This clinical practice guideline is not intended as a sole source of guidance in managing hoarseness (dysphonia). Rather, it is designed to assist clinicians by providing an evidence-based framework for decision-making strategies. The guideline is not intended to replace clinical judgment or establish a protocol for all individuals with this condition, and may not provide the only appropriate approach to diagnosing and managing this problem.

Objective To present 5-year outcomes from a prospective cohort of patients with obstructive sleep apnea (OSA) who were treated with upper airway stimulation (UAS) via a unilateral hypoglossal nerve implant. Study Design A multicenter prospective cohort study. Setting Industry-supported multicenter academic and clinical trial. Methods From a cohort of 126 patients, 97 completed protocol, and 71 consented to a voluntary polysomnogram. Those having continuous positive airway pressure failure with moderate to severe OSA, body mass index <32 kg/m, and no unfavorable collapse on drug-induced sleep endoscopy were enrolled in a phase 3 trial. Prospective outcomes included apnea-hypopnea index (AHI), oxygen desaturation index, and adverse events, as well as measures of sleepiness, quality of life, and snoring. Results Patients who did and did not complete the protocol differed in baseline AHI, oxygen desaturation index, and Functional Outcomes of Sleep Questionnaire scores but not in any other demographics or treatment response measures. Improvement in sleepiness (Epworth Sleepiness Scale) and quality of life was observed, with normalization of scores increasing from 33% to 78% and 15% to 67%, respectively. AHI response rate (AHI <20 events per hour and >50% reduction) was 75% (n = 71). When a last observation carried forward analysis was applied, the responder rate was 63% at 5 years. Serious device-related events all related to lead/device adjustments were reported in 6% of patients. Conclusions Improvements in sleepiness, quality of life, and respiratory outcomes are observed with 5 years of UAS. Serious adverse events are uncommon. UAS is a nonanatomic surgical treatment with long-term benefit for individuals with moderate to severe OSA who have failed nasal continuous positive airway pressure.

O bstructive sleep apnea (OSA) is a common disorder that affects sleep and quality of life. Because many people with OSA cannot or will not comply with the standard treatment with a continuous positive airway pressure (CPAP) mask, alternative treatments have been sought. Upper-airway stimulation using unilateral stimulation of the hypoglossal nerve is a possible option. This multicenter, prospective, single-group, cohort trial and a follow-up randomized therapy-withdrawal trial were performed to evaluate the clinical safety and effectiveness of upper-airway stimulation for treating moderate to severe OSA.Patients who had difficulty accepting or adhering to CPAP treatment were included and served as their own controls. After initial screening, including polysomnography, qualified patients underwent surgery to implant the upper-airway stimulation system in which a stimulation electrode was placed on the hypoglossal nerve to recruit tongue-protrusion function. The sensing lead was placed between the internal and external intercostal muscles to detect ventilatory effort, and the neurostimulator was implanted in the right ipsilateral midinfraclavicular region. A month after implantation, patients had a second baseline diagnostic polysomnographic exam before the device was activated. Patients used a controller to initiate and stop therapy each night and then were assessed at 2, 3, 6, 9, and 12 months. The primary outcome was the change in the severity of OSA as determined by the apneahypopnea index (AHI; number of apnea or hypopnea events per hour; score ≥15 indicates moderate to severe OSA) and the O 2 desaturation index (ODI; number of times per hour of sleep that the blood O 2 level drops by ≥4 percentage points from baseline). At the 12-month assessment, a response to treatment was defined as an AHI reduction of 50% or greater from baseline and a score of less than 20 events per hour along with an ODI reduction of 25% or greater from baseline. The primary efficacy objectives were response rates of 50% or greater as assessed in the AHI and ODI. Secondary outcomes were the Epworth Sleepiness Scale, the Functional Outcomes of Sleep Questionnaire (FOSQ), and the percentage of sleep time with the O 2 saturation of less than 90%. Consecutive patients with a response were included in a randomized controlled therapywithdrawal trial in which they were assigned in a 1:1 ratio to either the therapy-maintenance or therapy-withdrawal group. The withdrawal group had the device turned off for 7 days; the maintenance group continued using the device. Polysomnography was done to measure the effects of withdrawal compared with continued use of therapy. Serious adverse events were those that led to death, lifethreatening illness, permanent impairment, or new or prolonged hospitalization with serious health impairment.Of the 126 participants, 83% were men; mean age was 54.5 years, and mean body mass index was 28.4 kg/m 2 . The mean AHI score on the initial screening polysomnography was 32.0 events per hour, and the mean ODI score was ...

Long-term 3-year improvements in objective respiratory and subjective quality-of-life outcome measures are maintained. Adverse events are uncommon. UAS is a successful and appropriate long-term treatment for individuals with moderate to severe OSA.

The study suggests that chemoradiation may provide superior swallowing outcome to surgery/radiation in patients with oropharyngeal primary. Patients with depressed mental health and prolonged feeding tubes may be at higher risk of long-term dysphagia.

Objective Neck masses are common in adults, but often the underlying etiology is not easily identifiable. While infections cause most of the neck masses in children, most persistent neck masses in adults are neoplasms. Malignant neoplasms far exceed any other etiology of adult neck mass. Importantly, an asymptomatic neck mass may be the initial or only clinically apparent manifestation of head and neck cancer, such as squamous cell carcinoma (HNSCC), lymphoma, thyroid, or salivary gland cancer. Evidence suggests that a neck mass in the adult patient should be considered malignant until proven otherwise. Timely diagnosis of a neck mass due to metastatic HNSCC is paramount because delayed diagnosis directly affects tumor stage and worsens prognosis. Unfortunately, despite substantial advances in testing modalities over the last few decades, diagnostic delays are common. Currently, there is only 1 evidence-based clinical practice guideline to assist clinicians in evaluating an adult with a neck mass. Additionally, much of the available information is fragmented, disorganized, or focused on specific etiologies. In addition, although there is literature related to the diagnostic accuracy of individual tests, there is little guidance about rational sequencing of tests in the course of clinical care. This guideline strives to bring a coherent, evidence-based, multidisciplinary perspective to the evaluation of the neck mass with the intention to facilitate prompt diagnosis and enhance patient outcomes. Purpose The primary purpose of this guideline is to promote the efficient, effective, and accurate diagnostic workup of neck masses to ensure that adults with potentially malignant disease receive prompt diagnosis and intervention to optimize outcomes. Specific goals include reducing delays in diagnosis of HNSCC; promoting appropriate testing, including imaging, pathologic evaluation, and empiric medical therapies; reducing inappropriate testing; and promoting appropriate physical examination when cancer is suspected. The target patient for this guideline is anyone ≥18 years old with a neck mass. The target clinician for this guideline is anyone who may be the first clinician whom a patient with a neck mass encounters. This includes clinicians in primary care, dentistry, and emergency medicine, as well as pathologists and radiologists who have a role in diagnosing neck masses. This guideline does not apply to children. This guideline addresses the initial broad differential diagnosis of a neck mass in an adult. However, the intention is only to assist the clinician with a basic understanding of the broad array of possible entities. The intention is not to direct management of a neck mass known to originate from thyroid, salivary gland, mandibular, or dental pathology as management recommendations for these etiologies already exist. This guideline also does not address the subsequent management of specific pathologic entities, as treatment recommendations for benign and malignant neck masses can be found elsewhere. Instead,...

Objective Sialendoscopy and other gland-preserving techniques such as extracorporeal shockwave lithotripsy (ESWL), transoral stone removal, and combinations of these methods have fundamentally changed the therapeutic approach to salivary stones. Since 2003, all patients presenting with sialolithiasis have been diagnosed and treated with the same algorithm and routine salivary gland endoscopy (SGE). Study Design Case series with chart review of patients with sialolithiasis treated between 2003 and 2008 using an algorithm for gland preservation. Setting Tertiary referral academic medical center. Subjects and Methods A total of 1154 patients with suspected sialolithiasis were identified and reviewed. Factors analyzed included stone location, size, surgical method, rate of stone clearance, complications, and rate of short- and long-term symptom resolution. Successful treatment was defined as freedom from symptoms at follow-up. Results Diagnostic sialendoscopy confirmed 221 parotid stones and 812 submandibular stones, of which 206 and 736, respectively, were treated. Transoral stone removal was the most frequently used method to remove submandibular stones (92%), with a smaller percentage able to be removed by SGE alone (5%) with long-term success rates ≥90%. Only 4% (29/736) required submandibular gland removal. Parotid stones were removed by SGE (22%), combined SGE and incisional technique (26%), or ESWL (52%), with long-term success rates of 98%, 89%, and 79%, respectively. Only 8 of 206 (4%) patients eventually required parotidectomy. Conclusion Salivary gland endoscopy is an important diagnostic and therapeutic tool in the management of sialolithiasis but must be combined with additional techniques to ensure a high rate of stone clearance, symptom resolution, and gland preservation.

It has been documented previously that defects in the generation of C(18)-ceramide, a product of ceramide synthase 1 (CerS1), also known as longevity assurance gene 1 (hLASS1), play important roles in the pathogenesis and/or progression of HNSCC. However, whether altered levels of ceramide generation in HNSCC tumors have any clinical relevance remains unknown. In this study, the levels of endogenous ceramides were measured in tumor tissues of 45 HNSCC patients as compared to their normal tissues using high-pressure liquid chromatography/mass spectrometry (LC/MS), and then possible link between ceramide levels and the clinical parameters of HNSCC were examined. The data showed that the levels of C(16)-, C(24)-, C(24:1)-ceramides were significantly elevated in the majority of tumor tissues compared to their normal tissues, while the levels of only C(18)-ceramide were significantly decreased in HNSCC tumors, especially in tumor tissues of male patients. Importantly, it was also shown here that decreased C(18)-ceramide levels in HNSCC tumor tissues were significantly associated with the higher incidences of lymphovascular invasion, and pathologic nodal metastasis. Importantly, attenuation of C(18)-ceramide was also positively linked to the higher overall stages of the primary HNSCC tumors. Therefore, these data suggest, for the first time, that the defects in the generation/accumulation of C(18)-ceramide might have important clinical roles in HNSCC, especially in lymphovascular invasion and nodal disease.