chi-square test. Kaplan Meier and Cox regression hazard models were used for survival analysis. The median follow up was 36 months.

Results

The only factor that significantly predicted positive bony margins was lymphovascular emboli. The 3-year OS with bony margin positivity was 36.9%, compared to 67.5% for patients with adequate margins. When the tumor infiltrated the bone beyond mucosa (20.25%) the survival outcomes were significantly worse than the other patterns. Microscopic spread was seen in 10% cases, at a distance of 8 mm, the presence of which significantly impacted survival outcomes. Analysis of the receiver operating curve identified a cutoff of more than 15 mm as appropriate for classifying adequate bony margins. When the margins were taken above this, a significant positive impact on survival outcomes was present.

Conclusion

The presence of lymphovascular emboli may impact the status of bony margins. Based on our results, to achieve an "adequate margin in bone" we propose taking the bony cut at least 15 mm away from the clinically discernible tumor when treating advanced oral cancers.

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Qualitative and quantitative scintigraphy in sialorrhea before and after botulinum toxin injection

Objectives/Hypothesis

Sialorrhea is excessive saliva production and its usual escape of from the oral cavity. The use of botulinum toxin has been preconized, but its effectiveness until now has been unreliably measured. Our objective was to qualitatively and quantitatively determine the effectiveness of botulinum toxin injection in the reduction of saliva production by the parotid gland.

Study Design

Outcomes research.

Methods

Patients with moderate‐to‐critical sialorrhea had one of the parotid glands injected with 50 U of botulinum toxin, leaving the other as the control. Fifteen days after the toxin injection, they underwent scintigraphic analyses with intravenous injection of 10 mCi (37 MBq) of Tc‐99 m (sodium pertechnetate). After this, the noninjected gland was treated for therapeutic complementation.

Results

The glands injected with botulinum toxin showed uptake reduction in 100% of patients. The uptake reduction in counts per second varied from 8% to 36%. The Wilcoxon paired test comparing the control glands with those injected showed a significant difference for the action of botulinum toxin (P = .0039).

Conclusions

The scintigraphic study of parotid glands shows that botulinum toxin is effective in reducing sodium pertechnetate uptake.

Level of Evidence

2c Laryngoscope, 2019

http://bit.ly/2G6oVyB

Eye movement desensitization and reprocessing as a treatment for tinnitus

Objectives/Hypothesis

To determine the effectiveness of eye movement desensitization and reprocessing (EMDR) as a treatment for tinnitus.

Study Design

Single‐site prospective interventional clinical trial at a university hospital in the United Kingdom.

Methods

Participants were provided with tEMDR. This is a bespoke EMDR protocol that was developed specifically to treat individuals with tinnitus. Participants received a maximum of 10 sessions of tEMDR. Outcome measures including tinnitus questionnaires and mood questionnaires were recorded at baseline, discharge, and at 6 months postdischarge.

Results

Tinnitus Handicap Inventory and Beck Depression Inventory scores demonstrated a statistically significant improvement at discharge after EMDR intervention (P = .0005 and P = .0098, respectively); this improvement was maintained at 6 months postdischarge. There was also a moderate but not significant (P = .0625) improvement in Beck Anxiety Inventory scores.

Conclusions

This study has demonstrated that the provision of tEMDR has resulted in a clinically and statistically significant improvement in tinnitus symptoms in the majority of those participants who took part. Furthermore, the treatment effect was maintained at 6 months after treatment ceased. This study is of particular interest, as the study protocol was designed to be purposefully inclusive of a diverse range of tinnitus patients. However, as a small uncontrolled study, these results do not consider the significant effects of placebo and therapist interaction. Larger high‐quality studies are essential for the verification of these preliminary results.

Level of Evidence

4 Laryngoscope, 2019

http://bit.ly/2FVL8jF

Comparison of balance outcomes according to treatment modality of vestibular schwannoma

Objectives

We sought to compare balance outcomes according to treatment modality of vestibular schwannoma (VS) via a meta‐analysis that divided measuring tools of balance outcomes into three categories based on type.

Methods

A comprehensive review of the literature from January 1966 to September 2017 was performed, looking for studies about long‐term balance outcomes after microsurgery (MS), radiotherapy (RT), or observation for VS. A comprehensive meta‐analysis was used to analyze effect sizes, explore possible causes of heterogeneity, and check publication bias with a funnel plot and Egger's regression.

Results

Among 633 references, 34 were included in the meta‐analysis. Perceived dizziness improvement rate was significantly higher in the MS group than in the RT group (odds ratio [OR]: 1.61; 95% confidence interval [CI]: 1.08 to 2.40; P < .05, I ² = 4.18], but no significant difference was observed between the two groups with regard to validated dizziness questionnaire score (standardized mean difference: 0.04; 95% CI: −0.36 to 0.44; P = .84, I ² = 69.61) or dizziness or disequilibrium‐related symptom incidence rate (OR: 0.91; 95% CI: 0.50 to 1.68; P = .77, I ² = 0). In a subanalysis conducted within the groups after intervention, the MS group demonstrated a lower vertigo incidence rate (P < .001), and the RT group experienced a significant reduction in validated dizziness questionnaire score (P < .05).

Conclusions

Our results indicate that MS should be considered at least equal to RT in regard to resolving long‐term dizziness and improving balance outcomes. Furthermore, well‐designed studies are necessary to predict balance outcomes after VS treatment and to choose from among possible treatment options.

Level of Evidence

2a Laryngoscope, 2019

http://bit.ly/2G6oODb

Positive airway pressure ventilation and complications in pediatric tracheocutaneous fistula repair

Objectives

Surgical repair of persistent tracheocutaneous fistula in children may be complicated by tracheal air leak with resultant subcutaneous emphysema, pneumomediastinum, and/or pneumothorax. We first sought to identify clinical risk factors for postoperative complications after primary repair of persistent tracheocutaneous fistula in children. Second, the type and frequency of complications in patients administered positive airway pressure ventilation (e.g., bag‐valve mask ventilation, continuous positive airway pressure [CPAP], or bilevel positive airway pressure [BiPAP]) postoperatively was determined and compared to a control population.

Methods

This was a retrospective investigation of all pediatric patients (n = 108) undergoing surgical repair of persistent tracheocutaneous fistula from January 2000 and April 2016 at a tertiary, academic referral center. Type and frequency of postoperative complications were compared among patients who were administered positive airway pressure ventilation postoperatively versus those who were not.

Results

Of 108 pediatric patients, complications after tracheocutaneous fistula repair occurred in 22 (20.4%) patients. These included symptoms of respiratory distress requiring intervention (e.g., supplemental O₂, racemic epinephrine, intubation), subcutaneous emphysema, pneumomediastinum and/or pneumothorax, bleeding, wound infection, and readmission. Frequency of all postoperative complications was significantly higher in patients administered positive airway pressure ventilation versus those who were not (50.0% vs. 16.7%, P = 0.015), as were rates of subcutaneous emphysema, pneumomediastinum, and/or pneumothorax (33.3% vs. 4.2%, P = 0.005).

Conclusion

Positive airway pressure ventilation after primary repair of persistent tracheocutaneous fistula in children may increase risk of serious respiratory complications. In practice, we advocate for avoidance of bag‐valve mask ventilation and caution when utilizing CPAP or BiPAP postoperatively in these patients.

Level of Evidence

4. Laryngoscope, 2019

http://bit.ly/2FUEytF

Otolaryngology boot camps: Current landscape and future directions

Objectives

Simulation‐based boot camps have gained popularity over the past few years, with some surgical specialties implementing mandatory national boot camps. However, there is no consensus in otolaryngology on boot camp timing, learner level, or curriculum. The purpose of this study is to examine the current landscape and gather opinions regarding future curriculum and standardization of boot camps in otolaryngology.

Methods

A survey was developed to examine current resident participation and boot camp content while also seeking opinions regarding improving boot camp enrollment and standardizing curriculum. A cross‐sectional survey of all otolaryngology residency program directors in the United States and Puerto Rico was performed via SurveyMonkey. Responses were collected anonymously, and results were analyzed by descriptive statistical analysis.

Results

Of the 45% (48 of 106) who responded, 76.6% reported their residents participate in boot camps. The most common skills taught were basic suturing and airway management skills. The majority (95%) was likely to send residents to a local boot camp, with 56% favoring early postgraduate year (PGY)‐1 participation and 42% favoring a 1‐day boot camp. Subsidized expenses, improved regional access, and supplementary boot camp information would help the program director in their decision to send residents to boot camp. Only 32% felt boot camps should be standardized, and 27% felt they should be mandatory.

Conclusion

Many otolaryngology residency programs participate in boot camps. Additional data on the benefits of boot camps, improved access, and reduced financial burden may improve participation. Further discussion of ideal timing, PGY level, and standardized curriculum should occur in conjunction with the otolaryngology academic societies and oversight from accreditation and certifying bodies.

Level of Evidence

NA. Laryngoscope, 2019

http://bit.ly/2G6oLHv

In response to letter to the editor regarding: Clinical implications of magnetic resonance imaging in temporomandibular disorders patients presenting ear fullness

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