Prosthodontic guidelines for surgical reconstruction of the maxilla: a classification system of defects

Surgical reconstruction of maxillectomy defects has been described as an alternative to prosthetic rehabilitation to close the oral cavity. Advancements in microvascular surgical techniques require comprehensive treatment planning guidelines for functional rehabilitation. This retrospective study evaluated acquired maxillectomy defects after surgical reconstruction and/or prosthodontic rehabilitation in an attempt to establish surgical and prosthodontic guidelines that could be organized into a classification system. Forty-seven consecutive patient treatments of palatomaxillary reconstruction at a single facility, The Mount Sinai Medical Center (New York, N.Y.), were reviewed. All patients were rehabilitated with a tissue-borne obturator, a local advancement flap, a fasciocutaneous free flap, or a vascularized bone-containing free flap. Palatomaxillary defects were divided into 3 major classes and 2 subclasses. The aim of this defect-oriented classification system was to organize and define the complex nature of the restorative decision-making process for the maxillectomy patient.

Granular cell tumor of the parotid

A case of granular cell tumor of the major salivary glands is presented. This tumor appeared as an expansive multinodular mass that arose from facial nerve trunks. The presenting symptoms of facial pain and paresis and the intraoperative findings of tumor adhesion to nerves led to the clinical impression of malignancy. At intraoperative consultation, the tumor resembled an acinic cell carcinoma. Pathologists should be aware that granular cell tumors may involve the major salivary glands and that it should be considered in the diagnostic differential diagnosis.

Benign intratracheal thyroid: a possible cause for preoperative overstaging

We report a rare case of intratracheal thyroid ectopia in the setting of papillary thyroid carcinoma, resulting in the preoperative clinical impression of an aggressive, high-stage tumor. A 24-year-old opera singer presented with complaints of a gagging or choking sensation. The results of computed tomography revealed a mass in the left thyroid lobe with multiple small calcifications consistent with papillary thyroid carcinoma as well as a soft tissue mass in the adjacent left tracheal lumen thought to be direct invasion by the thyroid tumor. A total thyroidectomy was performed including excision of half of the first and second tracheal cartilages and the lower portion of the hemicricoid cartilage. The final histological findings revealed that the intratracheal component was composed of benign thyroid tissue and strands of benign thyrocytes coursed through the first tracheal membrane. Intratracheal thyroid ectopia is a rare symptomatic occurrence with a striking female predisposition. We have identified 23 cases of intratracheal thyroid ectopia from the literature. They occur most often at the level of the cricoid, usually posteriorly with a slight predisposition for the left side. Continuity between the intratracheal component and the thyroid lobe may be seen. Clinicians and pathologists must be aware of this entity to avoid mistaking it for evidence of thyroid invasion by a malignant neoplasm.

HPV detection using "hot start" polymerase chain reaction in patients with oral cancer: a clinicopathological study of 64 patients

We examined the incidence of human papillomavirus (HPV) in intraoral cancers from 64 patients as determined by the highly sensitive technique of "hot start" polymerase chain reaction (PCR) in formalin-fixed paraffin-embedded tissues. Polymerase-chain-reaction-amplified HPV DNA was detected in the carcinomas of 16 patients (25%). The percentage of men in the HPV-positive (HPV+) group was greater than that in the HPV-negative (HPV-) group (86% versus 68%), but the difference was not statistically significant. There was no intraoral site preference for the HPV+ tumors. The mean age of viral-positive and -negative groups was similar (55 versus 53.8 yr). Three of 16 HPV+ patients (19%) had never smoked cigarettes; however, 16% of the HPV- group had also never smoked. Of interest, 38% of patients interviewed had occupation-related exposures that may have contributed to their carcinogenesis, and a disproportionate percentage of these patients (57%) were from the HPV+ group. There were no statistically significant differences between HPV+ and HPV- cases regarding T stage, clinical stage, and tumor differentiation. The disease-free interval did not differ significantly for HPV+ and HPV- patients in total nor when patients were stratified for tumor stage and clinical stage. The only group that showed some difference in outcome was that of the stage III/IV patients with oral cancer. We observed a shorter survival time for the HPV+ patients as compared with the HPV- patients (P = 0.09). We conclude that, in general, HPV is associated with a minority of intraoral cancers and its presence is not predictive of patient outcome.

Evaluation and management of congenital cervical teratoma. Case report and review

Congenital cervical teratoma can be clinically dramatic, although essentially benign. Prognosis is good provided that the airway is quickly stabilized and resection is not delayed. We present a case of massive cervical teratoma diagnosed using antenatal magnetic resonance imaging. The child was maintained on maternal circulation after cesarean section until successfully intubated, with a second team ready for emergent bronchoscopy or tracheotomy. After delivery, the lesion grew rapidly with persistent bleeding; biopsy revealed a benign, immature teratoma. On computed tomography all anatomy ventral to the vertebrae was obliterated. At surgery, however, the tumor was easily resected. The literature is reviewed, with attention to malignancy in neonatal cervical teratoma. Surgery was delayed because of the aggressive imaging appearance and rapid growth. This case suggests that when evaluating neonatal tumors, the standard criteria for infiltration and resectability may require modification.

Carotid artery resection and bypass for neck carcinoma

Twenty-six patients were treated by carotid artery resection and vascular replacement for recurrent cancer of the neck. The incidence of postoperative neurologic sequelae was 7%. The absolute 12-month disease-free survival for metastatic squamous cell carcinoma was 25%. It is concluded that in selected patients, this aggressive surgical therapy is indicated.

Salvage surgery for recurrent neck carcinoma after multimodality therapy

Recurrent carcinoma of the neck after treatment by radical neck dissection and radiotherapy leads to a progressive downhill course if no further therapy is instituted. Nine such patients having fixed, recurrent neck tumors with carotid artery involvement underwent 10 salvage procedures with carotid artery resection and replacement. One patient developed a transient hemiparesis that resolved in 3 days, and in another, a permanent hemiparesis occurred. Three patients have survived longer than 12 months. One patient is free of disease at 42 months following two salvage operations. We attribute the low operative morbidity to the frequent use of the subclavian artery for proximal anastomosis and myocutaneous flaps to resurface cutaneous and mucosal defects. We conclude that salvage surgery with carotid artery replacement can be performed on selected patients who have failed combined therapy as a palliative and possibly curative measure.

Cricoid collapse. A new technique for management of glottic incompetence

A new procedure corrects glottic incompetence in patients following extended horizontal partial laryngectomy. The procedure consists of making vertical, cartilaginous cuts to collapse one half of the cricoid cartilage to a fixed midline position. In selected patients, this procedure has been demonstrated to permit decannulation where conventional methods have failed.