eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Head & Neck Surgery

Management of the N3 Neck: Treatment

Author: Niels Kokot, MD, Assistant Professor, Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine of the University of Southern California
Coauthor(s): Gregory S Weinstein, MD, FACS, Professor and Vice-Chairman, Department of Otorhinolaryngology-Head and Neck Surgery, Director of Division of Head and Neck Surgery, Director of Head and Oncology Fellowship, Director of Otorhinolaryngology-Head and Neck Clinic, Co-director of The Center for Head and Neck Surgery, University of Pennsylvania School of Medicine
Contributor Information and Disclosures

Updated: Apr 8, 2009

Treatment

Medical Therapy

Local control with chemoradiation therapy has been reported to be as high as 90%. Clinical response, however, does not correlate with pathologic response. Although studies have shown that no clinical or pathologic parameters are able to predict a response to chemoradiation therapy, studies suggest that a tumor volume of less than 20 mL, tumor grade, lower epidermal growth factor receptor (EGFR) overexpression, and response to induction chemotherapy predict response to chemoradiation.

Concurrent chemoradiation therapy has survival rates that are similar to those of surgical therapy and preserves the function of important structures. Surgical therapy, however, carries better locoregional control rates. Although chemoradiation reduces nodal positivity and extracapsular spread, pathologic nodes are still found in 38-56% of cases after chemoradiation, thus necessitating neck dissection for the N2 and the N3 neck.

Complete response to chemoradiation therapy requires a complete disappearance of all clinical, radiologic, and pathologic (if applicable) evidence of disease. Anything less than a complete response requires surgery of the primary site and the neck nodes, if possible.

Treatment of the neck following chemoradiation is controversial. In the presence of a partial or incomplete response in the neck to chemoradiation, a completion neck dissection is mandatory (assuming the primary site is controlled or is resectable). In the presence of a complete response in the neck to chemoradiation, reports vary regarding the need for planned neck dissection. Lau et al (2008) did not plan a neck dissection following chemoradiation for patients with N2-N3 neck disease and achieved a 95% 2-year locoregional recurrence-free survival.17

On the other hand, Brizel et al (2004) found a higher rate of regional rate of relapse in patients with N2-N3 neck disease following chemoradiation who did not undergo planned neck dissection compared with those patients who did have neck dissection.18 Results of most studies are difficult to apply to the patient with N3 neck disease because most studies combine N2 and N3 neck disease because of the small number of patients with N3 disease.

The following complications are associated with chemoradiation therapy:

  1. Feeding tube (required in 32% of patients)
  2. Mucositis
  3. Neutropenia
  4. Carotid stenosis (range, 30-50% of patients)19
  5. Renal insufficiency
  6. Ototoxicity
  7. Esophageal stricture

Surgical Therapy

Surgery alone for the N3 neck carries a local failure rate of 21% and 5-year survival rate of 15%. Surgery for stage N3 neck should always be in conjunction with chemoradiation or radiation (performed either preoperatively or postoperatively). The complication rates for a neck dissection after concurrent chemoradiation range from 8-35%.

The type of neck dissection chosen is dictated by what structures are involved, as follows:

  • Radical neck dissection - Removal of the spinal accessory, sternocleidomastoid muscle (SCM), and internal jugular vein
  • Modified neck dissection
    • Type 1: The spinal accessory nerve is preserved and the SCM and the internal jugular vein are resected.
    • Type 2: The spinal accessory nerve and the SCM are preserved and the internal jugular vein is resected.
    • Type 3: The spinal accessory nerve, internal jugular vein, and sternocleidomastoid muscle are preserved.
  • Extended neck dissection – Resection of structures other than those that are routinely removed in a neck dissection.

Carotid artery resection is controversial. A 13-year retrospective study by Freeman et al (2004) reported on 41 patients whose carotid arteries were resected and reconstructed and 11 patients who underwent preoperative embolization or intraoperative ligation of the carotid artery.20 The median disease-specific survival and the median disease-free interval were both 12 months. Distant metastasis developed in 24% of patients, and 20% of patients had recurrence within 6 months of the resection. Eight of 41 patients (20%) who underwent resection and reconstruction of the carotid artery developed stroke postoperatively. Three of the 11 patients (27.7%) who underwent embolization or ligation of the carotid artery developed stroke postoperatively.

Cancer seldom invades the lumen of the carotid artery; based on a study by Huvos et al, only 42% of patients had invasion of the adventitia and external elastic membrane.21

The treatment options in the management of cervical metastasis that involves the carotid artery are as follows:

  • Permanent occlusion can be performed if collateral circulation is adequate.
  • Resection with carotid shunt and reconstruction can be performed if collateral circulation is inadequate.
  • Nonsurgical palliation is an option if collaterals are inadequate and reconstruction is not possible.
  • Nussbaum et al (2000) developed a unique technique in the management of carotid involvement in head and neck cancer.22 Endovascular stenting of the carotid artery is initially placed and followed by a staged neck dissection after 1 month of placement. Because the neoendothelial barrier has formed in the stent and prevents bleeding, dissection of the arterial wall with neck dissection can be performed. This is a technical case report that is currently under investigation.

Lore and Boulos reported that one third of their patients who underwent carotid artery resection lived longer than 2 years after the procedure, and meta-analysis on carotid resection by Snyderman showed improved local control.23,24 The decision to resect the carotid artery depends on the risk-benefit ratio in relation to local control, survival, stroke risk, quality of life, mortality, and available expertise.

The external carotid artery should be resected as needed; however, the authors' view is that resection of the carotid bulb or internal carotid artery is rarely, if ever, indicated. This is because the chance for cure is exceedingly low. The hypoglossal and or vagus nerve can also be invaded aside from the carotid artery. Resection of both the hypoglossal and vagus nerves increases the morbidity and mortality. Stroke is a risk, even when results of balloon occlusion studies are favorable. Even with resection of the carotid, the median survival is only 12 months.

Preoperative Details

Consider the primary site during treatment planning. Generally, primary site management dictates the plan for the neck. Patients who will undergo surgery for the primary site must also have resectable neck disease. As discussed previously, incomplete resection of the neck disease is of no benefit to the patient  (see Contraindications). Careful inspection of preoperative imaging is critical to making this assessment. 

Certain patients may not have an operable primary tumor and would not normally undergo a neck dissection. However, they may have morbidity associated with advanced neck disease and could benefit from a palliative neck dissection. This situation includes patients with the following:

  • Nonhealing ulcer
  • Bleeding neck mass not attached to vascular structure     
  • Unresponsive to conservative wound care
  • Unresponsive tumor embolization
  • Neck mass is operable, resectable, and adequate margins can be achieve

This highly selected subset of patient may be a candidate for palliative neck dissection. However, one must carefully weigh the risks of creating a worse wound and having the patient hospitalized for his or her remaining life against potential quality-of-life improvements.

Intraoperative Details

Intraoperatively, the surgeon must assess whether the N3 neck is completely resectable. Involvement of structures not normally included in the standard neck dissection must be assessed and resected as needed to achieve a complete resection. However, unless the tumor is completely resectable, resecting important neurovascular structures, causing unnecessary morbidity, is not advisable. (See Relevant Anatomy and Surgical Therapy.) 

Postoperative Details

When possible, patients benefit from adjuvant therapy following neck dissection for advanced neck disease. Chan et al (2003) showed that patients with N3 disease treated with surgery and postoperative radiotherapy had improved survival when compared with surgery and preoperative radiotherapy or surgery alone.25 Patients with advanced neck disease derive additional benefit from postoperative concurrent chemoradiation.16  

Follow-up

Following treatment for the N3 neck, patients require close follow-up, as they are at high risk for both regional recurrence and distant metastases. The risk of relapse is highest in the first 2 years following treatment. Many surgeons advocate monthly physical examinations, and imaging every 3 months in the first year following treatment. 

Complications

The following are complications associated with surgical resection of the N3 neck:

  • Perioperative stroke (range, 0.2-4.8%)
  • Wound complications (range, 8-35%)
  • Fistula
  • Bleeding
  • Infection
  • Carotid artery rupture
  • Chyle leak

Carotid artery rupture is a dreaded complication of advance neck disease. Rupture may be preceded by a sentinel bleed, wherein a patient has a short-lived episode of bleeding from the mouth, neck, or stoma. After bleeding subsides, all may appear to be well, but hospitalized patients may need to be placed on carotid artery precautions unless the patient refuses resuscitation. Precautions include a prepositioned stretcher to quickly take the patient to the operating room (OR) and rolled gauze bandages to obtain adequate pressure to the artery. Make no attempt to clamp the vessel. The following are the appropriate sequence of events in the management of carotid blowout:

(1) Apply pressure and volume support.

(2) Transfer the patient to the OR immediately.

(3) Manage the condition either by endovascular stent graft or by surgically obtaining proximal and distal control followed by surgical repair or ligation, depending on hemodynamic status and condition of the tissue.

More on Management of the N3 Neck

Overview: Management of the N3 Neck
Workup: Management of the N3 Neck
Treatment: Management of the N3 Neck
Follow-up: Management of the N3 Neck
Multimedia: Management of the N3 Neck
References
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References

  1. Spiro RH, Alfonso AE, Farr HW, Strong EW. Cervical node metastasis from epidermoid carcinoma of the oral cavity and oropharynx. A critical assessment of current staging. Am J Surg. Oct 1974;128(4):562-7. [Medline].

  2. Bocca E, Pignataro O. A conservative technique in radical neck dissection. Ann Otol Rhinol Laryngol. 1967;76(5):975-87.

  3. Garavello W, Ciardo A, Spreafico R, Gaini RM. Risk factors for distant metastases in head and neck squamous cell carcinoma. Arch Otolaryngol Head Neck Surg. Jul 2006;132(7):762-6. [Medline].

  4. Buck G, Huguenin P, Stoeckli SJ. Efficacy of neck treatment in patients with head and neck squamous cell carcinoma. Head Neck. Jan 2008;30(1):50-7. [Medline].

  5. Ferlito A, Shaha AR, Silver CE, Rinaldo A, Mondin V. Incidence and sites of distant metastases from head and neck cancer. ORL J Otorhinolaryngol Relat Spec. Jul-Aug 2001;63(4):202-7. [Medline].

  6. Ferlito A, Silver CE, Shaha AR, Rinaldo A. Management of N3 neck. Acta Otolaryngol. Mar 2002;122(2):230-3. [Medline].

  7. Robbins KT, Clayman G, Levine PA, et al. Neck dissection classification update: revisions proposed by the American Head and Neck Society and the American Academy of Otolaryngology-Head and Neck Surgery. Arch Otolaryngol Head Neck Surg. Jul 2002;128(7):751-8. [Medline].

  8. Freudenberg LS, Fischer M, Antoch G, et al. Dual modality of 18F-fluorodeoxyglucose-positron emission tomography/computed tomography in patients with cervical carcinoma of unknown primary. Med Princ Pract. May-Jun 2005;14(3):155-60. [Medline].

  9. Troell RJ, Terris DJ. Detection of metastases from head and neck cancers. Laryngoscope. Mar 1995;105(3 Pt 1):247-50. [Medline].

  10. Loh KS, Brown DH, Baker JT, Gilbert RW, Gullane PJ, Irish JC. A rational approach to pulmonary screening in newly diagnosed head and neck cancer. Head Neck. Nov 2005;27(11):990-4. [Medline].

  11. Keski-Santti HT, Markkola AT, Makitie AA, Back LJ, Atula TS. CT of the chest and abdomen in patients with newly diagnosed head and neck squamous cell carcinoma. Head Neck. Oct 2005;27(10):909-15. [Medline].

  12. Yousem DM, Hatabu H, Hurst RW, et al. Carotid artery invasion by head and neck masses: prediction with MR imaging. Radiology. Jun 1995;195(3):715-20. [Medline].

  13. Yoo GH, Hocwald E, Korkmaz H, et al. Assessment of carotid artery invasion in patients with head and neck cancer. Laryngoscope. Mar 2000;110(3 Pt 1):386-90. [Medline].

  14. Grubb RL Jr, Powers WJ, Derdeyn CP, Adams HP Jr, Clarke WR. The Carotid Occlusion Surgery Study. Neurosurg Focus. Mar 15 2003;14(3):e9. [Medline].

  15. Howlett DC, Menezes L, Bell DJ, et al. Ultrasound-guided core biopsy for the diagnosis of lumps in the neck: results in 82 patients. Br J Oral Maxillofac Surg. Feb 2006;44(1):34-7. [Medline].

  16. Bernier J, Bentzen SM. Radiotherapy for head and neck cancer: latest developments and future perspectives. Curr Opin Oncol. May 2006;18(3):240-6. [Medline].

  17. Lau H, Phan T, Mackinnon J, Matthews TW. Absence of planned neck dissection for the N2-N3 neck after chemoradiation for locally advanced squamous cell carcinoma of the head and neck. Arch Otolaryngol Head Neck Surg. Mar 2008;134(3):257-61. [Medline].

  18. Brizel DM, Prosnitz RG, Hunter S, et al. Necessity for adjuvant neck dissection in setting of concurrent chemoradiation for advanced head-and-neck cancer. Int J Radiat Oncol Biol Phys. Apr 1 2004;58(5):1418-23. [Medline].

  19. Abayomi OK. Neck irradiation, carotid injury and its consequences. Oral Oncol. Oct 2004;40(9):872-8. [Medline].

  20. Freeman SB, Hamaker RC, Borrowdale RB, Huntley TC. Management of neck metastasis with carotid artery involvement. Laryngoscope. Jan 2004;114(1):20-4. [Medline].

  21. Huvos AG, Leaming RH, Moore OS. Clinicopathologic study of the resected carotid artery. Analysis of sixty-four cases. Am J Surg. Oct 1973;126(4):570-4. [Medline].

  22. Nussbaum ES, Levine SC, Hamlar D, Madison MT. Carotid stenting and "extarterectomy" in the management of head and neck cancer involving the internal carotid artery: technical case report. Neurosurgery. Oct 2000;47(4):981-4. [Medline].

  23. Lore JM Jr, Boulos EJ. Resection and reconstruction of the carotid artery in metastatic squamous cell carcinoma. Am J Surg. Oct 1981;142(4):437-42. [Medline].

  24. Snyderman CH, D'Amico F. Outcome of carotid artery resection for neoplastic disease: a meta-analysis. Am J Otolaryngol. Nov-Dec 1992;13(6):373-80. [Medline].

  25. Chen KY, Mohr RM, Silverman CL. Interstitial iodine 125 in advanced recurrent squamous cell carcinoma of the head and neck with follow-up evaluation of carotid artery by ultrasound. Ann Otol Rhinol Laryngol. Dec 1996;105(12):955-61. [Medline].

  26. Carvalho AL, Kowalski LP, Agra IM, Pontes E, Campos OD, Pellizzon AC. Treatment results on advanced neck metastasis (N3) from head and neck squamous carcinoma. Otolaryngol Head Neck Surg. Jun 2005;132(6):862-8. [Medline].

  27. Ballonoff A, Raben D, Rusthoven KE, et al. Outcomes of patients with n3 neck nodes treated with chemoradiation. Laryngoscope. Jun 2008;118(6):995-8. [Medline].

  28. Owen RP, Silver CE, Ravikumar TS, Brook A, Bello J, Breining D. Techniques for radiofrequency ablation of head and neck tumors. Arch Otolaryngol Head Neck Surg. Jan 2004;130(1):52-6. [Medline].

  29. Serin M, Erkal HS, Cakmak A. Radiation therapy, cisplatin and hyperthermia in combination in management of patients with recurrent carcinomas of the head and neck with metastatic cervical lymph nodes. Int J Hyperthermia. Sep-Oct 1999;15(5):371-81. [Medline].

  30. Wust P, Stahl H, Dieckmann K, et al. Local hyperthermia of N2/N3 cervical lymph node metastases: correlationof technical/thermal parameters and response. Int J Radiat Oncol Biol Phys. Feb 1 1996;34(3):635-46. [Medline].

  31. Castro DJ, Sridhar KS, Garewal HS, et al. Intratumoral cisplatin/epinephrine gel in advanced head and neck cancer: a multicenter, randomized, double-blind, phase III study in North America. Head Neck. Sep 2003;25(9):717-31. [Medline].

  32. Jäger HR, Taylor MN, Theodossy T, Hopper C. MR imaging-guided interstitial photodynamic laser therapy for advanced head and neck tumors. AJNR Am J Neuroradiol. May 2005;26(5):1193-200. [Medline].

  33. Lou PJ, Jager HR, Jones L, Theodossy T, Bown SG, Hopper C. Interstitial photodynamic therapy as salvage treatment for recurrent head and neck cancer. Br J Cancer. Aug 2 2004;91(3):441-6. [Medline].

  34. Lamont JP, Nemunaitis J, Kuhn JA et al. Intratumoral ONYX-O15 adenovirus and chemotherapy for recurrent squamous cell carcinoma of head and neck. Ann surg oncol. 2000, Sept;7(8):588-92.

  35. Machtay M, Rosenthal DI, Chalian AA, et al. Pilot study of postoperative reirradiation, chemotherapy, and amifostine after surgical salvage for recurrent head-and-neck cancer. Int J Radiat Oncol Biol Phys. May 1 2004;59(1):72-7. [Medline].

  36. Allegretti JP, Panje WR. Electroporation therapy for head and neck cancer including carotid artery involvement. Laryngoscope. Jan 2001;111(1):52-6. [Medline].

  37. Yao M, Graham MM, Hoffman HT, et al. The role of post-radiation therapy FDG PET in prediction of necessity for post-radiation therapy neck dissection in locally advanced head-and-neck squamous cell carcinoma. Int J Radiat Oncol Biol Phys. Jul 15 2004;59(4):1001-10. [Medline].

  38. Tan A, Adelstein DJ, Rybicki LA, et al. Ability of positron emission tomography to detect residual neck node disease in patients with head and neck squamous cell carcinoma after definitive chemoradiotherapy. Arch Otolaryngol Head Neck Surg. May 2007;133(5):435-40. [Medline].

  39. Adelstein DJ, Lavertu P, Saxton JP, et al. Mature results of a phase III randomized trial comparing concurrent chemoradiotherapy with radiation therapy alone in patients with stage III and IV squamous cell carcinoma of the head and neck. Cancer. Feb 15 2000;88(4):876-83. [Medline].

  40. AJCC Staging Manual. 6.

  41. Bernier J, Cooper JS, Pajak TF, et al. Defining risk levels in locally advanced head and neck cancers: a comparative analysis of concurrent postoperative radiation plus chemotherapy trials of the EORTC (#22931) and RTOG (# 9501). Head Neck. Oct 2005;27(10):843-50. [Medline].

  42. Brisman MH, Sen C, Catalano P. Results of surgery for head and neck tumors that involve the carotid artery at the skull base. J Neurosurg. May 1997;86(5):787-92. [Medline].

  43. Chan SW, Mukesh BN, Sizeland A. Treatment outcome of N3 nodal head and neck squamous cell carcinoma. Otolaryngol Head Neck Surg. Jul 2003;129(1):55-60. [Medline].

  44. Conley BA. Treatment of advance head and neck cancer: what lessons have we learned? J of Clin Oncology. 2006, March;24(7):1023-1024.

  45. Dagum P, Pinto HA, Newman JP, et al. Management of the clinically positive neck in organ preservation for advanced head and neck cancer. Am J Surg. Nov 1998;176(5):448-52. [Medline].

  46. Dare AO, Gibbons KJ, Gillihan MD, Guterman LR, Loree TR, Hicks WL Jr. Hypotensive endovascular test occlusion of the carotid artery in head and neck cancer. Neurosurg Focus. Mar 15 2003;14(3):e5. [Medline].

  47. Derdeyn CP, Grubb RL Jr, Powers WJ. Indications for cerebral revascularization for patients with atherosclerotic carotid occlusion. Skull Base. Feb 2005;15(1):7-14. [Medline].

  48. Doweck I, Denys D, Robbins KT. Tumor volume predicts outcome for advanced head and neck cancer treated with targeted chemoradiotherapy. Laryngoscope. Oct 2002;112(10):1742-9. [Medline].

  49. Ferlito A, Buckley JG, Rinaldo A, Mondin V. Screening tests to evaluate distant metastases in head and neck cancer. ORL J Otorhinolaryngol Relat Spec. Jul-Aug 2001;63(4):208-11. [Medline].

  50. Gavilan J, Herranz-Gonzalez J, Lentsch EJ. Cancer of the neck. In: Cancer of the head and neck. 4th edition: Saunder Co; 2003:407-430.

  51. Giatromanolaki A, Koukourakis MI, Georgoulias V, Gatter KC, Harris AL, Fountzilas G. Angiogenesis vs. response after combined chemoradiotherapy of squamous cell head and neck cancer. Int J Cancer. Mar 15 1999;80(6):810-7. [Medline].

  52. Induction chemotherapy plus radiation compared with surgery plus radiation in patients with advanced laryngeal cancer. The Department of Veterans Affairs Laryngeal Cancer Study Group. N Engl J Med. Jun 13 1991;324(24):1685-90. [Medline].

  53. Lesley WS, Chaloupka JC, Weigele JB, Mangla S, Dogar MA. Preliminary experience with endovascular reconstruction for the management of carotid blowout syndrome. AJNR Am J Neuroradiol. May 2003;24(5):975-81. [Medline].

  54. McHam SA, Adelstein DJ, Rybicki LA, et al. Who merits a neck dissection after definitive chemoradiotherapy for N2-N3 squamous cell head and neck cancer?. Head Neck. Oct 2003;25(10):791-8. [Medline].

  55. Moore MG, Bhattacharyya N. Effectiveness of chemotherapy and radiotherapy in sterilizing cervical nodal disease in squamous cell carcinoma of the head and neck. Laryngoscope. Apr 2005;115(4):570-3. [Medline].

  56. Morrissey DD, Andersen PE, Nesbit GM, Barnwell SL, Everts EC, Cohen JI. Endovascular management of hemorrhage in patients with head and neck cancer. Arch Otolaryngol Head Neck Surg. Jan 1997;123(1):15-9. [Medline].

  57. Okamoto Y, Inugami A, Matsuzaki Z, et al. Carotid artery resection for head and neck cancer. Surgery. Jul 1996;120(1):54-9. [Medline].

  58. Pellitteri PK, Ferlito A, Rinaldo A, et al. Planned neck dissection following chemoradiotherapy for advanced head and neck cancer: is it necessary for all?. Head Neck. Feb 2006;28(2):166-75. [Medline].

  59. Pitman KT, Bradley PJ. Management of the N3 neck. Curr Opin Otolaryngol Head Neck Surg. Apr 2003;11(2):129-33. [Medline].

  60. Shah J. Cervical lymph nodes. In: Head and Neck Surgical Oncology. Mosby Co. 2003;353-393.

  61. Stell PM. Fixed, bilateral cervical nodes. J Laryngol Otol. Sep 1983;97(9):851-6. [Medline].

  62. Thompson SK, McKinnon JG, Ghali WA. Perioperative stroke occurring in patients who undergo neck dissection for head and neck cancer: unanswered questions. Can J Surg. Oct 2003;46(5):332-4. [Medline].

  63. Thompson SK, Southern DA, McKinnon JG, Dort JC, Ghali WA. Incidence of perioperative stroke after neck dissection for head and neck cancer: a regional outcome analysis. Ann Surg. Mar 2004;239(3):428-31. [Medline].

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Further Reading

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Keywords

neck disease, advanced neck disease, lymph nodes neck, n3 neck, neck cancer, squamous cell carcinoma, neck treatment, head neck cancer, cancer treatment, cancer management, SCCA, inoperable cancer of the neck, N3 disease of the neck, stage IV disease, tonsil cancer, cancer of the tonsil

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Contributor Information and Disclosures

Author

Niels Kokot, MD, Assistant Professor, Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine of the University of Southern California
Niels Kokot, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society, and Society of University Otolaryngologists-Head and Neck Surgeons
Disclosure: Nothing to disclose.

Coauthor(s)

Gregory S Weinstein, MD, FACS, Professor and Vice-Chairman, Department of Otorhinolaryngology-Head and Neck Surgery, Director of Division of Head and Neck Surgery, Director of Head and Oncology Fellowship, Director of Otorhinolaryngology-Head and Neck Clinic, Co-director of The Center for Head and Neck Surgery, University of Pennsylvania School of Medicine
Gregory S Weinstein, MD, FACS is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Laryngological Association, American Laryngological Rhinological and Otological Society, American Medical Association, American Radium Society, American Society for Head and Neck Surgery, Pennsylvania Medical Society, Philadelphia County Medical Society, and Society of University Otolaryngologists-Head and Neck Surgeons
Disclosure: Nothing to disclose.

Medical Editor

William M Lydiatt, MD, Professor and Division Director, Head and Neck Surgical Oncology, Department of Otolaryngology-Head and Neck Surgery, University of Nebraska Medical Center
William M Lydiatt, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Head and Neck Society, and Nebraska Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Karen Hall Calhoun, MD, Professor, Department of Otolaryngology-Head and Neck Surgery, The Ohio State University
Karen Hall Calhoun, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Head and Neck Society, American Medical Association, American Rhinologic Society, Association for Research in Otolaryngology, Society of University Otolaryngologists-Head and Neck Surgeons, Southern Medical Association, Texas Medical Association, and Texas Medical Association
Disclosure: Nothing to disclose.

CME Editor

Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders
Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine
Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society
Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation unstricted gift unknown; Axis Three Corporation Ownership interest Consulting; Omni Biosciences Ownership interest Consulting; Sentegra Ownership interest Board membership; Syndicom Ownership interest Consulting; Oxlo  Consulting; Medvoy Ownership interest Management position

 
 
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