Ectopic Thymic Tissue Presenting as a Neck Mass in Children: A Report of 3 Cases

The presentation of ectopic cervical thymic tissue as an anterior neck mass is rare. We report 3 similar cases in 3 boys—2 who had a thymic cyst and 1 who had an ectopic cervical thymus. We discuss the radiographic presentation on ultrasound and magnetic resonance imaging in these cases. We also review the typical histologic picture; histology is the only way of diagnosing this condition.

Ectopic thymic tissue presenting as a neck mass in children: a report of 3 cases

The presentation of ectopic cervical thymic tissue as an anterior neck mass is rare. We report 3 similar cases in 3 boys-2 who had a thymic cyst and 1 who had an ectopic cervical thymus. We discuss the radiographic presentation on ultrasound and magnetic resonance imaging in these cases. We also review the typical histologic picture; histology is the only way of diagnosing this condition.

Hydatid disease of the skull base: report of three cases and a literature review

We report three cases of hydatid disease of the skull base and the treatment thereof. The first involved the anterior cranial fossa and paranasal sinuses. The second was located in the infratemporal fossa. The last involved the temporal bone and posterior cranial fossa. Hydatid disease is endemic in many parts of the world where livestock farming is practiced and is highly endemic in sub-Saharan Africa. Although hydatid disease of the head and neck is rare, it should be considered in the differential diagnosis of cystic disease in the head and neck region. Of the three forms of hydatid disease, Echinococcus granulosis is most common and gives rise to cystic hydatid disease. Most hydatid cysts are "silent," but become clinically apparent because of their mass effects, when they rupture, or if they become superinfected. Computed tomography scanning and magnetic resonance imaging are the best diagnostic tools. Hydatid disease can be successfully treated by a combination of surgery and chemotherapy.

Recent changes in the treatment of patients with advanced laryngeal cancer

Since the original data from the Department of Veterans Affairs Laryngeal Cancer Study Group demonstrated that nonsurgical therapy could achieve survival rates comparable to total laryngectomy in selected cases, there has been a progressive increase in employment of nonsurgical therapy for the management of advanced laryngeal cancer. Both neoadjuvant chemotherapy followed by conventionally fractionated or hyperfractioned radiotherapy for chemotherapy responders, or simultaneously administered chemoradiation has resulted in a significant number of patients who achieved cure while preserving their larynges. Nevertheless, combined chemotherapy and external beam radiation is associated with a variety of acute and chronic sequelae that can have a debilitating impact on function and quality of life. Although no therapeutic option is without risk, the decision regarding the modality of therapy for a patient with advanced laryngeal cancer should prompt a careful review of the current surgical techniques available for treatment. Data on quality of life and aging, as well as advances in minimally invasive surgical techniques, are available today that were not available at the time of the Veterans study. Selection of optimal therapy is often complex and raises the question whether the pendulum may have swung too far in the direction of nonsurgical therapy for advanced laryngeal cancer. This article reviews the current options available for a patient with advanced laryngeal cancer and discusses the impact of therapy.

Elective supraomohyoid neck dissection for oral cavity squamous cell carcinoma: Is dissection of sublevel IIB necessary?

Spinal accessory nerve (SAN) dysfunction and related shoulder disability are common consequences of supraomohyoid neck dissection (SOHND). Nerve dysfunction is usually attributed to excessive nerve traction or devascularization during clearance of the lymph nodes posterior and superior to the SAN (sublevel IIB). The need for routine dissection of this sublevel with elective neck dissection has recently been questioned. This review article discusses whether preserving sublevel IIB lymph nodes is justified in elective SOHND for patients with squamous cell carcinoma (SCC) of the oral cavity. A review of the literature was conducted on studies of sublevel IIB dissection in elective SOHND for SCC of the oral cavity. Only two studies have prospectively investigated the incidence of lymph node metastasis in patients with clinically N0 SCC of the oral cavity. Data from these two prospective pathologic and molecular analyses of neck dissection specimens, including 122 patients with N0 oral cancer, revealed 7.3% with positive neck nodes at sublevel IIB for oral cancer in general, and 12% for tongue cancer in particular. When considering the merits of preservation of sublevel IIB, the benefit of preservation of SAN function has to be weighed against potentially reduced oncologic control.

Is total glossectomy for advanced carcinoma of the tongue justified?

Total glossectomy (with or without total laryngectomy) followed by postoperative radiotherapy remains the principal treatment method for advanced base of tongue carcinoma. The procedure remains controversial owing to poor cure rates and the inevitable functional deficits associated with it. However, even though total glossectomy is a major surgical procedure that impacts on speech, deglutition and quality of life, it may offer patients the best chance of cure in many centres, especially in the developing world.

METHODS

We did a retrospective chart review of all patients at Groote Schuur Hospital, Cape Town, who had undergone total glossectomy, with or without total laryngectomy, for stage IV squamous cell carcinoma (SCC) of the tongue between 1998 and 2004.

RESULTS

Eight patients had a total glossectomy performed during the study period. At 2, 3 and 5 years 63%, 38% and 25% of patients respectively were alive without disease. No patient required permanent nasogastric or gastrostomy feeding, and all returned to a full oral diet. Three of 5 patients who had laryngeal preservation and could be assessed for speech had intelligible speech. All but 1 patient (88%) reported pain relief following surgical excision. Perineural invasion was present in 75%, and 38% had positive resection margins. Five patients had recurrence, 2 cervical, 1 local, and 2 local and cervical.

CONCLUSION

Advanced SCC of the tongue is a devastating disease causing severe pain and disorders of speech and swallowing. Total glossectomy (with or without total laryngectomy) and postoperative radiotherapy is a reasonable treatment option, particularly in the developing world setting. It has cure rates superior to primary radiotherapy, and provides motivated patients with excellent pain relief and a reasonable quality of life.

An outline of the history of head and neck oncology

This review analyzes the development of head and neck oncology as outlined in medical history articles. A systematic literature survey was conducted with the search engines "Google Scholar" and "PubMed" and the retrieved publications were cross-referenced. In addition, books and, when possible, original sources were consulted. While most of the material was obtained from publications from the modern era reviewing historical data, some of the information was derived from original source material. The obtained articles on the history of cancer were then analyzed for details on head and neck oncology. The cradle of oncology was located in ancient Egypt and Greece. The search showed that the first tumors treated in the head and neck were either cutaneous malignancies or cancers on the mucosal surfaces of the oral cavity. The origin, diagnosis and treatment of more deeply situated tumors of the larynx and hypopharynx remained obscure for many centuries. The medieval age brought little progress to medicine in general, and in head and neck oncology in particular, due to religious concerns. Renaissance medicine was characterized by advances in medicine and oncology made by systematic dissection studies of normal and pathologic anatomy. The 19th and 20th century reflect the development of head and neck oncology in the era of science based medicine. Almost all of our current understanding of head and neck oncology, our diagnostic methods and treatment strategies have been developed in these two centuries. The analysis showed that many oncologic problems, which occupy our minds today, were also concerns of our medical ancestors.

Thyroglossal duct cyst: personal experience and literature review

The thyroglossal duct cyst [TDC, or thyroglossal tract remnant (TTR)] is a well recognized developmental abnormality which arises in some 7% of the population. As a consequence, it represents the most common type of developmental cyst encountered in the neck region. It typically presents as a mobile, painless mass in the anterior midline of the neck, usually in close proximity to the hyoid bone. Less often, TDCs may present with signs and symptoms of secondary infection, or with evidence of a fistula. While TDCs are most often diagnosed in the pediatric age group, a substantial minority of patients with TDCs are over 20 years of age at the time of diagnosis. The standard surgical approach to TDC, encompassing removal of the mid-portion of the hyoid bone in continuity with the TDC and excision of a core of tissue between the hyoid bone and the foramen cecum, dates back to the late 19th and early 20th centuries and is often referred to as Sistrunk's operation. Malignancy is rarely encountered in TDCs; when such rare tumors do develop (in the order of 1% or so of patients with TDCs), they usually take the form of either papillary carcinoma of thyroid origin, or squamous carcinoma.

Modern reconstruction techniques for oral and pharyngeal defects after tumor resection

Several techniques have been developed to reconstruct oral and pharyngeal defects following surgery, in order to restore function and cosmesis. These are primary closure, skin grafts, local transposition of skin, mucosa and/or muscle, regional flaps and free vascularized flaps. Because of the 'bulky', pedicled nature and problems with the donor area of locoregional flaps, and consequently frequently unsatisfactory functional results, free vascularized flaps have gained popularity during the last decade. The authors review the current options available to give physicians, who are not experienced in the field of reconstruction in the head and neck, an impression of the range of techniques available for reconstruction of oral and pharyngeal defects following tumor resection. For reconstruction of oral cavity and pharyngeal defects, fasciocutaneous (e.g. radial forearm and anterolateral thigh flaps) and myocutaneous free flaps (e.g. rectus abdominis and latissimus dorsi) have proven to be very reliable. Free vascularized osteocutaneous flaps (e.g. fibula and iliac crest) permit reconstructive options for bony defects of the mandible or maxilla that can be adapted to a variety of defects. Depending on the site, size and involved tissues of the surgical defect and patient factors, a variety of reconstructive options are available. For both soft tissue and bony defects of the upper aerodigestive tract, microvascular free flaps provide good functional outcomes.

Mesenchymal chondrosarcoma of the head and neck

Mesenchymal chondrosarcoma of the head and neck is an uncommon tumor with a potential for exhibiting highly aggressive behavior. When these tumors arise in the head and neck region, they appear to have a predilection for the maxillofacial skeleton; less often, they may involve other soft tissue sites in the head and neck. The diagnosis is challenging and may be assisted by molecular pathologic techniques when only limited tissue is available for analysis. Management is primarily surgical. Although adjuvant radiation appears to convey some benefit by reducing tumor bulk when these lesions have extended beyond bony confines, there is no evidence to suggest that this is associated with improved outcome. Chemotherapy does not appear to be effective in the limited experience documented thus far. Patients with complete local control following resection should be followed closely for development of distant metastasis, which signifies a worse clinical outcome. Future effective therapy may be found in the identification of molecular targets responsive to adjuvant chemotherapy or biologic modifiers.

Parotidectomy in Cape Town--a review of pathology and management

BACKGROUND

The spectrum of parotid disease in southern Africa has not previously been reported.

METHODS

A review of all parotidectomies performed by a single surgeon over a period of 10 years (1994 - 2004) in Cape Town, South Africa, is presented. Data were collected from a retrospective chart review.

RESULTS

One hundred and ninety-nine parotidectomies were performed and 196 pathology reports were reviewed. Pleomorphic adenoma was the most common benign tumour and metastatic cutaneous squamous cell carcinoma (SCC) was the most common malignancy. Warthin's tumour had an equal gender distribution. Forty-five per cent of parotid tumours in males were malignant. The sensitivity, specificity and accuracy of fine-needle aspiration cytology (FNAC) in diagnosing malignancy were 73%, 98% and 94% respectively.

CONCLUSIONS

In South African males almost half of parotid tumours are malignant. Warthin's tumours are less common in Africa than in the West, and did not show a male preponderance. FNAC is a highly reliable method of excluding malignancy.

Role of limited parotidectomy in management of pleomorphic adenoma

There is continued controversy over the extent of parotidectomy required for removal of a benign pleomorphic adenoma from the parotid gland. Currently, consensus exists that the integrity of the facial nerve must be preserved when the tumour is totally removed.

As a result of experience gained in the first half of the twentieth century, it was recommended that superficial parotidectomy with facial nerve dissection should be the minimal biopsy for pleomorphic adenoma. Since that time, however, research has indicated that partial parotidectomy or extracapsular dissection of benign pleomorphic adenoma can be accomplished with preservation of the facial nerve without an increase in tumour recurrence. Partial parotidectomy or extracapsular dissection results in impaired cosmetic results and a lower incidence of Frey's syndrome, and thus may be the preferred approach when undertaken by experienced surgeons.

Buccinator myomucosal flap: clinical results and review of anatomy, surgical technique and applications

Background:

The buccinator musculomucosal flap is an axial-pattern flap based on either the buccal or the facial artery. We present our experience with this flap and describe its surgical anatomy, the surgical techniques utilised to raise the flap and its clinical applications.

Materials and methods:

We retrospectively reviewed all patients who had had buccinator myomucosal flaps created at the Groote Schuur Hospital between 1999 and 2004. Patients were also recalled to assess flap sensation and to record reduction of mouth opening as a consequence of donor site scarring.

Results:

Of the 14 patients who had had a buccinator myomucosal flap created, there was one flap failure. Sensation was present in 71 per cent of flaps, and there was no trismus due to donor site scarring.

Conclusions:

The buccinator myomycosal flap is a dependable flap with good functional outcome and low morbidity.

European Surgeons Were the First to Perform Neck Dissection

The history of the surgical treatment of cervical lymph node metastases began in the 19th century, and, unfortunately, the initial attempts at surgical treatment of neck metastases were disastrous. Although some European surgeons reported few cases of radical en bloc dissection, the first successful surgical procedure was performed and described in detail by Franciszek Jawdyński, a Polish surgeon, in 1888. George Washington Crile popularized and illustrated radical en bloc neck dissection in the early 20th century.

Is diagnostic tonsillectomy indicated in all children with asymmetrically enlarged tonsils?

OBJECTIVES

The aims of the study were: (i) to determine the necessity for diagnostic tonsillectomy in children with asymmetrically enlarged tonsils; (ii) to determine the accuracy of clinical assessment of tonsillar asymmetry; and (iii) to determine how to manage children with clinical tonsillar asymmetry in a developing-world practice.

METHODS

A prospective study was carried out at Red Cross War Memorial Children's Hospital in Cape Town, over an 8-month period. All children undergoing tonsillectomy or adenotonsillectomy had a clinical assessment of tonsil symmetry done, and all tonsil and adenoid specimens were examined histologically. The maximum diameter and volume of the resected tonsils were measured. A comparison was done of true tonsil asymmetry in patients with asymmetrical tonsils and a subgroup of matched controls with symmetrical tonsils.

RESULTS

A total of 344 tonsils were analysed (172 patients). The 13 patients (7.6%) diagnosed as having clinically asymmetrically enlarged tonsils had no significant pathological diagnosis. In the patients with symmetrical tonsils there were 2 abnormal pathological findings (tuberculosis of the adenoids and T-cell lymphoma of the tonsils and adenoids). In the clinically asymmetrical tonsil group, true tonsillar asymmetry was 3 mm (maximum diameter), and 2.2 cm(3) (volume), compared with 1.9 mm and 1.5 cm(3) in the symmetrical tonsil group. When patients with clinical tonsillar asymmetry and symmetry were compared, the difference in maximum diameter (p = 0.62) and volume (p = 0.73) was not significantly different.

CONCLUSIONS

Clinical tonsillar asymmetry is usually apparent rather than real. The incidence of significant pathology in children with asymptomatic, asymmetrical tonsils is low. Diagnostic tonsillectomy is indicated in children with asymmetrically enlarged tonsils associated with constitutional symptoms, cervical lymphadenopathy, rapid tonsil enlargement or significant tonsillar asymmetry.

Squamous cell carcinoma in black patients with discoid lupus erythematosus

Squamous cell carcinoma has rarely been reported in black African people, with only 11 cases reported in the world literature to date. We report on 2 further cases, the first to be reported in southern Africa, of squamous cell carcinoma in lesions of discoid lupus erythematosus

Suprahyoid approach to base-of-tongue squamous cell carcinoma

OBJECTIVE

To evaluate the suprahyoid approach to treatment of squamous cell carcinoma of the base of the tongue at Groote Schuur Hospital between 1999 and 2004.

DESIGN AND METHOD

Retrospective analysis was done of patients with base-of-tongue squamous cell carcinoma treated using the suprahyoid approach.

RESULTS

Seventeen patients underwent treatment for base-of-tongue squamous cell carcinoma utilising the suprahyoid approach. Complete medical records were available for 15 of these patients. The most common presenting symptoms were neck mass (40%) and referred otalgia (33%). Alcohol was a risk factor in more patients (64%) than smoking (47%). Adverse pathological findings were present in less than 50% of patients (involved margins 20%, perineural invasion 40%, vascular invasion 33%). Functional outcome in terms of speech intelligibility was excellent and there were minimal swallowing problems, with most patients using compensatory strategies and dietary modification. There were 2 subsequent deaths (13%) as a result of distant metastasis and a second primary.

CONCLUSION

The suprahyoid approach to treatment of base-of-tongue squamous cell carcinoma provides good exposure, local tumour control and excellent functional outcome.

Adult tonsillectomy--are long waiting lists putting patients at risk?

There is a paucity of data on morbidity associated with long waiting lists for adult tonsillectomy. The aim of this study was to assess the morbidity associated with long waiting lists for adult tonsillectomy in a developing world setting. Of 350 patients on the waiting list at Groote Schuur Hospital for 18 months or more, only 55 were contactable. This low yield (15.7%) from the telephonic survey highlighted the difficulty of managing long waiting lists efficiently in a developing world setting. As only 1/55 patients on the waiting list had a complication (quinsy), it appears to be safe to delay tonsillectomy in adult patients. Only half of patients ultimately required tonsillectomy because of a natural reduction in the number of episodes of tonsillitis with time. In order to avoid unnecessary tonsillectomy we need to find better prognosticators to identify the subgroup of adult patients likely to have continued recurrent tonsillitis.

South African survey on disinfection techniques for the flexible nasopharyngoscope

This random survey was to determine the flexible nasopharyngoscope disinfection practice employed by South African otolaryngologists and to establish whether a breach in the disinfection process exists. The study also aimed to identify organisms most likely to be transmitted via endoscopy and to propose a protocol for the disinfection of the flexible nasopharyngoscope.

A questionnaire regarding disinfection techniques used for the flexible nasopharyngoscope was sent to 90 otolaryngologists in South Africa. All provinces were equally represented in the survey.

Forty-five otolaryngologists out of a total of 90 participated in the study. Many of the otolaryngologists had no access to a flexible nasopharyngoscope and were therefore not included in the study. Fewer than 50 per cent of the 45 surgeons washed the instrument with soap/detergent and water after use. Only 42 per cent of surgeons used a FDA-approved disinfectant, 52 per cent of which immersed the scope for a shorter period than the recommended contact time. Of the 58 per cent using non-FDA-approved products, 33 per cent used only a 70 per cent Isopropyl alcohol wipe, without immersion of the scope in disinfectant solution. The remaining 25 per cent used non-FDA-approved disinfectants either by wiping or limited immersion of the scope. Of the 45 surgeons, 49 per cent used a different method of disinfection for high-risk patients.

Strict guidelines have been proposed for the disinfection of this semi-critical device by the Association of Professionals for Infection Control (APIC) and the Centers for Disease Control (CDC). These guidelines are currently not being followed by many South African otolaryngologists. There is therefore a real risk of transmitting infectious diseases, especially tuberculosis, via endoscopy.

Extensive calvarial tuberculosis: rare complication of tuberculous mastoiditis

Tuberculous mastoiditis is a well-documented entity with decreasing incidence in recent years. Tuberculous osteitis of the skull is even rarer. The case of a 58-year-old male with tuberculous mastoiditis complicated by extensive tuberculous osteitis of the skullis presented. This case serves to demonstrate both the difficulty in establishing the diagnosis of tuberculosis and the potentially disastrous consequences of the disease.

Primary neuroblastoma: a rare cause of a retropharyngeal mass in a neonate

Neuroblastoma is the most common extra-cranial solid malignancy in children and the most common tumour occurring during infancy. This tumour arises from undifferentiated precursor cells of the sympathetic nervous system. The abdomen (65 per cent) is the most common site for these tumours, followed by the throat (15 per cent), pelvis (5 per cent) and cervical region (5 per cent).

We report a case of primary retropharyngeal neuroblastoma in a three-week-old baby boy presenting with upper airway obstruction

Cost of tracheoesophageal prostheses in developing countries. Facing the problem from an internal perspective

CONCLUSIONS

All the discussants of our questionnaire agreed that the price of tracheoesophageal (TE) prostheses was too expensive for developing countries. The problem could be addressed in terms of international laws regarding companies' patent rights. TE prosthesis manufacturers from rich countries could move their manufacturing in part to developing countries. High production standards could allow TE prostheses to be exported to developed countries. Another approach to the problem may be based on a partnership between non-profit-making Western laryngological societies with specific medical and technical prosthetic know-how and local manufacturers. The aim of this cooperation could be the low-cost production of advanced TE prostheses in the developing countries.

OBJECTIVES

In communities in the developing world, most laryngeal and hypopharyngeal carcinomas are diagnosed at advanced stages and require total laryngectomy. Prosthetic TE voice restoration is the method of choice for voice rehabilitation after total laryngectomy in developed countries. Unacceptably high costs are a significant limitation to Third World use of TE voice prostheses. The aims of this paper are to discuss the consequences of the high costs of TE prostheses in developing countries with head and neck surgeons working in Third World hospitals and to propose how European and American laryngological societies can promote TE speech in the developing countries.

MATERIAL AND METHODS

A questionnaire was given to a group of expert head and neck surgeons working in developing countries and their answers and suggestions discussed.

Pre- and intra-operative staging of the neck in a developing world practice

Most patients with squamous cancer of the head and neck treated at Groote Schuur Hospital are from a poor socio-economic background with a high prevalence of tuberculosis (TB), human immunodeficiency virus (HIV) and other infections that may cause cervical lymphadenopathy resulting in overstaging of the neck. A retrospective review of 186 patients requiring therapeutic and elective neck dissection was undertaken and the sensitivity and specificity of clinical and intra-operative staging of the neck determined. Results showed overall sensitivity of staging at 80.1 per cent. Specificity was 52.2 per cent. Staging of the N(1), N(2b) and N(2c) necks had positive predictive values of 53.2, 65.8 and 68.2 per cent respectively. Occult nodal metastases were present in 32 per cent elective neck dissections (END)s. Specificity of intra-operative staging of the N(0) neck was 33.3 per cent and sensitivity was 72.4 per cent. Conclusions were that our indications for elective neck dissection are appropriate. The high false positive rates for staging of the N(1), N(2b) and N(2c) necks, necessitate a change in management strategy.

Tracheoesophageal speech in a developing world community

OBJECTIVES

To determine the tracheoesophageal speech results in a Third World medical practice; to examine the impact of socioeconomic status, literacy, and proximity to specialist services on tracheoesophageal speech; to assess whether these factors should affect patient selection for fistula speech; and to determine guidelines for voice prosthesis selection.

DESIGN

Retrospective analysis.

SETTING

Groote Schuur Hospital, Cape Town, South Africa, which serves a Third World community.

PATIENTS

Ninety-seven consecutive patients who underwent total laryngectomy between January 1, 1996, and October 1, 1998. Patients who undergo total laryngectomy routinely have a primary tracheoesophageal fistula created for speech.

MAIN OUTCOME MEASURES

Speech outcomes after total laryngectomy; tracheoesophageal speech in relation to social class, literacy, and proximity to specialist services; and experience with removable and indwelling valves.

RESULTS

Fifty-nine (81%) of 73 patients acquired useful speech. Speech outcome was not affected by employment status or proximity to specialist services. Although speech was affected by literacy and housing, several illiterate shack dwellers acquired good speech. Average device life of removable prostheses was 16 weeks (>4 months in 35% [64/183]). Indwelling prostheses had an average life of 28 weeks.

CONCLUSIONS

Tracheoesophageal speech results in a Third World community equate with those in the Developed World. All patients who undergo laryngectomy and have adequate manual dexterity and cognitive function should be given a trial of fistula speech. Removable voice prostheses can successfully be used as indwelling prostheses.

Laser ablation of granulation tissue at the tracheoesophageal puncture site

BACKGROUND

Tracheoesophageal fistula speech may be complicated by granulation tissue around the puncture site. Treatment includes antibiotics, antifungals, chemical or electrocautery, and surgical excision of the granulation tissue. Chemical cautery generally requires repeated treatment sessions.

METHODS

We report our technique and results of CO(2) laser ablation of granulation tissue at the tracheoesophageal puncture site performed as an outpatient office procedure.

RESULTS

Seven of 9 patients (78%) were cured with a single treatment. The prosthesis was replaced immediately after laser ablation of granulation tissue. Of the remaining 2 patients, 1 had a recurrence a year later, requiring repeated laser. The second patient had a large mass requiring 4 laser ablations. There were no complications.

CONCLUSIONS

CO(2) laser has the following advantages compared with other methods of treating stomal granulation tissue: office procedure; 78% cured with single treatment; and the extent of tissue necrosis is predictable.

A parapharyngeal myxoid liposarcoma

We present a case of a parapharyngeal space myxoid liposarcoma. This case highlights the importance of wide surgical resection margins, and the difficult histological diagnosis.

Treatment of the N+ neck in squamous cell carcinoma of the upper aerodigestive tract

This article discusses the following aspects of the management of the N+ neck: evolution of neck dissection; specificity of staging of the clinically N+ neck; limitations of neck dissection in patients with adverse histologic features; management of bilateral nodal metastases, fixed nodes, and nodes with involvement of skin, nerves or the carotid artery; retropharyngeal nodes; and salvage treatment of the N+ neck following prior irradiation. A summary of the author's own approach is then presented.

Perineural invasion in squamous cell carcinoma of the head and neck

OBJECTIVE

To determine if perineural invasion (PNI) of small nerves affects the outcome of patients with squamous cell carcinoma (SCC) of the upper aerodigestive tract.

DESIGN

Retrospective clinicopathological study of patients with at least 2 years of follow-up and with negative margins and no prior, synchronous, or metachronous SCC.

SETTING

Academic otolaryngology department.

PATIENTS

One hundred forty-two patients who had SCC of the oral cavity, oropharynx and hypopharynx, or larynx resected between 1981 and 1991.

INTERVENTION

Surgery with or without adjuvant therapy.

MAIN OUTCOME MEASURES

Local recurrence was examined with respect to PNI, nerve diameter, and microvascular or microlymphatic invasion. Perineural invasion was correlated with lymph node metastasis, extracapsular spread, and survival.

RESULTS

Perineural invasion of nerves less than 1 mm in diameter was present in 74 patients, lymphatic invasion in 53, and vascular invasion in 9. Perineural invasion was significantly associated with local recurrence (23% for PNI vs 9% for no PNI; P=. 02), and disease-specific mortality (54% mortality for PNI vs 25% for no PNI; P<.001). With extralaryngeal tumors, PNI was associated with nodal metastasis (73% vs 46%; P=.03). Perineural invasion was not associated with extracapsular spread (P=.47). Microvascular invasion, lymphatic invasion, and nerve diameter were not significantly related to local recurrence.

CONCLUSIONS

Perineural invasion of small nerves is associated with an increased risk of local recurrence and cervical metastasis and is, independent of extracapsular spread, a predictor of survival for patients with SCC of the upper aerodigestive tract.

Implications of cartilage invasion in surgically treated laryngeal carcinoma

BACKGROUND

Cartilage invasion adversely affects the outcome of laryngeal carcinoma treated with radiotherapy. The UICC and American Joint Committee on Cancer (AJCC) classify laryngeal carcinoma with cartilage invasion as T4 or stage IV.

METHODS

This study examines the prognostic significance of cartilage involvement in T3,4 N0,1 glottic carcinoma treated with total laryngectomy. Patients with tumor extension to pharynx, tongue, and thyroid gland, extracapsular spread, positive resection margins, and less than 2 years' follow-up were excluded.

RESULTS

Sixty-seven pT3 (cartilage free of tumor) and 37 pT4 (cartilage invaded by tumor) cases were studied. The difference between the pT3 and pT4 groups in terms of local or regional recurrence, distant metastasis, and determinate survival was not significant.

CONCLUSIONS

The results of this study question the use of cartilage invasion as a staging parameter for surgically treated laryngeal carcinoma. However, further studies with larger sample sizes are required to fully elucidate the prognostic significance, if any, of cartilage invasion in surgically treated cancer of the larynx.

Histopathological features of a cochlear implant and otogenic meningitis in Mondini dysplasia

The temporal bones of a 6-year-old boy with a cochlear implant for profound hearing loss associated with Mondini dysplasia were studied histopathologically. Despite having severe Mondini dysplasia, he was able to detect sound with the implant. On histological examination of the temporal bone, he had more than 10000 spiral ganglion cells. Histopathological changes in the inner ear associated with the cochlear implant were minimal. Patients with severe Mondini dysplasia and profound hearing loss may, therefore, benefit from cochlear implantation. In the contralateral ear, the patient had suppurative labyrinthitis and meningitis associated with chronic otitis media. Histopathological evidence of inflammatory necrosis of the round window membrane was consistent with suppurative labyrinthitis secondary to otitis media.

Intranasal endoscopic excision of a juvenile angiofibroma

Intranasal endoscopic excision of a juvenile nasopharyngeal angiofibroma (JNA) was performed in a 13 year old white male. The patient remains disease-free 24 months after the operation. Although endoscopic surgical techniques have been applied to the therapy of some benign nasal tumors, such as inverting papilloma, endoscopic resection of a documented JNA has not been previously reported. This technique is reserved for tumors which are limited to the nasal cavity and paranasal sinuses with minimal extension into the pterygopalatine fossa.

Nasopharyngeal angiofibromas: selecting a surgical approach

BACKGROUND

A review of 16 juvenile nasopharyngeal angiofibromas, managed at the University of Pittsburgh, is presented.

METHODS

A retrospective chart review was done. Surgical approaches and factors affecting recurrence are analyzed.

RESULTS

Endoscopic transnasal, transpalatal, medial maxillectomy, facial translocation, and infratemporal fossa approaches, with or without craniotomy, were employed. The 37.5% recurrence rate reflects the advanced stage of the tumors. A major risk factor for recurrence was tumor involvement of the cranial base.

CONCLUSIONS

The surgical approach should be selected according to tumor location and effectiveness of embolization. In young patients, the approach should minimize the potential for facial growth retardation. Tumors confined to the nasopharynx, nasal cavity, and paranasal sinuses may be removed endoscopically. Medial maxillectomy is recommended for tumors that extend to the medial intratemporal fossa or medial cavernous sinus. Significant involvement of the infratemporal fossa, cavernous sinus, or middle cranial fossa requires infratemporal fossa or transfacial approaches.

Neurilemomas of the parapharyngeal space

OBJECTIVE

To review the surgical management of neurilemomas of the parapharyngeal space (PPS).

DESIGN

Retrospective survey of the clinical presentation, radiological features, surgical approaches, surgical findings, and postoperative neurological sequelae of neurilemomas of the PPS.

SETTING

Academic tertiary care head and neck referral center.

PATIENTS

Fourteen patients with neurilemomas of the PPS, 12 were in the poststyloid compartment.

INTERVENTIONS

Preoperative evaluation with computed tomography and/or magnetic resonance imaging with or without angiography. Surgical resection was performed through a transcervical approach.

MAIN OUTCOME MEASURES

Radiological features, adequacy of surgical approach, and neurological sequelae of surgery.

RESULTS

Radiological studies could distinguish prestyloid from poststyloid tumors and, with poststyloid tumors, can usually differentiate between glomus tumor and neurilemoma. The transcervical approach permitted adequate surgical access. Five of the tumors in the poststyloid space were neurilomomas originating from the sympathetic nervous system, and all 5 patients with these tumors developed Horner syndrome postoperatively.

CONCLUSIONS

Computed tomographic and/or magnetic resonance studies should be routinely obtained to evaluate tumors of the PPS, but angiography is indicated only in selected cases. Both prestyloid and poststyloid neurilemomas can be resected through a transcervical approach. Resection of neurilemomas has an attendant risk for neurological dysfunction.

Management of the thyroid gland with laryngectomy for cT3 glottic carcinomas

Is routine hemithyroidectomy justified in laryngectomy for laryngeal carcinoma? Hemithyroidectomy with laryngectomy causes hypothyroidism in up to 25% of patients, and if combined with radiotherapy, in up to 70%. In this review of 102 total laryngectomies with routine hemithyroidectomy for cT3 glottic carcinoma, laryngeal carcinoma involved the thyroid gland in two. Both had subglottic tumour extension. The tumour approached within 3 mm of the thyroid capsule in seven. It is proposed that thyroidectomy should be performed only in selected laryngeal carcinomas. Intraoperative assessment of the thyroid gland should determine the need for thyroidectomy in glottic and transglottic carcinomas. Carcinoma invasion of the thyroid gland should be confirmed by frozen section before proceeding to thyroidectomy. In the absence of thyroid gland involvement, both thyroid lobes may be preserved. Total thyroidectomy should be performed if the thyroid gland has been invaded. Total thyroidectomy should be routinely performed with subglottic carcinomas.

Late recurrences of laryngeal papillomatosis

Laryngeal papillomotasis recurred in 2 patients after 44 and 47 years of remission. The recurrence of papillomatosis after such lengthy periods of remission underscores the fact that, while surgical treatment of laryngeal papillomatosis may maintain the airway and voice, and in some cases control clinically overt disease, it does not address the subclinical mucosal human papillomavirus infection that may lead to recurrence many years after surgery.

Tracheostomy and peristomal recurrence

Emergency tracheostomy prior to laryngectomy for laryngeal carcinoma has been associated with peristomal recurrence. Is the peristomal recurrence caused by the tracheostomy per se, or is it due to the association of tracheostomy with subglottic tumours and locally advanced tumours? This study examines the association between tracheostomy, as an independent variable, and peristomal recurrence. Forty-three patients with T3 glottic carcinomas and treated by a combination of total laryngectomy and radiotherapy were studied. The difference in peristomal recurrence between the tracheostomy and non-tracheostomy patients was not statistically significant. Nor was there a correlation between the time interval between tracheostomy and laryngectomy, and the incidence of peristomal recurrence. It is concluded that tracheostomy, as an independent variable, does not cause peristomal recurrence.

Nasopharyngeal lipoma--a rare clinico-pathological entity

A lipoma situated within the posterior wall of the nasopharynx is reported. Only three lipomas of the nasopharynx in adults have previously been reported. The value of CT scan and cytology in making the preoperative diagnosis of a lipoma at this location is discussed.

A prospective study of anaesthesia for quinsy tonsillectomy

A prospective study of 50 adult quinsy tonsillectomy anaesthetics was performed. There were no significant anaesthetic or surgical complications and the mean intra-operative blood loss was 176 ml. The Mallampati score did not correlate with the Cormack and Lehane glottic view and there were no difficult intubations. Pre-operative trismus resolved completely during induction in 77.4% of cases. We concluded that the Mallampati grading system is not applicable in quinsies and in cases with palatopharyngeal arch distortion, that trismus in quinsies is due to muscle spasm and resolves completely during induction in most cases and that pre-anaesthetic drainage of the abscess together with rehydration and antibiotics are important contributing factors to safe anaesthesia for quinsy.

Excision of adenoid cystic carcinoma of the cervical trachea via an anterior castellated approach

Adenoid cystic carcinoma of the cervical trachea is rare and its diagnosis and surgical management challenging. We report a case with an unusual presentation and discuss the diagnosis and management. The preferred surgical management is tracheal resection, however this is often not feasible and many alternative techniques have been used. Here an anterior castellated approach is described, a modification of that more commonly used for benign tracheal strictures. We found it gave excellent access to the posterior tracheal wall which we feel is superior to a straight vertical tracheal incision. It also facilitates a tracheal widening procedure if indicated, and safeguards the recurrent laryngeal nerves which are particularly vulnerable in the cervical part of the trachea.