Sclerosing bone dysplasias with involvement of the craniofacial skeleton

In this review we provide a complete overview of the existing sclerosing bone dysplasias with craniofacial involvement. Clinical presentation, disease course, the craniofacial symptoms, genetic transmission pattern and pathophysiology are discussed. There is an emphasis on radiologic features with a large collection of CT and MRI images. In previous reviews the craniofacial area of the sclerosing bone dysplasias was underexposed. However, craniofacial symptoms are often the first symptoms to address a physician. The embryology of the skull and skull base is explained and illustrated for a better understanding of the affected areas.

Localization of the gene for hyperostosis cranialis interna to chromosome 8p21 with analysis of three candidate genes

Hyperostosis cranialis interna (HCI) is a rare autosomal dominant disorder characterized by intracranial hyperostosis and osteosclerosis, which is confined to the skull, especially the calvarium and the skull base. The rest of the skeleton is not affected. Progressive bone overgrowth causes nerve entrapment that leads to recurrent facial nerve palsy, disturbance of the sense of smell, hearing and vision impairments, impairment of facial sensibility, and disturbance of balance due to vestibular areflexia. The treatment is symptomatic. Histomorphological investigations showed increased bone formation with a normal tissue structure. Biochemical parameters were normal. Until today the disease has been described in only three related Dutch families with common progenitors and which consist of 32 individuals over five generations. HCI was observed in 12 family members over four generations. Patients are mildly to severely affected. Besides HCI, several bone dysplasias with hyperostosis and sclerosis of the craniofacial bones are known. Examples are Van Buchem disease, sclerosteosis, craniometaphyseal dysplasia, and Camurati-Engelmann disease. However, in these cases the long bones are affected as well. Linkage analysis in a family with HCI resulted in the localization of the disease-causing gene to a region on chromosome 8p21 delineated by markers D8S282 and D8S382. Interesting candidate genes in this region are BMP1, LOXL2, and ADAM28. Sequence analysis of these genes did not reveal any putative mutations. This suggests that a gene not previously involved in a sclerosing bone dysplasia is responsible for the abnormal growth in the skull of these patients.

Neurophysiologic, audiometric and vestibular function tests in patients with hyperostosis cranialis interna

OBJECTIVE

Hyperostosis cranialis interna (HCI) is an autosomal dominant sclerosing bone dysplasia affecting the skull base and the calvaria, characterized by cranial nerve deficits due to stenosis of neuroforamina. The aim of this study is to describe the value of several neurophysiological, audiometric and vestibular tests related to the clinical course of the disorder.

METHODS

Ten affected subjects and 13 unaffected family members were recruited and tested with visual evoked potentials, masseter reflex, blink reflex, pure tone and speech audiometry, stapedial reflexes, otoacoustic emissions, brainstem evoked response audiometry and electronystagmography.

RESULTS

Due to the symmetrical bilateral nature of this disease, the sensitivity of visual evoked potentials (VEPs), masseter reflex and blink reflex is decreased (25-37.5%), therefore reducing the value of single registration. Increased hearing thresholds and increased BERA latency times were found in 60-70%. The inter-peak latency I-V parameter in BERA has the ability to determine nerve encroachment reliably. 50% of the patients had vestibular abnormalities. No patient had disease-related absence of otoacoustic emissions, because the cochlea is not affected.

CONCLUSION

In patients with HCI and similar craniofacial sclerosing bone dysplasias we advise monitoring of vestibulocochlear nerve function with tone and speech audiometry, BERA and vestibular tests. VEPs are important to monitor optic nerve function in combination with radiological and ophthalmologic examination. We do not advise the routine use of blink and masseter reflex.

Imaging features and progression of hyperostosis cranialis interna

BACKGROUND AND PURPOSE

HCI is a unique autosomal-dominant sclerosing bone dysplasia affecting the skull base and the calvaria, characterized by cranial nerve deficits due to stenosis of neuroforamina, whereby the mandible is affected to a lesser extent. The aim of this study is to describe the specific radiologic characteristics and course of the disorder.

MATERIALS AND METHODS

CT scans of affected individuals within 1 family were analyzed and compared with scans of their unaffected family members and with an age- and sex-matched control group. Linear measurements were performed of the inner table, the medulla, and the outer table of different skull locations, and attenuation (density) measurements of the same regions were recorded. Neuroforamina widths were recorded as well.

RESULTS

There was significant thickening of the skull in the frontal, parietal, temporal, and occipital regions, which was mainly due to thickening of the inner table of the skull. The attenuation of the deposited hyperostotic bone was lower than normal cortical bone.

CONCLUSIONS

HCI is the only genetic bone dysplasia known that is confined to the craniofacial area. The hyperostotic bone is less attenuated than normal cortical bone. The observed radiologic abnormalities explain the possible impairment of the olfactory, optic, trigeminal, facial, and vestibulocochlear nerves.

Marked differences in survival rate between smokers and nonsmokers with HPV 16-associated tonsillar carcinomas

Oncogenic human papillomavirus (HPV) is a causative agent in a subgroup of head and neck carcinomas, particularly tonsillar squamous cell carcinomas (TSCC). This study was undertaken because controversial data exist on the physical status of HPV-DNA and the use of p16(INK4A) overexpression as surrogate HPV marker, and to examine the impact of HPV and tobacco consumption on the clinical course of TSCC. Tissue sections of 81 TSCC were analyzed by HPV 16-specific fluorescence in situ hybridization (FISH) and p16(INK4A)-specific immunohistochemistry. Results were correlated with clinical and demographic data. HPV 16 integration was detected by FISH as punctate signals in 33 out of 81 (41%) TSCC, 32 of which showed p16(INK4A) accumulation. Only 5 out of 48 HPV-negative tumors showed p16(INK4A) immunostaining (p < 0.0001). The presence of HPV furthermore correlates significantly with low tobacco (p = 0.002) and alcohol intake (p = 0.011), poor differentiation grade (p = 0.019), small tumor size (p = 0.024), presence of a local metastasis (p = 0.001) and a decreased (loco)regional recurrence rate (p = 0.039). Statistical analysis revealed that smoking significantly increases the risk of cancer death from TSCC and that non-smoking patients with HPV-containing TSCC show a remarkably better disease-specific survival rate. HPV 16 is integrated in 41% of TSCC and strongly correlates with p16(INK4A) overexpression, implicating the latter to be a reliable HPV biomarker. Patients with HPV-positive tumors show a favorable prognosis as compared to those with HPV-negative tumors, but tobacco use is the strongest prognostic indicator. These findings indicate that oncogenic processes in the tonsils of non-smokers differ from those occurring in smokers, the former being related to HPV 16 infection.

Primary temporal bone secretory meningioma presenting as chronic otitis media

We report an extremely rare case of a secretory meningioma primarily involving the temporal bone. A 56-year old female patient presented to us with a history of a chronic otitis media and unilateral hearing loss. Diagnostic investigations revealed a tumor arising from the temporal bone without signs of intracranial involvement. Histopathological examination showed a meningioma of the secretory type. The tumor was partially resected and serial imaging at follow-up revealed no extension of the tumor. No new symptoms developed 1 year after surgery. Secretory meningioma is a rare meningioma subtype and extracranial presentation in the temporal bone is very unusual. We present the first case of a primary temporal bone secretory meningioma in the otorhinolaryngological literature. As radical as possible surgical excision with serial imaging at follow-up is recommended.

Infiltrating aggressive epitheliosis of the temporal bone: a newly described disease entity

Two patients with a highly destructive histologic nondysplastic squamous epithelial lesion of the temporal bone are described. Both tumors were characterized by the production of copious amounts of keratin material which progressively extended in the temporal bone, surrounding bony structures, soft tissue and intracranially, with concomitant functional disorders. Only small amounts of epithelial cells were found. CT scanning revealed extensive and progressive destruction of the temporal bone, skull base in both patients, clivus and arch of atlas in one patient, besides intracranial and intracerebellar abscess formation. Despite extensive surgical therapy, the disorder was unmanageable. Histology showed a normal squamous epithelial basal cell layer with remarkable acanthosis and extensive hyperkeratosis. Material obtained at autopsy demonstrated intracerebellar extension of keratin material in one patient and in the hemicerebellectomy specimen of the other patient. To our knowledge, this disease entity has not been reported before.

Paraneoplastic syndromes in patients with primary malignancies of the head and neck. Four cases and a review of the literature

Paraneoplastic syndromes rarely affect patients with head and neck cancer. Four patients with different histological types of head and neck cancer are presented in which the primary malignancy was preceded and/or accompanied by a paraneoplastic syndrome. In the first patient erythrodermia preceded the diagnosis of a nasopharyngeal carcinoma. The second patient presented with a B cell lymphoma of the nasopharynx in association with the syndrome of inappropriate secretion of arginine vasopressine (Schwartz-Bartter syndrome). In the third patient paraneoplastic polyarthritis had been diagnosed 5 months before a hypopharyngeal carcinoma was diagnosed. In the last patient the paraneoplastic anti-Hu positive encephalomyelitis was associated with a primary malignancy in the larynx with neck metastases. Diagnostic procedures, treatment and follow-up of these patients are reported and accompanied by a review of the literature.

Compliance, quality of life and quantitative voice quality aspects of hands-free speech

CONCLUSIONS

With the use of a new automatic stoma valve (ASV) it appears possible to rehabilitate patients who have previously been unsuccessful in acquiring hands-free speech. As well as making daily ASV use possible for an additional group of patients, this new device was also appreciated by many patients as an additional rehabilitation tool for specific occasions. Despite statistically significant improvements in aspects of voice and breathing using this novel ASV, improvement of peristomal adhesion is probably the main factor needed to further increase success rates. Nevertheless, our results show that it makes sense to keep trying to achieve hands-free speech, even if previous attempts have failed.

OBJECTIVE

To make a long-term (6 months) assessment of compliance and aspects of voice, breathing and quality of life using a new ASV: the Provox FreeHands heat and moisture exchanger (HME).

MATERIAL AND METHODS

This was a prospective clinical multicentre trial in 79 laryngectomized patients (8 regular ASV users, 58 previously unsuccessful users and 13 new users). Data were collected at baseline and after 1 and 6 months by means of European Organization for Research and Treatment of Cancer Quality of Life questionnaires and specific structured questionnaires concerning compliance, skin adhesion, voicing and pulmonary aspects. An objective assessment of voice parameters (maximum phonation time, maximum phonation time while counting, dynamic loudness range and number of pauses in a standard read-aloud text) was made for comparison of different stoma occlusion methods (digital occlusion via an HME and two different ASVs). A subjective assessment of overall voice quality was made.

RESULTS

After 6 months, 19% of patients used the new ASV on a daily basis (mean 5 h/day), while 57% used it on an irregular basis as an additional rehabilitation tool for special occasions. Two-thirds of the study group indicated that they would continue to use the new ASV after the study period. With respect to the objective parameters, statistically significantly better maximum phonation times and dynamic loudness ranges were observed with the new ASV compared to the Blom-Singer ASV. However, the best results for all the objective parameters were obtained with digital occlusion via the Provox HME.

Quality of life assessment in laryngectomized individuals: do we need additions to standard questionnaires in specific clinical research projects?

OBJECTIVES

To assess, whether the EORTC questionnaires QLQ-C30 and QLQ-H&N35 give enough detailed information to study specific quality of life (QoL) related issues in laryngectomized individuals.

DESIGN

Multicentre, prospective clinical trial; baseline measurement with EORTC questionnaires and an additional questionnaire, focusing on specific postlaryngectomy problems.

SETTING

Head and Neck Department of one Comprehensive Cancer Center and three Academic Medical Hospitals in the Netherlands.

PARTICIPANTS

Eighty laryngectomized individuals, selected to participate in a prospective clinical trial on hands-free tracheoesophageal speech.

MAIN OUTCOMES MEASURES

Comparison of QoL dimensions, as assessed with the standard EORTC questionnaires, with the information obtained with additional questions, aimed at discovering in more detail, e.g. voice and respiratory problems in laryngectomized individuals.

RESULTS

Based on the EORTC QoL questionnaires a good overall and voice specific QoL-level was found. However, the additional questionnaire showed that especially concerning voice and respiration more specific information was obtained. For example, despite an overall satisfaction with many aspects of the voice in more than three-quarters of the patients, speaking in a noisy environment was reported by 63% of the patients as being a serious problem, and a significant relation could be established between pulmonary and voicing problems (r = 0.28, P < 0.05), something also undetectable with the EORTC questionnaires.

CONCLUSIONS

These findings underline the necessity to develop and use more specific additional questionnaires as an adjunct to the existing EORTC questionnaires, when studying specific symptoms in laryngectomized individuals, especially in order to detect intervention related changes over time.

Thymic cyst in the neck

A rare case of a thymic cyst in the neck containing both thymus and parathyroid tissue in a 7-year-old boy is presented. The clinical presentation, diagnostic evaluation, surgical management and histopathological features are described. The embryology of cervical thymic cysts and the differential diagnosis of cystic neck masses in children are briefly reviewed. The diagnosis is seldom made preoperatively. Surgical resection is the treatment of choice for definitive diagnosis, resolution of symptoms and cure.

Help-seeking behaviour of hearing-impaired persons aged > or = 55 years; effect of complaints, significant others and hearing aid image

OBJECTIVE

To determine factors influencing help-seeking behaviour in hearing-impaired persons aged > or = 55 years

MATERIAL AND METHODS

The study comprised 1,419 persons (480 females, 939 males) aged > or = 55 years who participated voluntarily in a driving test. Pure-tone audiometry was performed in all subjects. Participants without a hearing aid with an average hearing loss of > or = 30 dB in the better ear for the frequencies 0.5, 1, 2 and 4 kHz were asked how they perceived their hearing by means of a structured questionnaire. The questionnaire provided insight into why some hearing-impaired people seek help from a general practitioner (GP) and others do not. Four factors were examined.

RESULTS

A total of 483/1.419 (34%) participants tested had a hearing loss exceeding 30 dB. Fewer than half of these had visited their GP with complaints of hearing impairment. Of those who had not sought help from a GP, 57% nevertheless judged their hearing as poor. Social pressure exerted by significant others was less in the non-consulters group. Hearing aid image did not differ significantly between the two groups.

CONCLUSION

The help-seeking behaviour of hearing-impaired elderly people is related to the degree of hearing disability and the social pressure exerted by significant others as well as the willingness to try hearing aids.

[Diagnostic image (114). A woman with pulse-synchronous tinnitus. Glomus tumor in the ear]

A 58-year-old woman with pulse-synchrone tinnitus was diagnosed with a glomus tumour in the right middle ear.

Effects of early auditory deprivation and stimulation on auditory brainstem responses in the rat

The purpose of this study was to investigate the effect of auditory sound deprivation or stimulation on auditory brainstem responses (ABRs) during the maturation period of the rat auditory system. At postnatal day (PND) 21, 40 newborn Norway Brown male rats were categorized into 3 groups: (i) an auditory deprivation group in which a bilateral average conductive hearing loss of 27 dB was induced; (ii) an auditory activation group exposed to 65-90 dB sound pressure level; and (iii) a control group. ABR recordings were made on PND 84. In order to compare group differences in interpeak latency (IPL), sensation level (SL), defined as stimulus intensity above threshold, was used. IPL measurements and analysis were restricted to the 20-60 dB SL range. No differences were observed in the IPLs of peaks I-IV between the three groups. Small, but not statistically significant, differences in mean estimated IPLs of peaks I-IV were shown in the ranges > 50 dB SL and < 25 dB SL. Possible confounding factors explaining the apparent discrepancy between these results and those of other animal studies are reviewed.

The ex utero intrapartum treatment (EXIT) procedure in fetal neck masses: a case report and review of the literature

Large fetal neck masses can cause airway obstructions with potential fetal demise after delivery. The relationship of the neck mass to airway structures can be defined prenatally with ultrasound and magnetic resonance imaging (MRI). The ex utero intrapartum treatment (EXIT) procedure can be used to obtain a fetal airway while feto-maternal circulation is preserved to optimise fetal outcome. We present a case in which prenatally a large fetal neck mass was diagnosed on ultrasound and a successful EXIT procedure was performed. A review of the literature is given and the prenatal use of ultrasonography and MRI in case of fetal neck masses is discussed.

Metabolic gene polymorphism frequencies in control populations

Using the International Project on Genetic Susceptibility to Environmental Carcinogens (GSEC) database containing information on over 15,000 control (noncancer) subjects, the allele and genotype frequencies for many of the more commonly studied metabolic genes (CYP1A1, CYP2E1, CYP2D6, GSTM1, GSTT1, NAT2, GSTP, and EPHX) in the human population were determined. Major and significant differences in these frequencies were observed between Caucasians (n = 12,525), Asians (n = 2,136), and Africans and African Americans (n = 996), and some, but much less, heterogeneity was observed within Caucasian populations from different countries. No differences in allele frequencies were seen by age, sex, or type of controls (hospital patients versus population controls). No examples of linkage disequilibrium between the different loci were detected based on comparison of observed and expected frequencies for combinations of specific alleles.

Improved prediction of metastasis in tongue carcinomas, combining vascular and nuclear tumor parameters

BACKGROUND

Predicting the presence of metastasis, based on tumor or tumor-related characteristics is of utmost importance. The authors studied the significance of tumor DNA features and tumor-related angiogenesis to predict the occurrence of metastasis in squamous cell carcinomas (SCCs) of the tongue.

METHODS

Paraplast blocks from resection specimens of 20 metastasized and 20 nonmetastasized SCCs of the tongue with a minimum follow-up of 24 months were used. Tissue sections were stained with anti-CD34 monoclonal antibodies for vessel visualization, and according to Feulgen to stain DNA. Using image analysis, data from both stainings were computed for each of the 40 carcinomas. A logistic regression model to predict the presence of metastasis, based on vascular and nuclear morphology features, was developed.

RESULTS

The intratumor variation of chromatin condensation and the percentage vessels smaller than 5 microm in diameter were selected for the model. The model correctly predicted metastasis in 90% of patients and excluded metastasis correctly in 75% of nonmetastasized tumors. Taking into account the prevalence of metastasis in SCC of the tongue of between 30% and 60%, this means a predictive value for a negative outcome of between 95% and 83%.

CONCLUSIONS

The proposed model shows an improvement of predictive values compared with previous models with single parameters. Therefore, a multiparameter model appears to predict the multiparameter process of metastasis better.

Reanimation of the paralyzed face by indirect hypoglossal-facial nerve anastomosis

BACKGROUND

The results of indirect hypoglossal facial nerve anastomosis with interposition of a free nerve graft, end-to-end to the periferal facial nerve stump, and end-to-side to the hypoglossal nerve are prospectively evaluated. This technique is supposed to overcome loss of hypoglossal function.

METHODS

Tongue function in 39 consecutive patients and facial reanimation in 29 patients who completed 24 months follow-up were assessed. Facial nerve function was judged using the House-Brackmann (HB) grading system.

RESULTS

Tongue movements were normal in all operated on patients. Initial facial movements occurred on average 7.5 months postoperatively. The results were graded HB II in 6 (20.9%), HB III in 13 (44.6%), HB IV in 7 (24.1%), HB V in 2 (6.8%) patients, and HB VI in 1 (3.4%) patient. The results were significantly better in young patients and when a short time interval between paralysis and surgery existed.

CONCLUSIONS

Indirect hypoglossal-facial anastomosis is the preferred technique in most patients for whom the classical direct hypoglossofacial anastomosis is indicated.

[Successful reanimation of facial paralysis with an indirect anastomosis between hypoglossal nerve and facial nerve, without loss of function of the tongue]

OBJECTIVE

To describe the surgical procedure and the results of the indirect hypoglossal-facial nerve anastomosis using a free nerve graft in patients with facial nerve paralysis. This technique leaves the tongue function intact.

DESIGN

Prospective study.

METHODS

Tongue function was assessed in 39 consecutive patients who underwent this procedure and facial reanimation was assessed in 29 of these patients who had completed at least 24 months follow-up. Facial nerve function was judged using the House-Brackmann (HB) facial nerve grading system.

RESULTS

Tongue movements were normal in all operated patients; one patient had mild homolateral atrophy. Initial facial movements occurred on average 7.5 months postoperatively (range 4 to 18 months) in all but one patient. The results were graded HB II in 6 patients (20.9%), HB III in 13 (44.6%), HB IV in 7 (24.1%), HB V in 2 (6.8%) and HB VI in 1 patient (3.4%). Hemifacial synkineses were noticeable but no mass movements or gross hypertonia were observed (as are often present in direct hypoglossal-facial anastomosis). The results of facial reanimation were significantly better in young patients and when a short time interval between paralysis and surgery existed. HB grade II was achieved only if the duration of paralysis was less than 12 months.

CONCLUSION

Indirect hypoglossal-facial anastomosis with interposition of a nerve graft allows preservation of tongue function together with good overall facial reanimation, and is therefore to be preferred to the classical direct hypoglossal-facial anastomosis.

Specific steps in aneuploidization correlate with loss of heterozygosity of 9p21, 17p13 and 18q21 in the progression of pre-malignant laryngeal lesions

Laryngeal squamous-cell carcinoma is often preceded by pre-malignant lesions. In this study, pre-malignant as well as malignant laryngeal lesions were analyzed using p53 immunohistochemistry and in situ hybridization for chromosomes 1, 7, 9, 17 and 18. Microsatellite analysis was performed on laser-microdissected tissue fragments with the aim of studying loss of heterozygosity (LOH) of 9p21, 17p13 and 18q21. Sequential biopsies were analyzed from a few cases to study genetic progression in more detail. The following genetic progression patterns were observed: (i) histologically normal mucosa and hyperplastic lesions without malignant progression were typically disomic for all chromosomes tested and showed no or only basal cell layer positivity for p53 and no allelic loss; (ii) hyperplastic lesions preceding dysplastic/invasive growth frequently showed trisomy for chromosome 7 and LOH of 9p21 and 17p13, and small foci within these lesions sometimes showed tetraploidization and p53 positivity; (iii) dysplastic lesions were characterized by a tetraploid chromosome content, LOH of 9p21 and 17p13 and p53 positivity; (iv) carcinoma in situ lesions and invasive laryngeal carcinomas showed a more unbalanced chromosome pattern and an additional 18q21 LOH. These results show that different steps in aneuploidization correlate with LOH of 9p21, 17p13 and 18q21 in early laryngeal carcinogenesis. These genomic changes could be of potential use in the diagnosis and prognosis of pre-malignant laryngeal lesions.

Quantification of tumour vascularity in squamous cell carcinoma of the tongue using CARD amplification, a systematic sampling technique, and true colour image analysis

The aims of this study of head and neck tissue samples were to develop an immunohistochemical protocol based on the catalysed reporter deposition (CARD) technique to enhance staining results for use in automated true colour image analysis, to assess the reproducibility of systematic tissue sampling in the angiogenic hot spot selection, and quantification of microvessel density (MVD) and other vessel characteristics. The latter data were compared between six metastasised tongue squamous cell carcinomas, vs. four non-metastasised. In comparison to the standard immunohistochemical protocol with anti-CD34 antibodies, CARD amplification resulted in both more intensely stained and larger numbers of vessels. Averaging the 10 most vascularised fields of the 40 to 60 systematically sampled fields in a tissue section resulted in an overall acceptable interobserver reproducibility for most assessed vessel parameters (r> or =0.76 and p< or =0.01). The percentage vessels with diameter <5 microm was significantly higher in the non-metastasised tongue carcinomas (p=0.02). However, for a number of tumours the effect of tissue sampling was significant. We conclude that CARD amplification is needed for reliable segmentation of vessels by image analysis systems, and that tumour heterogeneity is a limiting factor for all procedures in which tumour vascularity is assessed in a single tissue section. Figures on http://www.esacp.org/acp/2001/22-4/hannen.htm.

Mapping of resection margins of oral cancer for p53 overexpression and chromosome instability to detect residual (pre)malignant cells

Oral squamous cell cancers (OSCCs) have a high local recurrence rate, partly due to problems in the recognition of minimal residual disease. The use of molecular markers is shown to increase the sensitivity of detection of residual malignant cells in tumour margins of OSCC. p53 immunohistochemistry was combined with in situ hybridization for chromosomes 1 and 7 to determine the presence of genetically unstable cells in resection specimens of OSCC containing invasive cancer. An increased frequency of genetically aberrant cells was observed, as detected by p53 overexpression and/or aneusomy, with histological progression of normal mucosa via hyperplasia to dysplasia. Of clinical importance was the finding that 11 of 20 resection margins, all of which were initially diagnosed as being tumour-free, were found to contain genetically aberrant (pre)malignant cells. In these areas, closer histological examination of the genetically aberrant compartment within these margins often also revealed small dysplastic areas that were missed in the initial diagnosis, showing that this genetic approach can assist in diagnosis.

The double auditory meatus--a rare first branchial cleft anomaly: clinical presentation and treatment

OBJECTIVE

To discuss the embryology, classification, clinical experience with, and management of first branchial cleft anomalies.

STUDY DESIGN

Retrospective case review.

SETTING

Tertiary referral center.

PATIENTS

Patients with a first branchial cleft anomaly.

INTERVENTION

Surgery or revision surgery.

MAIN OUTCOME MEASURES

Classifications according to Work, Olsen, Chilla; previous diagnostic and therapeutic pitfalls; outcome of intervention (including facial nerve function).

RESULTS

Between 1984 and 1999, first branchial cleft anomalies were diagnosed in 18 patients. Surgical treatment was the treatment of choice. The authors' approach in Work type I and type 2 lesions is described, and surgical aspects of revision surgery are discussed. The importance of early establishment of the relationship of the anomaly to the facial nerve is stressed. In 8 patients, previous surgical attempts had been undertaken without establishment of the diagnosis first. After intervention, the outcome was favorable.

CONCLUSIONS

First branchial cleft anomalies occur sporadically in ordinary clinical practice. They may go unrecognized or may be mistaken for tumors or other inflammatory lesions of in the periauricular region. However, the distinct clinical features, which can be derived from embryologic development, usually lead to the correct diagnosis. This avoids both treatment delay and eventual failure.

Chromosome instability as an indicator of malignant progression in laryngeal mucosa

PURPOSE

Routine histologic examination cannot predict whether premalignant laryngeal lesions will progress toward invasive growth. The acquisition of changes in chromosome constitution has been suggested to be essential for driving tumor progression by enhancing mutagenic mechanisms. The aim of the present study was to determine whether chromosomal changes occur in the subsequent stages of early laryngeal carcinogenesis and, if so, whether these changes can be of prognostic value.

MATERIALS AND METHODS

Numerical aberrations for chromosomes 1 and 7 were detected in tissue sections from archival material using an improved in situ hybridization protocol. In total, eight benign laryngeal lesions, 37 premalignant laryngeal lesions, and 16 specimens containing histologically normal epithelia adjacent to laryngeal squamous cell carcinomas were studied. Both the histologic and the cytogenetic classifications were correlated with progression to laryngeal cancer.

RESULTS

No evidence for chromosome alterations was obtained in the control group, nor in histologically normal epithelia adjacent to laryngeal squamous cell carcinomas, nor in all but one hyperplastic lesion (n = 11). In contrast, 14 of 15 dysplastic lesions and nine of 11 carcinomas-in-situ contained numerical chromosomal aberrations. Tetrasomy was present in the majority of the dysplastic lesions. An unstable chromosome content (indicated by the presence of chromosome imbalances and/or polyploidization) in the premalignant lesion strongly predicted its malignant progression.

CONCLUSION

Our results show that laryngeal tumor development involves chromosome tetraploidization. The further change from a stable to an unstable chromosome constitution is of importance for malignant progression.

Stapedius muscle fibre composition in the rat

The stapedius muscle (SM) is supposed to prevent cochlear damage by noise. Consequently functional demands are the ability of fast contraction with long endurance. This implies the presence of a large fraction of myosin type II fibres with an appreciable oxidative capacity. We determined the myosin composition of SM fibres using consecutive complete SM cross-sections (6 week old rats) which were processed by enzyme histochemistry (EHC) to determine acid/alkali lability of myofibrillar adenosine triphosphatase (mATPase) or by immunohistochemistry (IHC) using myosin heavy chain (MyHC) antibodies. Method accuracy was determined in co-processed extensor digitorum longus (EDL). Four hundred SM and 200 EDL fibres were assigned to mATPase type I, IIA, IIB, IIX or 'miscellaneous' ('Misc') categories. Per mATPase category the fibres were attributed to groups with specific MyHC composition. In the EDL, mATPase type I and IIB fibres expressed only MyHC I and IIB respectively, whereas about 10% of the type IIA and 40% of the type IIX fibres expressed more than one MyHC. Thus IHC detects amounts of myosin isoforms which are not detected by EHC. The mATPase IIX category criterion leaves the possibility that this category contains fibres with myosin type IIA and/or IIB in larger amounts. The criteria of the mATPase categories type I, IIA or IIB preclude assignment to these categories of fibres which also contain other myosin isoforms in larger amounts. Such fibres were classified in one of the mATPase 'Misc' categories. Thus in the EDL the capability of the EHC criteria to select 'pure' fibres in terms of myosin differs per mATPase category. None of the SM fibres were assigned to the mATPase type I or IIB categories, about 25% to the type IIA, 60% to type IIX and 15% (including most fibres which expressed MyHC I) to a 'Misc' category. All SM fibres expressed two or more MyHC isoforms, MyHC IIB occurring in all fibres and substantial amounts of MyHC IIA and/or IIX in most. These findings confirm the hypothesis that such fibres have the capacity to contract fast and have the better fatigue resistance.

Expression of intermediate filament proteins in benign lesions of the oral mucosa

Immunohistochemistry with monospecific antibodies was used to study the expression patterns of cytokeratins (Cks) and vimentin in non-dysplastic lesions of the oral cavity, including lichen planus and fibromas. In hyperplastic lesions, Ck expression did not deviate significantly from the normal non-keratinizing squamous epithelium of the oral cavity. Hyperkeratotic lesions showed pronounced aberrations in their Ck profile. These lesions were characterized by extended expression of the keratinization marker Ck 10, the basal cell Ck 14 and the hyperproliferation-associated Ck 16 in the suprabasal compartment. The stratification markers Cks 4 and 13 showed a decreased expression. Coexpression of Cks and vimentin was found in lesions having accumulations of inflammatory cells in the subepithelial cell layer. These changes are felt to characterize benign mucosal lesions without dysplasia and might be helpful for distinguishing these lesions from potentially malignant ones.

Mould constituents in the middle ear, a hearing-aid complication

During the placement of a mould for a hearing-aid by a hearing-aid dispenser, moulding material entered the middle ear through pre-existent perforations in the tympanic membrane in both ears. Besides hearing loss, there were no other symptoms. Surgical removal of the moulding material by tympanotomy was necessary, and was complicated by encirclement of the ossicles by the material. All the material could be removed and the hearing was saved. Recommendations for an improved procedure of mould-making are made including more detailed information of the otoscopic findings at the prescriptions for hearing-aid moulds.

Chronic otitis media with effusion during infancy, have parent-reported symptoms prognostic value? A prospective longitudinal study from 0 to 2 years of age

As a part of a prospective study (age, 0-2 years), the prognostic value of parent-reported symptoms relative to chronic otitis media with effusion (COME) was examined in a group of 122 infants. The occurrence of hearing loss, ear infection, mouth breathing, snoring and common cold was inventoried using a standardised questionnaire filled in by parents at 3-monthly intervals. Tympanometric and otoscopic records were combined for assessment of middle ear status. Subjects were categorized into three groups: none (n = 13), mild (n = 78) and severe (n = 31) COME. Analysis revealed that all symptoms in the first year of life were significantly associated with severe COME. In the second year, only hearing loss was associated with a higher risk for severe COME. The risk for severe COME increased when symptoms were combined. In conclusion, a questionnaire based on only symptoms during the first year of life may assist in screening and managing severe COME.

Definition of hearing impairment and its effect on prevalence figures. A survey among senior citizens

In order to explain the variation found in the literature, this article describes how the definition of hearing impairment affects reported prevalence when applied to the same population. The study comprised 1041 persons (354 women, 687 men) aged 55 years or older (mean age 67 years, SD 7 years). Pure tone audiometry was performed on all subjects. They were asked about their hearing by means of a structured questionnaire. The prevalences of hearing impairment were calculated based on nine criteria including: participants' subjective impression, five Dutch and international audiometric definitions, consultation of a General Practitioner, referral to an ENT specialist and hearing aid possession. Results showed a variation in prevalence figures from 6 to 30% and 10 to 49%, for women and men, respectively. Definitions including 4 kHz emphasized sex differences more strongly. In conclusion, gross differences in prevalence figures on hearing impairment are found as a result of the definition used. The variation in prevalence figures found in the literature can, at least partly, be explained by the use of different definitions.

Lemierre syndrome and acute mastoiditis

Lemierre syndrome seldom follows an episode of pharyngotonsillitis. Characteristically, it is comprised of septic thrombosis of the internal jugular vein and bacteremia, leading to lung emboli and metastatic abscess formation. We describe Lemierre syndrome that complicates an acute mastoiditis, with considerations regarding its pathogenesis and management. Despite its sporadic occurrence, awareness of Lemierre syndrome is important, since early recognition reduces both the morbidity and mortality associated with it.

Cervical spondylodiscitis after removal of a fishbone. A case report

STUDY DESIGN

A case report of cervical spondylodiscitis after removal of a lodged fishbone.

OBJECTIVES

To present a rare case of cervical spondylodiscitis and to inform the readers that a lodged fishbone can give rise to this complication after its removal.

SUMMARY OF BACKGROUND DATA

In the literature, only one mention of this complication was found.

METHODS

The literature, clinical presentation, technical examinations, and treatment are reviewed.

RESULTS

Prolonged antibiotic treatment and immobilization of the cervical spine resulted in a cure of the spondylodiscitis.

CONCLUSIONS

After removal of a lodged fishbone, a cervical spondylodiscitis is possible, but this is a very rare complication. In this patient, conservative treatment resulted in a cure of the infection. Successive magnetic resonance imaging investigations showed the extent of the destruction of the vertebral bodies and disc very well, as well as the curation of the spondylodiscitis after 5 months.

A longitudinal study of the validity of parental reporting in the detection of otitis media and related hearing impairment in infancy

A total of 150 full-term and 66 pre-term infants were selected at birth and prospectively examined at three-monthly intervals from birth until the age of 27 months. Parental reports of middle ear infection and/or hearing impairment were obtained prior to otoscopic and audiometric evaluation. The relationships between parental reports and the diagnoses acute otitis media (AOM), otitis media with effusion (OME) and hearing impairment (HI), were assessed in terms of sensitivity, specificity and positive and negative predictive values, using the data obtained during the follow-up period. AOM and OME were diagnosed using otoscopy and tympanometry. Hearing was assessed by conditioned orientation reflex audiometry. HI was defined as averaged thresholds > or = 20 dB compared with age-appropriate response levels. Despite the repeated feedback which parents received on the middle ear condition and hearing of their infants, the majority fail to recognize the presence of AOM, OME and HI. The limited sensitivity of parental reporting should discourage both researchers and clinicians from using it as a diagnostic or monitoring instrument, but they should not disregard parental concern when confronted with it.

Multi-institutional assessment of the Provox 2 voice prosthesis

OBJECTIVES

To verify the initial results of a new anterograde replacement method of the second-generation indwelling Provox voice prosthesis, Provox 2 (Atos Medical AB, Hörby, Sweden), and to determine its device life.

DESIGN

Nonrandomized, multi-institutional, controlled clinical trial.

SETTING

Four academic hospitals and/or comprehensive cancer centers in The Netherlands.

PATIENTS

Two hundred thirty-nine consecutive patients who had undergone laryngectomy and were visiting the outpatient clinic for replacement of their voice prosthesis.

INTERVENTION

Anterograde replacement of the Provox 2 voice prosthesis.

MAIN OUTCOME MEASURES

Evaluation of ease of use by the medical professional and appreciation by the patients, by means of structured questionnaires; comparison of device life between the original Provox and the new Provox 2 voice prosthesis in a subset of patients.

RESULTS

Voice prostheses replaced were Provox (n = 188), Groningen (Medin, Groningen, The Netherlands) (n = 47), and Nijdam (Medin) (n = 4). Anterograde replacement of Provox 2 was always possible. The new anterograde method was preferred by the medical professionals in 97.1% of cases and by 93.7% of the patients, who reported significantly reduced discomfort (P<.001). There was no significant difference in device life between Provox and Provox 2 (median, 125.5 and 104 days, respectively). In 57.5% of patients, the Provox 2 device life was shorter and in 42.5% it was longer (sign test, P = .09).

CONCLUSIONS

The results of the initial study concerning ease of use for the medical professionals and decreased discomfort for the patients of the new anterograde replacement procedure of the Provox 2 prosthesis were confirmed. The device life of Provox and that of Provox 2 were comparable, despite the alterations needed to optimize the Provox 2 prosthesis for the anterograde procedure.

Click-evoked oto-acoustic emission measurement in preterm infants

Click-evoked oto-acoustic emissions (CEOAE) are acoustic responses produced by the inner ear, reflecting functional auditory integrity. We studied both the success rate of the CEOAE method and the CEOAE presence in preterm infants during their stay at the Neonatal Intensive Care Unit (NICU), by analysis of the results of longitudinal CEOAE measurements in 19 preterm infants. The CEOAE method proved to be feasible in the majority of the population under study; the CEOAE measurement failed in 8% of the total of 226 attempts. Within the range of 30-40 weeks post-conceptional age (PCA) the CEOAE presence increased from about 50% to 80%. These results show the possible clinical application of CEOAE in a NICU for the monitoring of cochlear function during treatment of preterm infants.

CONCLUSION

Bedside CEOAE measurement in preterm infants in a NICU is feasible at a PCA as low as 30 weeks.

A prospective study of speech and voice rehabilitation after total laryngectomy with the low-resistance Groningen, Nijdam and Provox voice prostheses

In a prospective study the Groningen, Nijdam, and Provox voice prostheses were evaluated with respect to speech and voice rehabilitation. At approximately 1, 4, and 10 months after operation, patients were submitted to a standardized speaking task to evaluate phonatory skills (phrase length, phonation duration, dynamics on tone, dynamics on sentence, speech rate and availability of sound), speech quality (fluency and overall intelligibility), voice quality and stoma technique (stoma noise). Tracheoesophageal speech rehabilitation proved to be successful in 94-100% of patients, as measured at approximately 10 months after operation. Furthermore, no significant overall differences were found between the three prostheses. There was a significant improvement in time for speech rate and stoma noise. As for the time effects (e.g. improvement in performance over time) no differences between the three prostheses were found.

Retrograde approach to pharyngo-esophageal obstruction

BACKGROUND

The entrance of the esophagus has to be identified for treatment of a pharyngo-esophageal obstruction. If transoropharyngeal identification is unsuccessful, a retrograde approach might be indicated.

METHODS

By way of a mini-laparotomy and gastrotomy, a flexible gastroscope can be passed into the esophagus. In one patient with a Zenker's diverticulum, a guidewire was inserted through the accessory channel of the gastroscope and passed through a stenosis, caused by marked hypertrophy of the cricopharyngeal muscle, into the oral cavity. Thereafter antegrade dilatation and laser assisted myotomy could be performed. In another patient with a membranous obstruction of the esophageal entrance due to radiotherapy, the occlusion was perforated transoropharyngeally and bluntly dilatated guided by the light from the gastroscope.

RESULTS

In both cases the esophageal passage was restored. No complications occurred as a result of the procedures.

CONCLUSIONS

The retrograde approach may be a good alternative when antegrade identification of the esophageal entrance fails.

Plasma glutathione S-transferase P1-1 levels in patients with head and neck squamous cell carcinoma

BACKGROUND

Many tumors contain high amounts of the detoxification enzyme glutathione S-transferase P1-1 (GSTP1-1). Elevated levels of GSTP1-1 have also been detected in serum and plasma from patients with gastrointestinal, lung, or head and neck tumors. The authors of this report evaluated the role of GSTP1-1 as a plasma tumor marker in patients with head and neck squamous cell carcinoma (HNSCC) of the larynx, hypopharynx, or oropharnyx and in patients with benign head and neck lesions (BHNL).

METHODS

GSTP1-1 levels were measured in EDTA plasma combined with ethylenediaminetetraacetic acid using a recently developed sensitive and specific sandwich enzyme-linked immunoadsorbent assay. A normal reference level with an upper limit of 21.8 microg GSTP1-1 per liter of plasma was calculated from results obtained with samples from 230 blood donors.

RESULTS

Median GSTP1-1 levels in samples from 53 patients with oral/oropharyngeal SCC (10.6 microg/L; range, 3.7-46.1 microg/L), 12 patients with hypopharyngeal SCC (11.9 microg/L; range, 5.2-146.6 microg/L), and 28 patients with laryngeal SCC (14.4 microg/L; range, 6.4-141.5 microg/L) were significantly elevated when compared with plasma GSTP1-1 levels in samples from 45 patients with BHNL (8.1 microg/L; range, 3.3-32.3 microg/L; P < 0.0001, P < 0.01, and P < 0.0001, respectively). However, only 6 of 53 patients (11%) with oral/oropharyngeal SCC, 1 of 12 patients (8%) with hypopharyngeal SCC, and 6 of 28 patients (21%) with laryngeal SCC had plasma GSTP1-1 levels above the upper limit of the normal reference level. Thus, only 13 of 93 patients (14%) with HNSCC had elevated plasma GSTP1-1 levels overall. No significant relation between plasma GSTP1-1 levels and TNM classification of the tumors was observed.

CONCLUSIONS

GSTP1-1 is not a suitable plasma tumor marker for HNSCC.

Double-target fluorescence in situ hybridization distinguishes multiple genetically aberrant clones in head and neck squamous cell carcinoma

Genomic heterogeneity has been observed in several solid tumor types. To investigate this phenomenon in head and neck squamous cell carcinoma (HNSCC), we analyzed macroscopically distinct tissue samples of 12 resected tumors by a combination of fluorescence in situ hybridization (FISH) and DNA flow cytometry. Using a panel of centromeric DNA probes, numerical chromosomal aberrations were detected in 10 tumors, 9 of which showed a single DNA aneuploid peak. Imbalances in chromosomal copy numbers resulted in unique patterns of chromosomal aberrations for each tumor case. Two types of tumors could be distinguished, i.e., tumors (n = 5) containing a single aneusomic clone and tumors (n = 5) with multiple aneusomic clones. The center of this latter group of tumors was shown to be genetically more heterogeneous than the tumor margin. In conclusion, this study showed that 1) the pattern of chromosomal aberrations varies greatly between different HNSCC, 2) a major clone with a specific pattern of chromosomal aberrations has spread throughout most HNSCC, and 3) a subgroup of HNSCCs contains additional clones with a different pattern of chromosomal aberrations. Based on these results, HNSCC can be divided into a genetically more homogeneous and a genetically more heterogeneous group.

An image analysis study on nuclear morphology in metastasized and non-metastasized squamous cell carcinomas of the tongue

In a retrospective case-control study on 46 metastasized and 34 non-metastasized primary tongue carcinomas, the nuclear morphology and chromatin pattern were assessed in 3 microns thick, formalin-fixed, paraffin-embedded, and Feulgen-stained tissue sections of surgical resection specimens, by means of high-resolution computer-assisted image analysis. The aim of this study was to disclose differences in karyometric features, such as nuclear size-, shape-, and chromatin-pattern features, between these groups, with a view to developing a discriminant function that can predict the occurrence of metastasis for the individual patient. In addition, the lymph node metastases of 31 patients and the normal tongue epithelium of 21 patients were also assessed, to study the possible differences between these two groups and primary tumours. In the metastasized tumours, the chromatin was significantly more condensed (P = 0.01) and exhibited significantly less variation in chromatin condensation (P < 0.001) than in the group of non-metastasized carcinomas. Comparison of lymph node metastases with their primary tumours disclosed only minor differences in chromatin pattern. These findings suggest that only minor genetic differences exist between primary tongue carcinomas and their metastases. Tumour cells of tongue carcinomas showed highly significant differences from cells of normal tongue mucosa for most karyometric features. Logistic regression analysis resulted in a classifier, based on the circularity of the nucleus (CIRC) and the standard deviation of the chromatin condensation (SD COND), to predict the occurrence of lymph node metastases. After cross-validation, the percentages of correct classifications in the group of metastasized and non-metastasized tumours were 72 and 62 per cent, respectively. These results are comparable to the classification results obtained from a classifier based on the clinical T-stage, but our karyometric classification results show a much more equal distribution between the sensitivity and specificity. Karyometric features appeared to be more appropriate to predict metastases than biomarkers such as p53, bcl-2, and Ki-67.