Background, For tumors that express somatostatin receptors (SSTR), radiolabeled somatostatin analogs, such as In-111-pentetreotide, can demonstrate the presence of tumor by radioligand uptake using somatostatin receptor scintigraphy (SRS). The use of In-111-pentetreotide for SRS depends on the specific high affinity of octreotide for SSTR subtypes 2, 3, and 5. Of these, SSTR2 has the greatest affinity for octreotide and the greatest relevance for tumor detection with Octreoscan imaging. Discriminating between postoperative changes and residual or recurrent tumor after extensive skull base surgery is often difficult, but in a case of recurrent esthesioneuroblastoma (ENB) we found the use of Octreoscan imaging clinically useful. To better define the general relevance of this imaging technique in this setting, we analyzed SSTR subtype expression in a panel of ENB; tumors.Methods. The case history and correlations between MRI and In-111-pentetreotide SRS of a patient with recurrent ENB were reviewed. The expression pattern of the SSTR subtypes in a panel of ENB tumors was then analyzed by reverse transcriptase-polymerase chain reaction (RT-PCR) to better define the potential of more general use of Octreoscan for imaging ENB. To correlate SSTR2 protein expression with In-111-pentetreotide uptake, immunohistochemistry to detect SSTR2 was performed on tumor samples from regions of increased uptake on Octreoscan.Results. The SSTR2 message was expressed at high levels in all five ENB tumor samples, and either SSTR2 protein or histologic findings typical for ENB were found in all tumor tissue obtained from regions of increased In-111-pentetreotide uptake. Furthermore, Octreoscan imaging in this case proved useful in clinical decision making.Conclusion. The expression pattern of SSTR2 and the specificity of the Octreoscan for regions of active tumor growth support further investigation of the utility of Octreoscan imaging in the diagnosis and surveillance of ENB. Recent advances in novel therapies based on SSTR ligand binding also provide the rationale to consider such novel therapeutic approaches in patients with ENB. (c) 2006 Wiley Periodicals, Inc.

Background: Depression is an important predictor of post therapy quality of life (QOL) in head and neck (H&N) cancer patients. In addition, depression rates may vary among cultures. Objective: As part of a larger cross cultural study on post therapy QOL differences in H&N cancer patients, the goal of this project was to translate a well-validated English language depression scale into Swahili, and then validate this scale in Kenyan H&N cancer patients. Methods, Settings and Subjects: In Part 1 of the study, we translated the Patient Health Questionnaire-9 (PHQ-9) into Swahili, adhering to established International Quality of Life Association (IQOLA) guidelines. In Part 2, we psychometrically validated the newly translated scale using a prospective study of 48 patients at the Kenyatta National Hospital ENT clinic in Nairobi, Kenya. Results: The Swahili PHQ-9 had good test retest reliability (Intraclass correlation coefficient, 0.71) and internal consistency (Cronbach's alpha=0.80). It also had good construct validity, as scores correlated strongly with TNM stage (Chi square=123, p < 0.05), and with the composite and global scores of an H&N cancer specific QOL scale (UW-QOL, r = −0.87, p < 0.05). Conclusion: The Swahili version of the PHQ-9 is a reliable scale in Kenyan H&N cancer patients, and is a valuable tool in screening for and monitoring of depression as a function of QOL in this population.

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BACKGROUND: Psychiatric disorders are associated with increased symptom burden when combined with chronic medical conditions. However, there are no reports of how psychiatric distress influences outcomes with surgical treatment for chronic rhinosinusitis (CRS). We hypothesized that subjects with psychiatric distress (somatization, anxiety, and depression) would report more severe long-term sinus symptoms and worse quality of life (QOL) than subjects without psychiatric distress.METHODS: This is a community-based, prospective, observational cohort study of patients diagnosed with CRS presenting for surgery. Patients were interviewed before surgery; CT scans were reviewed, and questionnaires were completed about sinusitis-related symptoms (SNOT-16), general health status and QOL (SF-36), and psychiatric distress (BSI and PHQ). Outcomes were also assessed 1, 3, 6, and 12 months postoperatively.RESULTS: Ninety-five patients had complete records for analysis. Psychiatric distress was prevalent, with 31% screening positive for somatization, 17% positive for anxiety, and 25% positive for depressive disorders. Subjects with somatization had significantly worse SNOT-16 scores at each time point compared with those without somatization (P < 0.05). Subjects with depression reported more severe symptoms at 6 and 12 months after surgery than those without depression (P < 0.05). The presence of somatization preoperatively was also independently associated with worse symptom severity 12-months after surgery, even after adjusting for prior sinus surgery, CT stage, Charlson Index, and deviated septum. In addition, subjects with psychiatric distress reported significantly worse SF-36 physical and mental component summary scores 12-months after surgery than subjects without psychiatric distress.CONCLUSIONS: Psychiatric distress is associated with worse reported sinus symptoms and lower QOL throughout surgical management of chronic rhinosinusitis. Despite this, subjects with psychiatric distress report a similar degree of improvement in sinus symptoms after surgery compared with those without distress.CLINICAL SIGNIFICANCE: Psychiatric distress should be considered in patients with persistent symptoms after surgery. Psychiatric distress should also be considered in efforts to design a chronic sinusitis staging system.

OBJECTIVESTo determine the impact of sinus computed tomography (CT) on treatment decisions by otolaryngologists and to explore the factors leading to choice of surgical treatment for patients suspected of having chronic sinusitis.DESIGNProspective cohort study.SETTINGA tertiary academic medical center.PATIENTSQuestionnaires were administered to 3 otolaryngologists in a tertiary academic institution regarding diagnosis and treatment decisions in 27 patients suspected of having chronic sinusitis, before and after they reviewed sinus CT scans.MAIN OUTCOME MEASURESThe dichotomous decisions regarding surgical or nonsurgical treatment and the agreement of treatment decisions among surgeons were evaluated. The factors strongly influencing surgeons' treatment decisions regarding patients selected for surgery were also determined.RESULTSThe dichotomous treatment decisions were changed in one third of patients (9 of 27) after the sinus CT scans were reviewed. The agreement of treatment decisions among the 3 surgeons was markedly improved after they reviewed sinus CT scans. The factors favorably influencing surgical treatment were obstruction of the ostiomeatal complex on CT and concordance of CT abnormality with a patient's symptoms. Lund-Mackay stage, symptoms, and corticosteroid or antibiotic use were not significant predictors.CONCLUSIONSDespite the common belief that treatment decisions for chronic sinusitis should be solely based on clinical grounds, with sinus CT providing only anatomic detail before surgery, our study indicates that the decision to perform surgery was altered by CT in a substantial portion of the patients. In our preliminary study, CT increased the tendency to elect surgical treatment by all 3 surgeons.

Purpose/Objective: The purpose of this study was to determine if radiation therapy (XRT), given either preoperatively or postoperatively, has any effect on the rate and/or severity of postoperative complications in patients who undergo microvascular free flap reconstruction after surgical resection for cancers of the head and neck. Materials/Methods: We retrospectively reviewed 100 consecutive patients treated between 1995 and 2002 at the University of Washington Medical Center; all of the patients underwent mandibular reconstruction with a fibular microvascular free tissue transfer. Seventy-two patients had squamous carcinoma of the head and neck (62 of the oral cavity), and 13 patients had other malignancies, including adenoid cystic carcinoma, acinic cell carcinoma, and osteogenic sarcoma. Fifteen patients had benign disease; the most common indication for a fibular free flap for reconstruction was trauma. The study cohort was examined as three radiotherapy subgroups: 1) no radiation therapy (28 patients), 2) preoperative XRT (37 patients), and 3) postoperative XRT (35 patients). The median radiation dose was 6,840 cGy (range 5,040–7,700 cGy). 11 patients received systemic therapy (2 in the no XRT group, 5 in the preop XRT group, and 4 in the postop XRT group). Postoperative complications were categorized according to severity: 1) mild sequelae not requiring surgical intervention (typically dehiscence which resolved with wound care), 2) moderate sequelae requiring reoperation (severe dehiscence, exposed bone/graft, orocutaneous fistula, acute thrombus), or 3) flap loss (either partial or complete). Formal statistical comparison of complication rates for the different subgroups, as well as associations between other surgical risk factors and complication rates, was performed using chi-square analysis. Results: Of the 100 patients, 54 patients (54%) had at least one complication. No complete flap losses were observed in this study. There were no differences among the three radiotherapy subgroups in the incidence of overall complications (15/28 patients (54%) in the no XRT group, 24/37 patients (65%) in the preop XRT group, and 15/35 patients (43%) in the postop XRT group, p=0.17). There were no statistical differences in the incidence of mild (21%, 40%, and 20% respectively, p=0.09) or moderate (25%, 16%, and 20% respectively, p=0.63) complications, or partial flap loss (7.1%, 8.1%, and 5.7% respectively, p=0.92). We observed no statistical correlations between the rate/severity of post-operative complications and the following factors: total radiation dose, size of the radiation field, systemic therapy, type of anastamoses, presence of serious medical co-morbidities, or tobacco use. Conclusions: This retrospective review of our institutional experience suggests that radiation therapy does not predispose patients to more frequent or severe surgical complications following microvascular free flap reconstructive surgery. The growing use of free tissue transfer techniques and aggressive adjuvant radiotherapy (with or without chemotherapy) for high-risk head and neck cancer strongly argues for continued study of this issue.

INTRODUCTION:Limited information is available regarding surveillance patterns after head and neck cancer radiotherapy. We cataloged follow-up for a specified patient cohort treated at three neighboring university, community, and Veterans Administration institutions. METHODS:One hundred fifteen patients were treated with curative intent between 1994-1998 with definitive or postoperative radiotherapy for newly diagnosed squamous cell carcinoma of the oral cavity, oropharynx, larynx, or hypopharynx. One hundred patients had continuous follow-up at their treating institution and were included for analysis. Median follow-up until disease recurrence or censorship was 28.5 months. RESULTS:Median follow-up frequency was 5.7 visits/year and was highly variable. Although visit frequency correlated with disease stage and the presence of high-risk disease features, this association was lost when patients with early recurrences were removed from analysis. Procedure and test utilization closely mirrored visit frequency, resulting in a wide range of estimated yearly charges (0-15,668 dollars/year; median, 1,772 dollars/year). Actuarial 3-year overall survival for the study group was 71%. Eighty-six percent (19 of 22) of potentially salvageable locoregional failures were discovered secondary to symptomatic complaint rather than by test results. Disease failure, whether detected by symptom or testing, predicted for poor survival (22% at 24 months after recurrence). CONCLUSIONS:Postradiotherapy surveillance for head and neck cancer is inconsistently pursued. A proven correlation between intensive follow-up and improved patient survival is lacking. Surveillance directed by patient symptoms should be investigated as an alternative approach.

BACKGROUND:Patients with significant medical problems requiring major otolaryngology procedures are at high risk for both medical and surgical complications.OBJECTIVE:To identify risk factors associated with perioperative complications in medically compromised patients undergoing major otolaryngology procedures.METHODS:Ninety-three consecutive patients with significant comorbid medical illnesses (eg, diabetes, hypertension) undergoing major head and neck surgical procedures were referred to a medical consultation center for preoperative assessment and medical management. Patient and surgical characteristics as well as perioperative complications were identified and recorded. Univariate and multivariate analyses were performed to determine which characteristics were associated with complications.RESULTS:Thirty-two patients (34%) had postoperative complications. Twenty-six patients (28%) had serious medical complications, and 18 (19%) had surgical complications. No deaths occurred in the study population. On univariate analysis, the factors associated with all complications included history of hepatitis, flap reconstruction, oncologic surgery, preoperative radiation therapy, preoperative gastrostomy placement, intraoperative transfusion, anesthesia time (> or =8 hours), and those with greater intraoperative fluid replacement and estimated blood losses. Only anesthesia time (> or =8 hours) remained independently significant on multivariate analysis. A history of hepatitis and prolonged anesthesia time were the only independent predictors of medical complications. The only independent predictor of surgical complications was the volume of intraoperative fluid administered.CONCLUSIONS:Prolonged anesthesia times of 8 hours or more, a history of hepatitis, and large-volume intraoperative fluid resuscitations predicted adverse outcomes. Special care must be taken in counseling these patients preoperatively and in caring for them during their operative and postoperative course.

BACKGROUND:Currently, the classification of oral squamous cell carcinoma (OSCC) depends heavily on the clinical and pathologic examination of tissue. This system can lead to the classification of potentially heterogeneous tumors into single groups when they may have different degrees of aggressiveness. No system to date has incorporated genetic changes as a factor by which to classify OSCC tumors. METHODS:To test the hypothesis that OSCC has a genome-wide genetic expression profile that differs from normal oral tissue and that transcriptional expression profiling can be used to characterize the heterogeneity among tumors, the authors examined the genetic expression profiles of 26 invasive squamous cell carcinomas of the oral cavity and oropharynx, 2 premalignant lesions, and 18 normal oral tissue samples using oligonucleotide arrays that contained probes representing approximately 7000 full-length human genes. RESULTS:Using hierarchical clustering analysis, the data show that oral carcinomas are distinguishable from normal oral tissue based on genome-wide transcriptional expression patterns. However, there is genetic expression profile heterogeneity among tumors of a particular histopathologic grade and stage. In addition, using a statistical approach that integrated normalization and regression analysis, the authors found 314 genes that were expressed differentially in the OSCC samples with statistical significance (P <or= 0.05). Of these, 239 genes were overexpressed in the OSCC samples, whereas 75 genes were down-regulated. CONCLUSIONS:No statistically significant differences in gene expression were found between early-stage disease and late-stage disease or between metastatic tumors and nonmetastatic tumors. The implications of these findings for the prediction of clinical outcome and for the discovery of new OSCC tumor markers are discussed.

In 1999, Drs Robbins and Shaha 1 delivered the inaugural presidential lectures, which highlighted the traditions and history of our 2 founding societies. Last year, President Medina 2 drew our attention to some formidablechallenges with respect to workforce, the direct consequences of poor reimbursement, and the potential that we might lose our impact on head and neck disease if we fall prey to "tragic optimism." These concerns were recently echoed by Academy President Jack Gluckman, 3 who identified head and neck surgery as a "specialty in crisis."

\Background. There are numerous head and neck specific quality of life questionnaires, each having its own merits and disadvantages. The University of Washington questionnaire has been widely used and is notable by the inclusion of a shoulder dysfunction domain, domain importance ratings, and patient free text. It is short, simple to process, and provides clinically relevant information. However, it has lacked any psychological dimension of quality of life. The aim of this study was to report the inclusion of two psychological domains (mood, anxiety) to the most recent refinement of the questionnaire (version 3).Method. A cross-sectional survey was performed in April 2000. Questionnaires were sent to 183 patients alive and disease free after surgery for oral and oro-pharyngeal malignancy. Replies were received from 145 patients (79% response rate).Results. The new domains (mood and anxiety) correlated significantly with the emotional functioning domains from the EORTC C30 and with the pain and appearance domains of UW-QOL. There were also significant correlations between the "global quality of life" item and the two new domains. Mood (p = .005) and anxiety (p < .001) scores were associated with patient age but with no other clinicodemographic variable.Conclusion. The addition of mood and anxiety domains makes the UW-QOL version 4 a single broad measure suitable for effective health-related quality of life evaluation in the routine clinical setting. (C) 2002 Wiley Periodicals, Inc.

OBJECTIVE Our goal was to measure the impact of chronic rhinosinusitis (CRS) on the use and cost of health care by adults in a health maintenance organization (HMO). SETTING AND SUBJECTS In the setting of the Group Health Cooperative, an HMO in Washington State, we conducted a study of all 218,587 adults (≥18 years) who used services during 1994. Using automated data, 20,175 adults were identified with one or more CRS diagnoses during 1994. OUTCOME MEASURES We identified nonurgent outpatient visits, pharmacy fills, urgent visits, hospital days, and their associated costs (per adult per year). RESULTS The marginal utilization associated with a diagnosis of CRS was 2.0 nonurgent outpatient visits, 5.1 pharmacy fills, 0.01 urgent visit, and −0.07 hospital day. The marginal total cost of CRS was $206. CONCLUSIONS Adults with CRS had higher costs primarily because of increased nonurgent outpatient visit and pharmacy fill utilization. The overall direct cost of CRS in the United States in 1994 is estimated to have been $4.3 billion.

BACKGROUNDDuring a 5-year period, we analyzed 3 patient subsets from the University of Washington Quality of Life (UW-QOL) Registry and published the results. In each instance, editorial review has raised legitimate concerns regarding the UW-QOL instrument that deserve public comment. We present our response to these criticisms. Since our original publication (1993), we have added domains to the original UW-QOL instrument. These additions reflected our concern that we might be missing important elements in the spectrum of disease-specific response to treatment. Using the data we have accumulated in the last 5 years, we present an analysis of the internal consistency of the UW-QOL. We have identified those domains that are responsive (or not responsive) to treatment effect and have revised the UW-QOL accordingly to create the UW-QOL-R, which is recommended for future use.DESIGNThe project began January 1, 1993, after approval by the UW Human Subjects Committee. Critical comments offered by external review were collated and responded to. Internal consistency was evaluated by interitem correlation matrix (Cronbach alpha) testing.SUBJECTSAll new patients presenting to the UW Medical Center (Seattle) with a diagnosis of head and neck cancer were asked to participate in a prospective analysis of QOL changes during and after treatment.INTERVENTIONPatients completed the pretreatment QOL questionnaire on the day of their initial workup. The format for the pretreatment test was an interviewer-supervised self-administered test; the subsequent tests were self-administered and were completed at 3, 6, 12, 24, and 36 months. Other data entered for each patient included site, stage, treatment, histologic classification, reconstruction, and current status. A QOL registrar was responsible for patient follow-up, data collection, and collation. All data were entered into the departmental relational database.RESULTSCriticisms by external review included the following: "it is improper to call it [UW-QOL] a measure of quality of life"; "the summary scale is problematic because it implies that each of the subscales are weighted or 'valued' equally"; "some domain questions relate to surgery specific issues. while others are specific to radiation"; "we were confused by the scoring"; and "the UW-QOL index does not specifically address the psychological impact of the disease and its treatment." After evaluation of internal consistency, the UW-QOL was modified by removing 2 domains that correlated poorly with the others. This resulted in a 10-item instrument (UW-QOL-R) with an overall internal consistency score of 0.85.CONCLUSIONSThe UW-QOL can be effectively and accurately used to compare treatment effects in the management of head and neck cancer. With this revised instrument, the 10 items appear to measure the domains of overall QOL in a highly consistent and reliable fashion over time.

OBJECTIVES:To summarize our quality-of-life (QOL) research findings for patients with head and neck cancer, to suggest areas for future productive QOL research, and to discuss how to undertake QOL studies in a cost-effective manner.DESIGN:Review of previously published analyses of advanced larynx cancer, advanced oropharynx cancer, and neck-dissection cases and current data from the complete set of patients.PATIENTS:From January 1, 1993, through December 31, 1998, data on 549 patients were entered in our head and neck database. Of these patients, 364 met additional criteria for histologic findings (squamous cell carcinoma) and the restriction of their cancer to 4 major anatomical sites (oral, oropharynx, hypopharynx, or larynx). Of these, 339 patients were more than 1 year beyond initial treatment. Complete baseline TNM staging and QOL data were obtained for 260 of these patients, of whom 210 presented with an untreated first primary tumor (index cases) to the University of Washington, Seattle.INTERVENTION:Pretreatment QOL was assessed with an interviewer-supervised self-administered questionnaire. Subsequent self-administered tests were completed at 3, 6, 12, 24, and 36 months. Other data collected on each patient included cancer site, stage, treatment, histologic findings, type of surgical reconstruction, and current disease and vital status.RESULTS/CONCLUSIONS:It is difficult to achieve "statistically significant" results in a single-institution setting. The "composite" QOL score may not be a sufficiently sensitive tool. Analysis of separate domains may be more effective.

Because treatments for patients with cancer of the head and neck can have major impact on physical, social, and psychological function, the collection of quality of life (QOL) data in this group of patients is critical for our specialty. The University of Washington Quality of Life data have been collected and analyzed on three subsets of cancer patients. Information learned from these patients is summarized and strategies for future projects are outlined.

Objectives: For decades, the gold standard for treatment of cervical metastasis was radical neck dissection (IND), Current oncologic philosophy allows for treatment of appropriately staged neck disease with modified radical neck dissection (MRND) or selective neck dissection (SND). The purposes of this study were to determine the impact of various forms of neck dissection on patients' quality of life (QOL) and to evaluate the responsiveness of the University of Washington (UW) QOL shoulder domain. Study Design: Prospective accumulation of QOL data from patients treated for head and neck cancer at UW. Methods: Eighty-four patients were identified from the UW QOL registry who had undergone neck dissection and had completed pretreatment and posttreatment QOL questionnaires at 6 and 12 months. Results: Compared with pretreatment scores, the MRND and RND groups reported worse shoulder function at 6 and 12 months (P < .0005). The MRND group reported greater shoulder disability at 6 months compared with the SND group (P = .002), but by 12 months, there was no difference between the two groups. Shoulder function for the RND group was worse than the SND group at 6 and 12 months (P = .004), There was a trend toward decreased pain after treatment in the SND and MRND groups. There were no significant differences in subjective appearance, activity, recreation, chewing, swallowing, or speech in the three groups after treatment. Conclusions: Consistent with findings of published functional studies, this study confirmed that the three forms of neck dissection affect patients' QOL differently. This study demonstrates that the UW QOL shoulder domain is a responsive instrument in assessing the effect of neck dissection on shoulder function.

This study describes the reliability, validity, and responsiveness of the Sinonasal Outcome Test-16 (SNOT-16), a rhinosinusitis-specific health-related quality-of-life instrument, in the University of Washington Department of Otolaryngology-Head and Neck Surgery patient population. The SNOT-16 was completed by 47, 24, and 22 patients at weeks 0, 6, and 12, respectively. In addition, all 47 patients completed the Short-form 36-item Health Survey (SF-36) at week 0. Furthermore, an additional cohort of patients from the otology clinic who denied symptoms of rhinosinusitis or previous physician diagnoses of rhinosinusitis were asked to complete the SNOT-16. These scores were subsequently used to determine discriminant validity of the instrument. Cronbach's alpha was 0.89, indicating a high degree of homogeneity of the test items. The SNOT-16 demonstrated excellent discriminant validity, and mean total SNOT-16 scores were significantly correlated with patient-reported overall health, overall bother, and 7 of the 8 SF-36 subscales. The standardized response mean calculated between weeks 0 and 6 was 0.69, indicating moderate sensitivity to change. We conclude that the SNOT-16 is a reliable, valid, and responsive instrument for measuring rhinosinusitis-specific health-related quality of life.

The purpose of this study was to determine the functional disabilities and overall quality of life (QOL) of patients successfully treated (ie, without evidence of disease at two years) for laryngeal or hypopharyngeal cancer by a total laryngectomy.

Percutaneous tracheostomy (PT) is an ancient procedure that has recently attracted increasing interest. While there are numerous publications in the literature, there remains confusion due to the large variety of techniques and instruments with which it has been performed and the wide disparity in clinical outcome. This study evaluates the international literature on over 1,500 cases, classifies the techniques that have been used, analyzes the safety of each method, and reports a prospective outcome and cost analysis of 130 cases undergoing what we determined to be the safest method. We found that PT performed with the correct instruments and technique under bronchoscopic surveillance has a lower incidence of complications than open tracheostomy (OT). Cost estimation demonstrated that PT may be significantly more expensive than bedside OT. While we recommend PT as a relatively safe and expedient method of tracheostomy for selected intubated patients in an intensive care unit, it does not offer an advantage for patients who must be taken to the operating room, and should not deprive house officers of necessary experience in OT in this setting.