Aman M. Patel

Objective: To investigate occult nodal metastasis (ONM) and overall survival (OS) in patients undergoing elective neck dissection (END) for clinically node‐negative submandibular gland cancer (SMGC). Methods: The 2006 to 2018 National Cancer Database was retrospectively reviewed for patients with cT1‐4 N0M0 SMGC undergoing surgical resection. Linear, binary logistic, Kaplan–Meier, and Cox proportional hazards regression models were implemented. Results: A high proportion of patients were female ( N = 710, 54.6%) and White ( N = 1059, 82.5%) with adenoid cystic carcinoma histology ( N = 567, 43.6%) classified as cT1 ( N = 545, 41.9%). A minority of patients ( N = 255, 19.6%) underwent END. Academic/research reporting facility, high grade, cT3, and cT4 classification were associated with higher odds of undergoing END; Medicare insurance was associated with lower odds ( p < 0.05). ONM was identified in 63 (24.7%) patients undergoing END. The rate of ONM increased with cT classification (13.2% in cT1, 27.9% in cT2, 22.0% in cT3, and 50.0% in cT4) and grade (6.5% in well‐differentiated, 9.5% in moderately differentiated, and 40.3% in poorly differentiated). END was not associated with OS (hazard ratio [HR] 1.11, 95% confidence interval [CI] 0.84–1.46, p = 0.461). However, ONM was associated with worse OS (HR 3.69, 95% CI, 2.25–6.05, p < 0.001); 5‐year OS for patients without and with ONM was 83% and 50%, respectively ( p < 0.001). Conclusion: END is performed frequently in SMGC but is not associated with OS. Although the rate of ONM approaches 25%, these findings suggest that END should not be routinely performed for prognostic purposes alone, especially in the absence of adverse features. Level of Evidence: 4.

Objective: Charlson–Deyo Comorbidity Index (CCI) predicts 10‐year mortality for a patient based on a range of comorbid conditions. Objective preoperative risk assessment tools inform physician decision making. Our study examines the relationship between CCI and overall survival (OS) following upfront laryngectomy for laryngeal squamous cell carcinoma (LSCC). Methods: A retrospective analysis of the 2004–2016 National Cancer Database (NCDB) was conducted to identify adult patients with pT1‐4 N0‐3 M0 LSCC undergoing upfront laryngectomy. Kaplan–Meier survival analysis and Cox proportional hazards modeling were performed to evaluate the association between CCI and OS. Results: Of the 25,720 patients satisfying inclusion criteria, 16,204 (63.0%) were CCI = 0, 6812 (26.5%) were CCI = 1, 1948 (7.6%) were CCI = 2, and 756 (2.9%) were CCI ≥ 3. On univariate analysis, CCI groups differed by age (65.1% were < 65 years old in CCI = 0 vs. 57.3%, 49.6%, and 48.9% in CCI = 1, 2, and ≥ 3; p < 0.001), sex ( p < 0.001), and race ( p < 0.001). Differences also existed across CCI groups in primary site, T‐stage, N‐stage, systemic therapy, and radiotherapy ( p < 0.001). On Kaplan–Meier analysis, 5‐year OS for CCI = 0, 1, 2, and ≥ 3 was 55.3%, 47.8%, 39.5%, and 34.0%, respectively ( p < 0.001). CCI = 1 (aHR 1.20, 95% CI 1.14–1.26, p < 0.001), CCI = 2 (aHR 1.57, 95% CI 1.45–1.71, p < 0.001), and CCI ≥ 3 (aHR 1.77, 95% CI 1.56–2.01, p < 0.001) were associated with worse OS than CCI = 0. Conclusion: In an adult cohort with pT1‐4 N0‐3 M0 LSCC undergoing upfront laryngectomy, increasing CCI was associated with worse OS. During perioperative counseling, CCI should be optimized and considered as a factor influencing survival outcomes. Level of Evidence: 4.

Objective: To evaluate national trends in Advanced Practice Provider (APP) participation in Otolaryngology (ear‐nose‐throat [ENT]) care and assess their role in improving access to ENT services within the Medicare population from 2018 to 2022. Methods: We analyzed Medicare Provider Utilization and Payment Data from 2018 to 2022, including the Physician and Other Supplier Detailed and Aggregate Files. We examined 25 ENT‐relevant CPT codes for provider type, procedural volume, and Medicare reimbursement. Providers were categorized as either ENTs or APPs based on their reported formal specialty designation. Descriptive statistics, t‐tests, chi‐square tests, and regression analyses were utilized to evaluate differences in service delivery, geographic distribution, and provider trends over time. Results: Between 2018 and 2022, the number of ENTs declined by 2.1% (95% CI, −2.4% to −1.8%), while the number of APPs increased by 36.1% (95% CI, 35.8%–36.4%). APPs performed an increasing share of ENT procedures, including diagnostic nasal endoscopy, laryngoscopy, and sinus debridement, and were more likely to practice in rural areas. APP participation grew across all U.S. regions. Although ENTs maintained higher mean procedural volumes and reimbursement rates, APPs demonstrated a broader geographic distribution and expanded independent billing capabilities. Conclusion: APPs have become essential contributors to the delivery of ENT care in the United States. Their involvement in procedures and presence in underserved areas highlight their role as an effective strategy to address workforce shortages and improve access to otolaryngologic services.

Objective(s): Current preoperative risk stratification for uvulopalatopharyngoplasty (UPPP) primarily relies on anatomic and disease‐severity measures, which do not capture physiologic reserve or vulnerability to postoperative complications. This study aimed to compare the predictive performance of the risk analysis index (RAI) and the modified frailty index‐5 (mFI‐5) in stratifying postoperative risk among patients undergoing UPPP. Methods: Adult patients who underwent UPPP between 2005 and 2020 were identified. Frailty was assessed, and associations with postoperative complications, length of stay, discharge disposition, and mortality were evaluated. Multivariable regression and receiver operating characteristic analysis were conducted. Results: A total of 2129 patients were included and severe frailty (RAI > 31) was strongly associated with adverse postoperative outcomes, including Clavien–Dindo (CD) II complications (OR 21.3, 95% CI 3.7–123.8), CD IV (OR 4.6, 95% CI 2.0–10.6), extended length of stay (eLOS) (OR 29.4, 95% CI 5.4–160), non‐home discharge (NHD) (OR 6.1, 95% CI 3.0–12.6), and deep surgical site infection (DSSI) (OR 17.5, 95% CI 1.7–176.3) (all p < 0.05). The mFI‐5 predicted CD II, eLOS, and NHD but not CD IV or DSSI among severely frail patients (mFI‐5 > 3). RAI consistently outperformed mFI‐5 across outcomes, including mortality (AUC 0.813 vs. 0.580), CD II (0.784 vs. 0.652), CD IV (0.704 vs. 0.654), eLOS (0.767 vs. 0.669), and NHD (0.767 vs. 0.618). Conclusion: Although both RAI and mFI‐5 are associated with postoperative outcomes following UPPP, RAI provides superior discrimination for mortality and major morbidity. These findings support the incorporation of RAI into preoperative risk stratification for sleep surgery to better inform perioperative planning and resource allocation. Level of Evidence: 3.

Objective: To analyze Medicare reimbursement and utilization trends of Zenker's diverticulectomy from 2000 to 2024. Study Design: Retrospective cross‐sectional study. Setting: Centers for Medicare and Medicaid Services (CMS) Physician Fee Schedule (2000–2024) and Part B Medicare Fee‐For‐Service National Summary Data (2000–2022). Methods: Utilization and payment trends for open (Current Procedural Terminology [CPT] code 43130) and endoscopic (CPT code 43180, introduced in 2015) repair of Zenker's diverticulum were analyzed, with reimbursement rates adjusted for inflation using the Consumer Price Index (CPI). Linear regression analysis was performed to assess the relationship between reimbursement rates and time. Results: From 2000 to 2022, the total number of Zenker's diverticulectomy procedures decreased by 14.8% (1775–1513), with a 72.1% decrease (1775–495) for open approach. There was a 22.5% increase (831–1018) in endoscopic approach from 2015 to 2022. By 2022, endoscopic procedures accounted for 67.3% of all Zenker's diverticulectomies, compared to 32.7% for the open approach. From 2000 to 2024, inflation‐adjusted reimbursement for open procedures declined by 49.96% ($1586.26–$670.41), with an annual decrease of 2.08%. Endoscopic procedures, tracked separately from 2015 to 2024, saw a 29.32% decline ($773.24–$547.13) and an annual decrease of 3.26%. Unadjusted reimbursement for both approaches combined declined by an average of 0.88% per year, while inflation‐adjusted rates decreased by 3.45% annually ( p < 0.001). Conclusion: There has been a downward trend in the Medicare reimbursement of Zenker's diverticulectomy, with an average adjusted decline of 3.45% annually. This trend raises concerns about the sustainability of such specialized procedures, potentially limiting access for elderly patients reliant on Medicare coverage. Level of Evidence: 4.

Objective: To investigate adjuvant therapy considerations, utilization, and associated overall survival (OS) following upfront laryngectomy for laryngeal squamous cell carcinoma (LSCC). Methods: The 2010 to 2017 National Cancer Database was retrospectively reviewed for patients undergoing upfront laryngectomy ( N = 3360). Kaplan–Meier, multivariable binary logistic, and Cox proportional hazards regression models were implemented. Results: Among 2997 patients with consideration(s) for adjuvant radiotherapy (aRT) (i.e., pT3‐4, pN2‐3 classification, lymphovascular invasion, pathologic extranodal extension (pENE), and/or positive surgical margins [PSM]), 1176 (39.2%) did not undergo adjuvant therapy and were considered to have missed aRT. Among 992 patients with consideration(s) for adjuvant chemoradiotherapy (aCRT) (i.e., pENE and/or PSM), 169 (17.0%) underwent aRT alone and were considered to have missed aCRT. Older age and increased distance to the reporting facility were associated with higher adjusted odds of both missed aRT ( p < 0.001) and missed aCRT ( p < 0.025). Patients with pENE only ( N = 343, 57.6%) and pENE and PSM ( N = 96, 56.8%) underwent aCRT more frequently than those with PSM only ( N = 97, 42.5%) ( p < 0.001). Missed aRT was associated with worse OS among 2005 patients with consideration(s) for aRT alone (i.e., pT3‐4, pN2‐3 classification, and/or LVI without pENE or PSM) (aHR 1.23, 95% CI 1.05–1.44, p = 0.011) and among 992 patients with consideration(s) for aCRT (aHR 1.85, 95% CI 1.52–2.24, p < 0.001). Conclusion: Missed aRT following upfront laryngectomy for LSCC occurs frequently and portends worse OS. Identifying patients at risk of off‐guideline management may create opportunities for quality improvement in the multidisciplinary care of patients undergoing upfront laryngectomy for LSCC. Level of Evidence: 4.

Objective: To investigate the impact of clinical surveillance, primary radiotherapy, and primary surgery on overall survival (OS) in laryngeal carcinoma in situ (Cis). Methods: The 2006–2020 National Cancer Database was queried for adults with a biopsy‐proven diagnosis of laryngeal Cis. Multivariable binary logistic and Cox proportional hazards regression models were implemented. Results: Of 3567 unique patients satisfying inclusion criteria, 514 (14.4%) underwent clinical surveillance, 1074 (30.1%) underwent primary radiotherapy, and 1979 (55.5%) underwent primary surgery. Receiving treatment at an academic/research facility was associated with higher odds of undergoing primary surgery compared to primary radiotherapy. Among 646 patients undergoing primary surgery with known pT classification and margins, 570 (76.6%) had pTis and NSM and 174 (23.4%) had pT1 and/or PSM. 5‐year OS of clinical surveillance, primary radiotherapy, and primary surgery was 73%, 81%, and 86%, respectively ( p < 0.001). Patients undergoing primary surgery with invasive or residual disease (i.e., pT1 and/or PSM) had similar 5‐year OS as those without (84% vs. 88%, p = 0.057). Compared with primary radiotherapy, clinical surveillance (aHR 1.29, 95% CI 1.06–1.57, p = 0.003) was associated with worse OS, and primary surgery (aHR 0.80, 95% CI 0.69–0.92, p = 0.003) was associated with higher OS. Conclusion: Primary surgery is associated with higher OS than clinical surveillance and primary radiotherapy among patients with laryngeal Cis. Level of Evidence: 4.

Objectives: Objective preoperative risk assessment tools inform physician and patient decision making. Our study examines the relationship between the Charlson–Deyo comorbidity index ( CCI ) and overall survival ( OS ) following surgery for sinonasal squamous cell carcinoma ( SNSCC ). Methods: In a retrospective cohort study, the 2004–2016 National Cancer Database was used to extract adult patients with pT1 ‐4 N0 ‐3 M0 SNSCC undergoing surgery. Kaplan–Meier survival analysis and Cox‐proportional hazards modeling were used to analyze the impact of CCI on OS . Results: Of the 3307 patients satisfying inclusion criteria, 2613 (79.0%) were CCI = 0, 533 (16.1%) were CCI = 1, and 161 (4.9%) were CCI = 2+. On univariate analysis, CCI groups differed by age (42.8% were ≥ 65 years old in CCI = 0 vs. 53.3% and 64.0% in CCI groups 1 and 2+, respectively, p < 0.001) and race ( p < 0.001). There was no significant difference between CCI groups in sex, T‐stage, N‐stage, margin status, primary site, radiation therapy, or systemic therapy. On Kaplan–Meier analysis, 5‐year OS for CCI = 0, CCI = 1, and CCI = 2+ was 58.6%, 48.0%, and 42.9%, respectively ( p < 0.001). CCI = 1 ( HR 1.20, 95% CI 0.99–1.45, p = 0.069) was not associated with worse OS than CCI = 0. CCI = 2+ ( HR 1.43, 95% CI 1.05–1.96, p = 0.025) was associated with worse OS than CCI = 0. Conclusions: In a cohort of adult patients with SNSCC undergoing surgery, higher CCI was independently associated with worse OS . These findings support the use of CCI as a predictor of postoperative outcomes in SNSCC patients. Future studies should explore how comorbidity burden interacts with frailty and other prognostic factors to refine risk stratification tools. Level of Evidence: 4

Parapharyngeal follicular dendritic cell sarcoma (FDCS) is rare and may occur with Castleman disease. We describe the successful transoral robotic resection of a parapharyngeal FDCS associated with Castleman disease, highlighting the role of the robotic approach in achieving tissue diagnosis and definitive treatment.