Drainless thyroid surgeries including goiter or central neck dissection: a case-control study

BACKGROUND

Despite ample of evidence regarding feasibility of simple drainless thyroid surgeries, the evidence of feasibility of such procedures in goiters and central neck dissections remains limited.

METHODS

Patients undergoing total thyroidectomy (TT) between January 2017 and July 2022 were included. The study included two study groups: drainless TT with central neck dissection (CND) and drainless TT due to goiter, which were compared to two controls: non-goiter drainless TT and drained TT for goiter or with CND. Main outcome was post-operative seroma rate.

RESULTS

156 patients met the inclusion criteria for each of the group. No significant differences between groups were found for permanent hypocalcemia, and other complications. Post-operative seroma was found in nine patients (5.8%), all from study groups. No significant differences between groups were found for local infections, aspirations, post-discharge drain insertion.

CONCLUSIONS

Complex drainless thyroid surgeries, including goiter and CND, are feasible and do not seem to significantly increase rate of post-operative seromas or infections.

The utility of parathyroid autofluorescence as an adjunct in thyroid and parathyroid surgery 2023

Thyroid and parathyroid surgery requires careful dissection around the vascular pedicle of the parathyroid glands to avoid excessive manipulation of the tissues. If the blood supply to the parathyroid glands is disrupted, or the glands are inadvertently removed, temporary and/or permanent hypocalcemia can occur, requiring post-operative exogenous calcium and vitamin D analogues to maintain stable levels. This can have a significant impact on the quality of life of patients, particularly if it results in permanent hypocalcemia. For over a decade, parathyroid tissue has been noted to have unique intrinsic properties known as "fluorophores," which fluoresce when excited by an external light source. As a result, parathyroid autofluorescence has emerged as an intra-operative technique to help with identification of parathyroid glands and to supplement direct visualization during thyroidectomy and parathyroidectomy. Due to the growing body of literature surrounding Near Infrared Autofluorescence (NIRAF), we sought to review the value of using autofluorescence technology for parathyroid detection during thyroid and parathyroid surgery. A literature review of parathyroid autofluorescence was performed using PubMED. Based on the reviewed literature and expert surgeons' opinions who have used this technology, recommendations were made. We discuss the current available technologies (image vs. probe approach) as well as their limitations. We also capture the opinions and recommendations of international high-volume endocrine surgeons and whether this technology is of value as an intraoperative adjunct. The utility and value of this technology seems promising and needs to be further defined in different scenarios involving surgeon experience and different patient populations and conditions.

Remote-Access Thyroidectomy in the Pediatric Population: a Systematic Review

INTRODUCTION

Remote-access thyroidectomy has been reported in the pediatric population in a limited fashion.

METHODS

This was a systematic review in PubMed and Scopus for pediatric remote-access thyroidectomy.

RESULTS

Seventy-eight articles were identified and screened, of which 13 met the inclusion criteria, including 231 patients; 70% of publications reported six or fewer patients. The mean age was 15.3 years (range 5-19). Sixty percent of surgeries were total thyroidectomy. Transaxillary robotic approach was most commonly performed (48.9%). Sixty-seven percent of the cases were operated on for a malignancy. Tumor size ranged between 0.4 and 1.8 cm. Recurrent laryngeal nerve injury rate was 1.9%. Transient and permanent hypocalcemia rates were 23.9% and 2.2%, respectively.

CONCLUSION

Pediatric remote-access thyroidectomy is not widely employed currently. Comparative studies with better quality are needed to establish its safety. Among selected pediatric patients, it can provide an alternative to open approaches, especially when neck scar is of major concern.

Scarless Neck Feminization by Transoral Endoscopic Vestibular Approach Chondrolaryngoplasty: A Prospective Cohort

OBJECTIVE

Chondrolaryngoplasty (laryngeal-prominence reduction) is a gender affirmation surgery for transgender women, or for cisgender people desiring an esthetic correction. Up until recently, chondrolaryngoplasty required a visible neck scar. The transoral endoscopic vestibular approach (TOEVA) is gaining widespread use as a scarless alternative for thyroid/parathyroid surgeries. This study aims to describe the feasibility, safety, and outcomes of TOEVA-chondrolaryngoplasty, based on the first-ever performed cases.

STUDY DESIGN

A prospective cohort.

SETTING

An academic referral center.

METHODS

Adult patients interested in chondrolaryngoplasty underwent scarless TOEVA-chondrolaryngoplasty between 2019 and 2022, according to the described protocol. Video stroboscopy was recorded pre-and postoperatively. Surgical data, adverse events, and complications were recorded. Patients' satisfaction was measured using an outcome instrument for esthetic chondrolaryngoplasty.

RESULTS

Twelve patients (10 transgender women, a cisgender man, and a woman) were included. The mean age was 26.7 ± 6.5 years, ranging from 19 to 37. The average operative time was 3:01 ± 0:51 hours. The thyroid cartilage and laryngeal prominence were easily and safely approached and reduced, with no adverse events or major complications. All patients were discharged on postoperative day 1. A single patient had a temporary mental nerve hypoesthesia that resolved spontaneously. Otherwise, no other complications were encountered. Vocal folds' function remained unchanged in all patients. Patients were very much to completely satisfied with the surgical results as measured by the outcome instrument; median (interquartile range), 25 (21-27.75).

CONCLUSION

In this first reported cohort of scarless TOEVA-chondrolaryngoplasty, this approach was proven to be safe and feasible, with no adverse events or major complications, and with high patient satisfaction.

Neck Surgery for Non-Well Differentiated Thyroid Malignancies: Variations in Strategy According to Histopathology

Lymph node metastases in non-well differentiated thyroid cancer (non-WDTC) are common, both in the central compartment (levels VI and VII) and in the lateral neck (Levels II to V). Nodal metastases negatively affect prognosis and should be treated to maximize locoregional control while minimizing morbidity. In non-WDTC, the rate of nodal involvement is variable and depends on the histology of the tumor. For medullary thyroid carcinomas, poorly differentiated thyroid carcinomas, and anaplastic thyroid carcinomas, the high frequency of lymph node metastases makes central compartment dissection generally necessary. In mucoepidermoid carcinomas, malignant peripheral nerve sheath tumors, sarcomas, and malignant thyroid teratomas or thyroblastomas, central compartment dissection is less often necessary, as clinical lymphnode involvement is less common. We aim to summarize the medical literature and the opinions of several experts from different parts of the world on the current philosophy for managing the neck in less common types of thyroid cancer.

Impact of drainless neck dissection on surgical outcome: a matched case-control study

PURPOSE

The safety of drainless lateral neck dissection (ND) remains to be proven. Hereby, we describe outcomes of drainless ND using fibrin sealant (FS).

METHODS

A retrospective, single academic institute, matched cased control. The study group included patients who underwent drainless ND (drainless group), matched to control patients by age, sex, body mass index, laterality and median number of levels dissected. Additional comparison of patients who underwent at least II-IV lateral ND for a thyroid cancer indication was also conducted. Outcomes were post-operative seroma\infections.

RESULTS

A total of 118 patients (42 cases and 76 controls) were included in the study. Groups did not differ in pre-operative characteristics, percentage of bilateral ND, and extension of ND. No significant difference was found in terms of post-operative infections, seroma, aspirations, and post-operative antibiotic use. The additional analysis included 23 drainless lateral ND and matched controls, of which 91% underwent concomitant level V dissection. No significant difference was found in terms of post-operative seroma or infection. These findings were confirmed with a multivariate analysis.

CONCLUSIONS

Drainless ND using FS in non-violating mucosa surgeries appears to be feasible and safe, without significantly increasing post-operative seroma and its associated complications.

[SCAR FREE THYROIDECTOMY AND PARATHYROIDECTOMY USING TRANSORAL ENDOSCOPIC VESTIBULAR APPROACH - THE FIRST 100 PATIENTS CASE SERIES IN ISRAEL]

INTRODUCTION

The use of transoral endoscopic vestibular approach for thyroidectomy (TOETVA) and parathyroid (TOEPVA) has been increasing worldwide, including in Israel.

AIMS

To describe a single institute experience of the first 100 patients undergoing TOETVA or TOEPVA.

METHODS

A prospective study of all patients undergoing TOETVA or TOEPVA. Outcomes were defined as the ability to complete surgery endoscopically (success rate), safety profile and length of operation.

RESULTS

A total of 100 patients were included; 81 (81%) underwent TOETVA and the remaining (19%) TOEPVA. Of 81 TOETVA patients, 73 (90.1%) underwent hemithyroidectomy. The success rate was 98.8% (80/81). Six temporary recurrent laryngeal injuries (6.7% of nerves at risk) were documented. No permanent complication was documented, including hypocalcemia. Mean length of operation (hemithyroidectomy) was 2.6±0.9 hours. The removal of thyroid cancer using TOETVA was performed in 51 patients (63%). All tumors were resected with clean margins. Parathyroid adenoma was located in 94.7% of the patients undergoing TOEPVA (18/19). All surgeries were completed endoscopically, without complications. Calcium levels normalized in 100% of the patients following surgery.

Revisiting the role of surgery in the treatment of Graves' disease

Graves' disease (GD) can be managed by antithyroid drugs (ATD), radioactive iodine (RAI) and surgery. Thyroidectomy offers the highest success rates for both primary and persistent disease, yet it is the least recommended or utilized option reaching <1% for primary disease and <25% for persistent disease. Several surveys have found surgery to be the least recommended by endocrinologists worldwide. With the development of remote access thyroidectomies and intraoperative nerve monitoring of the recurrent laryngeal nerve, combined with current knowledge of possible risks associated with RAI or failure of ATDs, revaluation of the benefit to harm ratio of surgery in the treatment of GD is warranted. The aim of this review is to discuss possible reasons for the low proportion of surgery in the treatment of GD, emphasizing an evidence-based approach to the clinicians' preferences for surgical referrals, surgical indications and confronting traditional reasons and concerns relating to the low referral rate with up-to-date data.

Drainless parotidectomy using tissue fibrin sealant - A retrospective case-control study

The aim of this study was to evaluate the impact of drainless parotidectomy using fibrin sealant on length of stay, post-operative seroma and related complications. For this purpose, a retrospective matched case-control series was held in a single academic center. All patients who underwent drainless parotidectomies, including deep lobe tumors and revision surgeries, were compared to matched controls in which a suction drain was inserted. Main outcomes were length of hospital stay and post-operative seroma. A total of 123 patients (41 cases and 82 controls) were included in the study. Fibrin sealant group had higher rates of total parotidectomy compared with the control group (25.0% vs. 10.5%, p = 0.054). Length of stay was significantly shorter in the fibrin sealant group (1.0 ± 0.3 days vs. 1.5 ± 0.6 days, p < 0.001, respectively). No statistically significant difference was found between the fibrin sealant group and the control regarding post-operative seromas (9.8% vs. 14.6%, p = 0.574, respectively), aspirations rate (7.3% vs. 14.6%, p = 0.381), and infection rates (0% vs.3.7%, p = 0.550). In conclusion, drainless parotidectomy does not increase post operative seroma rates and related complications, and can also be implemented for revision surgery.

Current therapeutic options for low-risk papillary thyroid carcinoma: A scoping evidence review

Most cases of thyroid carcinoma are classified as low risk. These lesions have been treated with open surgery, remote access thyroidectomy, active surveillance, and percutaneous ablation. However, there is lack of consensus and clear indications for a specific treatment selection. The objective of this study is to review the literature regarding the indications for management selection for low-risk carcinomas. Systematic review exploring inclusion and exclusion criteria used to select patients with low-risk carcinomas for treatment approaches. The search found 69 studies. The inclusion criteria most reported were nodule diameter and histopathological confirmation of the tumor type. The most common exclusions were lymph node metastasis and extra-thyroidal extension. There was significant heterogeneity among inclusion and exclusion criteria according to the analyzed therapeutic approach. Alternative therapeutic approaches in low-risk carcinomas can be cautiously considered. Open thyroidectomy remains the standard treatment against which all other approaches must be compared.

Primary hyperparathyroidism: Disease of diverse genetic, symptomatic, and biochemical phenotypes

Genetic, symptomatic, and biochemical heterogeneity of patients with primary hyperparathyroidism (PHPT) has become apparent in recent years. An in-depth, evidence-based review of the phenotypes of PHPT was conducted. This review was intended to provide the resulting information to surgeons who operate on patients with hyperparathyroidism. This review revealed that the once relatively clear distinction between familial and sporadic PHPT has become more challenging by the finding of various germline mutations in patients with seemingly sporadic PHPT. On the one hand, the genetic and clinical characteristics of some syndromes in which PHPT is an important component are now better understood. On the other hand, knowledge is emerging about novel syndromes, such as the rare multiple endocrine neoplasia type IV (MEN4), in which PHPT occurs frequently. It also revealed that, currently, the classical array of symptoms of PHPT is seen rarely upon initial presentation for evaluation. More common are nonspecific, nonclassical symptoms and signs of PHPT. In areas of the world where serum calcium levels are checked routinely, most patients today are "asymptomatic" and they are diagnosed after an incidental finding of hypercalcemia; however, some of them have subclinical involvement of bones and kidneys, which is demonstrated on radiographs, ultrasound, and modern imaging techniques. Last, the review points out that there are three distinct biochemical phenotypes of PHPT. The classical phenotype in which calcium and parathyroid hormone levels are both elevated, and other disease presentations in which the serum levels of calcium or intact parathyroid hormone are normal. Today several, distinct phenotypes of the disease can be identified, and they have implications in the diagnostic evaluation and treatment of patients, as well as possible screening of relatives.

Transoral endoscopic vestibular approach for thyroidectomy and parathyroidectomy - From promise to practice

OBJECTIVES

To describe the evolution and recent series on transoral endoscopic vestibular approach thyroidectomy and parathyroidectomy (TOET/PVA).

DATA SOURCES

PubMed, Google Scholar.

REVIEW METHODS

Review of the available English literature.

RESULTS

TOET/PVA may offer several advantages over other remote access thyroidectomy approaches and has been adopted by many centers worldwide with excellent success rates. Indications include benign disease and early thyroid cancer patients. Complication rate is comparable to the trans-cervical approach. The suggested framework has been validated in recent studies and its feasibility confirmed.

CONCLUSION

TOET/PVA has now been used to treat thousands of patients worldwide due to low cost, short learning curve and excellent cosmetic outcomes. Further studies will be necessary to demonstrate oncologic non-inferiority and also the true value that is added by the approach.

Impact of high-quality ultrasound following community ultrasound on surgical planning and active surveillance in patients with thyroid cancer

OBJECTIVE

Ultrasound (US) has gained a critical role in thyroid cancer treatment planning, yet it is limited by its user-dependent nature. The aim of this study was to compare the impact of US performed by radiologists specializing in thyroid imaging (hqUS) and US performed by radiographers in the community (cUS) on treatment plans of patients diagnosed with well-differentiated thyroid malignancies.

DESIGN

Retrospective single-centre case series with chart review.

PATIENTS

Patients diagnosed with thyroid cancer during 2017-2019 that had cUS followed by hqUS pre-operative counselling were included in this retrospective analysis.

MEASUREMENTS

The main outcome was management alternations based on one of two sonographic measures: (1) extrathyroid extension (ETE); (2) The presence of central or lateral lymph nodes suspicious for metastases (LNM), which were compared with the final pathology.

RESULTS

Among those with non-recurrent tumour (n = 76), ETE was reported 22 times more by hqUS compared with cUS (28.9% vs 1.3%, P < .001). Central and lateral LNM were reported approximately 6.5 and 1.5 times more by hqUS, respectively (25.0% vs 3.9%, P < .001 and 15.8% vs., 9.2%, P = .227, respectively). Overall, hqUS altered the initial treatment plan of 35.5% of patients. In 27.6% of patients, hqUS and its subsequent surgery resulted in a change to the patients' 2015 ATA risk stratification system. In 40% of patients with microcarcinomas, hqUS findings mandated surgery according to findings that were not reported by cUS. False-positive rate was 5.2%.

CONCLUSIONS

Community US may under-diagnose important features such as ETE and LNM, leading to potential under-treatment in many patients. High-quality US of the neck should be considered in patients with differentiated thyroid carcinoma before making any treatment decisions.

Standardization for oncologic head and neck surgery

The inherent variability in performing specific surgical procedures for head and neck cancer remains a barrier for accurately assessing treatment outcomes, particularly in clinical trials. While non-surgical modalities for cancer therapeutics have evolved to become far more uniform, there remains the challenge to standardize surgery. The purpose of this review is to identify the barriers in achieving uniformity and to highlight efforts by surgical groups to standardize selected operations and nomenclature. While further improvements in standardization will remain a challenge, we must encourage surgical groups to focus on strategies that provide such a level.

Preferences for thyroidectomy technique: Comparing traditional and transoral approaches

BACKGROUND

We investigated preferences between the transcervical and transoral thyroidectomy approach in the United States and Israel.

METHODS

An online survey assessing scar attitudes and surgical preferences, in English and Hebrew, was distributed on ThyCa.com and other platforms.

RESULTS

928 and 339 responses from the United States and Israel cohorts, respectively, were analyzed. In both countries, individuals without prior thyroidectomy preferred a scarless approach when hypothetical risks equaled those of traditional thyroidectomy (77% United States, 76% Israel, p = 0.61). U.S. respondents without thyroidectomy had greater preference to avoid a scar and would pay more to do so than those with thyroidectomy (both p < 0.001). Many respondents with prior thyroidectomy still expressed interest in scarless alternatives (57% United States).

CONCLUSIONS

Populations in Israel and the United States prefer scarless thyroidectomy when risks equal the traditional approach. While individuals without prior thyroidectomy are more likely to favor a scarless option, former thyroidectomy patients may have preferred avoiding a scar.

Para-tracheal neck dissection - is dissection of the upper part of level Ⅵ necessary?

Papillary thyroid carcinoma (PTC) has a high propensity for regional metastases, however, the impact of such metastases on the outcome of the patients is minimal. The central compartment of the neck is considered the first and the most common echelon of metastases from thyroid carcinoma. Physical examination along with ultrasonography are the gold standard pre-operative evaluation of patients with PTC. Ultrasonography is highly sensitive in evaluating lateral neck nodes, however, its value in evaluating the central compartment is limited, resulting in a relatively high rate of occult metastases in this compartment. The main potential complications of para-tracheal neck dissection (PTND) are recurrent laryngeal nerve paralysis and hypocalcemia and these may be higher in patients undergoing PTND compared to thyroidectomy alone. New histological data is available showing no evidence of lymph nodes in the central compartment above a level parallel to the inferior border of the cricoid cartilage. These findings support withholding dissection of the upper para-tracheal region routinely as a part of PTND in patients with well-differentiated thyroid cancer. By doing that, the complications may be lower and identical to thyroidectomy alone, thus may abolish arguments against more common use of elective PTND in patients with thyroid carcinoma.

Adoption of the transoral endoscopic vestibular approach by head and neck surgeons without prior laparoscopic/robotic experience

BACKGROUND

Transoral endoscopic vestibular approach (TOEVA) for thyroidectomy (TOETVA) and parathyroidectomy (TOEPVA) is gaining popularity, yet knowledge is based on a limited number of studies, mostly performed by surgeons experienced in laparoscopic\robotic surgery.

METHODS

All patients who underwent TOEVA at our institution between February 2018 and October 2019 were followed prospectively. Main outcomes were ability to accomplish surgery endoscopically (failure defined as conversion to open approach) and complications.

RESULTS

Seventy-one patients (52 TOETVA and 19 TOEPVA) were included. 98% (51/52) and 100% (19/19) of TOETVA and TOEPVA surgeries were accomplished endoscopically, respectively. Transient vocal cord and mental nerve injuries rates were 8.4% (6/71) and 2.8% (2/71), respectively. Thyroid carcinoma was diagnosed in 27 patients (51.9%), all completely excised with clean margins.

CONCLUSIONS

Adoption of the TOEVA suggested framework by head and neck surgeons without prior experience in laparoscopic/robotic techniques is feasible resulting in nearly 100% of surgeries accomplished endoscopically.

Insertion of a vacuum based drain for post-parotidectomy non-resolving seroma in an outpatient setting

We describe a novel technique for the insertion of a vacuum drain, in an outpatient setting, for persistent seroma post-parotidectomy. This is a retrospective case series of a single academic centre. The complete medical records of all patients who underwent parotidectomy between 2014 and 2019 were reviewed. Data regarding demographics, comorbidities, and intraoperative and postoperative courses were extracted for patients for whom a vacuum drain was inserted due to persistent seroma. A size 8 Fr drain was inserted using a novel approach through the parotidectomy incision using 'Biovac' (Biometrix) 50ml, Trocar kit, that had been adjusted and modified for this purpose. Two hundred and eighteen patients had had parotidectomy during the study period. Eight patients (3.6%) underwent insertion of the drain due to persistent seroma. In three patients (37.5%) no drain was inserted during the initial surgery. The mean (SD) time between surgery and insertion of the outpatient vacuum drain was 10 (5) days. All drain insertions were uneventful and no complications were noted. The mean (SD) time for outpatient vacuum drain removal was 12.75 (4.3) days. A single patient (12.5%) underwent additional needle aspiration of 5cc few days following removal of the drain. Persistent seromas may be managed in an outpatient clinic with good results and a high safety profile.

Papillary Thyroid Cancer-Aggressive Variants and Impact on Management: A Narrative Review

Introduction

Aggressive variants of papillary thyroid cancer (PTC) have been described with increasing frequency. These variants include diffuse sclerosing variant, tall cell variant, columnar cell variant, solid variant, and hobnail variant.

Methods

We have performed a review of the more aggressive variants of PTC with respect to main characteristics, histological and molecular features, and the consequences that the knowledge of these variants should have in the treatment of the patients.

Results

At the present time, we do not know the prognostic value of these aggressive PTC variants. The extent of the surgical treatment and adjuvant therapy necessary should be decided on the basis of the extent of the tumor at presentation and the opinion of experienced clinicians.

Conclusion

These aggressive variants should be known by clinicians, to avoid underdiagnosis, and treated according to the latest recommendations in the literature.

Scarless Neck Feminization: Transoral Transvestibular Approach Chondrolaryngoplasty

Importance: Chondrolaryngoplasty or reduction of laryngeal prominence is a gender affirmation surgery for transgender women, or for male patients desiring an aesthetic surgery. Several variations of the procedure were suggested, yet to date, all described chondrolaryngoplasty procedures involved a visible neck scar. Objective: To describe a novel technique for scarless chondrolaryngoplasty, transoral endoscopic vestibular approach (TOEVA)-chondrolaryngoplasty, and to report the results of first ever performed cases. Design, Setting, and Participants: This was a prospective cohort at an academic referral center. Adult transgender women, interested in chondrolaryngoplasty who never had previous surgery of their neck or vocal folds, were offered both transcervical chondrolaryngoplasty and scarless TOEVA-chondrolaryngoplasty. Four patients aged 21 to 33 years, who preferred TOEVA-chondrolaryngoplasty, were consented and recruited. Interventions: The surgical technique was successfully examined on two cadavers. Subsequently, all surgical procedures were conducted according to the described study protocol and technique, between April and June 2019. Main Outcomes: Vocal assessment was recorded preoperatively and repeated 4 to 6 weeks after surgery for comparison. Surgical documentations as well as adverse surgical events and complications were recorded. To measure outcome, 1-2 months postoperatively, all patients filled an outcome instrument for aesthetic chondrolaryngoplasty (seven questions on a 5-point Likert scale) based on previously designed questionnaires for chondrolaryngoplasty and facial plastic surgery. Results: Duration of operative time ranged from 90 to 150 min. No adverse events or complications were recorded during surgery. All patients were discharged 1 day postoperatively. A single patient had a mild temporary mental hypoesthesia that resolved 2 months after surgery, no other complications were encountered. Vocal folds' function remained unchanged in all four patients. All operated patients were highly satisfied with the surgical results as measured by the outcome instrument; three out of the four patients responded with perfect scores, and the fourth patient responded with 90% of the perfect score. Conclusions: This report is the first description of scarless chondrolaryngoplasty through TOEVA. On a series of four patients, TOEVA-chondrolaryngoplasty appeared to be safe, with no adverse events or major complication, and with extremely high patient satisfaction. Further clinical evidence is required to establish a widespread use of this surgical technique.

Parotidectomy via Individualized Mini-Blair Incision

BACKGROUND

The modified Blair incision is the standard facial incision for the vast majority of parotid gland lesions. We utilize three types of incisions: "classic mini-Blair" for parotid body tumors, "cervical mini-Blair" for parotid tail tumors, and "vertical mini-Blair" for anterior parotid tumors. In this study, we describe the surgical and esthetic outcomes of these individually tailored incisions.

METHODS

Patients undergoing parotidectomy between 2011 and 2013 were included. The surgical outcomes and patients' satisfaction were assessed.

RESULTS

Of 122 patients, 89 were included. All patients completed a questionnaire assessing the postoperative course and patients' satisfaction regarding the surgery in general and the scar in particular. Among these patients, 78 (87%) had a benign pathology and 11 (13%) had malignant tumors. The tumors were located at the parotid body in 57 patients (64%), at the parotid tail in 19 (21%), at the deep lobe in 8 (9%), and at the anterior parotid gland in 5 (6%). All tumors were removed successfully with negative margins on pathology. No inadvertent permanent facial nerve paralysis occurred. The median operation time was 72 min (23-211). The average patient scores of satisfaction with the surgical scar and with the surgery were 9.54 and 9.72, respectively.

CONCLUSIONS

Individualized mini-Blair incision is feasible for benign as well as selected malignant parotid tumors.

The Role of the Otorhinolaryngologist in the Management of Central Skull Base Osteomyelitis

Background

Skull base osteomyelitis (SBO) typically evolves as a complication of external otitis in diabetic patients and involves the temporal bone. Central SBO (CSBO) mainly involves the sphenoid or occipital bones without coexisting external otitis. We characterized a group of patients with CSBO. The endoscopic nasopharyngeal and clival biopsy technique is described.

Methods

Medical records of patients diagnosed as having SBO were retrospectively analyzed (from 2001 to 2006). Patients’ symptoms and signs, laboratory findings, imaging characteristics, endoscopic clival and periclival histopathology results, treatment, and outcome were retrieved.

Results

Of 20 patients with SBO, 6 patients without external otitis were studied (age range, 54–76 years; 5 men; mean follow-up, 21 months). All patients suffered from unilateral headache, three of six patients had serous otitis media (SOM), three of six patients had cranial nerve (CN) palsies, and five of six patients had elevated acute-phase reactants. Computed tomography (CT) findings were clival cortical bone erosion and adjacent soft tissue swelling. Magnetic resonance (MR) findings were texture changes and enhancement of the involved bones and soft tissues. Biopsy specimens revealed chronic inflammation. All six patients were treated with antibiotics for 3–6 months. Headache disappeared in five of six patients, SOM resolved in two of three patients, and CN palsies partially recovered in two of three patients. Imaging findings improved in five of six patients.

Conclusion

CSBO may mimic malignancy and represents a diagnostic challenge. Typical clinical picture and imaging findings together with a positive response to ciprofloxacin may suffice to establish the diagnosis and obviate the need for biopsies. When in doubt, nasopharyngeal and clival biopsies are performed to rule out malignancy.

Molecular markers in well-differentiated thyroid cancer

PURPOSE

Thyroid nodules are of common occurrence in the general population. About a fourth of these nodules are indeterminate on aspiration cytology placing many a patient at risk of unwanted surgery. The purpose of this review is to discuss various molecular markers described to date and place their role in proper perspective. This review covers the fundamental role of the signaling pathways and genetic changes involved in thyroid carcinogenesis. The current literature on the prognostic significance of these markers is also described.

METHODS

PubMed was used to search relevant articles. The key terms "thyroid nodules", "thyroid cancer papillary", "carcinoma papillary follicular", "carcinoma papillary", "adenocarcinoma follicular" were searched in MeSH, and "molecular markers", "molecular testing", mutation, BRAF, RAS, RET/PTC, PAX 8, miRNA, NIFTP in title and abstract fields. Multiple combinations were done and a group of experts in the subject from the International Head and Neck Scientific Group extracted the relevant articles and formulated the review.

RESULTS

There has been considerable progress in the understanding of thyroid carcinogenesis and the emergence of numerous molecular markers in the recent years with potential to be used in the diagnostic algorithm of these nodules. However, their precise role in routine clinical practice continues to be a contentious issue. Majority of the studies in this context are retrospective and impact of these mutations is not independent of other prognostic factors making the interpretation difficult.

CONCLUSION

The prevalence of these mutations in thyroid nodule is high and it is a continuously evolving field. Clinicians should stay informed as recommendation on the use of these markers is expected to evolve.

Treatment of pain after head and neck surgeries: Control of acute pain after head and neck oncological surgeries

Objective

To devise an effective postoperative analgesic protocol.

Study Design and Setting

Two consecutive groups participated in this study. In the first group (n = 100), the pain-control management was pro re nata (PRN). In the second group, (n = 109) we tailored a procedure-specific pain-control protocol for each patient according to the level of pain recorded in the first group. These patients were treated with analgesics given at predetermined hours. Pain was evaluated by using a verbal scale of 1 to 10.

Results

In the first group, a significant reduction in the level of pain was monitored 1 hour after PRN drug administration; however, patients reported the return of pain several hours later, after the drug effect subsided. Overall, the patients suffered a substantial level of pain during the entire postoperative period. In the second group, significant reduction in the level of pain was recorded throughout the hospitalization.

Conclusion

The PRN protocol is not adequate for management of pain after head and neck surgeries.

Significance

We can substantially reduce our patients' postoperative pain by adopting a procedure-specific analgesic regimen instead of a PRN regimen. EBM rating: B-3b.

The Sensitivity of Preoperative Scanning in Regional Recurrence of Papillary Thyroid Cancer

BACKGROUND: The treatment of patients with regionally recurrent papillary carcinoma of the thyroid is a matter of controversy. Radioactive nodal picking was proposed as an alternative to neck dissection in these patients.

METHODS: We analyzed neck dissection specimens in 20 patients with PTC and compared the results to preoperative total-body scan (TBS) following a therapeutic dose of I131 and ultra-sonographic findings.

RESULTS: Eighteen patients underwent paratracheal neck dissection and 10 patients had a lateral neck dissection. Preoperative TBS detected the correct number of positive nodes in only 1 patient (5%) and the correct number of patients with positive nodes in 6/20 (30%) of the patients. US detected 32/98 positive nodes (36%) and 20/20 (100%) of the patients. Prediction of the number of positive nodes for both TBS and US was low (5% and 10%, respectively).

CONCLUSIONS: Preoperative TBS and/or US cannot satisfactorily predict metastatic lymph node involvement and cannot safely delineate limited surgery to replace formal neck dissection in patients with regionally recurrent PTC.

Parathyroid Hormone: A Sensitive Predictor of Hypocalcemia Following Total Thyroidectomy

OBJECTIVE: To investigate whether monitoring parathyroid hormone (PTH) could predict hypocalcemia following total thyroidectomy or other bilateral thyroid manipulations.

STUDY DESIGN AND SETTING: Forty patients undergoing total thyroidectomy as well as other bilateral thyroid procedures were prospectively enrolled. PTH levels were measured preoperatively and 30 minutes postoperatively. Calcium levels were measured preoperatively and every 8–12 hours for the first 72 postoperative hours. Changes in PTH levels as well as symptoms of hypocalcemia were correlated with postoperative hypocalcemia.

RESULTS: Hypocalcemia developed in 13/40 patients (32.5%), mainly those patients undergoing total thyroidectomy in conjunction with paratracheal neck dissections. The respective sensitivity and specificity of a drop in PTH for detecting hypocalcemia was 92% and 66% (50% drop), 23% and 75% (75% drop), and 46% and 100% (drop below normal range).

CONCLUSIONS: A 50% drop in PTH levels 30 minutes following bilateral thyroid procedures is a sensitive predictor of hypocalcemia. A drop of 75% is a highly specific indicator of postoperative hypocalcemia, though not highly sensitive.

Curcumin: A new radio-sensitizer of squamous cell carcinoma cells

PURPOSE: Curcumin, a potential chemopreventive agent, was found to inhibit cancer cells in S/G2M phases of the cell cycle, when radiation is more effective. The purpose of the current study was to investigate whether curcumin can sensitize squamous cell carcinoma (SCC) cells to the ionizing effects of irradiation.

METHODS: Curcumin (3.5 μM) was added for 48 hours to an SCC cell line prior to irradiation. Cell growth (counts) and colony-formation (colonogenic assay) were examined after radiation.

RESULTS: Incubation with curcumin only (3.75 μM) for 48 hours did not decrease the number of cells or the ability to form colonies in the absence of radiation. However, in plates that were exposed to 1–5 Gy of radiation, cell counts dropped significantly if pretreated with curcumin with a maximal effect at 2.5 Gy (where the cell counts dropped from 1240 to 1017, P < 0.001). The colonogenic assay revealed a significant decrease in the ability to form colonies following pretreatment with curcumin in all radiation doses ( P < 0.05).

CONCLUSIONS: Given the appropriate doses, curcumin exhibits radio-sensitizing effects on SCC cells in vitro.

Surgical management of parapharyngeal space tumors: A 10-year review

OBJECTIVE:

The purpose of this article is to describe the diagnostic evaluation and surgical approaches to parapharyngeal space tumors in a tertiary referral center.

STUDY DESIGN AND SETTING:

The study is a retrospective review of 47 patients diagnosed with tumors of the parapharyngeal space (12 with malignant diseases and 35 with benign lesions) and surgically treated during a 10-year period. The transcervical (40%) and the transcervical-transparotid approaches (46%) were the most commonly performed surgical procedures followed by the orbitozygomatic-middle fossa approach (12%) and the transmandibular approach (2%).

RESULTS:

The surgical procedures were uneventful and there were no postoperative mortalities. Complications were rare; the most common was transient facial nerve paralysis (5 patients). After an average follow-up of 35 months, only 1 of 35 patients with benign diseases had a recurrence 5 years following transcervical resection of a pleomorphic adenoma. Of 12 patients with malignant tumors, 5 (42%) are alive with no evidence of disease. The sensitivity of preoperative fine needle aspiration biopsy (n = 23 patients) was 87% for detection of malignant disease and specificity was 100%.

CONCLUSIONS:

Most benign parapharyngeal space tumors can be removed surgically with a low rate of complications and recurrence. Malignant neoplasms, however, carry an ominous prognosis and a low rate of disease-free survival. Fine needle aspiration may be helpful in preoperative diagnostic evaluation of patients with parapharyngeal space tumors.

4D MRI for the Localization of Parathyroid Adenoma: A Novel Method in Evolution

The sestamibi scan (MIBI) and ultrasound (US) are used for preoperative localization of parathyroid adenoma (PTA), with sensitivity as high as 90%. We developed 4-dimensional magnetic resonance imaging (4D MRI) as a novel tool for identifying PTAs. Eleven patients with PTA were enrolled. 4D MRI from the mandible to the aortic arch was used. Optimization of the timing of image acquisition was obtained by changing dynamic and static sequences. PTAs were identified in all except 1 patient. In 9 patients, there was a complete match between the 4D MRI and the US and MIBI, as well as with the operative finding. In 1 patient, the adenoma was correctly localized by 4D MRI, in contrast to the US and MIBI scan. The sensitivity of the 4D MRI was 90% and after optimization, 100%. Specificity was 100%. We concluded that 4D MRI is a reliable technique for identification of PTAs, although more studies are needed.

The upper limits of central neck dissection

IMPORTANCE

Central neck dissection (CND) is considered an imperative part of the treatment of patients with high-risk, well-differentiated thyroid carcinoma.

OBJECTIVE

To examine the presence of lymphatic tissue and/or metastatic nodes in the upper part of the paratracheal region to determine the need to dissect this region as part of a paratracheal neck dissection.

DESIGN, SETTING, AND PARTICIPANTS

We prospectively enrolled 27 nonselective patients with surgical thyroid cancer (4 men and 23 women; median age, 43 years; range, 21-74 years) from June 1, 2010, through March 31, 2011, from a head and neck surgical oncology specialist group practice within the largest private hospital in Israel. All patients were scheduled to undergo unilateral (n = 23) or bilateral (n = 4) CND as their definitive surgical care.

INTERVENTIONS

A total of 31 paratracheal neck dissections were performed among the 27 patients. The surgical specimens were divided into upper and lower paratracheal regions, separated by the nerve curve line (corresponding to the level of the cricoid). These specimens were thoroughly examined separately for normal and metastatic lymph nodes. A standard pathologic technique was used, with no dedicated personnel.

MAIN OUTCOMES AND MEASURES

The existence of lymphatic tissue and metastatic cells in all upper paratracheal surgical specimens.

RESULTS

The surgical procedures were uneventful. Postoperative complications included temporary vocal cord palsy, minimal chyle leak, and wound infection. A median of 8 nodes were retrieved (range, 2-21). No lymphatic tissue was identified in all upper paratracheal dissection specimens. All benign and metastatic lymph nodes (mean, 5.3 and 2.5, respectively) were located in the lower paratracheal region specimens. All upper paratracheal surgical specimens (n = 31) consisted of only fibrofatty connective tissue and were devoid of lymph nodes, metastatic cells, or other endothelial-lined lymphatic structures.

CONCLUSIONS AND RELEVANCE

In this series of paratracheal neck dissections, the upper part of the paratracheal region contained no lymphatic tissue or cancer-bearing lymph nodes. The necessity to dissect this region, as part of conventional CND, is therefore challenged.

Neuromonitoring of the laryngeal nerves in thyroid surgery: a critical appraisal of the literature

One of the most significant complication of thyroid surgery is injury of the recurrent laryngeal nerve. Injury of the external branch of the superior laryngeal nerve is a less obvious but occasionally significant problem. Recently, neuromonitoring during thyroidectomy has received considerable attention because of literature encouraging its use, but there is no consensus about its advantages and utility. A critical assessment of the literature on neuromonitoring was conducted in order to define its effectiveness, safety, cost-effectiveness and medical-legal impact. Available data does not show results superior to those obtained by traditional anatomical methods of nerve identification during thyroid surgery. Data about cost-effectiveness is scarce. The literature shows inconsistencies in methodology, patient selection and randomization in various published studies which may confound the conclusions of individual investigations. The current recommendation for use in "high risk" patients should be assessed because definition heterogeneity makes identification of these patients difficult. As routine use of neuromonitoring varies according to geography, its use should not be considered to be the standard of care.

Diagnosis and treatment of recurrent laryngeal cancer following initial nonsurgical therapy

Surgery is the preferred modality for curative treatment of recurrent laryngeal cancer after failure of nonsurgical treatments. Patients with initial early-stage cancer experiencing recurrence following radiotherapy often have more advanced-stage tumors by the time the recurrence is recognized. About one third of such recurrent cancers are suitable for conservation surgery. Endoscopic resection with the CO(2) laser or open partial laryngectomy (partial vertical, supracricoid, or supraglottic laryngectomies) have been used. The outcomes of conservation surgery appear better than those after total laryngectomy, because of selection bias. Transoral laser surgery is currently used more frequently than open partial laryngectomy for treatment of early-stage recurrence, with outcomes equivalent to open surgery but with less associated morbidity. Laser surgery has also been employed for selective cases of advanced recurrent disease, but patient selection and expertise are required for application of this modality to rT3 tumors. In general, conservation laryngeal surgery is a safe and effective treatment for localized recurrences after radiotherapy for early-stage glottic cancer. Recurrent advanced-stage cancers should generally be treated by total laryngectomy.

Targeting ErbB-1 and ErbB-4 in irradiated head and neck cancer: results of in vitro and in vivo studies

BACKGROUND

ErbB oncogenes have a major role in cancer. The role of ErbB-4 in cancer cell biology and the effect of anti-ErbB-1 and anti-ErbB-4 monoclonal antibodies were evaluated in this study.

METHODS

ErbB-4 expression and binding was evaluated by Western blot, enzyme-linked immunosorbent assay (ELISA), fluorescent microscopy, and flow cytometry. Cell survival was measured by XTT assay. Tumor progression was followed up in nude mice model.

RESULTS

High ErbB-1 levels in head and neck cancer cell lines were determined, whereas ErbB-4 expression varied. Specific antibody binding to the cells was demonstrated. High ErbB-4 expressing squamous cell carcinoma 1 (SCC-1) cells proliferated faster and generated faster growing tumors in mice. Cetuximab and mAb-3 reduced cell survival proportional to ErbB-1 and ErbB-4 expression. Combination of antibodies with irradiation was most effective in reducing cell survival and tumor growth.

CONCLUSION

ErbB-4 plays a role in head and neck cancer cell biology. Anti-ErbB-4 targeted therapy can serve as a new strategy against head and neck cancer when combined with established treatments.

Level V in therapeutic neck dissections for papillary thyroid carcinoma

Neck dissection for papillary thyroid carcinoma (PTC) is the standard of care for patients with clinical evidence of regional metastases. However, the extent of neck dissection is debatable. The purpose of the current study was to develop evidence-based recommendations for when to include level V, or 1 of its sublevels, among patients with PTC undergoing neck dissection. A literature review of all studies evaluating the occurrence of metastases in level V in patients with regional metastases from PTC undergoing neck dissection was performed. Occurrence of metastases at level V is low in most series (5% to 10%), although a wide range was noticed. In cases in which metastases were found at level V, they occurred almost exclusively at sublevel VB. Sublevel VA was rarely, if ever, involved with metastatic lymph nodes. However, only recently have investigators begun to specify which sublevels of level V are at risk. Therapeutic dissection of level V is indicated when there is clinical evidence of disease involving this zone. Elective dissection of sublevel VB is indicated when there is involvement of level IV, or possibly multiple nodes at levels II and III. Under these circumstances, dissection of sublevel VB is indicated but sublevel VA may be spared.

A comprehensive algorithm for anterior skull base reconstruction after oncological resections

OBJECTIVE

To present our method for anterior skull base reconstruction after oncological resections.

METHODS

One hundred nine patients who had undergone 120 anterior skull base resections of tumors (52 malignant [43%], 68 benign [57%]) via the subcranial approach were studied. Limited dural defects were closed primarily or reconstructed using a temporalis fascia. Large anterior skull base defects were reconstructed by a double-layer fascia lata graft. A split calvarial bone graft, posterior frontal sinus wall, or three-dimensional titanium mesh were used when the tumor involved the frontal, nasal, or orbital bones. A temporalis muscle flap was used to cover the orbital socket for cases of eye globe exenteration, and a rectus abdominis free flap was used for subcranial-orbitomaxillary resection. Pericranial flap wrapping of the frontonaso-orbital segment was performed to prevent osteoradionecrosis if perioperative radiotherapy was planned.

RESULTS

The incidence of cerebrospinal fluid (CSF) leak, intracranial infection, and tension pneumocephalus was 5%. Histopathological and immunohistochemical analysis of fascia lata grafts in reoperated patients (n = 7) revealed integration of vascularized fibrous tissue to the graft and local proliferation of a newly formed vascular layer embedding the fascial sheath.

CONCLUSION

A double-layer fascial graft alone was adequate for preventing CSF leak, meningitis, tension pneumocephalus, and brain herniation. We describe a simple and effective method of anterior skull base reconstruction after resections of both malignant and benign tumors.

Curcumin: a potential radio-enhancer in head and neck cancer

OBJECTIVES/HYPOTHESIS

To investigate whether curcumin enhances the cytotoxic effect of radiotherapy in head and neck squamous cell carcinoma (HNSCC).

METHODS

HNSCC cell lines SCC-1, SCC-9, KB, as well as A431 cell line were treated with curcumin, irradiation, or their combination. Cell viability was evaluated by XTT assay. Cyclooxygenase-2 (COX-2), epithelial growth factor receptor (EGFR), and p-Erk1/2 were measured by Western blot analysis. CD-1 athymic nude mice with orthotopic implanted SCC-1 cells, were treated with control diet, curcumin containing diet, local single-dose radiation, or combination.

RESULTS

Curcumin (IC50 range, 15-22 microM) and radiation inhibited cell viability in all cell lines were tested. The combination of curcumin and radiation resulted in additive effect. Curcumin decreased COX-2 expression and inhibited phosphorylation of EGFR in SCC-1 cells. In tumor-bearing mice the combination regimen showed a decrease in both tumor weight (25%, P = .09) and tumor size (15%, P = .23) compared to the nontreated mice.

CONCLUSIONS

: Curcumin inhibited HNSCC cell growth and augmented the effect of radiation in vitro and in vivo. A possible mechanism is inhibition of COX-2 expression and EGFR phosphorylation.

Attachment-oriented endoscopic surgical strategy for sinonasal inverted papilloma

BACKGROUND

It is well documented that inverted papillomas (IP) have a localized attachment site. Still, instead of concentrating on the attachment site, endoscopic surgeons often perform an extended resection similar to the one achieved after external surgery.

OBJECTIVE

Our objective was to evaluate an attachment-oriented endoscopic surgical strategy and to determine IP attachment diameter and location.

METHODS

A prospective study was conducted. Thirty-three consecutive patients who underwent endoscopic IP excision (2001--2007) were enrolled. Thirty patients had adequate follow-up. Attachment diameters were measured in 25/33 patients. Surgery included debulking, identifying the precise mucosal attachment site, subperiosteal dissection and excision of the attachment, frozen section control, and resection/drilling of underlying bone.

RESULTS

The mean measured attachment diameter (n = 25) was 8.4 +/- 6 mm (range, 3-23 mm). Attachment locations included maxillary sinus (39%), ethmoid sinus (21%), nasal cavity (21%), frontal sinus (6%), sphenoid sinus (6%), lamina papyracea (3%), and cribriform plate (3%). The mean follow-up (n = 30) was 40 +/- 21 months. Three patients had Krouse stage 1, 10 patients had stage 2, and 17 patients had stage 3. Nine patients had undergone previous surgeries. After attachment-oriented endoscopic surgery, three patients had persistent disease. Nasolacrimal duct stenosis was the only complication (n = 1).

CONCLUSION

Even advanced IP have small attachments. Their Identification facilitates efficacious resection with minimal morbidity.

Elective paratracheal neck dissection for lateral metastases from papillary carcinoma of the thyroid: is it indicated?

BACKGROUND

Therapeutic paratracheal neck dissection for patients with papillary carcinoma of the thyroid is standard treatment. Its use as an elective procedure is controversial.

METHODS

Thirty-seven patients with papillary carcinoma of the thyroid and evidence of positive adenopathy at levels II-V underwent selective neck dissection and elective/therapeutic paratracheal neck dissection. Results of preoperative ultrasonography of the neck were compared with the dissection specimens.

RESULTS

Morbidity of the surgical procedure was minimal (1 permanent hypocalcemia). All specimens showed metastases from papillary thyroid carcinoma: 100% (37/37) in the jugular chain of lymphatics and 83.7% (31/37) in the paratracheal region. The rate of occult (negative physical examination and ultrasonography) metastases in the paratracheal region in the presence of metastases in the ipsilateral jugular chain was 83.3% (20/24).

CONCLUSION

The high rate of occult metastases in the paratracheal region and the low rate of surgical morbidity speak in favor of elective paratracheal neck dissection in patients with metastatic papillary carcinoma of the thyroid.

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.

Quality of life in patients older than 75 years following major head and neck surgery

BACKGROUND

This study was designed to evaluate the quality of life (QOL) of patients older than 75 years undergoing major head and neck surgery.

METHODS

Three groups of patients were included: elderly patients (>75, n = 35) and younger patients (65 to 75 years, n = 30) undergoing major head and neck surgery and healthy controls (>75, n = 40). Measurements were made using the SF-12 health survey, the University of Washington QOL questionnaire, and measurements of the "sense of burden" on the caregiver.

RESULTS

With the SF-12, the role physical, role emotional, and bodily pain were decreased by the surgical intervention, while physical function was affected by age alone. With the UW-QOL Questionnaire, overall QOL was preserved. "Appearance" and "Leisure" subscales were affected by the surgical intervention and old age. "Chewing" and "Activity" were decreased by the surgical intervention in the older patients, and "Speech" was affected by the surgical intervention alone. The "sense of burden" was alleviated by surgery in the elderly patients.

CONCLUSIONS

Several QOL domains are decreased in elderly patients undergoing major head and neck surgery.

Assessing the effectiveness of Dead Sea products as prophylactic agents for acute radiochemotherapy-induced skin and mucosal toxicity in patients with head and neck cancers: a phase 2 study

BACKGROUND

Mucositis and dermatitis are frequently encountered in patients treated with radiochemotherapy. Dead Sea products that contain minerals and other properties have proven effective in treating various skin diseases.

OBJECTIVES

To evaluate the effectiveness of Dead Sea products in reducing acute radiochemotherapy-induced side effects in patients with head and neck cancer.

METHODS

In this phase 2 study we compared the outcomes in 24 treated patients and 30 conventionally treated patients matched for age, tumor site, and type of treatment. The Dead Sea products comprised a mouthwash solution (Lenom) and a skin cream (Solaris) used three times daily for 1 week before, during, and up to 2 weeks after completion of radiotherapy. Mucositis and dermatitis were evaluated using common toxicity criteria.

RESULTS

Thirteen treated patients (54%) had grade 1-2 and none had 3-4 mucositis, while 17 controls (57%) had grade 1-2 and 4 (13%) had grade 3-4 mucositis. Thirteen treated patients (54%) had grade 1-2 dermatitis; there was no instance of grade 3-4 dermatitis, while 11 patients in the control group (37%) had grade 1-2 and 5 (17%) had grade 3-4 dermatitis. More patients in the control arm needed a break than did patients in the treatment the control arm needed a break than did patients in the treatment arm (P = 0.034).

CONCLUSIONS

The two Dead Sea products tested decreased skin and mucosal toxicity in head and neck cancer patients receiving radiochemotherapy.

Necrotizing Fasciitis of the Skull Base and Neck in a Patient with AIDS and Non-Hodgkin's Lymphoma

Necrotizing fasciitis is a rapidly progressing, life-threatening soft tissue bacterial infection found more frequently in immunocompromised subjects and rarely in the head and neck. We report a rare case of a patient with acquired immunodeficiency syndrome (AIDS) and non-Hodgkin's lymphoma (NHL) who presented with a high fever and supraorbital cellulitis 1 week after undergoing chemotherapy. He received intravenous antibiotic therapy but soon developed dyspnea and trismus with rapid extension of the cellulitis to the face, ipsilateral infratemporal fossa (ITF), and bilateral neck. An awake tracheotomy was followed by surgical exploration and drainage and debridement of the supraorbital and ITF areas, parotid gland, and bilateral neck. He received intravenous antibiotic therapy and the surgical wound was regularly debrided for 10 days. Following a gradual recovery, the patient was discharged 2 weeks later. Early antibiotic therapy, wide surgical exploration, and a secured airway are the therapeutic mainstay for necrotizing fasciitis of the skull base and neck.

Systemic corticosteroids for allergic fungal rhinosinusitis and chronic rhinosinusitis with nasal polyposis: a comparative study

OBJECTIVES

To compare the effect of preoperative high-dose systemic corticosteroids on the radiographic and endoscopic appearance of allergic fungal rhinosinusitis (AFRS) and chronic rhinosinusitis with nasal polyposis (CRSwNP).

STUDY DESIGN AND SETTING

Eight AFRS and 10 CRSwNP patients underwent computed tomographic (CT) scans and then received preoperative 1 mg/kg prednisone for 10 days. CT scans were repeated 1 day before surgery and compared with pretreatment scans (Lund-MacKay radiologic scoring system). The endoscopic appearance was recorded intraoperatively.

RESULTS

The score dropped from 16 (66.4%) to 4.75 in the AFRS group and from 18.4 (23%) to 14.1 in the CRSwNP group (P=0.0064). Intraoperatively, most sinus mucosal surfaces appeared normal in the AFRS patients but were markedly edematous in the CRSwNP patients.

CONCLUSION

Radiographic response of AFRS to systemic corticosteroids is significantly greater compared with CRSwNP. This finding is supported by endoscopic observation.

[Recurrent pleomorphic adenoma of the parotid gland]

Recurrent pleomorphic adenoma of the parotid gland is a challenging surgical experience. Resection of such recurrences is associated with an increased risk of facial nerve injury and a higher incidence of recurrent disease. Resection of the primary tumor with a cuff of normal tissue around it during the primary surgical resection lowers the incidence of such metastases, but even with them, metastases still occur. Surgery of such metastases requires high surgical expertise as well as intra-operative decision-making. Intraoperative monitoring of the facial nerve may be of help during these surgical interventions, but the surgeon need not rely on the monitor only, but identify the nerve based on its well known anatomy and use the monitor as another surgical tool for safe removal of the tumor. Resection of the facial nerve or some of its branches is usually not necessary, but if the nerve is the only site making the resection an incomplete one - then the nerve should sometimes be resected, after sufficient effort has been made to preserve it. In these cases, the nerve should be reconstructed with a cable graft (mainly greater auricular or sural) when possible. Radiotherapy is reserved for patients that had multiple recurrences or had massive tumor spillage during their surgical procedure of the recurrent tumor.