Triological Society: Combined Sections Meeting

MIAMI BEACH – Before you refer one of your pediatric patients with chronic rhinosinusitis to surgery, consider a trial of once-daily intranasal irrigation with isotonic saline, a pediatric otolaryngologist recommended, based on personal experience and results of a study with 40 children.

Participants in the 6-week study – children aged a mean 6 years – complied with the irrigation and experienced significant improvements in quality of life scores within 3 weeks. Prior to treatment, these children have "significant nasal stuffiness, and no matter how hard they blow their nose, nothing comes out," Dr. Julie L. Wei said.

"Nasal irrigation is effective as first-line and possibly the only treatment for chronic rhinosinusitis," Dr. Wei said. "Young children tolerate and like irrigation."

In the prospective, double-blind study, 19 children with chronic rhinosinusitis were randomized to daily irrigation with 80 mL saline only and 21 were randomized to 80 mL saline plus gentamicin. Congestion and cough were the most common presenting symptoms. The average duration of symptoms exceeded 8 weeks.

"Nasal irrigation is effective as first-line and possibly the only treatment for chronic rhinosinusitis."

With no significant difference in clinical improvement between the two groups at 3 and 6 weeks follow-up, results suggest that saline alone is efficacious, Dr. Wei said at the Triological Society Combined Sections Meeting.

"I had learned to use saline with gentamicin in it to irrigate adults, so I started to use it in children. I knew the [amount of] gentamicin in the saline was minuscule, and I wanted to prove to myself that saline would be just as efficacious," said Dr. Wei, who is on the otolaryngology–head and neck surgery faculty at the University of Kansas/KU Medical Center in Kansas City.

Symptom resolution post irrigation correlated with positive changes in Lund-MacKay scoring of before and after CT scans. All domains of the Sinus and Nasal Quality of Life Survey (SN5) significantly improved in both groups from baseline to 3 weeks, with continued improvements observed until 6 weeks. Full study results were published in September 2011 (Laryngoscope 2011;121:1989-2000).

One patient required functional endoscopic sinus surgery because of persistent symptoms. Four families reported otalgia during the study.

More than 90% of the children were compliant with the 6-week regimen and nasal irrigation was "absolutely safe," Dr. Wei said at the meeting, which was cosponsored by the Triological Society and the American College of Surgeons. In addition, children and families only require about 2 minutes of instruction in the technique.

Dr. Wei said that she had no relevant financial disclosures.

MIAMI BEACH – Before you refer one of your pediatric patients with chronic rhinosinusitis to surgery, consider a trial of once-daily intranasal irrigation with isotonic saline, a pediatric otolaryngologist recommended, based on personal experience and results of a study with 40 children.

Participants in the 6-week study – children aged a mean 6 years – complied with the irrigation and experienced significant improvements in quality of life scores within 3 weeks. Prior to treatment, these children have "significant nasal stuffiness, and no matter how hard they blow their nose, nothing comes out," Dr. Julie L. Wei said.

"Nasal irrigation is effective as first-line and possibly the only treatment for chronic rhinosinusitis," Dr. Wei said. "Young children tolerate and like irrigation."

In the prospective, double-blind study, 19 children with chronic rhinosinusitis were randomized to daily irrigation with 80 mL saline only and 21 were randomized to 80 mL saline plus gentamicin. Congestion and cough were the most common presenting symptoms. The average duration of symptoms exceeded 8 weeks.

"Nasal irrigation is effective as first-line and possibly the only treatment for chronic rhinosinusitis."

With no significant difference in clinical improvement between the two groups at 3 and 6 weeks follow-up, results suggest that saline alone is efficacious, Dr. Wei said at the Triological Society Combined Sections Meeting.

"I had learned to use saline with gentamicin in it to irrigate adults, so I started to use it in children. I knew the [amount of] gentamicin in the saline was minuscule, and I wanted to prove to myself that saline would be just as efficacious," said Dr. Wei, who is on the otolaryngology–head and neck surgery faculty at the University of Kansas/KU Medical Center in Kansas City.

Symptom resolution post irrigation correlated with positive changes in Lund-MacKay scoring of before and after CT scans. All domains of the Sinus and Nasal Quality of Life Survey (SN5) significantly improved in both groups from baseline to 3 weeks, with continued improvements observed until 6 weeks. Full study results were published in September 2011 (Laryngoscope 2011;121:1989-2000).

One patient required functional endoscopic sinus surgery because of persistent symptoms. Four families reported otalgia during the study.

More than 90% of the children were compliant with the 6-week regimen and nasal irrigation was "absolutely safe," Dr. Wei said at the meeting, which was cosponsored by the Triological Society and the American College of Surgeons. In addition, children and families only require about 2 minutes of instruction in the technique.

Dr. Wei said that she had no relevant financial disclosures.

MIAMI BEACH – Before you refer one of your pediatric patients with chronic rhinosinusitis to surgery, consider a trial of once-daily intranasal irrigation with isotonic saline, a pediatric otolaryngologist recommended, based on personal experience and results of a study with 40 children.

Participants in the 6-week study – children aged a mean 6 years – complied with the irrigation and experienced significant improvements in quality of life scores within 3 weeks. Prior to treatment, these children have "significant nasal stuffiness, and no matter how hard they blow their nose, nothing comes out," Dr. Julie L. Wei said.

"Nasal irrigation is effective as first-line and possibly the only treatment for chronic rhinosinusitis," Dr. Wei said. "Young children tolerate and like irrigation."

In the prospective, double-blind study, 19 children with chronic rhinosinusitis were randomized to daily irrigation with 80 mL saline only and 21 were randomized to 80 mL saline plus gentamicin. Congestion and cough were the most common presenting symptoms. The average duration of symptoms exceeded 8 weeks.

"Nasal irrigation is effective as first-line and possibly the only treatment for chronic rhinosinusitis."

With no significant difference in clinical improvement between the two groups at 3 and 6 weeks follow-up, results suggest that saline alone is efficacious, Dr. Wei said at the Triological Society Combined Sections Meeting.

"I had learned to use saline with gentamicin in it to irrigate adults, so I started to use it in children. I knew the [amount of] gentamicin in the saline was minuscule, and I wanted to prove to myself that saline would be just as efficacious," said Dr. Wei, who is on the otolaryngology–head and neck surgery faculty at the University of Kansas/KU Medical Center in Kansas City.

Symptom resolution post irrigation correlated with positive changes in Lund-MacKay scoring of before and after CT scans. All domains of the Sinus and Nasal Quality of Life Survey (SN5) significantly improved in both groups from baseline to 3 weeks, with continued improvements observed until 6 weeks. Full study results were published in September 2011 (Laryngoscope 2011;121:1989-2000).

One patient required functional endoscopic sinus surgery because of persistent symptoms. Four families reported otalgia during the study.

More than 90% of the children were compliant with the 6-week regimen and nasal irrigation was "absolutely safe," Dr. Wei said at the meeting, which was cosponsored by the Triological Society and the American College of Surgeons. In addition, children and families only require about 2 minutes of instruction in the technique.

Dr. Wei said that she had no relevant financial disclosures.

MIAMI BEACH – A novel hospitalist program has optimized inpatient otolaryngology care at the University of California, San Francisco, a retrospective study reveals.

Based on its success, the program is poised to expand further this year and could become a model for other health systems, said Dr. Matthew S. Russell, an otolaryngology hospitalist at UCSF Medical Center and clinical instructor in the department of otolaryngology–head and neck surgery. "Feedback from this service has been overwhelmingly positive. I would encourage others who are interested to undertake a pilot project to see if this model is generalizable to other institutions," he said.

Courtesy Matt Forbush, UCSF

A significant number of requests for otolaryngology care spurred the birth and growth of the program, which may be only one of its kind in the United States. After a pilot feasibility phase, clinicians officially launched the service in July 2009.

Study Data: Volumes of Consults, Interventions Speaks, Well, Volumes 

"As an otolaryngologist, I am providing mostly consultative services," Dr. Russell said at the meeting. "The types of problems I see are most commonly acute airway issues and complications of infectious processes in the head and neck. We perform a high volume of bedside procedures, and contrary to a popular assumption, the surgical volume is favorable."

Otolaryngology hospitalists provided a total 384 procedural or surgical interventions during the study period. Endoscopic sinonasal interventions were the most common procedure, followed by transnasal flexible laryngoscopy and operative endoscopy.

The UCSF otolaryngology hospitalists, therefore, work more like specialist consultants and less like traditional primary care hospitalists overseeing a cohort of inpatients, said Dr. Russell.

The study findings could be used to convince hospital administration of the need for this service. Improved time to consultation and surgery for many patients, for example, decreases resource utilization and shortens length of hospital stay, Dr. Russell said. "Prior to our hospitalist model, most of this care was clinically and financially invisible to the institution. We have been able to demonstrate qualitatively the benefit of our unique expertise in solving complex problems as well as mitigating risk from airway catastrophe."

The otolaryngology hospitalists work closely with a number of other clinicians at UCSF. "The program has had a significant clinical impact in both the operating rooms and ICU," Dr. Matt Aldrich, faculty member in the department of anesthesia and perioperative care at UCSF, said in an interview.

"On numerous occasions, Dr. Russell has been very helpful with emergency airway management," Dr. Aldrich said. "He is also an excellent general resource for questions regarding tracheostomy management. This includes being on ‘standby’ for possible emergency tracheostomy during difficult airway management – both intubations and extubations – as well as [providing] assistance in understanding airway anatomic abnormalities during fiber-optic intubation procedures."

"I’ve been very impressed by the speed with which he responds to our requests for help, as well as his clinical skills, knowledge, and professionalism," Dr. Aldrich said. With only a few minutes’ notice, Dr. Russell recently came to the operating room to evaluate a patient with a pharyngeal mucosal cyst prior to placement of a transesophageal echocardiography probe, for example.

UCSF is a 550-bed tertiary care and referral center. Hospitals smaller than approximately 500 beds might not be able to support a 100% full-time equivalent position for this model, he added.

But at UCSF, he is optimistic, predicting a measurably strong impact by year’s end: "This year we are on track to see over 700 unique patients with a significant bedside procedural and surgical volume," Dr. Russell said at the meeting, which was jointly sponsored by the Triological Society and the American College of Surgeons.

Dr. Russell and Dr. Aldrich reported having no financial disclosures.

MIAMI BEACH – A novel hospitalist program has optimized inpatient otolaryngology care at the University of California, San Francisco, a retrospective study reveals.

Based on its success, the program is poised to expand further this year and could become a model for other health systems, said Dr. Matthew S. Russell, an otolaryngology hospitalist at UCSF Medical Center and clinical instructor in the department of otolaryngology–head and neck surgery. "Feedback from this service has been overwhelmingly positive. I would encourage others who are interested to undertake a pilot project to see if this model is generalizable to other institutions," he said.

Courtesy Matt Forbush, UCSF

A significant number of requests for otolaryngology care spurred the birth and growth of the program, which may be only one of its kind in the United States. After a pilot feasibility phase, clinicians officially launched the service in July 2009.

Study Data: Volumes of Consults, Interventions Speaks, Well, Volumes 

"As an otolaryngologist, I am providing mostly consultative services," Dr. Russell said at the meeting. "The types of problems I see are most commonly acute airway issues and complications of infectious processes in the head and neck. We perform a high volume of bedside procedures, and contrary to a popular assumption, the surgical volume is favorable."

Otolaryngology hospitalists provided a total 384 procedural or surgical interventions during the study period. Endoscopic sinonasal interventions were the most common procedure, followed by transnasal flexible laryngoscopy and operative endoscopy.

The UCSF otolaryngology hospitalists, therefore, work more like specialist consultants and less like traditional primary care hospitalists overseeing a cohort of inpatients, said Dr. Russell.

The study findings could be used to convince hospital administration of the need for this service. Improved time to consultation and surgery for many patients, for example, decreases resource utilization and shortens length of hospital stay, Dr. Russell said. "Prior to our hospitalist model, most of this care was clinically and financially invisible to the institution. We have been able to demonstrate qualitatively the benefit of our unique expertise in solving complex problems as well as mitigating risk from airway catastrophe."

The otolaryngology hospitalists work closely with a number of other clinicians at UCSF. "The program has had a significant clinical impact in both the operating rooms and ICU," Dr. Matt Aldrich, faculty member in the department of anesthesia and perioperative care at UCSF, said in an interview.

"On numerous occasions, Dr. Russell has been very helpful with emergency airway management," Dr. Aldrich said. "He is also an excellent general resource for questions regarding tracheostomy management. This includes being on ‘standby’ for possible emergency tracheostomy during difficult airway management – both intubations and extubations – as well as [providing] assistance in understanding airway anatomic abnormalities during fiber-optic intubation procedures."

"I’ve been very impressed by the speed with which he responds to our requests for help, as well as his clinical skills, knowledge, and professionalism," Dr. Aldrich said. With only a few minutes’ notice, Dr. Russell recently came to the operating room to evaluate a patient with a pharyngeal mucosal cyst prior to placement of a transesophageal echocardiography probe, for example.

UCSF is a 550-bed tertiary care and referral center. Hospitals smaller than approximately 500 beds might not be able to support a 100% full-time equivalent position for this model, he added.

But at UCSF, he is optimistic, predicting a measurably strong impact by year’s end: "This year we are on track to see over 700 unique patients with a significant bedside procedural and surgical volume," Dr. Russell said at the meeting, which was jointly sponsored by the Triological Society and the American College of Surgeons.

Dr. Russell and Dr. Aldrich reported having no financial disclosures.

MIAMI BEACH – A novel hospitalist program has optimized inpatient otolaryngology care at the University of California, San Francisco, a retrospective study reveals.

Based on its success, the program is poised to expand further this year and could become a model for other health systems, said Dr. Matthew S. Russell, an otolaryngology hospitalist at UCSF Medical Center and clinical instructor in the department of otolaryngology–head and neck surgery. "Feedback from this service has been overwhelmingly positive. I would encourage others who are interested to undertake a pilot project to see if this model is generalizable to other institutions," he said.

Courtesy Matt Forbush, UCSF

A significant number of requests for otolaryngology care spurred the birth and growth of the program, which may be only one of its kind in the United States. After a pilot feasibility phase, clinicians officially launched the service in July 2009.

Study Data: Volumes of Consults, Interventions Speaks, Well, Volumes 

"As an otolaryngologist, I am providing mostly consultative services," Dr. Russell said at the meeting. "The types of problems I see are most commonly acute airway issues and complications of infectious processes in the head and neck. We perform a high volume of bedside procedures, and contrary to a popular assumption, the surgical volume is favorable."

Otolaryngology hospitalists provided a total 384 procedural or surgical interventions during the study period. Endoscopic sinonasal interventions were the most common procedure, followed by transnasal flexible laryngoscopy and operative endoscopy.

The UCSF otolaryngology hospitalists, therefore, work more like specialist consultants and less like traditional primary care hospitalists overseeing a cohort of inpatients, said Dr. Russell.

The study findings could be used to convince hospital administration of the need for this service. Improved time to consultation and surgery for many patients, for example, decreases resource utilization and shortens length of hospital stay, Dr. Russell said. "Prior to our hospitalist model, most of this care was clinically and financially invisible to the institution. We have been able to demonstrate qualitatively the benefit of our unique expertise in solving complex problems as well as mitigating risk from airway catastrophe."

The otolaryngology hospitalists work closely with a number of other clinicians at UCSF. "The program has had a significant clinical impact in both the operating rooms and ICU," Dr. Matt Aldrich, faculty member in the department of anesthesia and perioperative care at UCSF, said in an interview.

"On numerous occasions, Dr. Russell has been very helpful with emergency airway management," Dr. Aldrich said. "He is also an excellent general resource for questions regarding tracheostomy management. This includes being on ‘standby’ for possible emergency tracheostomy during difficult airway management – both intubations and extubations – as well as [providing] assistance in understanding airway anatomic abnormalities during fiber-optic intubation procedures."

"I’ve been very impressed by the speed with which he responds to our requests for help, as well as his clinical skills, knowledge, and professionalism," Dr. Aldrich said. With only a few minutes’ notice, Dr. Russell recently came to the operating room to evaluate a patient with a pharyngeal mucosal cyst prior to placement of a transesophageal echocardiography probe, for example.

UCSF is a 550-bed tertiary care and referral center. Hospitals smaller than approximately 500 beds might not be able to support a 100% full-time equivalent position for this model, he added.

But at UCSF, he is optimistic, predicting a measurably strong impact by year’s end: "This year we are on track to see over 700 unique patients with a significant bedside procedural and surgical volume," Dr. Russell said at the meeting, which was jointly sponsored by the Triological Society and the American College of Surgeons.

Dr. Russell and Dr. Aldrich reported having no financial disclosures.

To measure the impact of an otolaryngology hospitalist service on patient care and physician collaboration at UCSF Medical Center, Dr. Matthew S. Russell and his colleagues quantified their interventions between mid-2009 and December 2011.

During this period, otolaryngology hospitalists consulted on 375 new inpatients and generated 951 patient encounters. They most often evaluated general/pediatric cases (39%), laryngology concerns (29%), and rhinology issues (19%), according to a subanalysis of the first 18 months.

Respiratory failure was the most common specific diagnosis (12%) associated with a consult. They also consulted on patients with sinusitis (11%), stridor (11%), and dysphonia (8%), according to analysis of a billing database, including ICD-9 and CPT codes.

Otolaryngology hospitalists provided a total of 384 procedural or surgical interventions during the study period. Endoscopic sinonasal interventions were the most common procedure (122 codes), followed by transnasal flexible laryngoscopy (94 codes), and operative endoscopy (71 codes). A tally listing 19 specific codes was included in Dr. Russell’s poster presentation at the meeting.

Use of an administrative database is a potential limitation of the study that likely underestimated the number of otolaryngology hospitalist interventions, Dr. Russell said. "I was a bit surprised by the volume of consultations and procedures in the consortium model data, both of which seemed low compared to my experience this year as a sole service provider. I suspect this is a limitation of how the data was collected for administrative review rather than a true phenomenon."

An online search revealed no comparable otolaryngology service. "To our knowledge, ours is the first full-time otolaryngology hospitalist model in the United States," the investigators noted.

To measure the impact of an otolaryngology hospitalist service on patient care and physician collaboration at UCSF Medical Center, Dr. Matthew S. Russell and his colleagues quantified their interventions between mid-2009 and December 2011.

During this period, otolaryngology hospitalists consulted on 375 new inpatients and generated 951 patient encounters. They most often evaluated general/pediatric cases (39%), laryngology concerns (29%), and rhinology issues (19%), according to a subanalysis of the first 18 months.

Respiratory failure was the most common specific diagnosis (12%) associated with a consult. They also consulted on patients with sinusitis (11%), stridor (11%), and dysphonia (8%), according to analysis of a billing database, including ICD-9 and CPT codes.

Otolaryngology hospitalists provided a total of 384 procedural or surgical interventions during the study period. Endoscopic sinonasal interventions were the most common procedure (122 codes), followed by transnasal flexible laryngoscopy (94 codes), and operative endoscopy (71 codes). A tally listing 19 specific codes was included in Dr. Russell’s poster presentation at the meeting.

Use of an administrative database is a potential limitation of the study that likely underestimated the number of otolaryngology hospitalist interventions, Dr. Russell said. "I was a bit surprised by the volume of consultations and procedures in the consortium model data, both of which seemed low compared to my experience this year as a sole service provider. I suspect this is a limitation of how the data was collected for administrative review rather than a true phenomenon."

An online search revealed no comparable otolaryngology service. "To our knowledge, ours is the first full-time otolaryngology hospitalist model in the United States," the investigators noted.

To measure the impact of an otolaryngology hospitalist service on patient care and physician collaboration at UCSF Medical Center, Dr. Matthew S. Russell and his colleagues quantified their interventions between mid-2009 and December 2011.

During this period, otolaryngology hospitalists consulted on 375 new inpatients and generated 951 patient encounters. They most often evaluated general/pediatric cases (39%), laryngology concerns (29%), and rhinology issues (19%), according to a subanalysis of the first 18 months.

Respiratory failure was the most common specific diagnosis (12%) associated with a consult. They also consulted on patients with sinusitis (11%), stridor (11%), and dysphonia (8%), according to analysis of a billing database, including ICD-9 and CPT codes.

Otolaryngology hospitalists provided a total of 384 procedural or surgical interventions during the study period. Endoscopic sinonasal interventions were the most common procedure (122 codes), followed by transnasal flexible laryngoscopy (94 codes), and operative endoscopy (71 codes). A tally listing 19 specific codes was included in Dr. Russell’s poster presentation at the meeting.

Use of an administrative database is a potential limitation of the study that likely underestimated the number of otolaryngology hospitalist interventions, Dr. Russell said. "I was a bit surprised by the volume of consultations and procedures in the consortium model data, both of which seemed low compared to my experience this year as a sole service provider. I suspect this is a limitation of how the data was collected for administrative review rather than a true phenomenon."

An online search revealed no comparable otolaryngology service. "To our knowledge, ours is the first full-time otolaryngology hospitalist model in the United States," the investigators noted.

MIAMI BEACH – Using PET scans to diagnose distant metastasis in patients with advanced head and neck squamous cell carcinoma does not significantly prolong life expectancy, compared with other imaging techniques, according to a retrospective study.

Palliative chemotherapy did make a difference, however, significantly increasing life expectancy by 215 days in patients who received it, Dr. Matthew E. Spector and colleagues from the University of Michigan, Ann Arbor, reported at a meeting of the Triological Society.

"Over 90% of patients at University of Michigan have at least one PET scan at some point in their treatment," Dr. Spector said. Increased sensitivity is one reason for such widespread adoption of the imaging technique. "We were wondering, while it may be more sensitive to identify distant metastatic disease, was it changing what we were doing?"

In a retrospective look at 170 patients with such cancers at their institution, researchers found no significant difference in median survival between patients who had a PET scan (168 days) and those who did not (193 days). Determination of any survival difference was a primary aim of the study.

"A lot of studies have looked at PET scans, and we know in up to one-third of cases it may change our decisions," Dr. Spector said. For example, a negative PET scan might mean definitive treatment, whereas a positive PET finding might lead to palliative therapy. However, "no one has looked at the impact of the PET findings on the life expectancy after diagnosis."

All patients in the study had a distant metastasis diagnosis. "We found PET was more likely to diagnose multiple distant metastasis sites [P = .03]," Dr. Spector said. "But there were no differences in life expectancy when comparing PET to the various other imaging modalities like CT or chest x-ray."

Mean patient age was 59 years, and 135 of the patients were men.

Kaplan-Meier survival curves revealed no difference in survival between patients with a single distant metastatic site vs. multiple distant metastatic sites, said Dr. Spector, a head and neck surgery resident at the University of Michigan Health System in Ann Arbor.

The investigators intentionally controlled for chemotherapy use (110 patients, or 65%) in their survival calculations. "Chemotherapy could alter the course of their distant metastasis. Since [survival] was our main outcome measure, we wanted to control for that."

There were no differences in survival by patient age, sex, or site of primary tumor. Primary head and neck tumor sites included the oropharynx in 75 patients, the oral cavity in 40 patients, and the larynx in 36 others. The hypopharynx, nasopharynx, and some cases with unknown primary sites accounted for the remainder.

Dr. Spector and his associates did find a significant difference between the 86% of patients whose distant metastasis was detected during routine follow-up cancer care and the 14% who presented with symptoms. Median survival was 247 days in the routine surveillance group vs. 73 days for patients who might have come into the clinic complaining of chest pain after which subsequent imaging studies revealed a distant metastasis.

"Patients who were symptomatic, as you would imagine, had a worse life expectancy," Dr. Spector said. For the group detected on routine follow-up, the median time to distant metastasis diagnosis was 324 days.

Identification of any factors that did prolong survival was a second aim of the study. For the 85 patients who received palliative chemotherapy, median survival was significantly longer at 285 days, compared with 70 days for those who did not receive it.

Palliative chemotherapy was an independent factor that increased life expectancy, "and should be promoted for patients with these cancers," Dr. Spector said at the meeting, which was sponsored by the Triological Society and the American College of Surgeons. Previous chemotherapy did not alter patient response to palliative chemotherapy.

"Even for patients who were symptomatic at the time of diagnosis of their distant metastasis, palliative chemotherapy was still found to be effective," he added.

By cancer subtype, there was a nonsignificant trend for palliative chemotherapy to prolong survival among patients with primary oropharyngeal cancers (median, 333 days) compared with patients with primary laryngeal cancers (195 days).

Dr. Spector said that he had no relevant disclosures.

MIAMI BEACH – Using PET scans to diagnose distant metastasis in patients with advanced head and neck squamous cell carcinoma does not significantly prolong life expectancy, compared with other imaging techniques, according to a retrospective study.

Palliative chemotherapy did make a difference, however, significantly increasing life expectancy by 215 days in patients who received it, Dr. Matthew E. Spector and colleagues from the University of Michigan, Ann Arbor, reported at a meeting of the Triological Society.

"Over 90% of patients at University of Michigan have at least one PET scan at some point in their treatment," Dr. Spector said. Increased sensitivity is one reason for such widespread adoption of the imaging technique. "We were wondering, while it may be more sensitive to identify distant metastatic disease, was it changing what we were doing?"

In a retrospective look at 170 patients with such cancers at their institution, researchers found no significant difference in median survival between patients who had a PET scan (168 days) and those who did not (193 days). Determination of any survival difference was a primary aim of the study.

"A lot of studies have looked at PET scans, and we know in up to one-third of cases it may change our decisions," Dr. Spector said. For example, a negative PET scan might mean definitive treatment, whereas a positive PET finding might lead to palliative therapy. However, "no one has looked at the impact of the PET findings on the life expectancy after diagnosis."

All patients in the study had a distant metastasis diagnosis. "We found PET was more likely to diagnose multiple distant metastasis sites [P = .03]," Dr. Spector said. "But there were no differences in life expectancy when comparing PET to the various other imaging modalities like CT or chest x-ray."

Mean patient age was 59 years, and 135 of the patients were men.

Kaplan-Meier survival curves revealed no difference in survival between patients with a single distant metastatic site vs. multiple distant metastatic sites, said Dr. Spector, a head and neck surgery resident at the University of Michigan Health System in Ann Arbor.

The investigators intentionally controlled for chemotherapy use (110 patients, or 65%) in their survival calculations. "Chemotherapy could alter the course of their distant metastasis. Since [survival] was our main outcome measure, we wanted to control for that."

There were no differences in survival by patient age, sex, or site of primary tumor. Primary head and neck tumor sites included the oropharynx in 75 patients, the oral cavity in 40 patients, and the larynx in 36 others. The hypopharynx, nasopharynx, and some cases with unknown primary sites accounted for the remainder.

Dr. Spector and his associates did find a significant difference between the 86% of patients whose distant metastasis was detected during routine follow-up cancer care and the 14% who presented with symptoms. Median survival was 247 days in the routine surveillance group vs. 73 days for patients who might have come into the clinic complaining of chest pain after which subsequent imaging studies revealed a distant metastasis.

"Patients who were symptomatic, as you would imagine, had a worse life expectancy," Dr. Spector said. For the group detected on routine follow-up, the median time to distant metastasis diagnosis was 324 days.

Identification of any factors that did prolong survival was a second aim of the study. For the 85 patients who received palliative chemotherapy, median survival was significantly longer at 285 days, compared with 70 days for those who did not receive it.

Palliative chemotherapy was an independent factor that increased life expectancy, "and should be promoted for patients with these cancers," Dr. Spector said at the meeting, which was sponsored by the Triological Society and the American College of Surgeons. Previous chemotherapy did not alter patient response to palliative chemotherapy.

"Even for patients who were symptomatic at the time of diagnosis of their distant metastasis, palliative chemotherapy was still found to be effective," he added.

By cancer subtype, there was a nonsignificant trend for palliative chemotherapy to prolong survival among patients with primary oropharyngeal cancers (median, 333 days) compared with patients with primary laryngeal cancers (195 days).

Dr. Spector said that he had no relevant disclosures.

MIAMI BEACH – Using PET scans to diagnose distant metastasis in patients with advanced head and neck squamous cell carcinoma does not significantly prolong life expectancy, compared with other imaging techniques, according to a retrospective study.

Palliative chemotherapy did make a difference, however, significantly increasing life expectancy by 215 days in patients who received it, Dr. Matthew E. Spector and colleagues from the University of Michigan, Ann Arbor, reported at a meeting of the Triological Society.

"Over 90% of patients at University of Michigan have at least one PET scan at some point in their treatment," Dr. Spector said. Increased sensitivity is one reason for such widespread adoption of the imaging technique. "We were wondering, while it may be more sensitive to identify distant metastatic disease, was it changing what we were doing?"

In a retrospective look at 170 patients with such cancers at their institution, researchers found no significant difference in median survival between patients who had a PET scan (168 days) and those who did not (193 days). Determination of any survival difference was a primary aim of the study.

"A lot of studies have looked at PET scans, and we know in up to one-third of cases it may change our decisions," Dr. Spector said. For example, a negative PET scan might mean definitive treatment, whereas a positive PET finding might lead to palliative therapy. However, "no one has looked at the impact of the PET findings on the life expectancy after diagnosis."

All patients in the study had a distant metastasis diagnosis. "We found PET was more likely to diagnose multiple distant metastasis sites [P = .03]," Dr. Spector said. "But there were no differences in life expectancy when comparing PET to the various other imaging modalities like CT or chest x-ray."

Mean patient age was 59 years, and 135 of the patients were men.

Kaplan-Meier survival curves revealed no difference in survival between patients with a single distant metastatic site vs. multiple distant metastatic sites, said Dr. Spector, a head and neck surgery resident at the University of Michigan Health System in Ann Arbor.

The investigators intentionally controlled for chemotherapy use (110 patients, or 65%) in their survival calculations. "Chemotherapy could alter the course of their distant metastasis. Since [survival] was our main outcome measure, we wanted to control for that."

There were no differences in survival by patient age, sex, or site of primary tumor. Primary head and neck tumor sites included the oropharynx in 75 patients, the oral cavity in 40 patients, and the larynx in 36 others. The hypopharynx, nasopharynx, and some cases with unknown primary sites accounted for the remainder.

Dr. Spector and his associates did find a significant difference between the 86% of patients whose distant metastasis was detected during routine follow-up cancer care and the 14% who presented with symptoms. Median survival was 247 days in the routine surveillance group vs. 73 days for patients who might have come into the clinic complaining of chest pain after which subsequent imaging studies revealed a distant metastasis.

"Patients who were symptomatic, as you would imagine, had a worse life expectancy," Dr. Spector said. For the group detected on routine follow-up, the median time to distant metastasis diagnosis was 324 days.

Identification of any factors that did prolong survival was a second aim of the study. For the 85 patients who received palliative chemotherapy, median survival was significantly longer at 285 days, compared with 70 days for those who did not receive it.

Palliative chemotherapy was an independent factor that increased life expectancy, "and should be promoted for patients with these cancers," Dr. Spector said at the meeting, which was sponsored by the Triological Society and the American College of Surgeons. Previous chemotherapy did not alter patient response to palliative chemotherapy.

"Even for patients who were symptomatic at the time of diagnosis of their distant metastasis, palliative chemotherapy was still found to be effective," he added.

By cancer subtype, there was a nonsignificant trend for palliative chemotherapy to prolong survival among patients with primary oropharyngeal cancers (median, 333 days) compared with patients with primary laryngeal cancers (195 days).

Dr. Spector said that he had no relevant disclosures.

MIAMI BEACH – Patients who have undergone solid organ transplantation are at greater risk for subsequent tumor development, and head and neck cancers can be particularly aggressive, according to results of a single-institution study.

Dr. Robert H. Deeb and his associates at Henry Ford Hospital in Detroit studied 3,639 patients who underwent solid organ transplantation between January 1990 and December 2011. By retrospectively searching electronic medical records, they identified 95 people who developed cutaneous, salivary gland, or mucosal malignancies.

They found a 2.1% incidence of cutaneous cancers and a 0.5% incidence of noncutaneous head and neck cancers in this population. Despite a relatively low overall 2.6% incidence, there are reasons for concern, Dr. Deeb said at the Triological Society’s Combined Sections Meeting, which was jointly sponsored by the Triological Society and the American College of Surgeons. When cutaneous cancers did occur, they were more aggressive and were associated with shorter 1-year survival rates.

Henry Ford Transplant Institute maintains a noncutaneous tumor registry. This allowed the researchers to compare survival and other factors. Compared with the "nontransplant tumor registry in our institution, we found significantly fewer patients were alive at 1 year," Dr. Deeb said. Specifically, 55% of posttransplant patients with these cancers survived to 1 year, compared with 81% of nontransplant patients. There were no significant differences between groups in terms of age, sex, stage at diagnosis, or 5-year survival.

More than half (52%) of the patients who developed skin cancers had multiple head and neck cutaneous malignancies, pointing to the aggressive nature of these cancers, said Dr. Deeb of the department of otolaryngology–head and neck surgery at Henry Ford Hospital.

"We believe these patients require aggressive screening, treatment, and follow-up," Dr. Deeb said.

Of the 78 cutaneous head and neck cancers, 51% were squamous cell carcinomas, 36% were basal cell carcinomas, and the remaining 13% were other skin cancer types. The cheek and scalp were the most common sites. The patients’ average age was 61 years at the time of diagnosis, and 74% were men. Skin cancer developed a mean 4 years after transplant surgery.

Four patients had a salivary gland cancer and 13 had an upper aerodigestive tract mucosal malignancy. The average patient age in this group was 60 years, and 94% were men. Cancer was diagnosed a mean 66 months post transplantation. All 13 of the mucosal malignancies in the study were squamous cell carcinomas, Dr. Deeb said.

Kidney, liver, and heart were the most commonly transplanted organs among patients who ultimately developed these head and neck malignancies.

Although immunosuppressants are universally prescribed to prevent organ rejection following transplant surgery, the exact mechanism for subsequent cancer development remains unknown, Dr. Deeb said. Loss of immunosurveillance is one possibility; uncontrolled cell proliferation from chronic and low-level antigenic stimulation throughout the body is another. In addition, he said, immunosuppressants might somehow activate oncogenic viruses.

Despite the findings of this study, Dr. Deeb said that the benefits of solid organ transplantation still generally outweigh the risk of subsequent cancer development.

Henry Ford Hospital funded the study. Dr. Deeb said that he had no relevant disclosures.

MIAMI BEACH – Patients who have undergone solid organ transplantation are at greater risk for subsequent tumor development, and head and neck cancers can be particularly aggressive, according to results of a single-institution study.

Dr. Robert H. Deeb and his associates at Henry Ford Hospital in Detroit studied 3,639 patients who underwent solid organ transplantation between January 1990 and December 2011. By retrospectively searching electronic medical records, they identified 95 people who developed cutaneous, salivary gland, or mucosal malignancies.

They found a 2.1% incidence of cutaneous cancers and a 0.5% incidence of noncutaneous head and neck cancers in this population. Despite a relatively low overall 2.6% incidence, there are reasons for concern, Dr. Deeb said at the Triological Society’s Combined Sections Meeting, which was jointly sponsored by the Triological Society and the American College of Surgeons. When cutaneous cancers did occur, they were more aggressive and were associated with shorter 1-year survival rates.

Henry Ford Transplant Institute maintains a noncutaneous tumor registry. This allowed the researchers to compare survival and other factors. Compared with the "nontransplant tumor registry in our institution, we found significantly fewer patients were alive at 1 year," Dr. Deeb said. Specifically, 55% of posttransplant patients with these cancers survived to 1 year, compared with 81% of nontransplant patients. There were no significant differences between groups in terms of age, sex, stage at diagnosis, or 5-year survival.

More than half (52%) of the patients who developed skin cancers had multiple head and neck cutaneous malignancies, pointing to the aggressive nature of these cancers, said Dr. Deeb of the department of otolaryngology–head and neck surgery at Henry Ford Hospital.

"We believe these patients require aggressive screening, treatment, and follow-up," Dr. Deeb said.

Of the 78 cutaneous head and neck cancers, 51% were squamous cell carcinomas, 36% were basal cell carcinomas, and the remaining 13% were other skin cancer types. The cheek and scalp were the most common sites. The patients’ average age was 61 years at the time of diagnosis, and 74% were men. Skin cancer developed a mean 4 years after transplant surgery.

Four patients had a salivary gland cancer and 13 had an upper aerodigestive tract mucosal malignancy. The average patient age in this group was 60 years, and 94% were men. Cancer was diagnosed a mean 66 months post transplantation. All 13 of the mucosal malignancies in the study were squamous cell carcinomas, Dr. Deeb said.

Kidney, liver, and heart were the most commonly transplanted organs among patients who ultimately developed these head and neck malignancies.

Although immunosuppressants are universally prescribed to prevent organ rejection following transplant surgery, the exact mechanism for subsequent cancer development remains unknown, Dr. Deeb said. Loss of immunosurveillance is one possibility; uncontrolled cell proliferation from chronic and low-level antigenic stimulation throughout the body is another. In addition, he said, immunosuppressants might somehow activate oncogenic viruses.

Despite the findings of this study, Dr. Deeb said that the benefits of solid organ transplantation still generally outweigh the risk of subsequent cancer development.

Henry Ford Hospital funded the study. Dr. Deeb said that he had no relevant disclosures.

MIAMI BEACH – Patients who have undergone solid organ transplantation are at greater risk for subsequent tumor development, and head and neck cancers can be particularly aggressive, according to results of a single-institution study.

Dr. Robert H. Deeb and his associates at Henry Ford Hospital in Detroit studied 3,639 patients who underwent solid organ transplantation between January 1990 and December 2011. By retrospectively searching electronic medical records, they identified 95 people who developed cutaneous, salivary gland, or mucosal malignancies.

They found a 2.1% incidence of cutaneous cancers and a 0.5% incidence of noncutaneous head and neck cancers in this population. Despite a relatively low overall 2.6% incidence, there are reasons for concern, Dr. Deeb said at the Triological Society’s Combined Sections Meeting, which was jointly sponsored by the Triological Society and the American College of Surgeons. When cutaneous cancers did occur, they were more aggressive and were associated with shorter 1-year survival rates.

Henry Ford Transplant Institute maintains a noncutaneous tumor registry. This allowed the researchers to compare survival and other factors. Compared with the "nontransplant tumor registry in our institution, we found significantly fewer patients were alive at 1 year," Dr. Deeb said. Specifically, 55% of posttransplant patients with these cancers survived to 1 year, compared with 81% of nontransplant patients. There were no significant differences between groups in terms of age, sex, stage at diagnosis, or 5-year survival.

More than half (52%) of the patients who developed skin cancers had multiple head and neck cutaneous malignancies, pointing to the aggressive nature of these cancers, said Dr. Deeb of the department of otolaryngology–head and neck surgery at Henry Ford Hospital.

"We believe these patients require aggressive screening, treatment, and follow-up," Dr. Deeb said.

Of the 78 cutaneous head and neck cancers, 51% were squamous cell carcinomas, 36% were basal cell carcinomas, and the remaining 13% were other skin cancer types. The cheek and scalp were the most common sites. The patients’ average age was 61 years at the time of diagnosis, and 74% were men. Skin cancer developed a mean 4 years after transplant surgery.

Four patients had a salivary gland cancer and 13 had an upper aerodigestive tract mucosal malignancy. The average patient age in this group was 60 years, and 94% were men. Cancer was diagnosed a mean 66 months post transplantation. All 13 of the mucosal malignancies in the study were squamous cell carcinomas, Dr. Deeb said.

Kidney, liver, and heart were the most commonly transplanted organs among patients who ultimately developed these head and neck malignancies.

Although immunosuppressants are universally prescribed to prevent organ rejection following transplant surgery, the exact mechanism for subsequent cancer development remains unknown, Dr. Deeb said. Loss of immunosurveillance is one possibility; uncontrolled cell proliferation from chronic and low-level antigenic stimulation throughout the body is another. In addition, he said, immunosuppressants might somehow activate oncogenic viruses.

Despite the findings of this study, Dr. Deeb said that the benefits of solid organ transplantation still generally outweigh the risk of subsequent cancer development.

Henry Ford Hospital funded the study. Dr. Deeb said that he had no relevant disclosures.

MIAMI BEACH – Observation or a "watchful waiting" approach is an acceptable option vs. re-excision for patients with positive margins remaining after removal of head and neck skin cancers, according to a retrospective study.

"A lot of times we take these lesions off and they appear to be benign, not really knowing what the preoperative histologic diagnosis is. [Then we] find out the diagnosis is cancer, and not only that, but they have a positive margin." Dr. Justin Douglas said at the Triological Society Combined Sections meeting.

The question is, he said, "Do you have to rush them back in [and re-excise] or can you sit on them for a while?"

"Dr. Douglas addresses an interesting question," said session moderator Dr. Jeffrey H. Spiegel, chief of the division of facial plastic and reconstructive surgery at Boston University Medical Center and otolaryngology faculty member at Boston University. "I see a lot of people who had squamous cells and basal cells excised sent back for re-excision ... and he’ll help us understand if I even need to be doing that."

Dr. Douglas and his colleagues studied 492 patients at the Clarksburg Veterans Affairs Hospital in Morgantown, W.Va. All had skin cancers removed from their head or neck, including 387 basal cell carcinomas and 105 squamous cell carcinomas, over 5 years.

"Do you have to rush them back in [and re-excise] or can you sit on them for a while?"

About 40% or 197 lesions had a negative margin after wide local excision. The remaining 295 lesions featured a positive margin on permanent section analysis. The positive lesions included 232 basal cell carcinomas (BCCs) and 63 squamous cell carcinomas (SCCs).

"In the group of 232 positive basal cell lesions, everybody was offered re-excision. A total 105 chose re-excision and 127 decided to just watch it, despite our best judgment," said Dr. Douglas, an otolaryngologist at the Morgantown V.A.

"Even of the squamous cell patients, 26 still said they wanted to watch it," Dr. Douglas said at the meeting, which was cosponsored by the Triological Society and the American College of Surgeons.

Of the positive margin group, none of the BCC and four (3.8%) of the SCC lesions recurred within a median follow-up of 3.7 years. This finding suggests a role for clinical observation of low-risk, nonmelanomatous cancers, Dr. Douglas said.

The four SCC lesions that recurred included one lesion in the observation-only group and three in the re-excision group. Some of these patients likely had a more aggressive form of cancer, Dr. Douglas said.

"Essentially, we feel what we learned from this study is that ... given the fact that you can handle any recurrence of these lesions if they occur, you can watch the basal cells, even with positive margins," Dr. Douglas said. "We still feel all squamous cell lesions should be taken out until you get a clear margin."

Why the majority of positive margin patients who chose observation did not experience recurrence is poorly understood, Dr. Douglas said. However, it could be the patient’s immune system, secondary to the wound healing process, comes in and cleans up any residual cells. Another possibility is that patients die from other causes before recurrence can occur. "The truth of the matter is: We don’t know. We need more studies to figure this out."

The nose was the most common site for the T1, nonmelanoma lesions. The average size was 1.2 cm. Mean patient age was 61 years and 484 (98%) were men. Patients were excluded from the study if their lesion was previously treated or they chose an option other than re-excision or observation.

Although initial excision by a Mohs surgeon would be ideal, Dr. Douglas said, in his study dermatologists and otolaryngologists removed the lesions at one of the hospital ambulatory clinics. This strategy reflects some real-world limitations. "The problem is, at least in West Virginia, Mohs surgeons are very sparse. There are probably only a handful in the state." Operating room time and scheduling (particularly for patients with many lesions), availability of a pathologist to read frozen sections, and costs are additional challenges.

Dr. Douglas and Dr. Spiegel said that they had no relevant financial disclosures.

MIAMI BEACH – Observation or a "watchful waiting" approach is an acceptable option vs. re-excision for patients with positive margins remaining after removal of head and neck skin cancers, according to a retrospective study.

"A lot of times we take these lesions off and they appear to be benign, not really knowing what the preoperative histologic diagnosis is. [Then we] find out the diagnosis is cancer, and not only that, but they have a positive margin." Dr. Justin Douglas said at the Triological Society Combined Sections meeting.

The question is, he said, "Do you have to rush them back in [and re-excise] or can you sit on them for a while?"

"Dr. Douglas addresses an interesting question," said session moderator Dr. Jeffrey H. Spiegel, chief of the division of facial plastic and reconstructive surgery at Boston University Medical Center and otolaryngology faculty member at Boston University. "I see a lot of people who had squamous cells and basal cells excised sent back for re-excision ... and he’ll help us understand if I even need to be doing that."

Dr. Douglas and his colleagues studied 492 patients at the Clarksburg Veterans Affairs Hospital in Morgantown, W.Va. All had skin cancers removed from their head or neck, including 387 basal cell carcinomas and 105 squamous cell carcinomas, over 5 years.

"Do you have to rush them back in [and re-excise] or can you sit on them for a while?"

About 40% or 197 lesions had a negative margin after wide local excision. The remaining 295 lesions featured a positive margin on permanent section analysis. The positive lesions included 232 basal cell carcinomas (BCCs) and 63 squamous cell carcinomas (SCCs).

"In the group of 232 positive basal cell lesions, everybody was offered re-excision. A total 105 chose re-excision and 127 decided to just watch it, despite our best judgment," said Dr. Douglas, an otolaryngologist at the Morgantown V.A.

"Even of the squamous cell patients, 26 still said they wanted to watch it," Dr. Douglas said at the meeting, which was cosponsored by the Triological Society and the American College of Surgeons.

Of the positive margin group, none of the BCC and four (3.8%) of the SCC lesions recurred within a median follow-up of 3.7 years. This finding suggests a role for clinical observation of low-risk, nonmelanomatous cancers, Dr. Douglas said.

The four SCC lesions that recurred included one lesion in the observation-only group and three in the re-excision group. Some of these patients likely had a more aggressive form of cancer, Dr. Douglas said.

"Essentially, we feel what we learned from this study is that ... given the fact that you can handle any recurrence of these lesions if they occur, you can watch the basal cells, even with positive margins," Dr. Douglas said. "We still feel all squamous cell lesions should be taken out until you get a clear margin."

Why the majority of positive margin patients who chose observation did not experience recurrence is poorly understood, Dr. Douglas said. However, it could be the patient’s immune system, secondary to the wound healing process, comes in and cleans up any residual cells. Another possibility is that patients die from other causes before recurrence can occur. "The truth of the matter is: We don’t know. We need more studies to figure this out."

The nose was the most common site for the T1, nonmelanoma lesions. The average size was 1.2 cm. Mean patient age was 61 years and 484 (98%) were men. Patients were excluded from the study if their lesion was previously treated or they chose an option other than re-excision or observation.

Although initial excision by a Mohs surgeon would be ideal, Dr. Douglas said, in his study dermatologists and otolaryngologists removed the lesions at one of the hospital ambulatory clinics. This strategy reflects some real-world limitations. "The problem is, at least in West Virginia, Mohs surgeons are very sparse. There are probably only a handful in the state." Operating room time and scheduling (particularly for patients with many lesions), availability of a pathologist to read frozen sections, and costs are additional challenges.

Dr. Douglas and Dr. Spiegel said that they had no relevant financial disclosures.

MIAMI BEACH – Observation or a "watchful waiting" approach is an acceptable option vs. re-excision for patients with positive margins remaining after removal of head and neck skin cancers, according to a retrospective study.

"A lot of times we take these lesions off and they appear to be benign, not really knowing what the preoperative histologic diagnosis is. [Then we] find out the diagnosis is cancer, and not only that, but they have a positive margin." Dr. Justin Douglas said at the Triological Society Combined Sections meeting.

The question is, he said, "Do you have to rush them back in [and re-excise] or can you sit on them for a while?"

"Dr. Douglas addresses an interesting question," said session moderator Dr. Jeffrey H. Spiegel, chief of the division of facial plastic and reconstructive surgery at Boston University Medical Center and otolaryngology faculty member at Boston University. "I see a lot of people who had squamous cells and basal cells excised sent back for re-excision ... and he’ll help us understand if I even need to be doing that."

Dr. Douglas and his colleagues studied 492 patients at the Clarksburg Veterans Affairs Hospital in Morgantown, W.Va. All had skin cancers removed from their head or neck, including 387 basal cell carcinomas and 105 squamous cell carcinomas, over 5 years.

"Do you have to rush them back in [and re-excise] or can you sit on them for a while?"

About 40% or 197 lesions had a negative margin after wide local excision. The remaining 295 lesions featured a positive margin on permanent section analysis. The positive lesions included 232 basal cell carcinomas (BCCs) and 63 squamous cell carcinomas (SCCs).

"In the group of 232 positive basal cell lesions, everybody was offered re-excision. A total 105 chose re-excision and 127 decided to just watch it, despite our best judgment," said Dr. Douglas, an otolaryngologist at the Morgantown V.A.

"Even of the squamous cell patients, 26 still said they wanted to watch it," Dr. Douglas said at the meeting, which was cosponsored by the Triological Society and the American College of Surgeons.

Of the positive margin group, none of the BCC and four (3.8%) of the SCC lesions recurred within a median follow-up of 3.7 years. This finding suggests a role for clinical observation of low-risk, nonmelanomatous cancers, Dr. Douglas said.

The four SCC lesions that recurred included one lesion in the observation-only group and three in the re-excision group. Some of these patients likely had a more aggressive form of cancer, Dr. Douglas said.

"Essentially, we feel what we learned from this study is that ... given the fact that you can handle any recurrence of these lesions if they occur, you can watch the basal cells, even with positive margins," Dr. Douglas said. "We still feel all squamous cell lesions should be taken out until you get a clear margin."

Why the majority of positive margin patients who chose observation did not experience recurrence is poorly understood, Dr. Douglas said. However, it could be the patient’s immune system, secondary to the wound healing process, comes in and cleans up any residual cells. Another possibility is that patients die from other causes before recurrence can occur. "The truth of the matter is: We don’t know. We need more studies to figure this out."

The nose was the most common site for the T1, nonmelanoma lesions. The average size was 1.2 cm. Mean patient age was 61 years and 484 (98%) were men. Patients were excluded from the study if their lesion was previously treated or they chose an option other than re-excision or observation.

Although initial excision by a Mohs surgeon would be ideal, Dr. Douglas said, in his study dermatologists and otolaryngologists removed the lesions at one of the hospital ambulatory clinics. This strategy reflects some real-world limitations. "The problem is, at least in West Virginia, Mohs surgeons are very sparse. There are probably only a handful in the state." Operating room time and scheduling (particularly for patients with many lesions), availability of a pathologist to read frozen sections, and costs are additional challenges.

Dr. Douglas and Dr. Spiegel said that they had no relevant financial disclosures.

MIAM BEACH – Botulinum toxin injections provided good, long-term symptom control for many patients with oromandibular dystonia in a retrospective analysis of a series of patients treated at a single center.

Oromandibular dystonia (OMD) is involuntary, repetitive, or twisting spasms of the muscles around the mouth and lower face. Affected people experience jaw opening, jaw closing, lateral jaw deviation, or a combination of these forms.

"Long-term management of OMD with botulinum toxin has minimal morbidity and is useful for all clinical forms," Dr. Catherine F. Sinclair said at the Triological Society’s Combined Sections meeting. With no cure for the condition and oral medication that only improves symptoms for about one-third of patients, botulinum toxin is considered a treatment option, she added.

Along with colleagues Dr. Lowell E. Gurey and Dr. Andrew Blitzer, Dr. Sinclair reported on a series of 59 patients treated with onabotulinumtoxinA (Botox) for OMD since 1995. They assessed the long-term management of the patients and also sought to develop a treatment algorithm for OMD and compare the current series with an original cohort of 20 OMD patients treated by Dr. Blitzer in the 1980s (Ann. Otol. Rhinol. Laryngol. 1989;98:93-7).

In the current series, 10 patients required only one treatment session, another 10 had two sessions, and 39 returned more than twice for subsequent injections of onabotulinumtoxinA. Functional response determined the need and timing of subsequent injections. For example, patients with less than a 50% improvement on a 1 to 100 function rating scale were re-injected less than a month following their initial treatment. The overall median time between treatments was 3 months.

An advantage of onabotulinumtoxinA injections, compared with oral medications, is a greater ability to tailor the treatment. "Injections can be titrated by dose and site to address the predominant muscle systems involved," Dr. Sinclair said at the meeting, which was jointly sponsored by The Triological Society and the American College of Surgeons.

Initial injection dosage ranged from 2.4 U to 5.0 U onabotulinumtoxinA. "Regardless of clinical type, if a patient experiences no response or less than 50% functional improvement, they should be re-injected with either the same dose as the initial injection or with a dose increase of 5 U to 10 U botulinum toxin," said Dr. Sinclair, an otolaryngology fellow at St. Luke’s–Roosevelt Hospital in New York. Also consider treatment of additional muscles, she added.

OMD subtype dictated the specific muscles injected. The masseter and/or temporalis muscles were most often injected for the jaw closing subtype, for example. The internal pterygoid was most often injected for the jaw opening and lateral deviation types of OMD. All injections were percutaneous except for external pterygoid injections, where were done intra-orally, Dr. Sinclair said.

One major caveat is to avoid significant post-injection dysphagia. For this reason, Dr. Sinclair said, anterior digastric muscle injections are performed superficially to avoid diffusion into the underlying floor of the mouth and tongue base musculature. In the study patients, automated machine guidance coupled with visual inspection of areas of maximum muscular hypertrophy determined initial needle placement. Optimal placement was confirmed with voluntary movement.

Not surprisingly, large muscles such at the masseter and temporalis typically receive higher toxin dose and a higher median number of injections. For example, these two muscles are typically injected at five sites, compared with three each for the pterygoid or digastric muscles, Dr. Sinclair said.

The injections appear to be relatively safe in this population. There were no complications reported post-injection by any patient in the current series, Dr. Sinclair said.

The mean age among the 59 patients was 57 years, and 72% were women. The mean follow-up time was 4.3 years.

"Of note, significantly more patients with jaw opening form of OMD were treated in the more recent data set," Dr. Sinclair said. "In line with this, there was an increase in lateral pterygoid and anterior digastric injections," compared with the older series. Despite the increase in jaw opening dystonia in more recent years, the majority of patients (65%) still presented with the jaw closing form.

Dr. Sinclair reported having no relevant financial disclosures.

MIAM BEACH – Botulinum toxin injections provided good, long-term symptom control for many patients with oromandibular dystonia in a retrospective analysis of a series of patients treated at a single center.

Oromandibular dystonia (OMD) is involuntary, repetitive, or twisting spasms of the muscles around the mouth and lower face. Affected people experience jaw opening, jaw closing, lateral jaw deviation, or a combination of these forms.

"Long-term management of OMD with botulinum toxin has minimal morbidity and is useful for all clinical forms," Dr. Catherine F. Sinclair said at the Triological Society’s Combined Sections meeting. With no cure for the condition and oral medication that only improves symptoms for about one-third of patients, botulinum toxin is considered a treatment option, she added.

Along with colleagues Dr. Lowell E. Gurey and Dr. Andrew Blitzer, Dr. Sinclair reported on a series of 59 patients treated with onabotulinumtoxinA (Botox) for OMD since 1995. They assessed the long-term management of the patients and also sought to develop a treatment algorithm for OMD and compare the current series with an original cohort of 20 OMD patients treated by Dr. Blitzer in the 1980s (Ann. Otol. Rhinol. Laryngol. 1989;98:93-7).

In the current series, 10 patients required only one treatment session, another 10 had two sessions, and 39 returned more than twice for subsequent injections of onabotulinumtoxinA. Functional response determined the need and timing of subsequent injections. For example, patients with less than a 50% improvement on a 1 to 100 function rating scale were re-injected less than a month following their initial treatment. The overall median time between treatments was 3 months.

An advantage of onabotulinumtoxinA injections, compared with oral medications, is a greater ability to tailor the treatment. "Injections can be titrated by dose and site to address the predominant muscle systems involved," Dr. Sinclair said at the meeting, which was jointly sponsored by The Triological Society and the American College of Surgeons.

Initial injection dosage ranged from 2.4 U to 5.0 U onabotulinumtoxinA. "Regardless of clinical type, if a patient experiences no response or less than 50% functional improvement, they should be re-injected with either the same dose as the initial injection or with a dose increase of 5 U to 10 U botulinum toxin," said Dr. Sinclair, an otolaryngology fellow at St. Luke’s–Roosevelt Hospital in New York. Also consider treatment of additional muscles, she added.

OMD subtype dictated the specific muscles injected. The masseter and/or temporalis muscles were most often injected for the jaw closing subtype, for example. The internal pterygoid was most often injected for the jaw opening and lateral deviation types of OMD. All injections were percutaneous except for external pterygoid injections, where were done intra-orally, Dr. Sinclair said.

One major caveat is to avoid significant post-injection dysphagia. For this reason, Dr. Sinclair said, anterior digastric muscle injections are performed superficially to avoid diffusion into the underlying floor of the mouth and tongue base musculature. In the study patients, automated machine guidance coupled with visual inspection of areas of maximum muscular hypertrophy determined initial needle placement. Optimal placement was confirmed with voluntary movement.

Not surprisingly, large muscles such at the masseter and temporalis typically receive higher toxin dose and a higher median number of injections. For example, these two muscles are typically injected at five sites, compared with three each for the pterygoid or digastric muscles, Dr. Sinclair said.

The injections appear to be relatively safe in this population. There were no complications reported post-injection by any patient in the current series, Dr. Sinclair said.

The mean age among the 59 patients was 57 years, and 72% were women. The mean follow-up time was 4.3 years.

"Of note, significantly more patients with jaw opening form of OMD were treated in the more recent data set," Dr. Sinclair said. "In line with this, there was an increase in lateral pterygoid and anterior digastric injections," compared with the older series. Despite the increase in jaw opening dystonia in more recent years, the majority of patients (65%) still presented with the jaw closing form.

Dr. Sinclair reported having no relevant financial disclosures.

MIAM BEACH – Botulinum toxin injections provided good, long-term symptom control for many patients with oromandibular dystonia in a retrospective analysis of a series of patients treated at a single center.

Oromandibular dystonia (OMD) is involuntary, repetitive, or twisting spasms of the muscles around the mouth and lower face. Affected people experience jaw opening, jaw closing, lateral jaw deviation, or a combination of these forms.

"Long-term management of OMD with botulinum toxin has minimal morbidity and is useful for all clinical forms," Dr. Catherine F. Sinclair said at the Triological Society’s Combined Sections meeting. With no cure for the condition and oral medication that only improves symptoms for about one-third of patients, botulinum toxin is considered a treatment option, she added.

Along with colleagues Dr. Lowell E. Gurey and Dr. Andrew Blitzer, Dr. Sinclair reported on a series of 59 patients treated with onabotulinumtoxinA (Botox) for OMD since 1995. They assessed the long-term management of the patients and also sought to develop a treatment algorithm for OMD and compare the current series with an original cohort of 20 OMD patients treated by Dr. Blitzer in the 1980s (Ann. Otol. Rhinol. Laryngol. 1989;98:93-7).

In the current series, 10 patients required only one treatment session, another 10 had two sessions, and 39 returned more than twice for subsequent injections of onabotulinumtoxinA. Functional response determined the need and timing of subsequent injections. For example, patients with less than a 50% improvement on a 1 to 100 function rating scale were re-injected less than a month following their initial treatment. The overall median time between treatments was 3 months.

An advantage of onabotulinumtoxinA injections, compared with oral medications, is a greater ability to tailor the treatment. "Injections can be titrated by dose and site to address the predominant muscle systems involved," Dr. Sinclair said at the meeting, which was jointly sponsored by The Triological Society and the American College of Surgeons.

Initial injection dosage ranged from 2.4 U to 5.0 U onabotulinumtoxinA. "Regardless of clinical type, if a patient experiences no response or less than 50% functional improvement, they should be re-injected with either the same dose as the initial injection or with a dose increase of 5 U to 10 U botulinum toxin," said Dr. Sinclair, an otolaryngology fellow at St. Luke’s–Roosevelt Hospital in New York. Also consider treatment of additional muscles, she added.

OMD subtype dictated the specific muscles injected. The masseter and/or temporalis muscles were most often injected for the jaw closing subtype, for example. The internal pterygoid was most often injected for the jaw opening and lateral deviation types of OMD. All injections were percutaneous except for external pterygoid injections, where were done intra-orally, Dr. Sinclair said.

One major caveat is to avoid significant post-injection dysphagia. For this reason, Dr. Sinclair said, anterior digastric muscle injections are performed superficially to avoid diffusion into the underlying floor of the mouth and tongue base musculature. In the study patients, automated machine guidance coupled with visual inspection of areas of maximum muscular hypertrophy determined initial needle placement. Optimal placement was confirmed with voluntary movement.

Not surprisingly, large muscles such at the masseter and temporalis typically receive higher toxin dose and a higher median number of injections. For example, these two muscles are typically injected at five sites, compared with three each for the pterygoid or digastric muscles, Dr. Sinclair said.

The injections appear to be relatively safe in this population. There were no complications reported post-injection by any patient in the current series, Dr. Sinclair said.

The mean age among the 59 patients was 57 years, and 72% were women. The mean follow-up time was 4.3 years.

"Of note, significantly more patients with jaw opening form of OMD were treated in the more recent data set," Dr. Sinclair said. "In line with this, there was an increase in lateral pterygoid and anterior digastric injections," compared with the older series. Despite the increase in jaw opening dystonia in more recent years, the majority of patients (65%) still presented with the jaw closing form.

Dr. Sinclair reported having no relevant financial disclosures.