Open Access Policy Deposits

This series is automatically populated with publications deposited by UC Davis Department of Otolaryngology researchers in accordance with the University of California’s open access policies. For more information see Open Access Policy Deposits and the UC Publication Management System.

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Objective Fluoroscopic Outcomes After Endoscopic Staple Versus Laser Zenker's Diverticulotomy.

(2023)

Objective

Endoscopic Zenker's diverticulotomy (EZD) is typically performed via stapling (endoscopic staple diverticulotomy; ESD) or CO2 laser (endoscopic laser diverticulotomy; ELD). Conflicting reports exist on which approach provides optimal outcomes. This investigation compared objective fluoroscopic data between ESD and ELD.

Methods

A retrospective review of all patients undergoing primary EZD at a tertiary center between January 1, 2014 and January 10, 2022 was performed. Patients undergoing ESD and ELD were matched by preoperative diverticulum size. Primary outcome measures were postoperative diverticulum size and change in diverticulum size from pre- to postoperative swallowing fluoroscopy. Secondary outcome measures were the Eating Assessment Tool (EAT-10) score, penetration aspiration scale (PAS), pharyngeal constriction ratio (PCR), and pharyngoesophageal segment opening (PESo).

Results

Thirteen matched pairs with complete fluoroscopic data were identified. The mean (±SD) age of the cohort was 74.0 (±8.5) years. There were no age or gender differences between groups (p > 0.05). The mean pre-operative ZD size was 1.98 (±0.69) cm for ESD and 1.97 (±0.72) cm for ELD; the mean postoperative size was 0.84 (±0.62) cm for ESD and 0.34 (±0.27) cm for ELD (p < 0.05). Mean diverticulum size improved by 1.14 (±0.59) cm after ESD and 1.62 (±0.59) cm after ELD (p < 0.05). There were no significant differences in postoperative EAT-10, PAS, PCR, or PESo between groups.

Conclusion

The data suggest that endoscopic laser Zenker's diverticulotomy results in a greater improvement in diverticulum size than endoscopic staple diverticulotomy. The data did not suggest a difference in postoperative dysphagia symptom scores or other objective fluoroscopic parameters between staple and laser diverticulotomy.

Level of evidences

Level 3 Laryngoscope, 2023.

Using Item-Response Theory to Improve Interpretation of the Trans Woman Voice Questionnaire.

(2023)

Objective

The Trans Woman Voice Questionnaire (TWVQ) is commonly used to quantify self-perceptions of voice for trans women seeking gender-affirming voice care, but the interpretation of TWVQ scores remains challenging. The objective of this study was to use item-response theory (IRT) to evaluate the relationship between TWVQ items and persons on a common scale and identify improvements to increase the meaningfulness of TWVQ scores.

Methods

A retrospective review of TWVQ scores from trans women patients between 2018-2020 was performed. Rasch-family models were used to generate item-person maps positioning respondent location and item difficulty estimates on a logit scale, which was then converted into a scaled score using linear transformations.

Results

TWVQ responses from 86 patients were analyzed. Initial item-person maps demonstrated that the middle response categories ("sometimes" and "often") performed inconsistently across items (poor threshold banding); interpretability improved when these ratings were scored as one category. The models were rerun using revised scoring, which retained high reliability (0.93) and supported a unidimensional construct. Updated item-person maps revealed four scaled score zones (≤54, >54 to ≤101, >101 to ≤140, and >140) that each corresponded to an increasing pattern of item thresholds (probability of selecting one response category vs. others). These ranges can be interpreted as minimal, low, moderate, and high, respectively.

Conclusions

Empiric data from Rasch analysis supports new interval scoring for the TWVQ that advances the clinical and research utility of the instrument and lays the foundation for future improvements in clinical care and outcomes assessment.

Level of evidence

NA Laryngoscope, 133:1197-1204, 2023.

Metastatic skull base chordoma: A systematic review.

(2022)

Objective/hypothesis

To investigate the clinical features, management strategies and outcomes for patients with metastatic primary skull base chordomas.

Study design

Systematic review.

Methods

A systematic search through Pubmed/Medline, Web of Science, and EBSCOhost (CINAHL) was conducted without restriction on dates. After study screening and full-text assessment, two authors independently extracted all data using a pre-established abstraction form.

Results

Forty cases were included from 38 studies. The average age (standard deviation [SD]) of the sample at presentation was 28.5 (23.3) and was equally distributed across genders. The average time (SD) between initial diagnosis to local recurrence was 40.1 (60.3) months. The average time (SD) from primary tumor detection to the diagnosis of metastatic disease was 55.2 (49.0) months. The most common subsite for metastatic spread were the lungs (32.5%). Of the 33 patients with data on outcomes, 48.5% were found to have expired by the time of publication. The median overall survival was estimated to be 84 months (95% confidence interval [CI] 62.3-105.7).

Conclusions

The most common subsites for metastatic spread of skull base chordoma were the lungs and bone. Overall survival for patients in the current cohort was a median of 84 months, with no significant differences noted when stratifying by the extent of surgery or the site of metastases.

Level of evidence

3a.

The Status of Dysphagia Clinics During the COVID-19 Pandemic.

(2022)

The study aimed to determine the status of dysphagia clinics and procedures applied in dysphagia clinics during the COVID-19 pandemic. Clinicians working in an outpatient dysphagia clinic were included. A 30-question survey inquiring about the descriptive information of the participants and their clinics, their clinical practice, and the tele-health applications during the COVID-19 pandemic. The survey was administered via Google forms. The participants were asked to fill out the survey on behalf of their clinics. One survey was completed per dysphagia clinic. Twenty-three clinicians responded on behalf of their clinics. The number of patients and dysphagia evaluations decreased during the COVID-19 pandemic (p < 0.05). The COVID-19 screening procedures mostly performed before dysphagia evaluations were temperature check (n = 14, 60.9%), nasopharyngeal swab test (n = 9, 39.1%), anamnestic risk assessment (n = 6, 26.1%), and saturation test (n = 6, 26.1%). Protective equipments mostly used while dysphagia evaluations were surgical mask, FFP3 mask, standard gloves, glasses, and face shield. It was found that 69.6% (n = 16) of the dysphagia clinics were reported to be suitable for working under pandemic conditions, and 30.4% (n = 7) were reported to be unsuitable. The use of tele-health applications significantly increased from 13.0% (n = 3) to 52.2% (n = 12) (p = 0.003). The present study provides a general overview of the status of dysphagia clinics and procedures applied in dysphagia clinics during the COVID-19 pandemic period. The study showed that working conditions, the number of patients, and the total number of evaluations have changed throughout the pandemic, and the use of tele-health applications increased.

Cover page of Head and Neck Cutaneous Soft-Tissue Sarcoma Demonstrate Sex and Racial/Ethnic Disparities in Incidence and Socioeconomic Disparities in Survival.

Head and Neck Cutaneous Soft-Tissue Sarcoma Demonstrate Sex and Racial/Ethnic Disparities in Incidence and Socioeconomic Disparities in Survival.

(2022)

Background

Cutaneous soft-tissue sarcoma (CSTS) of the head and neck are rare and are known to have aggressive clinical course. The current study utilizes a population-based registry in the U.S. to characterize these malignancies and explore disparities.

Methods

National Cancer Institute's (NCI) Surveillance, Epidemiology and End Result (SEER) database from 2000 to 2018 was queried to report incidence and survival data in 4253 cases in the U.S.

Results

Males were 5.37 times more likely and Non-Hispanic-White people (NHW) were 4.62 times more likely than females and Non-Hispanic-Black people (NHB) to develop CSTS of the head and neck. The overall incidence was 0.27 per 100,000 persons in 2018, with a significant increase since 2000. Advanced age and stage, histologic group other than 'fibromatous sarcoma' and lower SES groups were independent factors for worse overall survival.

Conclusions

CSTS of the head and neck demonstrate sex and racial/ethnic disparities in incidence and socioeconomic disparities in overall survival.

Level of evidence

II.

Cover page of Intraoperative delineation of p16+ oropharyngeal carcinoma of unknown primary origin with fluorescence lifetime imaging: Preliminary report.

Intraoperative delineation of p16+ oropharyngeal carcinoma of unknown primary origin with fluorescence lifetime imaging: Preliminary report.

(2022)

Background

This study evaluated whether fluorescence lifetime imaging (FLIm), coupled with standard diagnostic workups, could enhance primary lesion detection in patients with p16+ head and neck squamous cell carcinoma of the unknown primary (HNSCCUP).

Methods

FLIm was integrated into transoral robotic surgery to acquire optical data on six HNSCCUP patients' oropharyngeal tissues. An additional 55-patient FLIm dataset, comprising conventional primary tumors, trained a machine learning classifier; the output predicted the presence and location of HNSCCUP for the six patients. Validation was performed using histopathology.

Results

Among the six HNSCCUP patients, p16+ occult primary was surgically identified in three patients, whereas three patients ultimately had no identifiable primary site in the oropharynx. FLIm correctly detected HNSCCUP in all three patients (ROC-AUC: 0.90 ± 0.06), and correctly predicted benign oropharyngeal tissue for the remaining three patients. The mean sensitivity was 95% ± 3.5%, and specificity 89% ± 12.7%.

Conclusions

FLIm may be a useful diagnostic adjunct for detecting HNSCCUP.

Intraoperative In Vivo Imaging Modalities in Head and Neck Cancer Surgical Margin Delineation: A Systematic Review.

(2022)

Surgical margin status is one of the strongest prognosticators in predicting patient outcomes in head and neck cancer, yet head and neck surgeons continue to face challenges in the accurate detection of these margins with the current standard of care. Novel intraoperative imaging modalities have demonstrated great promise for potentially increasing the accuracy and efficiency in surgical margin delineation. In this current study, we collated and analyzed various intraoperative imaging modalities utilized in head and neck cancer to evaluate their use in discriminating malignant from healthy tissues. The authors conducted a systematic database search through PubMed/Medline, Web of Science, and EBSCOhost (CINAHL). Study screening and data extraction were performed and verified by the authors, and more studies were added through handsearching. Here, intraoperative imaging modalities are described, including optical coherence tomography, narrow band imaging, autofluorescence, and fluorescent-tagged probe techniques. Available sensitivities and specificities in delineating cancerous from healthy tissues ranged from 83.0% to 100.0% and 79.2% to 100.0%, respectively, across the different imaging modalities. Many of these initial studies are in small sample sizes, with methodological differences that preclude more extensive quantitative comparison. Thus, there is impetus for future larger studies examining and comparing the efficacy of these intraoperative imaging technologies.

The Promise of Circulating Tumor DNA in Head and Neck Cancer.

(2022)

As the seventh most common cancer globally, head and neck cancers (HNC) exert considerable disease burden, with an estimated 277,597 deaths worldwide in 2020 alone. Traditional risk factors for HNC include tobacco, alcohol, and betel nut; more recently, human papillomavirus has emerged as a distinct driver of disease. Currently, limitations of cancer screening and surveillance methods often lead to identifying HNC in more advanced stages, with associated poor outcomes. Liquid biopsies, in particular circulating tumor DNA (ctDNA), offer the potential for enhancing screening, early diagnosis, and surveillance in HNC patients, with potential improvements in HNC patient outcomes. In this review, we examine current methodologies for detecting ctDNA and highlight current research illustrating viral and non-viral ctDNA biomarker utilities in HNC screening, diagnosis, treatment response, and prognosis. We also summarize current challenges and future directions for ctDNA testing in HNC patients.

Small molecule profiling to define synergistic EGFR inhibitor combinations in head and neck squamous cell carcinoma.

(2022)

Background

Head and neck squamous cell carcinoma (HNSCC) is a debilitating disease with poor survival. Although epidermal growth factor receptor (EGFR)-targeting antibody cetuximab improves survival in some settings, responses are limited suggesting that alternative approaches are needed.

Methods

We performed a high throughput drug screen to identify EGFR inhibitor-based synergistic combinations of clinically advanced inhibitors in models resistant to EGFR inhibitor monotherapies, and then performed downstream validation experiments on prioritized synergistic combinations.

Results

From our screen, we re-discovered known synergistic EGFR inhibitor combinations with FGFR or IGF-1R inhibitors that were broadly effective and also discovered novel synergistic combinations with XIAP inhibitor and DNMT inhibitors that were effective in only a subset of models.

Conclusions

Conceptually, our data identify novel synergistic combinations that warrant evaluation in future studies, and suggest that some combinations, although highly synergistic, will require parallel companion diagnostic development to be effectively advanced in patients.

Cover page of Are You Thinking What I'm Thinking? Exploring Response Process Validity Evidence for a Workplace-based Assessment for Operative Feedback.

Are You Thinking What I'm Thinking? Exploring Response Process Validity Evidence for a Workplace-based Assessment for Operative Feedback.

(2022)

Objective

Workplace-based assessments (WBAs) are used in multiple surgical specialties to facilitate feedback to residents as a form of formative assessment. The validity evidence to support this purpose is limited and has yet to include investigations of how users interpret the assessment and make rating decisions (response processes). This study aimed to explore the validity evidence based on response processes for a WBA in surgery.

Design

Semi-structured interviews explored the reasonings and strategies used when answering questions in a surgical WBA, the System for Improving and Measuring Procedural Learning (SIMPL). Interview questions probed the interpretation of the three assessment questions and their respective answer categories (level of autonomy, operative performance, case complexity). Researchers analyzed transcripts using directed qualitative content analysis to generate themes.

Setting

Single tertiary academic medical center.

Participants

Eight residents and 13 faculty within the Department of Otolaryngology-Head and Neck Surgery participating in a 6-month pilot of SIMPL.

Results

We identified four overarching themes that that characterized faculty and resident response processes while completing SIMPL: (1) Faculty and resident users had similar content-level interpretations of the questions and corresponding answer choices; (2) Users employed a variety of cognitive, behavioral, and emotional processes to make rating decisions; (3) Contextual factors influenced ratings; and (4) Tensions during interpretation contributed to rating uncertainty.

Conclusions

Response processes are a key source of evidence to support the validity for the formative use of WBAs. Evaluating response process evidence should go beyond basic content-level analysis as contextual factors and tensions that arise during interpretation also play a large role in rating decisions. Additional work and a continued critical lens are needed to ensure that WBAs can truly meet the needs for formative assessment.

Department of Otolaryngology, Head and Neck Surgery