QD Questions

  1. T or F?
    Local reactions from immunotherapy predict systemic reactions and/or anaphylaxis.
    The correct answer is: False 

    As this review details, this is not true and therefore dose changes usually do not need to be made based on seeing local reactions. 

    • Local reactions from subcutaneous allergen immunotherapy.  Immunotherapy. 2013 Dec;5(12):1339-45. Coop CA
    • .
  2. Common causes for increased local reaction in a patient receiving maintenance immunotherapy include all of the following except:

    - Development of new allergies since the original testing was performed
    - Superimposed viral illness
    - Higher than usual antigen exposure
    - Missed allergy medication doses
    Development of new allergies since original testing was performed.

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    • This is a not uncommon event and can be confusing to clinicians giving immunotherapy, but it is important to remember that superimposed viral illnesses, higher than usual antigen exposure and missed allergy medication doses can all cause increased local reactions to immunotherapy.

    • Local reactions from subcutaneous allergen immunotherapy.  Immunotherapy. 2013 Dec;5(12):1339-45. Coop CA
    • Local reactions from subcutaneous allergen immunotherapy are very common during the course of immunotherapy. These local reactions are not bothersome to patients. Local reactions from immunotherapy also do not predict future local or systemic reactions. This review discusses the studies that show that local reactions are not predictive of future reactions and that dose adjustments for local reactions from allergen immunotherapy are unnecessary. The article also focuses on factors that lead to patient noncompliance with immunotherapy and evaluates methods to prevent local reactions from subcutaneous allergen immunotherapy.
  3. Which of the following occurs a significant amount of the time unilaterally?
    Dermatochalasis describes laxity and redundancy of eyelid skin secondary to aging. Gravity, loss of elastic tissue in the skin, and weakening of the connective tissues of the eyelid frequently contribute to this lax and redundant eyelid tissue. These findings are more common in the upper eyelids but can be seen in the lower eyelids as well.

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    Blepharochalasis is an inflammatory syndrome of the eyelid that is characterized by exacerbations and remissions of eyelid edema, which results in a stretching and subsequent atrophy of the eyelid tissue, leading to the formation of redundant folds over the lid margins.  It typically affects the upper eyelids. and in approximately 50% of patients, it is unilateral.

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  4. A patient with a submandibular gland mass has a biopsy that reveals the following:

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    What is the likely pathology?
    Adenoid cystic carcinoma

    Perineural spread is a well-recognized phenomenon in head and neck cancers. SCCAs are the most frequent neoplasms to exhibit this behavior, followed by adenoid cystic carcinoma, lymphoma, and rhabdomyosarcoma. Because of their extensive and intricate network of nerve fibers within the head and neck, the trigeminal and facial nerves are the nerves most commonly affected. In addition, these nerves have various interconnections between them that serve as a mechanism for widespread dissemination. 

    • Perineural invasion and spread in head and neck cancer.  Johnston M1, Yu E, Kim J.Expert Rev Anticancer Ther. 2012 Mar;12(3):359-71. doi: 10.1586/era.12.9.
    • Perineural involvement is a well-recognized clinicopathologic entity found in head and neck (H&N) cancers, including mucosal epithelial carcinomas and salivary gland malignancies. Perineural disease remains a diagnostic, prognostic and therapeutic challenge for the multidisciplinary H&N oncology team. Nerves are important routes of tumor spread in H&N malignancies, yet the biology and prognostic implications of perineural tumor growth are not fully understood. On balance, the available evidence suggests that it is associated with an increased risk of locoregional recurrence but the impact on survival remains uncertain. Perineural involvement has implications for locoregional disease diagnosis and management. MRI is the best imaging modality to detect tumor extent. Advanced radiotherapy technologies such as intensity-modulated radiation therapy and image-guided radiation therapy have the potential for more accurate targeting and treatment of anatomically complex patterns of disease spread. This review is limited to nondermatologic H&N cancers.

  5. T or F?  Treatment of allergic rhinitis in children with attention deficit hyperactivity disorder (ADHD) improves both allergic rhinitis scores and ADHD scores.

    This prospective study included 68 children aged six to 16 years with untreated AR, all of whom were evaluated to determine AR symptom scores, ADHD symptom scores, and computerized continuous performance test scores, before and after AR therapy. Therapy included nonpharmacologic intervention, oral antihistamines, and topical steroids. Outcomes of these children were compared to those of 31 age-matched controls and 13 children with pure ADHD. The study found that after treatment for AR, AR symptom scores in children with AR decreased significantly, as did their ADHD scores. Age, drugs, AR subtypes, and multiple atopic diseases were significant predictors for improved ADHD scores.

    • Attention-deficit/hyperactivity disorder-related symptoms improved with allergic rhinitis treatment in children.  Yang MT, Chen CC, Lee WT, Liang JS, Fu WM, Yang YH.Am J Rhinol Allergy. 2016 May;30(3):209-14
    • BACKGROUND:  Increased prevalence of attention-deficit/hyperactivity disorder (ADHD) in children with allergic rhinitis (AR) has been reported. Our previous study showed that children with untreated AR had higher ADHD scores than did the controls.
    • OBJECTIVE:  This prospective follow-up study aimed to investigate whether elevated ADHD scores in children with AR could be decreased by AR treatment.
    • METHODS:  Sixty-eight children with AR (age range, 6-14 years) and who were drug naive were enrolled and evaluated by AR symptom score, ADHD symptom scores, and computerized continuous performance test, before and after AR therapy, which included nonpharmacologic intervention, oral antihistamines, and topical steroids. Thirty-one age-matched controls and 13 children with pure ADHD were also enrolled for comparison. The relationship between the AR and ADHD score change was analyzed by a partial correlation test, and univariate and multivariate linear regression models were applied to investigate possible predictors for the improvement of ADHD scores by AR treatment.
    • RESULTS:  AR symptom scores in children with AR decreased significantly after treatment (p < 0.001), and their ADHD scores also decreased significantly (p < 0.001). An improved AR symptom score was positively correlated with improved detectability (rp = 0.617, p = 0.001) and commission error (rp = 0.511, p = 0.011). Significant predictors for the improvement of ADHD scores included age, AR drugs, AR subtypes, and multiple atopic diseases (ps < 0.05).
    • CONCLUSION:  Higher ADHD scores in children with AR compared with healthy controls decreased significantly with AR treatment. For children with AR and borderline ADHD symptoms, who do not meet full ADHD diagnostic criteria, we recommend initially treating their AR and monitoring improvement of ADHD symptoms.
  6. Current 'Best Practices' would dictate that patients with asymptomatic unilateral tonsillar enlargement undergo__________?
    Observation with close follow up
    Observation with close follow up

    As this paper demonstrates, isolated asymptomatic unilateral tonsillar enlargement, periodic (suggested follow-up every 4 weeks for 3 months) monitoring of the patient along with noninvasive means of ruling out malignancy seems reasonable. 

    What is the best management of asymptomatic unilateral tonsillar enlargement?  Michelle S. Hwang BS,  Kathryn E. Kaye BS,  Jonathan A. Waxman MD, PhD,  Michael Friedman MDLaryngoscope Volume 125, Issue 11  November 2015 Pages 2438–2440
  7. Which of the following is a connection between CN V and CN VII?

    Chorda tympani
    Sphenopalatine ganglion
    Auriculotemporal nerve
    A and C
    All of the above
    All of the above.

    The trigeminal and facial nerves directly communicate in 3 locations. First, the sphenopalatine ganglion forms a junction between the Vidian nerve and branches of the maxillary nerve. The Vidian is derived from the greater superficial petrosal nerve, which is a branch of the facial nerve. Another branch of the facial nerve, the chorda tympani, directly joins the lingual nerve, a division of the mandibular nerve. Third, the auriculotemporal branch of the mandibular nerve crosses through the body of the parotid gland at right angles to the facial nerve and, here, usually has direct communications with the facial nerve.

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  8. T or F?  Spouses and long-term partners of patients with HPV positive oropharyngeal cancers have no increased prevalence of oral HPV infections.

    This multicenter, pilot study revealed that spouses and long-term partners of patients with oropharyngeal cancers related to infection with HPV  appear to have no increased prevalence of oral HPV infections.  Thus these long-term couples need not change their sexual practices. 

    • Oral human papillomavirus (HPV) infection in HPV-positive patients with oropharyngeal cancer and their partners.  D'Souza G1, Gross ND2, Pai SI2, Haddad R2, Anderson KS2, Rajan S2, Gerber J2, Gillison ML2, Posner MR2.J Clin Oncol. 2014 Aug 10;32(23):2408-15.
    • PURPOSE:  To better understand oral human papillomavirus (HPV) infection and cancer risk among long-term sexual partners of patients with HPV-positive oropharyngeal cancer (HPV-OPC).
    • PATIENTS AND METHODS:  An oral rinse sample, risk factor survey, cancer history, and oral examination (partners only) were collected from patients with HPV-OPC and their partners. Oral rinse samples were evaluated for 36 types of HPV DNA using PGMY 09/11 primers and line-blot hybridization and HPV16 copy number using quantitative polymerase chain reaction. Oral HPV prevalence was compared with infection among those age 45 to 65 years using National Health and Nutrition Examination Survey (NHANES) 2009-2010.
    • RESULTS:  A total of 164 patients with HPV-OPC and 93 of their partners were enrolled. Patients were primarily men (90%), were never-smokers (51%), and had performed oral sex (97%), with a median age of 56 years; they had a high prevalence of oncogenic oral HPV DNA (61%) and oral HPV16 DNA (54%) at enrollment. Female partners had comparable oncogenic oral HPV prevalence compared with members of the general population of the same age (1.2% v 1.3%). Among the six male partners, no oncogenic oral HPV infections were detected. No precancers or cancers were identified during partner oral cancer screening examinations. However, a history of cervical disease was reported by nine partners (10.3%) and two female patients (11.8%), and three patients (2.0%) reported a previous partner who developed invasive cervical cancer.
    • CONCLUSION:  Oral HPV16 DNA is commonly detected among patients with HPV-OPC at diagnosis, but not among their partners. Partners of patients with HPV-OPC do not seem to have elevated oral HPV infection compared with the general population.
  9. T or F?  Use of over-the-counter Vitamin C and Vitamin E may improve post radiation xerostomia in head and neck cancer patients

    The following recent study showed improvments in xerostomia after radiation when Vitamin C and Vitamin E were given during XRT.  It is a small trial, but the results are interesting, especially in light of the ease of use and relatively minor cost and side effect profile of these OTC vitamins.

    • Randomized Trial of Vitamin C/E Complex for Prevention of RadiationInduced Xerostomia in Patients with Head and Neck Cancer Chung MK, Kim do H, Ahn YC, Choi JY, Kim EH, Son YIOtolaryngology Head & Neck Surgery, September 2016
    • Objective. The present study was conducted to determine the preventive efficacy of vitamin C/E complex supplementation for radiotherapy (RT)–induced xerostomia in patients with head and neck cancer.
    • Study Design. Prospective, double-blinded, randomized, placebo-controlled study. Setting. A single tertiary referral institution.
    • Subjects and Methods. The trial group (n = 25) received antioxidant supplements (100 IU of vitamin E 1 500 mg of vitamin C) twice per day during RT, while the control group (n = 20) received an identical placebo. Pre-RT and 1 and 6 months post-RT, patient-reported xerostomia questionnaires, observer-rated American Head and Neck Society Journal Club Volume 9, December 2016 page 5 xerostomia score, and salivary scintigraphy were serially obtained to compare xerostomia severity between the 2 groups.
    • Results. The trial group showed greater improvements in xerostomia questionnaire and score at 6 months post-RT when compared with those at 1 month post-RT (P = .007 and .008, respectively). In contrast, the control group showed no changes between 1 and 6 months post-RT. By salivary scintigraphy, there was no difference in maximal accumulation or ejection fraction between the 2 groups. However, the trial group maintained significantly better oral indices at the prestimulatory (P = .01) and poststimulatory (P = .009) stages at 1 month post-RT, compared with the control group. At the final follow-up, there was no difference in overall survival and disease-free survival between the 2 groups.
    • Conclusions. Our data suggest that short-term supplementation with an antioxidant vitamin E/C complex exerts a protective effect against RT-induced xerostomia
  10. Which of the following defects is most likely to heal well by secondary intention?

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    • Classically, a relatively small wound in a concave area has been considered appropriate for secondary intention, as noted by many authors including the following.

    • Secondary intention healing: An alternative to surgical repair. Zitelli J.A.  Clinical Dermatol. 2, 92-106.(1984)
    • A little more rigorously done, the following study claims to be "the first study presenting statistical evidence of what has been known empirically for a long time- wounds in concave areas of the face that are left to heal by secondary intention have a high chance of healing with an excellent cosmetic outcome, especially if these wounds are small, superficial, and located near the medial canthus and medial cheek." 

    • Secondary intention healing after excision of nonmelanoma skin cancer of the head and neck: statistical evaluation of prognostic values of wound characteristics and final cosmetic results. Plast Reconstr Surg. 2008 Dec;122(6):1747-55.van der Eerden PA, Lohuis PJ, Hart AA, Mulder WC, Vuyk H.
    • They report that "the rating excellent was given more often to scars derived from wounds that were small and superficial and that were located in concave areas of the face, in particular, near the medial canthus and medial cheek."
  11. Which of the following are histological hallmarks of chronic rhinosinusitis?

    Thickened and/or metaplastic epithelium
    Absence of cilia
    Hyperplasia of mucosal glands
    All of the above
    All of the above.

    As this and many other studies show, there are multiple histologic hallmarks of chronic infection of the sinuses, including all of those listed above. 

    • Treatment of rhinosinusitis and histopathology of nasal mucosa: A controlled, randomized, clinical study.  Bizaki AJ1, Numminen J1, Taulu R1, Kholova I1, Rautiainen M1.Laryngoscope. 2016 Dec;126(12):2652-2658.
    • OBJECTIVES/HYPOTHESIS:  To study the pathology of upper airway mucosa, as well as valuate and compare changes in pathology after the treatment of chronic rhinosinusitis (CRS) patients with balloon sinuplasty versus uncinectomy.
    • METHODS:  A prospective randomized controlled trial in patients with CRS of the maxillary sinuses without severe pathology of other sinuses. Patients were randomized into two groups: uncinectomy and balloon sinuplasty. The main variables in our study are histopathology of nasal mucosa and expression of metalloproteinase-9 protein. These parameters were analyzed preoperatively and at 3 months, 6 months, and 12 months postoperatively.
    • RESULTS:  Thickened epithelium, absence of cilia, metaplasia of epithelium, hyperplasia of mucosal glands, angiogenesis, and increased inflammatory cells were observed in the majority of preoperative samples. History of allergy was associated with a higher number of goblet cells, and shedding of epithelium was associated with worse quality of life. A higher number of inflammatory cells were associated with an increased number of goblet cells preoperatively, as well as after treatment. Both treatments resulted in a decrease of inflammation in the mucosa and epithelium. Hypertrophy of the mucosal glands, hyperplasia of blood vessels, and mucosal edema decreased after treatment. These changes were more noticeable in uncinectomy group. Balloon sinuplasty was associated with a higher number of inflammatory cells at 6 months after treatment (P = 0.05).
  12. T or F?  In selected patients undergoing head and neck free tissue transfer, discharge by day 3 is possible with an acceptable flap survival rate.

    What a fascinating study, showing it is safe to discharge patients by day 3 that have no severe comorbidities. 

    • Short-stay hospital admission after free tissue transfer for head and neck reconstruction.  Devine CM1, Haffey TM1, Trosman S1, Fritz MA1.Laryngoscope. 2016 Dec;126(12):2679-2683.
    • OBJECTIVES/HYPOTHESIS:   To show that, for patients with few medical comorbidities and at low risk for airway compromise or fistula formation, early discharge after free tissue transfer for head and neck reconstruction is a safe and viable option.
    • STUDY DESIGN:   Retrospective chart review.
    • METHODS:   A cohort of patients who underwent free tissue transfer for head and neck reconstruction between February 2010 and December 2014 and who were discharged from the hospital by postoperative day 3 were reviewed.
    • RESULTS:   Fifty patients undergoing 51 free-tissue transfer surgeries were discharged by postoperative day 3. The surgeries performed included anterolateral thigh free flaps (ALT) (n = 46), radial forearm free flaps (n = 2), latissimus myogenous and myocutaneous free flaps (n = 1), supraclavicular free flap (n = 1), and serratus free flap (n = 1). All ALT flaps were harvested exclusively as perforator free flaps; and the vast majority used superficial temporal, angular, or facial vessels. All free flaps were viable without evidence of vascular compromise at discharge and the initial follow-up appointment. One patient required take-back for successful flap salvage. One patient experienced late flap failure (between 2-3 weeks postoperatively), requiring another surgery. This resulted in an overall success rate of 98% in this cohort. No other postoperative complications related to early discharge were identified.
    • CONCLUSION:  In a carefully selected subset of patients undergoing free tissue transfer, early discharge has been shown to be possible without compromising patient safety or surgery success rates.
  13. Which of the following is FALSE concerning PET/CT monitoring of patients who undergo chemoradiation for head and neck cancer, as opposed to planned neck dissection?

    Survival is equal in the two groups.
    Global quality-of-life scores are similar in the two groups.
    PET/CT surveillance spares over 50% of patients from getting a neck dissection.
    Planned neck dissection is more cost effective.
    "Planned neck dissection is more cost effective." is FALSE

    • PET-CT Surveillance versus Neck Dissection in Advanced Head and Neck CancerHisham Mehanna, et al for the PET-NECK Trial Management GroupN Engl J Med 2016; 374:1444-1454April 14, 2016
    • This study in the New England Journal of Medicine prospectively shows what manyretrospective studies have shown - that PET/CT is effective for determining response to chemoradiation in head and neck papers. What it also does, is show that it is a cheaper way of monitoring the patients as well.

    There has been lack of clarity about treatments after chemoradiotherapy and wide variation in the clinical treatment of patients with squamous-cell carcinoma of the head and neck who have advanced nodal disease and who have received chemoradiotherapy for primary treatment.1,2 Our trial showed that PET-CT–guided surveillance was noninferior to planned neck dissection and was equally effective in both HPV-positive and HPV-negative patient groups. Patients in the surveillance group were not disadvantaged by undergoing delayed neck dissection; the global quality-of-life scores and rates of surgical complications were similar in this group and in the group of patients who underwent earlier planned neck dissection. PET-CT surveillance resulted in far fewer operations; approximately 80% of patients were spared neck dissection. Surveillance was also more cost-effective than planned neck dissection over the trial period.
  14. Which is true concerning the pars flaccida?

    It is medial to the notch of Rivinus
    It is more mobile than the pars tensa
    It lacks a fibrous layer
    All of the above
    None of the above
    All of the above

    • The pars flaccida is situated above the lateral process of the malleus between the notch of Rivinus and the anterior and posterior malleal folds.  It consists of two layers, is relatively fragile, and is associated with eustachian tube dysfunction and cholesteatomas. 
    • The larger pars tensa region consists of three layers; skin, fibrous tissue, and mucosa.  It is comparatively robust and is the region most commonly associated with perforations.
  15. T or F?  In patients undergoing excision of a preauricular cyst, those that have had previous I&D done for infection in the cyst have a 6-fold higher rate of recurrence than those that have had FNA or were treated with antibiotics alone.

    • Association of Recurrence of Infected Congenital Preauricular Cysts Following Incision and Drainage vs Fine-Needle Aspiration or Antibiotic Treatment: A Retrospective Review of Treatment Options.  Rataiczak H1, Lavin J2, Levy M2, Bedwell J2, Preciado D2, Reilly BK2.JAMA Otolaryngol Head Neck Surg. 2017 Feb 1;143(2):131-134.
    • IMPORTANCE:  Treatment modalities for preauricular sinus tract infections vary.  Effort should be taken to decrease methods that lead to increased recurrence after surgical excision.
    • OBJECTIVE:  To determine whether incision and drainage (I & D) of infected congenital preauricular cysts is associated with increased rate of recurrence when compared with fine-needle aspiration or antibiotic treatment.
    • DESIGN, SETTING, AND PARTICIPANTS:  This was a 9-year (2006-2014) retrospective cohort study undertaken at a tertiary care pediatric hospital. Children treated for preauricular sinus tract infections were identified using the procedure code for excision of preauricular pit, cyst, or sinus tract.
    • MAIN OUTCOMES AND MEASURES:  Postexcision recurrence.
    • RESULTS:  Sixty-nine children ranging in age from 4 months to 17 years (mean age, 5.9 years) underwent excision of a preauricular cyst. Thirty-seven of 69 patients (54%) were female. Fifty-seven of 69 (83%) had a preoperative history of infection; the remainder had chronic drainage. Of children with preoperative infection, 27 were initially treated with incision and drainage (I & D), 12 were treated with fine-needle aspiration only, and 18 received antibiotic therapy alone. Overall, the recurrence rate was 8 in 69 (11.6%). Among the 27 patients with a preoperative history of infection treated with I & D, 5 lesions (18.5%) recurred, and among those who only received preoperative antibiotic therapy or fine-needle aspiration 1 in 30 lesions (3.3%) recurred (absolute difference of 15.2%; 95% CI, -1.7% to 33.6%).
    • CONCLUSIONS AND RELEVANCE:  Among infants and children undergoing excision of preauricular cysts, a history of infection was not associated with a higher recurrence rate. There was, however, evidence to suggest that a higher rate of recurrence exists among children who had a preoperative history of infection treated with I & D. Our results suggest a more conservative treatment of infected preauricular pit and/or sinus.
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