The complex facial trauma victim poses a genuine therapeutic challenge as a whole, and may be particularly challenging to the medical team. The literature on acute management of gunshot wounds to the face is scarce. We performed an extensive review of the English-language literature in an effort to better delineate the diagnosis and acute management of these injuries. Most of these injuries do not present with initial threat to life and can safely be managed non-operatively. Definitive treatment is often deferred in patients with multiple, or more severe, injuries. Airway compromise is the most frequent and most life-threatening early problem reported in most series. CT scan remains the most useful method in the evaluation of these types of injuries and associated cervical spine lesions. Facial bleeding is best controlled by angiography and subsequent embolization. Anatomic repair of soft tissue and bony injuries is recommended to obtain an optimal functional and aesthetic outcome. Despite the creation of some algorithms, no clear correlation has been found between the site of entrance wound and the injuries and outcome of gunshot wounds to the face.

Head and neck cancer is the ninth most common cancer in the USA, accounting for 3.3 % of all cancers. The incidence of head and neck cancer has plateaued recently; however, morbidity and mortality continue to remain high. Moreover, racial disparity between African-American and White patients has been studied in the head and neck community, and a vast difference still remains in mortality rate and late stage at presentation. A review of the English literature was performed using PubMed/MEDLINE for demographics, epidemiology, and studies that focused on the disparity in head and neck cancer between African-American and White patients. Age-adjusted incidence of head and neck cancer is increased in African-Americans, while the 5-year survival is decreased compared to Whites. African-American patients present with more advanced disease. When receiving similar multidisciplinary care, the overall survival was not significantly different, but racial disparity often persists in treatment regimens. Socioeconomic determinants such as insurance status play a critical role in racial disparity, along with low levels of public awareness, a lack of knowledge of specific risk factors, and a sense of mistrust that is seen in the African-American population. Disparity in the head and neck cancer community is worrisome, and although efforts have been taken to decrease the disparity, a significant difference exists. Fortunately, the disparity is reversible and can be eliminated. To do so, it is critical to extend to underserved community programs that provide appropriate screening and diagnosis, with subsequent follow-up and treatment following the standards of care.

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Academic centers embody the ideals of otolaryngology and are the specialty’s port of entry. Building a diverse otolaryngology workforce—one that mirrors society—is critical. Otolaryngology continues to have an underrepresentation of racial and ethnic minorities. The specialty must therefore redouble efforts, becoming more purposeful in mentoring, recruiting, and retaining underrepresented minorities. Many programs have never had residents who are Black, Indigenous, or people of color. Improving narrow, leaky, or absent pipelines is a moral imperative, both to mitigate health care disparities and to help build a more just health care system. Diversity supports the tripartite mission of patient care, education, and research. This commentary explores diversity in otolaryngology with attention to the salient role of academic medical centers. Leadership matters deeply in such efforts, from culture to finances. Improving outreach, taking a holistic approach to resident selection, and improving mentorship and sponsorship complement advances in racial disparities to foster diversity.

Purpose Epidermal growth factor receptor (EGFR) and cyclooxygenase 2 inhibitors synergistically inhibit head and neck squamous cell carcinoma tumorigenesis in preclinical studies. We conducted a phase I and pharmacokinetic study with the erlotinib and celecoxib combination in patients with advanced premalignant lesions. Patients and Methods 36 subjects with oral leukoplakia, mild, moderate, or severe dysplasia, or carcinoma in situ were screened for study participation; 12 consented and received therapy for a median of 5.38 months. Erlotinib was escalated following a standard 3+3 design at 50, 75, and 100mg orally daily and celecoxib was fixed at 400mg twice daily for 6 months. Biopsy of lesions and cytobrush of normal mucosa were performed at baseline, 3, 6 and 12 months. Erlotinib pharmacokinetics were analyzed in 10 subjects. Results The maximum tolerated dose of erlotinib with celecoxib 400mg BID was 50mg per day with skin rash being the main observed toxicity. Overall histologic response rate was 63% (complete response 43%, partial response 14%, stable disease 29%, disease progression 14%). With median follow-up of 36 months, mean time to progression to higher-grade dysplasia or carcinoma was 25.4 months. Downregulation of EGFR and p-ERK in follow-up biopsies correlated with response to treatment. Larger average erlotinib V/F (∼308L) and CL/F (8.3L/hr) compared to previous studies may be related to relatively large average bodyweights. Average erlotinib t1/2 was 25.6hr. Conclusion Encouraging responses to the celecoxib and erlotinib combination correlated with EGFR pathway inhibition. Although erlotinib-related rash was the main limitation to dose escalation, the intervention was well tolerated.

Purpose: Most recurrent squamous cell carcinomas of the head and neck have a dysfunctional p53 tumor suppressor pathway contributing to treatment resistance. We hypothesized that tumor p53 biomarkers may predict the efficacy of normal p53 delivered by gene therapy in these patients. Experimental Design: Tumor p53 biomarkers were evaluated in 116 patients, including 29 treated with methotrexate in a phase III randomized controlled trial. Profiles favorable for p53 gene therapy efficacy were hypothesized to have either normal p53 gene sequences or low-level p53 protein expression, whereas unfavorable p53 inhibitor profiles were predicted to have high-level expression of mutated p53 that can inhibit normal p53 protein function. Results: A statistically significant increase in tumor responses was observed for patients with favorable p53 efficacy profiles compared with those with unfavorable p53 inhibitor profiles [phase I/II trials: favorable (34 of 46, 74%) versus unfavorable (1 of 5, 20%), P = 0.0290; phase III trial: favorable (17 of 24, 71%) versus unfavorable (2 of 11, 18%), P = 0.0088]. In the phase III trial, there was statistically significant increased time to progression (TTP) and survival following p53 gene therapy in patients with favorable p53 profiles compared with unfavorable p53 inhibitor profiles (median TTP, 2.7 months versus 1.4 months, P = 0.0121; median survival, 7.2 months versus 2.7 months, P < 0.0001). In contrast, the biomarker profiles predictive of p53 gene therapy efficacy did not predict methotrexate response, TTP, or survival outcomes. Conclusions: These results indicate that tumor p53 biomarker profiles may predict p53 gene therapy efficacy in recurrent squamous cell carcinoma of the head and neck. (Clin Cancer Res 2009;15(24):7719-25)

Multidisciplinary therapy of ENB should be considered, especially for Kadish C and high-grade lesions. Craniofacial resection (CFR), Intensity modulated radiation therapy (IMRT), and chemotherapy should be investigated in a multi-institution trial of ENB.

Purpose/Objectives-To explore the perceived social support needs among older adult African American cancer survivors.Research Approach-Qualitative design using grounded theory techniques. Setting-Outpatient oncology clinics in the southeastern United States.Participants-Focus groups with 22 older adult African American cancer survivors.Methodologic Approach-Purposeful sampling technique was used to identify focus group participants. In-depth interviews were conducted and participants were interviewed until informational redundancy was achieved. Main Research Variables-Social support needs of older adult African American patients with cancer.Findings-Social support was influenced by (a) symptoms and treatment side effects, (b) perceptions of stigma and fears expressed by family and friends, (c) cultural beliefs about cancer, and (d) desires to lessen any burden or disruption to the lives of family and friends. Survivors navigated within and outside of their networks to get their social support needs met. In some instances, survivors socially withdrew from traditional sources of support for fear of being ostracized. Survivors also described feeling hurt, alone, and socially isolated when completely abandoned by friends. Conclusions-The support from family, friends, and fellow church members is important to positive outcomes among older African American cancer survivors. However, misconceptions, fears, and negative cultural beliefs persist within the African American community and negatively influence the social support available to this population.Interpretations-Early identification of the factors that influence social support can facilitate strategies to improve outcomes and decrease health disparities among this population.Hamilton can be reached at