OBJECTIVE:Nasal bone fractures are the most common facial bone fractures. However, there is limited literature on the etiology of these fractures, particularly distribution across sports and other recreational activities.METHODS:The Nationwide Electronic Injury Surveillance System (NEISS) national injury database was queried for emergency department visits involving the diagnosis of nasal or nose fractures associated with sports and recreation activities over the most recent 10 year span available. Demographic, disposition, and weighted incidence were analyzed.RESULTS:Total incidence of nasal fractures across 10 years was 158 979. The mean age of nasal bone fractures was 20.4 years old. Nasal fractures were more common in males (74.6%) and white patients (54.1%). National estimated incidence of nasal fractures decreased from 21 028 in 2009 to 11 108 in 2018, a reduction of 47.2%. The most common causes among all patients were basketball (23.2%), baseball (17.1%), softball (9.8%), soccer (7.4%), and football (7%). In pediatric patients, the most common cause was baseball (25.1%). The majority (98.1%) of patients were discharged from the emergency department, while 0.9% of patients were admitted.CONCLUSION:The most common recreational causes of nasal fractures are sports, with the most common being non-contact sports like basketball and baseball. However, the incidence of nasal bone fractures due to recreational causes nationwide has decreased significantly over the past 10 years. This may reflect improved safety protocols among athletes.

Objectives: To estimate the incidence of emergency department visits for pediatric ear foreign bodies. To identify the most common items and their trends. Methods: The Nationwide Electronic Injury Surveillance System (NEISS) was queried for emergency department visits involving the diagnosis of foreign bodies in the ear including pinna and canal in children over the most recent 10-year span available. National incidence estimates and demographic data were extracted from the same database. Results: Ear foreign bodies in children made up an estimated total 446,819 ED visits nationwide over the past 10 years. The mean age was 7.2 +/- 4.3 years old. The majority (55.6%, n = 248,531) of cases were female. The most common class of objects found was jewelry, primarily embedded earrings and beads, accounting for 55.5% visits, followed by paper products at 7.1%, pens and pencils at 4.1%, desk supplies (erasers) at 3.7%, BBs or pellets at 3.5%, and earplugs and earphones at 3%. Females were significantly more likely to have jewelry foreign bodies, and males were significantly more likely to have foreign bodies from all other categories other than first-aid supplies. Conclusion: Foreign bodies of the ear are a common reason for emergency department visits in children, primarily jewelry, paper products, and desk supplies. Recognition of commonly encountered objects can aid in both speedier recognition of unknown objects, as well as guide patient counseling.\

OBJECTIVE:This case report aims to increase awareness of the diagnosis of laryngeal cleft in adult patients and discuss treatment options.METHODS:Case report and review of the literature.RESULTS:We present a case of a 56-year-old male referred for hoarseness and chronic cough that was discovered to have a type 2 laryngeal cleft. He had chronic aspiration, recurrent pneumonia, and a hoarse voice for his entire life. In contrast to most described cases in adults, this patient was successfully treated with an endoscopic approach using absorbable suture.CONCLUSION:Laryngeal clefts are uncommon and almost always detected in childhood, making adult laryngeal clefts extremely rare. Endoscopic repair is a feasible and successful treatment option in these cases.

Objective::Racial disparities have been well characterized and African American (AA) patients have 30% lower 5-year survival rates than European Americans (EAs) for head and neck squamous carcinoma (HNSCC). This poorer survival can be attributed to a myriad of different factors. The purpose of this study was to characterize AA-EA similarities and differences in sociodemographic, lifestyle, clinical, and psychosocial characteristics in HNSCC patients near the time of surgery.Methods::Setting: Single tertiary care center. Participants: Thirty-nine newly diagnosed, untreated HNSCC patients ( n= 24 EAs, n= 15 AAs) who were to undergo surgery were recruited. Study Design: Cross-sectional study Sociodemographic, lifestyle factors, and disease factors (cancer site, AJCC clinical and pathologic stage, and HPV status)were assessed. Risk factors, leisure time, quality of life and social support were also assessed using validated questionnaires. Exposures: EA and AA patients were similar in the majority of sociodemographic factors assessed. AAs had a higher trend toward pathologically later stage disease compared to EAs and significantly increased time to treatment. Results::EA and AA patients were similar in the majority of sociodemographic factors assessed. AAs had a higher trend toward pathologically later stage disease compared to EAs. AAs also had significantly increased time to treatment ( P= 0.05). The majority of AA patients (62%) had later stage pathologic disease. AA were less likely to complete high school or college ( P= 0.01) than their EA counterparts. Additionally, AAs were more likely to report having a gap in health insurance during the past decade (37% vs. 15%). Conclusions::This preliminary study demonstrates a similar profile of demographics, clinical and psychosocial characteristics preoperatively for AAs and EAs. Key differences were AAs tending to have later pathologic stage disease, educational status, delays in treatment initiation, and gaps in health insurance.

Objectives: Changes in airflow dynamics after nasal surgery may have implications on voice quality. Multiple studies have evaluated the impact of nasal surgery on voice using heterogeneous outcome measures. We aim to systematically review the impact of nasal surgery on voice quality. Methods: Our study design was a systematic review with meta-analyses. A literature search of PubMed, Ovid, Cochrane from 1997 to 2017 was performed. Inclusion criteria included English language studies containing original data on nasal surgery and voice. Two investigators independently reviewed all manuscripts and performed a comprehensive quality assessment. Meta-analysis was completed on quantitative voice measurements. Results: Of 463 identified, 19 studies with 692 patients fulfilled eligibility. Nasal surgeries performed included endoscopic sinus surgery (11/20), septoplasty (11/20), rhinoplasty (2/20), and turbinate reduction (2/20). Voice outcomes measured included nasalance (8/20), fundamental frequency (11/20), jitter (10/20), shimmer (10/20), harmonic to noise ratio (HRN) (8/20), formants (5/20), and voice handicap index (VHI) (4/20). Voice examinations were assessed preoperatively and 1 to 30 months postoperatively. Meta-analysis revealed statistically significant changes in nasalance, (P < .01) 1 month postoperatively; there was no significant difference in nasalance at 6 months postoperatively. All other variables analyzed revealed no statistically significant differences. Five of nine studies showed majority of patients did not notice subjective change in voice after surgery, but with high heterogeneity of measurements. Conclusions: There may be a short-term increase in nasalance that resolves at longer follow-up, but there seem to be no other objective changes in voice. There may be subjective changes after surgery, but require further study to evaluate.

OBJECTIVES:To examine the national rates of complications, readmission, reoperation, death and length of hospital stay after laryngectomy. To explore the risks of neck dissection with laryngectomy using outcomes.METHODS:The American College of Surgeons National Quality Improvement Program (ACS-NSQIP) database was reviewed retrospectively. The database was analyzed for patients undergoing laryngectomy with and without neck dissection. Demographic, perioperative complication, reoperation, readmission, and death variables were analyzed.RESULTS:754 patients who underwent total laryngectomy during this time were found. Demographic analysis showed average age was 63 years old, 566 (75.1%) were white, and 598 (79.3%) were male. Of these patients, 520 (69.0%) included a neck dissection while 234 (31.0%) did not. When comparing patients who received a neck dissection to those who did not, there were no significant differences in median length of hospital stay (12.5 days w/vs. 13.3 days w/o, P = 0.99), rates of complication (40% w/vs. 35% w/o, P = 0.23), reoperation (13.5% w/vs. 14% w/o, P = 0.81), readmission (14% w/vs. 18% w/o, P = 0.27), and death (1.3% w/vs. 1.3% w/o, P > 0.99). Furthermore, neck dissection did not increase the risk of complication (P = 0.23), readmission (P = 0.27), reoperation (P = 0.81), death (P = 0.94), or lengthened hospital stay (P = 0.38).CONCLUSIONS:Concurrent neck dissection does not increase postoperative morbidity or mortality in patients undergoing total laryngectomies. These results may help physicians make decisions regarding concurrent neck dissection with total laryngectomy.

Background American Academy of Otolaryngology-Head and Neck Surgery rhinosinusitis guidelines have been adapted into quality measures intended to be a basis for adjusting physician reimbursement and as public information to help patients select physicians. Early and continual evaluation of these measures is therefore important, given the impacts these may have. Objective To examine the metrics used in by Medicare for reimbursement in the Physician Quality Reporting System (PQRS) used in Merit-based Incentive Payment System (MIPS). Methods This study is a retrospective review of the 2015–2016 Center for Medicare and Medicaid Services Physician Compare Initiative regarding quality metrics for acute and chronic rhinosinusitis for providers participating in MIPS. Results Data for 726 providers were extracted from the PQRS database. Otolaryngologists had a low enrollment with less than 50 responding for any 1 measure. Of the reported quality metrics, otolaryngologists prescribed a significantly greater number of antibiotics than other providers within 7 days of diagnosis or within 10 days after symptom onset (48.3% vs 11.3%, P < .001). There was a significant difference in the mean compliance between otolaryngologists and all other providers for the use of CT scans within 28 days of diagnosis (2.3% vs 0.2%, P < .001). There was no significant difference in the mean compliance for the use of multiple CT scans within 90 days of diagnosis (2.0% vs 2.3%, P = .8). Inverse metrics comprise 3 out of 4 measures. Conclusion This review of the quality metrics used in MIPS shows several differences between otolaryngologists and nonspecialists, but raise concerns regarding applicability.

Background Chronic rhinosinusitis (CRS) is a prevalent illness in the United States that accounts for 18–22 million physician visits annually. The American Academy of Otolaryngology–Head and Neck Surgery (AAO‐HNS) has defined diagnostic criteria, but a recent study demonstrated that nearly all patients diagnosed by nonspecialists did not meet these criteria. In this study we aimed to evaluate the diagnostic rate of CRS by primary care physicians and otolaryngologists. Methods We retrospectively reviewed a random sample of adult patients diagnosed with CRS in 2016, based on ICD‐10 codes from primary care and otolaryngology departments. Patients with previous CRS diagnosis, previous sinus surgery, and related comorbidities were excluded. Results A total of 502 patients with a new CRS diagnosis were analyzed (308 from primary care, 194 from otolaryngology). The percentage of diagnoses meeting the criteria was significantly higher from otolaryngology (28.9% vs 0.97%, p < 0.0001), but was low in both cohorts. Symptom duration <12 weeks was higher in primary care (81.6% vs 53.6%, p < 0.0001), as was lack of evidence of inflammation (97.4% vs 50.0%, p < 0.0001). Having <2 of the required symptoms was significantly higher in otolaryngology (63.8% vs 50.8%, p = 0.013). The most commonly unevaluated symptom was decreased sense of smell (97.7% in primary care, 69.1% in otolaryngology encounters). Conclusion CRS diagnoses commonly do not meet the diagnostic criteria outlined by the AAO‐HNS in both primary care and otolaryngology. As a specialty, we should aim to improve our adherence to the guidelines and educate our primary care colleagues to better identify patients with CRS and initiate appropriate treatment.

INTRODUCTION:Acute invasive fungal rhinosinusitis (AIFRS) is a potentially fatal infection, usually affecting immunocompromised patients. Isolated sphenoid sinus involvement is rare and has been reported in only a few cases. We discuss the clinical characteristics, histopathologic features, and differential diagnosis of AIFRS of the sphenoid sinus.CASE PRESENTATION:A 57-year-old man with a history of refractory non-Hodgkin lymphoma and neutropenia presented with a 1-week duration of left-sided headache and ipsilateral cheek paresthesia. Nasal endoscopy showed mucoid drainage from the sphenoethmoidal recess. Magnetic resonance imaging demonstrated left sphenoid mucosal thickening and enhancement along the adjacent skull base. The patient underwent endoscopic sinus surgery with extended sphenoidotomy and débridement. The lateral wall and recess of the left sphenoid sinus demonstrated pale mucosa and fungal debris. Pathologic analysis demonstrated necrotic tissue and fungal hyphae with angioinvasion. Microbiology studies isolated Aspergillus fumigatus. The right maxillary sinus contained a synchronous fungal ball, which was removed during surgery; there was no evidence of tissue necrosis or invasive fungus in the maxillary sinus. He was treated with long-term voriconazole therapy, and 6-month follow-up showed disease resolution.DISCUSSION:AIFRS should be considered in the differential diagnosis of immunocompromised patients with nonspecific sinonasal symptoms. Usually, AIFRS is diffuse with multiple sinus involvement; however, isolated sphenoid AIFRS can occur. This is one of the few cases of AIFRS demonstrating isolated sphenoid involvement and is thought to be the first case showing a synchronous noninvasive fungal ball of another sinus cavity. Prompt recognition and surgical treatment may be curative and lifesaving.

Objectives (1) Determine the rate of postoperative complications, reoperation, readmission, and death after uvulopalatopharyngoplasty (UPPP) for sleep apnea through multi-institutional clinical data. (2) Compare outcomes of UPPP between multilevel and single-level procedures for the treatment of sleep apnea. Study Design Retrospective database analysis. Methods The American College of Surgeons National Surgical Quality Improvement Program—a nationally validated, prospective, multi-institutional database from 2005 to 2013—was analyzed for patients who underwent UPPP, per corresponding Current Procedural Terminology codes. Patients were categorized into 3 groups: UPPP alone, UPPP + nasal cavity (NC), and UPPP + base of tongue (BOT). Perioperative outcome measures of interest include surgical/medical complications, reoperation, readmission, and death. Comparisons were made among surgical groups through univariate cross-sectional analysis. Results A total of 1079 patients underwent UPPP; 413 patients had UPPP + NC; and 200 patients had UPPP + BOT procedures. One death was reported for the entire cohort of patients. Among all 3 groups (UPPP, UPPP + NC, and UPPP + BOT), no differences were noted in the rates of medical complications (P = .445), surgical complications (P = .396), reoperation (P = .332), and readmission (P = .447). However, the length of hospital stay in days was greatest for the UPPP + BOT group (UPPP, 0.81 ± 0.69; UPPP + NC, 0.87 ± 0.90; UPPP + BOT, 1.50 ± 2.70; P < .001). Conclusion These national data demonstrate no significant increase in risk when UPPP is performed as a single- or multilevel procedure. When indicated, UPPP with multilevel procedures may be safely performed for treatment of sleep apnea. These data set a benchmark for perioperative risk in UPPP surgery and will prove useful for counseling patients.

Objectives/HypothesisTo determine the effect of surgeon experience with an upper airway stimulation (UAS) system on surgical time and complication rates.Study DesignRetrospective review.MethodsSurgical procedure times and complication rates observed in patients implanted at 22 study centers as part of a phase III, multicenter surgical trial of upper airway nerve stimulation therapy for obstructive sleep apnea were reviewed.ResultsThe study included 126 subjects who were predominantly male (83%), with a mean age of 54.5 years (range=31-80 years), and the mean body mass index was 28.42.6. There were an average of 5.7 (range=1-22) surgical implants per site, with an average surgical time of 2.520.98 hours (range=1.08-6.0 hours). The surgical implant time decreased significantly with surgeon experience, from 2.98 +/- 1.18 hours for a surgeon's first implant (n=22) to 2.08 +/- 0.55 hours for the fifth implant (n=10, P=.025). Surgical time was inversely correlated with the site implant number (rho=-0.334, P<.001). Procedure-specific complications were uncommon and self-limited and did not decrease appreciably with increasing experience.ConclusionsSurgical time for implantation of the UAS system decreased significantly after the first five implants and then stabilized. The rate of surgical complications did not decrease with surgeon experience, although this may be attributable to the low overall rate of serious surgical complications and low number of implants at some centers.

OBJECTIVE:(1) Determine if patients with anterior fossa spontaneous cerebrospinal fluid (SCSF) leaks demonstrate lateral skull base bone attenuation. (2) Examine the relation between body mass index (BMI; kg/m(2)) and skull base thickness.STUDY DESIGN:Retrospective cohort study.SETTING:Tertiary care hospital.SUBJECTS AND METHODS:Retrospective review from 2004 to 2013 identified 96 patients with anterior cranial fossa SCSF leaks. A control group was identified from a consecutive series of clinic patients. Controls had no history of chronic sinonasal or temporal bone pathology and were divided according to BMI into nonobese (<30 kg/m(2)) and obese (≥30 kg/m(2)) groups. Composite skull base thickness was calculated for lateral and anterior subsites through predefined points according to previously published protocols.RESULTS:Thirty-two patients were included in each group. Composite lateral skull base thickness was less in patients with SCSF leaks(0.7 ± 0.1 mm) when compared with nonobese controls (0.8 ± 0.1 mm, P = .004); no differences were apparent when SCSF leaks were compared with obese controls (0.7 ± 0.1 mm, P = .99). A direct relation was observed between anterior skull base and lateral skull base thickness (r = 0.48, P < .0001). An inverse correlation was noted between BMI and lateral skull base (r =-0.40, P < .0001).CONCLUSIONS:Patients with anterior fossa SCSF leaks demonstrate attenuation of the lateral skull base. A significant correlation between anterior skull base thickness and lateral skull base thickness was observed. BMI was inversely related to lateral skull base thickness. Taken together, SCSF leaks are associated with obesity, which appears to be partly responsible for diffuse skull base erosion observed in patients with this condition.

OBJECTIVES:(1) Identify all cases of myoepithelial carcinoma of the major salivary glands from the National Cancer Data Base (NCDB). (2) Analyze the effect of grade, stage, and regional nodal metastasis on survival in myoepithelial carcinoma of the major salivary glands.STUDY DESIGN:Retrospective review of NCDB.SETTING:Multicenter data pooled from 1998 to 2012 in the NCDB.METHODS:We identified all reported cases of myoepithelial carcinomas of the major salivary glands from the United States from 1998 to 2012 in the NCDB. Clinical parameters were then examined and analyzed for predictors of survival.RESULTS:A total of 473 cases of myoepithelial carcinoma were identified. Of the reported cases, 38.1% were low grade; 26.7%, intermediate grade; and 35.2%, high grade. When presenting stage was examined, 24.4% were stage I; 30.6%, stage II; 22.5%, stage III; 12.2%, stage IVa; 3.0%, stage IVb; and 4.1%, stage IVc. At presentation, 18.7% of patients had regional nodal disease, and 4.5% had distant metastases. The 3- and 5-year survival rates were 73% and 64%, respectively. The presence of nodal disease significantly reduced mean survival time versus those without (64 vs 108 months, P < .001), as did high-grade disease compared with low grade (67 vs 114 months, P < .001) and stage III/IV compared with stage I/II disease (61 vs 118 months, P < .001).CONCLUSIONS:The presence of regional nodal disease, high-grade disease, and advanced stage are predictors of lower survival in myoepithelial carcinoma. Further studies based on types of treatment are warranted.

Treatment recommendations for head and neck cancers have evolved over the last several decades, with a particularly clear shift in 2004 toward use of chemotherapy in late-stage patients. This study examines the national trends in treatment combinations for patients with stage IV oral cavity and pharyngeal cancer between 1998 and 2012 using the National Cancer Data Base (NCDB). Our analysis demonstrates that chemotherapy was widely integrated into the treatment plans for this population following 2004, confirming that recommendations were successfully translated into practice. Stage IV patients treated after this shift in treatment experienced higher 5-year survival rates compared to patients treated prior to the adoption of increased chemotherapy usage. We also examined the patient population for other changes over time and found that smaller primary tumors became more common and that 2 primary sites (base of tongue and tonsil) came to represent a larger percentage of the patient population; these changes may also contribute to a rising survival rate. Patients receiving the recommended trimodal therapy of surgery, radiation, and chemotherapy were found to be more geographically widespread over time, suggesting a penetrance of the recommendations into the medical system across the country.

BACKGROUND:Both obesity and chronic rhinosinusitis (CRS) are characterized by inflammation. Furthermore, both disease processes are independently associated with decreases in quality-of-life (QOL). We sought to investigate the role of comorbid obesity in QOL outcomes in CRS patients undergoing endoscopic sinus surgery (ESS).METHODS:Adult patients with medically refractory CRS (n = 241) were prospectively enrolled into a multi-institutional treatment outcomes investigation. Body mass index (BMI) calculations were used to differentiate patient weight groups (normal weight: 18.5 to 24.9, overweight: 25.0 to 29.9; and obese: ≥30.0). Preoperative and postoperative QOL (Rhinosinusitis Disability Index [RSDI] and the 22-item Sino-Nasal Outcome Test [SNOT-22]) were evaluated compared across BMI groups and obesity subclasses.RESULTS:The prevalence of comorbid obesity was 41% (n = 99). Higher prevalence of comorbid disease was found across increasing BMI groups including diabetes mellitus, asthma, and depression. No significant differences were found in mean preoperative QOL measures between any BMI groups. Significant improvement between preoperative and postoperative QOL mean scores (p ≤ 0.050) was found for all BMI groups. Despite no significant difference in mean QOL improvement between BMI groups (p ≥ 0.142), overweight and obese patients reported reduced relative mean percentage (%) improvement compared to normal weight participants on the RSDI total score (33% and 37% vs 55%, respectively) and SNOT-22 total score (29% and 40% vs 48%, respectively).CONCLUSION:Patients with comorbid obesity experience significant improvement in average QOL gains following ESS though the percentage of relative improvement in QOL may be decreased in patients with comorbid obesity and CRS as compared to those without.

Objective (1) To identify predictors of nodal disease in parotid malignancies using various clinical and pathologic variables. (2) To examine the effect of nodal disease on overall survival (OS) in parotid cancersStudy Design Retrospective database review.Setting National Cancer Data Base (1998-2012).Subjects and Methods We identified all cases of primary parotid malignancies in the United States between 1998 and 2012 in the National Cancer Data Base. Eight histopathologies, constituting >80% of all cases, were examined for nodal metastasis and survival.Results We identified 22,653 cases of primary parotid cancer. Eight major histologies were studied, with mucoepidermoid carcinoma (31%), acinic cell carcinoma (18%), adenocarcinoma (14%), and adenoid cystic carcinoma (9%) being most common. Regional nodal disease incidence was 24.4% overall and varied by histopathology. Salivary ductal carcinoma had the highest incidence of both nodal metastasis and occult lymph node metastasis. Overall, N0 patients lived significantly longer than N+ (5-year OS, 79% vs 40%; P < .001). Low-grade disease had significantly better survival than high-grade (5-year OS, 88% vs 69%; P < .001). Occult nodal disease was found in 10.2% and varied by histopathology.Conclusion Regional lymph node metastasis significantly decreases survival in many parotid malignancies. High-grade cancers had higher incidences of regional disease than did low grade. Adenocarcinoma had the highest mortality when regional disease was present. Incidence of occult disease varied by histology, but incidence was <10% for all low-grade disease. High T stage and grade are significant independent predictors of nodal disease for most histopathologies.

Objective. Radiation-induced xerostomia is one of the most common morbidities of radiation therapy in patients with head and neck cancer. However, in spite of its high rate of occurrence, there are few effective therapies available for its management. The aim of this study was to assess the efficacy of hyperbaric oxygen on the treatment of radiation-induced xerostomia and xerostomia-related quality of life.Study Design. PubMed, Google Scholar, and the Cochrane Library were searched for retrospective or prospective trials assessing subjective xerostomia, objective xerostomia, or xerostomia-related quality of life. To be included, patients had to have received radiation therapy for head and neck cancer, but not hyperbaric oxygen therapy (HBOT).Results. The systematic review initially identified 293 potential articles. Seven studies, comprising 246 patients, qualified for inclusion. Of the included studies, 6 of 7 were prospective in nature, and 1 was a retrospective study; and 2 of the 7 were controlled studies.Conclusions. HBOT may have utility for treating radiation-induced xerostomia refractory to other therapies. Additionally, HBOT may induce long-term improvement in subjective assessments of xerostomia, whereas other therapies currently available only provide short-term relief. The strength of these conclusions is limited by the lack of randomized controlled clinical trials.

The face of head and neck cancer has changed dramatically over the past 30 years. There has been a steady decline in the number of tobacco and alcohol related squamous cell carcinomas over the past 30 years, but and increasing incidence of human papillomavirus (HPV) related cancers. Some estimates suggest that 70-90% of new oropharyngeal cancers have evidence of HPV. These patients have different demographic patterns, in that they are more likely to be younger, white adults in their 40s and 50s who are never smokers or have reduced tobacco exposure. Studies have shown that a higher number of lifetime oral sex partners (>5) and a higher number of lifetime vaginal sex partners (>25) have been associated with increased risk of HPV positive head and neck cancer. People can also reduce their risk of HPV linked head and neck cancer by receiving the HPV vaccine series prior to becoming sexually active. Recent evidence suggests HPV related head and neck cancers present with different symptoms than those caused by tobacco. The most popular test for HPV status is the p16 immunohistochemical stain because it is cheap, simple, and studies have shown it to have comparable sensitivity and specificity to the previous standards. It is widely recommended that all cancers of the oropharynx be tested for the presence of HPV, and some recommend it for all head and neck cancers. Overall 2-year and 5-year survival for HPV positive head and neck cancer is significantly greater than for HPV negative cancers, likely due to HPV positive cancers being more responsive to treatment.