Y-Chromosome-Linked Genes Are Associated With Sex-Related Head-Neck Squamous Cell Carcinoma Survival

OBJECTIVE

To define novel gene biomarkers for prognosis of head and neck squamous cell carcinoma (HNSCC) patients' survival.

STUDY DESIGN

Retrospective study.

SETTING

The Cancer Genome Atlas (TCGA) HNSCC RNA-Seq dataset.

METHODS

Coexpressed gene clusters were extracted from TCGA RNA-seq data using our previously published method (EPIG). Kaplan-Meier estimator was then used for overall survival-relevant analysis, with patients partitioned into 3 groups based on gene expression levels: female, male_low, and male_high.

RESULTS

Male had better overall survival than female and male with higher expression level of Y-chromosome-linked (Y-linked) genes had significantly better survival than those with lower expression levels. In addition, male with a higher expression level of Y-linked genes showed even better survival when they have a higher level of coexpressed cluster of genes related to B or T cell immune response. Other clinical conditions related to immune responses also consistently showed favorable effects on the Y-linked genes for survival estimation. Male patients with higher expression level of Y-linked genes also have significantly higher tumor/normal tissue (T/N) ratio of those genes and higher level of several immune responses related clinical measurements (eg, lymphocyte and TCR related). Male patients with lower expression level of Y-linked genes benefited from radiation-only treatment.

CONCLUSIONS

The favorable role of a cluster of coexpressed Y-linked genes in HNSCC patients' survival is potentially associated with elevated level of immune responses. These Y-linked genes could serve as useful prognostic biomarkers for HNSCC patients' survival estimation and treatment.

Concordant palliative care delivery in advanced head and neck cancer

OBJECTIVES

To describe the palliative care consultation practices in an academic head and neck surgery practice.

METHODS

This is a retrospective review of a palliative care database and the health record for all palliative care consultations of patients suffering from advanced stage head and neck cancer within a 21-month period.

RESULTS

Ten head and neck cancer patients received palliative care consults while on the otolaryngology service. One consultation occurred preoperatively; nine occurred postoperatively, on a median of hospital day 9. At the time of referral, seven patients were in the ICU and three were on a surgical floor. Code status de-escalation occurred in six patients and psycho-socio-spiritual suffering was supported in all consultations. Nine patients died within six months, with a median post-consultation survival of 35 days. Of these, two died in an ICU, five were discharged to hospice, one to a SNF, and one to a LTACH.

CONCLUSION

Palliative care consultation in this advanced head and neck cancer cohort was commonly late, however, significant suffering was mitigated following most consults. Palliative care specialists are experts at eliciting patient values, determining acceptable tradeoffs and suffering limitations by employing a shared decision-making process that ends with a patient-centered value-congruent treatment recommendation. Oftentimes, this embraces curative-intent or palliative surgery, along with contingency plans for unacceptable value-incongruent postoperative outcomes. Enhanced awareness of the benefits of embracing concordant palliative care in advanced head and neck cancer patients may help overcome the significant barriers to involving palliative care experts earlier.

Early [18]FDG PET/CT scan predicts tumor response in head and neck squamous cell cancer patients treated with erlotinib adjusted per smoking status

Translational Relevance

Evaluation of targeted therapies is urgently needed for the majority of patients with metastatic/recurrent head and neck squamous cell carcinoma (HNSCC) who progress after immunochemotherapy. Erlotinib, a targeted inhibitor of epidermal growth factor receptor pathway, lacks FDA approval in HNSCC due to inadequate tumor response. This study identifies two potential avenues to improve tumor response to erlotinib among patients with HNSCC. For the first time, this study shows that an increased erlotinib dose of 300 mg in smokers is well-tolerated and produces similar plasma drug concentration as the regular dose of 150 mg in non-smokers, with increased study-specific defined tumor response. The study also highlights the opportunity for improved patient selection for erlotinib treatment by demonstrating that early in-treatment [18]FDG PET/CT is a potential predictor of tumor response, with robust statistical correlations between metabolic changes on early in-treatment PET (4-7 days through treatment) and anatomic response measured by end-of-treatment CT.

Purpose

Patients with advanced HNSCC failing immunochemotherapy have no standard treatment options. Accelerating the investigation of targeted drug therapies is imperative. Treatment with erlotinib produced low response rates in HNSCC. This study investigates the possibility of improved treatment response through patient smoking status-based erlotinib dose optimization, and through early in-treatment [18]FDG PET evaluation to differentiate responders from non-responders.

Experimental design

In this window-of-opportunity study, patients with operable HNSCC received neoadjuvant erlotinib with dose determined by smoking status: 150 mg (E150) for non-smokers and 300 mg (E300) for active smokers. Plasma erlotinib levels were measured using mass spectrometry. Patients underwent PET/CT before treatment, between days 4-7 of treatment, and before surgery (post-treatment). Response was measured by diagnostic CT and was defined as decrease in maximum tumor diameter by ≥ 20% (responders), 10-19% (minimum-responders), and < 10% (non-responders).

Results

Nineteen patients completed treatment, ten of whom were smokers. There were eleven responders, five minimum-responders, and three non-responders. Tumor response and plasma erlotinib levels were similar between the E150 and E300 patient groups. The percentage change on early PET/CT and post-treatment PET/CT compared to pre-treatment PET/CT were significantly correlated with the radiologic response on post-treatment CTs: R=0.63, p=0.0041 and R=0.71, p=0.00094, respectively.

Conclusion

This pilot study suggests that early in-treatment PET/CT can predict response to erlotinib, and treatment with erlotinib dose adjusted according to smoking status is well-tolerated and may improve treatment response in HNSCC. These findings could help optimize erlotinib treatment in HNSCC and should be further investigated.

Clinical Trial Registration

https://clinicaltrials.gov/ct2/show/NCT00601913, identifier NCT00601913.

Impact of outcomes data on the management of postoperative hypocalcemia in head and neck endocrine surgery patients

Postoperative hypocalcemia is a well-described outcome following thyroid and parathyroid surgery with symptoms ranging from clinically insignificant laboratory findings to tetany and seizures. The aims of this study were 1. To identify the characteristics and management patterns of postoperative hypocalcemia in head and neck endocrine surgery patients and 2. To compare outcomes between patients treated with empiric calcium and patients treated using a biochemically driven calcium replacement algorithm. Clinical electronic medical record (EMR) data was collected from patients who had undergone total thyroidectomy, completion thyroidectomy, and/or parathyroidectomy at Wake Forest Baptist Medical Center (WFBMC), a tertiary referral and academic institution. Between July 1, 2016, and June 30, 2017, 298 adult patients underwent surgery by a WFBMC Head & Neck (H&N) endocrine surgeon. Objective calcium and parathyroid hormone levels, postoperative supplementation with calcium and Vitamin D, 30-day physician access line (PAL) phone call utilization, emergency department (ED) encounters, and readmission rates were queried. The overall rate of hypocalcemia was 17.4%. No statistically significant difference in PAL utilization, ED visits, or readmissions was found between the empiric supplementation group and those whose supplementation was biochemically directed (PAL 5.0% vs. 5.0% [p = 0.983], ED visit 3.3% vs. 2.5% [p = 0.744], Readmission 1.7% vs. 0% [p = 0.276]). The overall postoperative rates of hypocalcemia and hypoparathyroidism following H&N endocrine surgery were consistent with the reported literature. Neither method of calcium supplementation was superior in reducing PAL utilization, ED encounters, or readmission.

Surgical management of Eagle syndrome: A 17-year experience with open and transoral robotic styloidectomy

Eagle Syndrome (ES) is a rare disorder that can present with symptoms ranging from globus sensation to otalgia that is attributed to an elongated styloid process and/or calcified stylohyoid ligament. No standardized treatment algorithm exists, and although various surgical approaches have been described, data on the use of transoral robotic surgery (TORS) in this population is limited. To investigate the utility of TORS in the treatment of ES, a retrospective review in 19 ES patients was carried out at a single academic, tertiary medical center between 2000 and 2017. Nineteen patients underwent twenty-one styloid resections: 6 performed via TORS and 15 via transcervical approach. Across all patients, 90% reported some degree of lasting improvement in symptoms while 55% reported significant improvement. When TORS was compared to transcervical resection, there was no difference in the subjective rate of "meaningful" (83 vs. 57%) versus rate of "non-meaningful" symptom improvement (17 vs. 43%) (p = 0.35). There was a trend towards less estimated blood loss (EBL), operative time, and post-operative length of stay (LOS) with TORS versus transcervical cases (9.2 mL vs. 30.0 mL, 98 vs. 156 min, and 0.7 vs. 1.2 days); however, these did not reach statistical significance (p = .11, 0.13, and 0.42, respectively). Three patients experienced complications associated with an open approach, as compared to none with TORS. In select patients, TORS styloidectomy is a reasonable surgical alternative to traditional transoral and transcervical techniques as it provides similar symptom improvement, and reduced length of stay, blood loss, and operative time.

Increased Expression of MuRF1 Is Associated with Radiation-induced Laryngeal Muscle Atrophy

BACKGROUND

Laryngeal muscles play an important role in breathing, sound production and trachea protection against food. Laryngeal dysfunctions during radiotherapy for head and neck cancers are common. In the present study, we aimed to investigate the early effect of radiation on the laryngeal muscles in vivo and possible mechanisms involved in this process.

MATERIALS AND METHODS

Eight-week-old female C57bl/ mice received neck irradiation with a single dose of 25 Gy and bilateral thyroarytenoid (TA) muscles of mice were collected at day 3, 7 and 10 post-irradiation for evaluating muscle size, myosins, myosin heavy chain (MyHC) composition and MuRF1 protein levels.

RESULTS

A significant reduction in the size of muscle fibers and myosins in the TA muscles were observed at days 3, 7, 10 after radiation (p<0.05). The loss of IIB myosin was more severe than that of IIA/X myosins at day 7 post-irradiation (75% vs. 64%). MuRF1 protein level was markedly increased at day 7 and 10 after radiation (p<0.05).

CONCLUSION

Radiation induced an acute muscle fiber atrophy and myosin loss in the intrinsic laryngeal muscles. MuRF1 may play an important role in the radiation-induced protein degradation in the laryngeal muscles and warrants further investigation.

Retrospective analysis of the impact of HPV status and smoking on mucositis in patients with oropharyngeal squamous cell carcinoma treated with concurrent chemotherapy and radiotherapy

OBJECTIVES

The standard concurrent radiotherapy and chemotherapy regimens for patients with oropharyngeal cancer are highly toxic. Human papillomavirus (HPV)-associated oropharyngeal squamous cell carcinoma (OPSCC) has recently emerged as a distinct biological and clinical entity with improved response to treatment and prognosis. A tailored therapeutic approach is needed to optimize patient care. The aim of our study was to investigate the impact of HPV and smoking status on early toxicities (primarily mucositis) associated with concurrent chemotherapy and radiotherapy in patients with OPSCC.

MATERIALS AND METHODS

We retrospectively evaluated 72 consecutive patients with OPSCC and known HPV status treated with concurrent radiotherapy and chemotherapy at our institution. Treatment-related toxicities were stratified by smoking and HPV status and compared using univariate and multivariate logistic regression.

RESULTS

HPV-positive patients had a 6.86-fold increase in the risk of having severe, grade 3-4 mucositis. This effect was preserved after adjusting for patient smoking status, nodal stage, radiotherapy technique and radiotherapy maximum dose. Additionally, HPV status had significant effect on the objective weight loss during treatment and at three months after treatment. Consistently, non-smokers had a significant 2.70-fold increase in the risk of developing severe mucositis.

CONCLUSION

Risk factors for OPSCC modify the incidence of treatment-related early toxicities, with HPV-positive and non-smoking status correlating with increased risk of high grade mucositis and associated outcomes. Retrospective single-institution studies need to be interpreted cautiously. However, this finding is important to consider when designing therapeutic strategies for HPV-positive patients and merits further investigation in prospective clinical trials.

Disposition of elderly patients after head and neck reconstruction

IMPORTANCE

A patient's needs at discharge, particularly the need for nursing facility placement, may affect hospital length of stay and health care costs. The association between age and disposition after microvascular reconstruction of the head and neck has yet to be reported in the literature.

OBJECTIVE

To determine whether elderly patients are more likely to be discharged to a nursing or other care facility as opposed to returning home after microvascular reconstruction of the head and neck.

DESIGN, SETTING, AND PARTICIPANTS

From January 1, 2001, through December 31, 2010, patients undergoing microvascular reconstruction at an academic medical center were identified and their medical records systematically reviewed. During the study period, 457 patients were identified by Current Procedural Terminology codes for microvascular free tissue transfer for a head and neck defect regardless of cause. Seven patients were excluded for inadequate data on the postoperative disposition or American Society of Anesthesiologists (ASA) score. A total of 450 were included for analysis.

MAIN OUTCOMES AND MEASURES

Demographic and surgical data were collected, including the patient age, ASA score, and postoperative length of stay. These variables were then compared between groups of patients discharged to different posthospitalization care facilities.

RESULTS

The mean age of participants was 59.1 years. Most patients (n = 386 [85.8%]) were discharged home with or without home health services. The mean age of those discharged home was 57.5 years; discharge to home was the reference for comparison and odds ratio (OR) calculation. For those discharged to a skilled nursing facility, mean age was 67.1 years (OR, 1.055; P < .001). Mean age of those discharged to a long-term acute care facility was 71.5 years (OR, 1.092; P = .002). Length of stay also affected the disposition to a skilled nursing facility (OR, 1.098), as did the ASA score (OR, 2.988).

CONCLUSIONS AND RELEVANCE

Elderly patients are less likely to be discharged home after free flap reconstruction. Age, ASA score, and length of stay are independent factors for discharge to a nursing or other care facility.

Polymorphous low-grade adenocarcinoma: a 17 patient case series

Polymorphous low-grade adenocarcinoma (PLGA) is a rare malignancy most commonly seen in the minor salivary glands. First described in 1983, this entity has been recognized to have an indolent course with rare metastases or deaths. We describe our experience with 17 patients treated at our institution for PLGA from 1984 to 2012. All tumors were located in the oral cavity or soft palate. All patients were treated surgically, with the exception of one patient who declined therapy. No deaths or metastases have been identified in subsequent follow-up. Three patients in this series had undergone prior surgery up to 20 years previously and were treated for recurrences at our institution; no other recurrences have been noted. In summary, PLGA is best treated with wide excision to negative margins with excellent prognosis, but long-term follow-up is recommended given the propensity for late recurrences.

Internal carotid artery in zone IIb and its implications: A case report

The potential for aberrant anatomy in the neck should be respected in order to avoid unexpected and potentially devastating injury during surgical and other procedures. Anatomic variations involving the internal carotid artery are believed to exist in as much as 6% of the population. We describe a case of a tortuous internal carotid artery that was found in zone IIb during a neck dissection in a 60-year-old man, and we discuss the implications of this anomaly.

Malignant fibrous histiocytoma of the head and neck: a case series

PURPOSE

The study objective is to evaluate the clinical features and outcomes of patients treated for head and neck malignant fibrous histiocytoma at a tertiary care medical facility.

MATERIALS AND METHODS

This is a retrospective case series of 17 adult subjects with malignant fibrous histiocytoma of the head and neck who were treated between January 1, 1965, and December 31, 2010. This study was conducted using patient charts at a tertiary medical center. Subject selection was conducted using Current Procedural Terminology numbers; International Classification of Diseases, Ninth Revision, codes; and a search of the tumor registry.

RESULTS

Chart review of the 17 identified subjects revealed an overwhelming male predominance (88%) with an overall mean age of 69 years(52-87 years). Thirteen patients (78%) underwent some form of surgical resection, 6 patients (35%) received radiation therapy, and 6 (35%) were given chemotherapy over the course of treatment. Nine tumors (53%) had a cutaneous origin, whereas 8 lesions (47.1%) were found in the soft tissue of the head and neck region. The local recurrence rate following a single resection was 46%. Overall median survival following diagnosis was found to be 65 months, with a 5-year survival rate of 52%. Median disease-free survival was 20 months, with a 5-year disease-free survival rate of 37%. Overall median and 5-year survival rates were found to increase with clear surgical margins, as was 5-year survival.

CONCLUSIONS

Aggressive surgical management to achieve clear margins is central to the effective treatment of malignant fibrous histiocytoma of the head and neck. Metastatic disease portends a dismal prognosis.

Parathyroid hormone early percent change: an individualized approach to predict postthyroidectomy hypocalcemia

PURPOSE

The purpose of this study is to evaluate a percent change model of postoperative parathyroid hormone level in thyroidectomy patients as a predictor of hypocalcemia.

MATERIALS AND METHODS

Chart review was completed on patients who had undergone total or completion thyroidectomy over a 22-month period in our department. Only those patients with a preoperative ionized calcium and parathyroid hormone (PTH) level and at least 1 postoperative result were included. Ionized calcium levels served as an internal control. The Student t test was used to compare PTH level between the normocalcemic and hypocalcemic groups at each time point. Logistic regression analysis was used to predict hypocalcemia based on the diagnostic criteria. Receiver operator curves were used to maximize sensitivity.

RESULTS

Fifty-two patients met the inclusion criteria during the study period. A total of 22 patients (42%) experienced hypocalcemia. We were unable to maximize both sensitivity and specificity at the same time point. When comparing preoperative to 6-hour postoperative PTH percent change, patients with a greater than 44% decrease are likely to have hypocalcemia, with a sensitivity of 100%. Likewise, in those patients without a greater than 44% decrease at 6 hours, early discharge can be considered safe, given the negative predictive value of 100%.

CONCLUSION

In our series, patients with a greater than 44% PTH decrease from preoperative to 6-hour postoperative are very likely to develop hypocalcemia. We would propose that these patients need further inpatient monitoring to progress to safe discharge. Likewise, patients with a less than 44% decrease at the 6-hour time point are unlikely to develop hypocalcemia and may be considered safe for discharge.

Prognostic Value of PET-CT for Oropharyngeal Carcinoma

Objective: Understand local, nodal, and distant cure rates and the prognostic value of [18F]Fluorodeoxyglucose positron emission tomography (PET-CT) after chemoradiation (CRT) for advanced oropharyngeal squamous cell carcinoma (OPSCC). Propose a potential algorithm for surveillance PET-CT based on patient history.

Method: A retrospective chart review of 53 patients treated from 2005 to 2008 with CRT for stage 3 (6%) or stage 4 (94%) OPSCC at a tertiary referral center. Variables reviewed included type of CRT, PET-CT results, and smoking history. Outcomes evaluated included patterns of recurrence, survival, and progression free survival (PFS).

Results: Overall PFS rate was 77% at 3 years. The first post-treatment PET-CT obtained a median of 2.3 months after CRT was normal in 32 patients, however 5 patients ultimately relapsed. Sixteen patients had elevated FDG uptake of which 3 recurred. The result of the first PET-CT was not significantly associated with recurrence ( P = .2988). The second post-treatment PET-CT, obtained a median of 8.6 months after CRT, was normal in 28 patients, of which only one relapsed. Four out of 12 patients with abnormal scans recurred. A normal delayed PET-CT predicted the absence of disease ( P = .0211).

Conclusion: A normal PET-CT early after CRT for OPSCC did not reflect the absence of disease. A normal PET-CT 6 to 8 months after treatment predicted good control of disease. The optimal time for PET-CT to demonstrate prognostic value may be 6 to 8 months after completion of CRT.

Surgical therapy of glomus vagale tumors

Lying between the carotid bifurcation and the jugular foramen, glomus vagale tumors share characteristics with paragangliomas of those two structures, such as invasion of the carotid artery, destruction of the skull base, and cranial neuropathies. This capability for local invasion provides a therapeutic challenge with regard to the proper assessment of tumor extent and the selection of appropriate treatment. In order to clarify an approach to the management of glomus vagale tumors, we reviewed a 10-year experience with 15 patients treated for this tumor at the University of Zürich Department of Otolaryngology, using a new system of classification. This system highlights the relative position of a vagal paraganglioma to the jugular foramen and is helpful in designing the proper therapy. Pitfalis in surgical technique, recommended preoperative evaluation, and the roles of balloon occlusion and irradiation in the treatment of these tumors, are discussed.

Lateral orbital/anterior midfacial degloving approach for nasopharyngeal angiofibromas with cavernous sinus extension

A case of nasopharyngeal angiofibroma removed through a modified lateral approach for an infratemporal fossa resection is reported. This modification involved removing the bone of the lateral orbital apex and posterior middle fossa to expose the dura and periorbita and, when combined with a midfacial degloving approach, provided full access to the tumor abutting the cavernous sinus extradurally while preserving middle ear function.

Functional outcomes and suitability of the temporalis myofascial flap for palatal and maxillary reconstruction after oncologic resection

OBJECTIVES/HYPOTHESIS

The temporalis myofascial flap (TMF) is a method of palatal reconstruction that offers a single-stage, reliable, and functional technique to repair oncologic defects involving the oral cavity following tumor removal. It is hypothesized that both speech and swallowing function are preserved following TMF.

STUDY DESIGN

In a retrospective and prospective case series, this study evaluated the surgical outcomes of 72 patients undergoing surgical resection and reconstruction of the hard and soft palate using a TMF. Of this series, 25 patients underwent nasalence and swallowing quality-of-life testing to determine speech and swallowing function following this procedure.

METHODS

Reliability, safety, and effectiveness data endpoints on TMF reconstruction were collected and analyzed. Instrumental measures of nasalence (KayPentax Nasometer, Lincoln Park, NJ) and swallowing quality of life measures (MD Anderson Dysphagia Inventory [MDADI] were acquired.

RESULTS

All TMF's were successfully transferred with complete healing of the oncologic defect. The group mean nasalence for connected speech tasks were within normal limits for connected speech--high- and low-pressure tasks (M = 21% and M = 17%). The group mean nasalence scores for sustained vowels were mildly affected (M = 26%). The group mean MDADI score was 79 (SD = 16), indicating good to mildly affected swallowing quality of life. Neither nasalence nor MDADI scores appeared to vary as a function of defect region.

CONCLUSIONS

The TMF is an oncologically safe and effective method of palate reconstruction that affords excellent quality of life to appropriately selected patients without reliance on other reconstructive techniques.

Parascapular free flaps in skin malignancies

This study was a retrospective review of a case series of nine patients, aged 40 to 83 years, presenting to the head and neck cancer department at Wake Forest Baptist Medical Center, with a diagnosis of head and neck cutaneous squamous cell carcinoma (SCC), requiring reconstruction after surgical resection. In this group of patients, parascapular fasciocutaneous free flaps proved to be a safe, reliable, and cosmetically effective choice for reconstruction of head and neck skin cancer defects. Choosing donor tissue from a relatively non-sun exposed area can prevent potential development of new malignancies that may arise from donor sites using sun-exposed skin. We discuss the benefits and versatility of the parascapular fasciocutaneous free flap and our experience in using this flap to reconstruct complex surgical defects.

Clinical, histopathologic, and radiographic indicators of malignancy in head and neck paragangliomas

OBJECTIVE: The goal of this study is to review our series of head and neck paragangliomas to identify factors that may help in predicting malignancy.

STUDY DESIGN: Case series with chart review.

SETTING: Academic medical center.

SUBJECTS AND METHODS: Subjects with head and neck paragangliomas at our institution from 1976 to current were reviewed. In addition to statistical comparisons of epidemiologic factors, pathologic and radiographic characteristics were reviewed.

RESULTS: Of the 84 subjects, there were seven malignant paragangliomas (8%). Age was found to be significantly different between the benign and malignant subgroups, with an average age of 54 ± 16 and 40 ± 12 years, respectively ( P = 0.02). Pain was a presenting complaint in five patients with benign disease (6%), and five of the seven malignant patients (71%) presented with pain, showing a significant association between pain and disease type ( P <0.0001). The odds ratio for a patient with pain having a malignant tumor was 36 (95% CI: 5.5–234). Enlarging neck mass was noted in all cases of malignant disease, but only in 31 percent of cases of benign disease ( P < 0.0001). In a secondary analysis of carotid body tumors alone, enlarging neck mass was not found to be significant between benign and malignant disease ( P = 0.14). However, pain continued to be significantly different, with 67 percent of malignant lesions demonstrating pain, compared with only 11 percent of benign lesions ( P = 0.01). CONCLUSION: This study suggests that pain, a rapidly enlarging neck mass, and younger age are predictive factors of underlying malignancy, which should prompt one to consider an aggressive diagnostic and management approach.

Minimizing complications in the use of titanium condylar head reconstruction prostheses

OBJECTIVE

The study goals were to evaluate the use of titanium condylar prostheses in the setting of tumor resection and to discuss the techniques used to minimize complications.

STUDY DESIGN AND SETTING

We conducted a retrospective review of a case series in a tertiary care hospital. Six patients underwent mandibulectomy, including the condyle, with primary reconstruction using titanium condylar prostheses. Charts were reviewed for operative technique, pathology, and complications.

RESULTS

Pathology included squamous cell carcinoma, Ewing's sarcoma, embryonic rhabdomyosarcoma, giant cell granuloma, and adenocarcinoma. Three patients are alive without disease. Follow-up spanned 6.4 years with premorbid occlusion established in all cases, and there were no prosthesis extrusions or erosions. The condylar head was wrapped in preserved joint capsule or adjacent temporalis muscle/fascia and secured with permanent purse-string sutures; careful duplication of the length, and angulation of the native mandible from the angle to the superior extent of the condylar head.

CONCLUSION

Titanium condylar prostheses are a viable choice in the setting of tumor resection and reconstruction, with appropriate technical precautions.

Combined intraoral and lateral temporal approach for palatal malignancies with temporalis muscle reconstruction

OBJECTIVE

To evaluate the use of a combined lateral temporal fossa and intraoral approach to resect palatal carcinomas and the use of a temporalis myofascial flap for reconstruction.

DESIGN

Retrospective chart review of a case series.

SETTING

Tertiary university referral hospital.

PATIENTS

Sixteen patients underwent a combined approach for resection of palatal carcinoma; 5 of the 16 were edentulous. Six types of tumors were treated: adenoid cystic carcinoma (3 patients), low-grade mucoepidermoid carcinoma (5 patients), squamous cell carcinoma (3 patients), polymorphous low-grade adenocarcinoma (2 patients), osteosarcoma (1 patient), ameloblastoma (1 patient), and hyalinizing clear cell carcinoma (1 patient).

MAIN OUTCOME MEASURES

The postoperative diet, velum competence, flap viability, complications, and survival.

RESULTS

Fifteen (94%) of 16 patients were able to resume their preoperative diets. No velopharyngeal insufficiency was encountered. All flaps survived and none required repeated surgical intervention. Five patients developed serous otitis media and 2 patients required flap revision secondary to posterior choanal obstruction. One patient died of complications unrelated to the procedure.

CONCLUSIONS

A combined intraoral and lateral temporal fossa approach allows for (1) en bloc resection of palatal malignancies along with resection of involved pterygoid muscles, (2) isolation and resection of descending palatine nerves and the proximal second division of the trigeminal nerve, and (3) primary reconstruction of the palatal defect by means of the temporalis muscle rotated into the operative defect. This method is especially useful in treating patients with perineural spread of palatal carcinoma, and in those who are edentulous.

The midfacial degloving procedure for nasal, sinus, and nasopharyngeal tumors

The midfacial degloving approach is more technically involved than a lateral rhinotomy and requires a basic level of proficiency and understanding of closed rhinoplasty incisions and anatomy of the nose, paranasal sinuses, and skull base structures. Current applications of the midfacial degloving procedure have allowed expansion of indications for this technique through the use of complementary endoscopic and subcranial approaches, permitting the exposure and removal of extensive skull base lesions without disfiguring facial incisions. Fundamental in these approaches is the basic midfacial degloving exposure, which is discussed in this article, along with the applications for treatment of skull base lesions.

Endovascular treatment of hemorrhage after tonsillectomy in children

SUMMARY

Endovascular therapy for hemorrhage after tonsillectomy or adenoidectomy is an important adjunct to the definitive treatment of this life-threatening occurrence. We report two cases of hemorrhage after tonsillectomy and/or adenoidectomy and describe the endovascular management of this complication in children.

Preservation of olfaction in anterior skull base surgery

OBJECTIVES/HYPOTHESIS

In selected unilateral tumors and defects of the anterior skull base, the preservation of contralateral olfaction is achievable through a localized subcranial approach without compromising surgical objectives of resection or repair.

STUDY DESIGN

Description of a functional adaptation of anterior skull base surgical techniques through a retrospective patient series.

METHODS

Nine patients underwent anterior skull base surgery for unilateral cribriform plate disease including four malignant and two benign tumors, two encephaloceles, and one iatrogenic cribriform injury with cerebrospinal rhinorrhea. All nine patients consented to a localized subcranial approach to the anterior skull base to preserve the contralateral olfactory nerves. In four patients with benign disease a portion of the ipsilateral nerves was additionally conserved. Postoperative olfaction was assessed objectively with a commercially available smell test. Indications, technique, results, and complications are reported and discussed.

RESULTS

All patients had eradication of disease with preservation of functional olfaction

CONCLUSIONS

Conservation of olfaction is possible in selected cases of anterior skull base surgery when the lesion is unilaterally confined.

Temporal approach for resection of juvenile nasopharyngeal angiofibromas

OBJECTIVE

To describe a lateral preauricular temporal approach for resection of juvenile nasopharyngeal angiofibroma (JNA).

STUDY DESIGN

A retrospective review of five patients with JNA tumors that were resected by a lateral preauricular temporal approach.

METHODS

The medical records of five patients who underwent resection of JNA tumors via a lateral preauricular temporal approach were reviewed, and the following data collected: tumor extent, blood loss, hospital stay, and surgical complications.

RESULTS

Five patients with JNA tumors had resection by a lateral preauricular temporal approach. These tumors ranged from relatively limited disease to more extensive intracranial, extradural tumors. Using the staging system advocated by Andrews et al., these tumors included stages II, IIIa, and IIIb. Four patients (stages II, IIIa, IIIa, and IIIb) who underwent primary surgical excision had minimal blood losses and were discharged on the first or third postoperative day with minimal transient complications (mild trismus, frontal branch paresis, serous effusion, and cheek hypesthesia). The remaining patient (stage IIIb) did well after surgery, despite having undergone preoperative radiation therapy and sustaining a significant intraoperative blood loss. There have been no permanent complications or tumor recurrences.

CONCLUSIONS

A lateral preauricular temporal approach to the nasopharynx and infratemporal fossa provides effective exposure for resection of extradural JNA tumors. The advantages of this approach include a straightforward route to the site of origin, the absence of facial and palatal incisions, and avoidance of a permanent ipsilateral conductive hearing loss.

Evaluation of airway obstruction using virtual endoscopy

OBJECTIVES

This study examines the use of virtual endoscopy (VE) in the evaluation of patients with upper airway obstruction. The utility of VE compared with actual endoscopy was investigated with respect to accuracy of diagnosis and reproduction of endoscopic images.

STUDY DESIGN

A random cohort of 30 patients with various causes of airway obstruction was examined.

METHODS

The computed tomography (CT) data were reconstructed using a proprietary VE software program, FreeFlight, blind to the actual endoscopic findings. The cause of obstruction was identified and compared with actual endoscopic findings. This included 21 patients with airway stenoses, 8 patients with laryngotracheomalacia, 3 tracheal tumors, 2 glottic webs, 5 patients with innominate artery compression, 2 tracheal granulomas, and 7 patients with impaired true vocal cord mobility.

RESULTS

Virtual endoscopic evaluation was accurate in assessing stenosis width and length of fixed airway lesions. Correlation of stenosis shape and contour between actual endoscopy and VE was excellent. The stenosis-to-lumen ratios were compared between VE and actual endoscopy and were found to be within 10% (SD = 8). However, virtual endoscopic evaluation could not illustrate one of the glottic webs, half of the cases of tracheomalacia, or any of the cases of impaired true vocal cord mobility.

CONCLUSIONS

Virtual endoscopy was not as sensitive as actual endoscopy in detecting the cause of airway obstruction that was based on dynamic movement. However, VE was excellent for the measurement and definition of fixed airway lesions.

Benefits of routine maxillectomy and orbital reconstruction with the rectus abdominis free flap

Maxillary defects lead to functional and cosmetic deficiencies, especially with tumor invasion of the orbit and cribriform plate. Additionally problematic is the near-total palatal resection in patients with poor dentition (ie, not useful for anchoring obturators) and the desire for return of deglutition and useful speech. A series of 12 patients is presented in whom a rectus abdominis free flap was used for reconstruction of the palate, maxilla, and/or orbit. Nine of 12 free flaps were used to reconstruct defects involving the maxilla and orbit; all were successful in restoring hard palate continuity and function without the use of an obturator. The remaining 3 patients underwent successful repair of defects involving the orbit and medial maxilla without complication. Four of those 9 patients with palatal reconstruction augmented their dental rehabilitation with either their existing upper denture plate or the use of a cosmetic appliance anchored to their remaining dentition. Objectively, the rectus abdominis myocutaneous free flap proved to be a reliable and expeditious method of restoring function and acceptable cosmesis. We believe this technique should be routinely considered in the reconstruction of these defects.

The effect of endothelial cell growth factor on peripheral nerve regeneration

Neural regeneration after grafting can be unpredictable. In an effort to enhance the return of function after cable grafting, we studied the effects of an angiogenic factor, endothelial cell growth factor (ECGF), on regenerating nerves. Cable grafts on the sciatic nerve were established in 18 rats and treated with ECGF or a control saline solution. At 5 weeks, nerve conduction studies were performed, and the animals were killed for histologic measurements of graft vascularity and axon counts. A significant increase in vascularity was noted in the treated group versus the control group; neither the axon counts nor the nerve conduction velocities differed significantly between the two groups, although the treated group appeared to show improved neural conduction compared with the control group.

Management of nonepidermoid cancer of the larynx

Nonepidermoid cancer of the larynx represents an extremely diverse group of diseases with differing prognoses and rationales of management. With the lack of specificity in symptoms and physical findings, proper and expeditious lesion characterization is therefore dependent on a high index of suspicion by the clinician and accurate consulting histopathology. These neoplasms can be grouped according to cells with secretory, connective tissue, lymphoreticular, or metastatic origins. Based upon this framework, this article discusses the unique aspects of these various diseases that can lead to their diagnosis, along with consideration of management options and prognostic variables.

Desmoplastic malignant melanoma of the oral mucosa. An underrecognized diagnostic pitfall

BACKGROUND

Although cutaneous desmoplastic malignant melanoma (DMM) has been well characterized, those arising from the oral mucosa have been less well defined.

METHODS

We evaluated the clinical and pathologic features of three patients with biopsy-proven DMM examined at the North Carolina Baptist Hospital. Routine hematoxylin and eosin-stained slides were reviewed in all three cases. Sections from all cases were examined immunohistochemically using the avidin-biotin-peroxidase (ABC) technique and employing commercially available antibodies to the following antigens: S-100 protein, HMB-45, NK1C3, and cytokeratin (AE1/AE3). Appropriate positive and negative controls were utilized throughout these procedures. Clinical data were obtained from the patients' medical records.

RESULTS

Age at diagnosis for the three male patients were 42, 64, and 75 years. Anatomically, these neoplasms arose from the left maxillary oral mucosa (two patients) and the vermilion border of the lower lip (one patient). Initial incisional biopsies of all three patients were misinterpreted as desmoid tumor (one patient) and squamous cell carcinoma (two patients), respectively. Histologically, all tumors were poorly circumscribed and composed of fascicles and bundles of spindle-shaped cells with hyperchromatic nuclei and associated with extensive stromal collagenization. Perineural invasion was noted in two tumors. An overlying atypical, intraepidermal melanocytic proliferation was observed in two tumors. Immunohistochemically, all three tumors showed positive immunoreactivity with S-100 protein and vimentin. One tumor also expressed HMB-45. Wide surgical incision was the primary mode of therapy in all patients. One patient also received multiple courses of radiation therapy and chemotherapy. One patient died of widespread metastatic disease.

CONCLUSIONS

DMM of the oral mucosa is a rare, often unrecognized, form of malignant melanoma associated with a fibrosarcoma-like morphologic appearance and abundant collagenization. Meticulous attention to histomorphology and judicious use of immunohistochemical stains will help prevent misdiagnosis.

Effect of intermittent acid and pepsin exposure on burned esophageal mucosa

PURPOSE

To determine if gastroesophageal reflux affects the healing of esophageal mucosa damaged by alkaline substances.

MATERIALS AND METHODS

In a rabbit model, the effects of intermittent acid and pepsin exposure (thereby mimicking gastroesophageal reflux) on post-caustic-burn esophageal mucosa were examined. Exposures were group I (n = 9), sodium hydroxide exposure alone; group II (n = 9), daily acid and pepsin exposure; and group III (n = 8), sodium hydroxide, then daily acid and pepsin exposure. After 3 weeks, the animals were killed and their esophagi examined.

RESULTS

Grossly, specimens in group II appeared normal; specimens in groups I and III were abnormal, displaying some scar tissue, but were not significantly different. Histologically, the differences between groups I and III approached significance. Increased numbers of intraepithelial eosinophils were seen in those specimens exposed to reflux.

CONCLUSIONS

Gastroesophageal reflux may retard the healing of injured esophageal mucosa and should be studied further in an effort to improve the care of patients who sustain alkaline esophageal burns.

Spontaneous cerebrospinal fluid otorrhea from defects of the temporal bone: a rare entity?

Cerebrospinal fluid (CSF) otorrhea is usually associated with a history of trauma or previous surgery. Spontaneous CSF otorrhea is uncommon. When such spontaneous CSF leakage occurs, it may be associated with dural herniation, with the production of conductive hearing loss from impingement on the ossicles. This type of leakage has characteristic findings which, if recognized, can lead to earlier diagnosis and avoidance of complications. A review of the world literature revealed 44 reported cases. This report presents the authors' experience with 12 patients with spontaneous CSF leakage from temporal bone defects. This entity may be more prevalent than is reported. The differential diagnosis and management of CSF otorrhea (secondary to temporal bone defects) are discussed and representative cases are presented.

Gunshot wounds to the mandible and midface: evaluation, treatment, and avoidance of complications

As American society becomes progressively violent, an ever-increasing number of gunshot wounds are being seen across the United States. Particularly challenging are injuries that involve the mandible and midface, not only because of problems with reconstructing bone and soft-tissue defects but also because of emergent problems with airway obstruction and neurovascular compromise. We present 40 cases of gunshot wounds to the mouth, mandible, and maxilla treated at Wake Forest University Medical Center during the past 7 years. The focus of this retrospective analysis is on emergency evaluation and treatment, complications encountered, and operative techniques used for reconstruction. Special emphasis is placed on recognizing and avoiding the complications of these injuries.

Transotic approach to the cerebellopontine angle

The transotic approach to the cerebellopontine angle for resection of tumors invading the internal auditory canal provides superior illumination and exposure for optimal preservation of facial nerve function. Separation of facial nerve from tumor is enhanced with an anterior exposure that allows visualization of the intracranial segment of the nerve before tumor removal without significantly increasing total operative time. Facial nerve grafting or hypoglossal-facial anastomosis may be incorporated into the procedure at the time of tumor resection using the transotic approach. When combined with a musculofascial patch secured to the dural defect, the initial subtotal petrosectomy with eustachian tube and middle ear cleft obliteration generally avoids the complication of an immediate or delayed postoperative cerebrospinal fluid leak. The transotic approach is indicated for tumors up to 2.5 cm in size that are not adherent to the brain stem.

Management decisions in laryngeal carcinoma in situ

Twenty-one patients with laryngeal carcinoma in situ (n = 12) or carcinoma in situ with microinvasion (n = 9) were treated with laser mucosal dissection of the vocal cords and/or superficial laser cordectomy. The normal architecture of the vocal cords was preserved because the depth of vaporization was usually superficial in these early cases. Five patients had recurrence, new tumor, or persistence of abnormal tissue that required additional laser surgical treatments. With a follow-up range of 6 months to 4 years, all patients currently are free of laryngeal abnormality, and no patient has needed open laryngeal surgery or radiation therapy. Transoral endoscopic laser resection of laryngeal carcinoma in situ with or without microinvasion should be the treatment of choice for these early lesions.

Tracheobronchial foreign bodies

A retrospective review of 88 cases of foreign body aspiration was undertaken. The patients ranged in age from 5 months to 73 years; the peak incidences of foreign body aspiration occurred in children less than 3 years of age and in adults older than 50 years. Sixty-one of the 88 patients were male. Physical examination was abnormal in 61% of patients. The most common radiographic abnormality was inspiratory-expiratory abnormality, seen in 27% of patients. Rigid endoscopy under general anesthesia was the preferred method for removal of the aspirated material. Multiple foreign bodies were found in 5% of the patients. Tracheobronchial foreign bodies should, therefore, be strongly suspected in susceptible patient populations who present with a suggestive history, even when no physical or radiographic evidence can be seen. Patients should be carefully examined for multiple foreign bodies at the time of rigid endoscopic removal.

Headache and the primary empty sella syndrome

Otolaryngologists frequently encounter patients with complaints of headaches. On occasion, normal physical examination findings may be accompanied by a roentgenographic enlargement of the sella turcica. In the process of evaluation for an intrasellar neoplasm, an "empty sella" is occasionally discovered. Patients with this condition commonly have headaches, although a cause-effect relationship is controversial. Endocrine and visual disturbances, although rare necessitate periodic evaluation of these patients.