Critical Role of Central Facilitation in the Glottic Closure Reflex

The sphincteric function of the larynx, essential to lower airway protection, is most efficiently achieved through strong reflex adduction by both vocal cords. We hypothesize that central facilitation is an essential component of a bilateral adductor reflex and that its disturbance could result in weakened sphincteric closure. Six adult 50-kg pigs underwent evoked response laryngeal electromyography under 0.5 to 1.0 minimal alveolar concentration (MAC) isoflurane anesthesia. The internal branch of the superior laryngeal nerve was stimulated through bipolar platinum-iridium electrodes, and recording electrodes were positioned in the ipsilateral and contralateral thyroarytenoid muscles. Consistent threshold responses were obtained ipsilaterally from 0.5 to 1.0 MAC anesthesia. However, the contralateral reflex responses approached 0% in successive trials as anesthetic levels approached 1.0 MAC. Alteration of central facilitation by deepening anesthesia abolishes the crossed adductor reflex, predisposing to a weakened glottic closure response. A precise understanding of this effect may improve the prevention of aspiration in patients emerging from prolonged sedation or under heavy psychotropic control.

Cancer of the pharynx and larynx

Carcinoma of the head and neck is among the most debilitating forms of cancer. Survival rates for these tumors vary and depend on the presence of early symptoms, anatomic accessibility, and lymphatic supply. Despite advances in therapy and novel surgical approaches, early diagnosis remains the best predictor of survival. This article reviews the diagnosis, staging criteria, and treatment strategies for nasopharyngeal carcinoma, hypopharyngeal carcinoma, and laryngeal carcinoma in an effort to heighten the clinical and endoscopic recognition of these lesions.

Horizontal maxillotomy for exposure of the central skull base: the Yale experience

Le Fort I osteotomy allows the surgeon to safely down-fracture the maxilla for wide exposure of the central skull base. This surgical approach is easily extended inferiorly to include the arch of C1, providing 8 cm of horizontal anterior exposure and 5 cm of posterior. Wide operative exposure and a low rate of complications afford superior functional and cosmetic preservation in removing tumors of the central cranial base.

Mandibular and temporomandibular joint arthropathy in the differential diagnosis of the parotid mass

OBJECTIVE

To increase awareness of temporomandibular joint and mandibular disease in the overall evaluation and diagnosis of the parotid mass.

STUDY DESIGN

We describe clinical presentations of pigmented villonodular synovitis and synovial chondrocalcinosis of the temporomandibular joint, as well as osteoma of the mandible, as they may initially suggest primary neoplasms of the parotid gland.

CONCLUSIONS

Preauricular swelling is a common presenting symptom for patients visiting an otolaryngologist. Often this symptom is suggestive of a parotid mass. However, lesions of the temporomandibular joint and mandible may also present in this fashion.

Distant metastases from ear and temporal bone cancer

Cancers of the temporal bone are rare. Cervical metastases occur in approximately 10% of cases and are much more likely once disease extends beyond the confines of the temporal bone. Nonlymphatic spread of squamous cell carcinoma is usually a late event resulting in metastatic deposits in the lung, bone, liver and brain. This chapter discusses detection of distant metastases and provides a recommended schedule for interval patient evaluation.

Molecular marker expression in oral and oropharyngeal squamous cell carcinoma

OBJECTIVE

To determine the relative prognostic value of p53, cyclin D1, epidermal growth factor receptor (EGFR), and vascular endothelial growth factor (VEGF) expression in patients with oral and oropharyngeal squamous cell carcinoma.

DESIGN

Retrospective cohort study.

PATIENTS

Fifty-six patients with oral and oropharyngeal squamous cell carcinoma referred to the Department of Therapeutic Radiology at Yale-New Haven Hospital (Conn) between 1981 and 1992 who were treated with gross total surgical resection and postoperative external beam radiotherapy.

RESULTS

Archival tumor tissue was stained with monoclonal antibodies directed against these 4 oncoproteins and scored for staining intensity and percent distribution by a pathologist blinded to the patients' clinical outcomes. Frequency of marker expression was 48% for p53, 20% for cyclin D1, 64% for EGFR, and 41% for VEGF. In multivariate analysis, EGFR positivity was protective against locoregional relapse (relative risk [RR], 0.27; 95% confidence interval [CI], 0.11-0.66; P =.002). In contrast, advanced N stage predicted poor locoregional relapse-free survival (RR, 1.94; 95% CI, 1.03-3.66; P =.04). Predictors of poor overall survival in multivariate analysis included VEGF positivity (RR, 3.53; 95% CI, 1.75-7.13; P<.001) and black race (RR, 2.48; 95% CI, 1.05-5.85; P =.04). Cyclin D1 and p53 expression were not significantly associated with prognosis in this cohort.

CONCLUSIONS

In oral and oropharyngeal squamous cell carcinoma treated with surgery and postoperative radiotherapy, VEGF and EGFR expression may influence clinical outcome. If confirmed, these results have potential implications for the determination of patient prognosis and the development of biologically based pharmacotherapies.

Adenoid cystic carcinoma: a retrospective clinical review

Adenoid cystic carcinoma (ACC) are uncommon tumors, representing about 10% to 15% of head and neck tumors. We compare the survival and control rates at our institution with those reported in the literature, and examine putative predictors of outcome. All patients registered with the tumor registry as having had ACC were identified. Demographic and survival variables were retrieved from the database. Additionally, a chart review of all patients was done to obtain specific information. Minor gland tumors were staged using the American Joint Committee on Cancer's criteria for squamous cell carcinomas in identical sites. Histopathologic variables retrieved included grade of the tumor, margins, and perineural invasion. Treatment modalities, field sizes, and radiation doses were recorded in applicable cases. An effort to retrieve archival tumor specimens for immunohistochemical analysis was undertaken. A total of 69 patients were treated for ACC from 1955 to 1999. One patient, who presented with fatal brain metastasis, was excluded from further analysis. Of the remaining 68 patients, 30 were men and 38 were women. The average age at diagnosis was 52 years, and mean follow-up was 13.2 years. Mean survival was 7.7 years. Overall survival (OS) rates at 5, 10, and 15 years were 72%, 44%, and 34%, and cause-specific survival was 83%, 71%, and 55%, respectively. Recurrence-free survival rates were 65%, 52%, and 30% at 5, 10, and 15 years, with a total of 29 of 68 (43%) eventually suffering a recurrence. Overall survival was adversely affected by advancing T and AJCC stage. Higher tumor grades were also associated with decreased OS, although the numbers compared were small. Primaries of the nasosinal region fared poorly when compared with other locations. Total recurrence-free survival, local and distant recurrence rates were distinctly better in primaries of the oral cavity/oropharynx when compared with those in other locations. Reduced distant recurrence-free survival was significantly associated with increasing stage. No other variables were predictive for recurrence. Additionally, we found that nasosinal tumors were more likely to display higher stage at presentation, and were more often associated with perineural invasion. Also of interest was the association of perineural invasion with margin status, with 15 of 20 patients with positive margins displaying perineural invasion, while only 5 of 17 with negative margins showed nerve invasion (P = 0.02). On immunohistochemistry, 2 cases of the 29 (7%) tumor specimens found displayed HER-2/neu positivity. No correlation between clinical behavior and positive staining could be demonstrated. Our data concur with previous reports on ACC in terms of survival and recurrence statistics. Stage and site of primary were important determinants of outcome. Grade may still serve a role in decision making. We could not demonstrate any differences attributable to primary modality of therapy, perhaps due to the nonrandomization of patients into the various treatment tracks and the inclusion of palliative cases. Similarly, perineural invasion, radiation dose and field size, and HER-2/neu positivity did not prove to be important factors in our experience.

Efficacy of adjunctive cricopharyngeus myotomy in supraglottic laryngectomy

This study investigates prospectively the effect of concurrent cricopharyngeus myotomy (CPM) on swallowing following horizontal supraglottic laryngectomy (SL) using fiberoptic, radiographic, and manometric evaluations and suggests possible mechanisms regarding the role of CPM following SL. Six patients undergoing horizontal SL between 1995 and 1997 were enrolled in a prospective evaluation with a followup of 0.5-2.25 years. Three patients underwent concurrent CPM and three did not. Fiberoptic, radiographic. and manometric assessments were performed postoperatively. Although mean resting pressures at the upper esophageal sphincter were reduced significantly by myotomy (12 mm Hg) compared with nonmyotomized patients (57 mm Hg), p < 0.01, no rehabilitative advantage was observed in the former group. In fact, of the myotomized patients, two required feeding gastrostomy tubes with resumption of an oral diet in one year and in two months, respectively, while the nonmyotomized patients were all capable of resuming a full oral diet within four weeks. It appears that CPM provides no rehabilitative advantage in patients undergoing SL.

Molecular markers in head and neck squamous cell carcinoma: their biological function and prognostic significance

Head and neck squamous cell carcinoma affects more than 500,000 people worldwide each year. Despite optimal treatment with surgery, irradiation, and chemotherapy, disease recurrence and progression remains a common and challenging oncological problem. Recently, interest has developed in identifying novel molecular markers that allow identification of those patients at increased risk for locoregional recurrence and death. This article reviews several such molecular markers studied in head and neck cancer, including p53, angiogenesis-related markers, cyclin D1, and epidermal growth factor receptor. The biological function of these markers and the potential clinical implications are discussed. The purpose of this review is to update the otolaryngologist on a rapidly emerging segment of applied translational research in our field.

Glottic closing force in an anesthetized, awake pig model: biomechanical effects on the laryngeal closure reflex resulting from altered central facilitation

Reflex sphincteric closure of the larynx, essential to lower airway protection, is most efficiently achieved through strong reflex adduction by both vocal cords. Because the conversion of a bilaterally evoked response to a unilaterally evoked one appears anesthesia-dependent, we hypothesized that central facilitation is an essential component of a bilateral adductor reflex and that its disturbance could result in weakened sphincteric closure. Six adult 50 kg pigs were used in this study. During electrical stimulation of the internal branch of the superior laryngeal nerve (iSLN) using bipolar platinum-iridium electrodes, the force of the evoked glottic closure response was measured using a pressure transducer positioned between both vocal cords, while electromyographic evoked response was recorded from both thyroarytenoid muscles under varying levels [0.5-1.0 minimal alveolar concentration (MAC)] of isoflurane anesthesia. The force of glottic closure appeared less under deep anesthesia, even with bilateral stimulation of the iSLN, than under light anesthesia with unilateral stimulation. As anesthetic levels approached 1.0 MAC, the glottic closing force decreased to 52-72% of the force measured under 0.5 MAC light anesthesia. Although it is generally understood that alteration of central facilitation by deepening anesthesia abolishes the crossed adductor reflex, the biomechanical effects of altered central facilitation on force differentials have never been previously demonstrated. Precise understanding of this effect may improve the prevention of aspiration in patients emerging from heavy sedation or under prolonged psychotropic control.

Prognostic significance of vascular endothelial growth factor protein levels in oral and oropharyngeal squamous cell carcinoma

PURPOSE

Vascular Endothelial Growth Factor (VEGF) promotes angiogenesis in many different tumor types. VEGF levels may affect tumor growth, metastatic potential, and response to radiotherapy. This study assesses the prognostic value of VEGF protein levels in a cohort of patients with oral and oropharyngeal squamous cell carcinomas. The relationships between clinical outcome and the covariables of tumor-node-metastasis stage, disease stage (I to IV), grade, margin status, race, sex, and age were also determined.

PATIENTS AND METHODS

Chart review identified 77 patients with oral or oropharyngeal squamous cell carcinoma treated with gross total surgical resection and postoperative radiation between 1981 and 1992. Sufficient follow-up data and tumor tissue were available in 56 patients (73%). VEGF protein levels were determined using immunohistochemistry. The association between VEGF status, covariables, and outcome was assessed in a bivariate and multivariate model using two-sided statistical tests.

RESULTS

Twenty-three tumors (41%) were positive for VEGF expression. VEGF-positive tumors were more likely to recur locally (relative risk [RR] = 3.08; 95% confidence interval [CI], 1.03 to 9.24) and distantly (RR = 4.62; 95% CI, 1.41 to 15.10). In bivariate analysis, VEGF positivity was the most significant predictor of poor disease-free survival (RR = 2.66; 95% CI, 1.27 to 5.56) and overall survival (RR = 3.21; 95% CI, 1.63 to 6.32). In multivariate analysis, VEGF positivity was the most significant predictor of poor disease-free survival (RR = 2.75; 95% CI, 1.30 to 5.79) and overall survival (RR = 3.53; 95% CI, 1.75 to 7.13).

CONCLUSION

In this cohort, VEGF positivity was the most significant predictor of poor prognosis. VEGF status may prove to be an important prognostic factor in head and neck cancer.

Understanding the motor innervation of the human cricopharyngeus muscle

A comprehensive understanding of the swallow mechanism continues to suffer from an incomplete appreciation of basic morphology and function. This article is intended to underscore our currently incomplete and pending understanding of cricopharyngeus motor innervation in humans. Given the critical function of this sphincteric muscle in the control of the proximal alimentary tract, a focused effort to unravel its motor innervation would go a long way to reduce the mystery of its overall role in normal and disordered function in patients.

Prognostic significance of cyclin D1 protein levels in early-stage larynx cancer treated with primary radiation

Recent laboratory experiments have demonstrated that cyclin D1 levels (cycD1) can influence radiosensitivity. The purpose of the current study is to evaluate the prognostic significance of cycD1 for local recurrence in early-stage larynx cancer treated with primary radiation therapy. The study was conducted using a matched case-control design in 60 early-stage (T1-T2/N0) larynx cancer patients. All patients had squamous cell carcinoma of the larynx and were treated with primary radiation to a total median dose of 66 Gy in daily fractions of 2 Gy, without surgery or chemotherapy. Thirty patients who suffered a local relapse in the larynx after treatment served as the index case population. These 30 cases were matched by age, sex, site (glottic vs. supraglottic), radiation therapy technique/dose, and follow-up, to 30 control patients who did not experience a local relapse. Immunohistochemical staining from cycD1 was performed on the paraffin-embedded specimens. The pathologist, blinded to the clinical information, scored each of the specimens on a four-point intensity scale (0 = no stain, 1 = faint, 2 = moderate, 3 = strong) and percent distribution. Patients were considered to be positive for cyclin D1 if the staining was 2+ or greater with a percent distribution of at least 5%. By design of the study, the two groups were evenly balanced with respect to age, sex, stage, radiation dose, and follow-up. CycD1 levels correlated with proliferating cell nuclear antigen levels. Low levels of cycD1 significantly correlated with local relapse; 19/30 (63%) of the index cases stained negative, while only 10/30 (33%) of the control cases stained negative (P = 0.03). These data suggest that low levels of cycD1 correlate with relatively radioresistant early-stage larynx carcinoma. With larger more confirmatory clinical and laboratory data, this data may have significant clinical implications. Int. J. Cancer (Radiat. Oncol. Invest.) 90, 22-28 (2000).

Sentinel lymph node radiolocalization in head and neck squamous cell carcinoma

OBJECTIVES

To determine the feasibility of sentinel node radiolocalization in stage N0 in head and neck squamous cell carcinoma and to gain insight as to whether the sentinel node could be prognostic of regional micrometastatic disease.

STUDY DESIGN

A prospective report on the application sentinel node radiolocalization in eight patients with N0 squamous cell carcinoma of the head and neck region.

METHODS

For each patient a peritumoral submucosal injection of filtered technetium (99mTc) prepared with sulfur colloid was performed immediately following intubation. After at least 30 minutes, focal areas of accumulation corresponding to a sentinel node were marked on the skin surface. Complete neck dissections were performed, and the sentinel nodes were identified for later histological evaluation and comparison to the remaining lymphadenectomy specimen.

RESULTS

Sentinel node radiolocalization accurately identified two or more sentinel lymph nodes in all eight cases. In one patient, two of the three lymph nodes containing micrometastatic disease were sentinel lymph nodes. There was no instance in which sentinel node was negative for micrometastatic disease while being positive in a nonsentinel lymph node.

CONCLUSIONS

Accurate localization of the sentinel lymph node using radiolabeled sulfur-colloid is feasible in patients with squamous cell carcinoma of the head and neck region. Although sentinel node radiolocalization in head and neck squamous cell cancer may potentially reduce the time, cost, and morbidity of regional lymph node management, more experience with technique is required before its role can be determined.

Motor innervation of the human cricopharyngeus muscle

Innervation of the human cricopharyngeus muscle remains historically controversial and unclear, encouraging numerous treatments inconsistently designed to pharmacologically or mechanically alter the contractile state of this muscle. Neuroanatomic controversy results from and is perpetuated by 1) use of nonhuman models, 2) observational misinterpretation of small-diameter, overlapping nerve fibers, and, most importantly, 3) lack of real-time verification of neural projections. We sought to overcome these difficulties by performing microdissections in 27 patients undergoing laryngectomy and using real-time electromyographic verification. We demonstrated 1) dual ipsilateral innervation by the pharyngeal plexus and recurrent laryngeal nerve, 2) segmental projection of the recurrent laryngeal nerve to anterior motor units, 3) pharyngeal plexus projection to posterior motor units, 4) absence of a sympathetic or external superior laryngeal nerve contribution, and 5) absence of contralateral innervation. Such dual ipsilateral innervation, segmentally projected, has not been previously described in any other form of neuromuscular organization. Neuroanatomic accuracy should improve diagnostic and therapeutic strategies for future management of pharyngeal dysphagia.

Evolving experience with direct puncture therapeutic embolization for adjunctive and palliative management of head and neck hypervascular neoplasms

OBJECTIVES

The use of percutaneous, direct puncture therapeutic embolization (DPTE) of hypervascular head and neck neoplasms is a relatively new modality that may be used to supplement or supplant conventional endovascular transarterial embolization. Although the preliminary clinical experience reported by a single group has been favorable, extensive case series experience is lacking. This prompted us to review our recent clinical experience with these techniques to determine safety, efficacy, and emerging role in the overall neurointerventional therapeutic armamentarium.

STUDY DESIGN

A retrospective analysis of the previous 34 consecutive cases of hypervascular tumors undergoing DPTE referred to our service for therapeutic devascularization was performed.

METHODS

Complete case record review was undertaken. Twenty-six of 34 cases involved DPTE of head and neck neoplasms. Conventional diagnostic angiography was performed for therapeutic planning and to assist in precise localization. When performed, standard microcatheter transarterial embolization techniques were used either before or after attempted DPTE. Cyanoacrylate embolic mixtures (n-butyl cyanoacrylate [NBCA], lipiodol, powdered tungsten) were used in 21 of 24 cases, and absolute ethanol in 3 of 24. Direct puncture angiography of the targeted tumor neovasculature was always performed before DPTE.

RESULTS

Twenty-four of 26 cases had technically successful DPTE. Combined transarterial embolization with DPTE was used in 16 of 24 cases, although for the last 12 cases, 9 were treated predominantly or exclusively by DPTE. There were no major or minor clinical complications, and there was one asymptomatic technical complication. Total or near-total devascularization was achieved in all cases. All preoperative cases had excellent hemostasis within the resected tumor bed.

CONCLUSIONS

Our results lend further support to the safety and efficacy of DPTE in the management of hypervascular neoplasms of the head and neck. With our increasing experience, this technique is evolving into a primary therapeutic modality for optimal tumor devascularization.

Recurrent carotid blowout syndrome: diagnostic and therapeutic challenges in a newly recognized subgroup of patients

BACKGROUND AND PURPOSE

To our knowledge, recurrent carotid blowout syndrome (rCBS) has not been well described. Our purpose was to review our institution's recent experience with patients who presented with multiple episodes of carotid blowout syndrome (CBS), and who were referred for emergent diagnostic angiography and endovascular therapy.

METHODS

We retrospectively reviewed the last 46 consecutive patients who had a clinical diagnosis of CBS. All patients were examined and treated prospectively according to a standardized protocol. Most patients (43 of 46) had undergone extensive primary and salvage radical surgery with intraoperative brachytherapy or external beam radiation or both. The remaining three patients had either traumatic or iatrogenic CBS.

RESULTS

Twelve patients (26%) in our series had more than one episode of CBS in which a total of 32 (20 recurrent) events were observed (average 2.7, range 2-4). Intervals of rCBS ranged from 1 day to 6 years. Thirteen (65%) of 20 recurrent events were attributed to progressive disease (PD), and seven (35%) of 20 to treatment failures (TFs). In the PD group, seven (54%) of 13 had recurrent ipsilateral disease, and six (46%) of 13 had recurrent contralateral disease. Etiologies of rCBS were as follows: seven exposed carotids; seven carotid pseudoaneurysms; eight small-branch pseudoaneurysms; five tumor hemorrhages; three hyperemic/ulcerated wounds; and one aortic arch rupture. Twenty-seven of 32 events were treated with endovascular therapy, which included the following: nine carotid occlusions; 11 small-branch embolizations; three transarterial tumor embolizations; one carotid stent; and two direct-puncture embolizations. Four of six TFs were retreated successfully with endovascular therapy; the remaining two TFs were managed successfully by surgery. In the PD group, hemorrhagic complications of rCBS were managed successfully in all but one patient, who died. No permanent neurologic or ophthalmologic complications occurred.

CONCLUSION

Recurrent CBS is a frequently encountered problem in which most cases are caused by PD resulting from both multifocal iatrogenic arteriopathy and occasional wound complications that are characteristic of aggressively managed head and neck surgical patients. Initial TFs are encountered often as well. Despite the diagnostic and therapeutic challenges of rCBS, most cases can be retreated effectively.

Effect of internal maxillary arterial occlusion on nasal blood flow in swine

OBJECTIVES

The precise effects of therapeutic occlusion of the internal maxillary artery (IMA) on distal nasal mucosal perfusion are unknown. A better understanding of these effects has important implications regarding the rationale and expected efficacy of certain therapeutic interventions for epistaxis management. The authors developed an animal model to assess these issues.

STUDY DESIGN

The effects of "proximal" and progressively more "distal" occlusions of the IMA on nasal mucosal blood flow (NBF) were assessed in anesthetized swine using continuous laser Doppler flowmetry. The levels of arterial occlusion were selected to simulate clinical therapeutic occlusions used for the management of epistaxis.

METHODS

Nineteen swine were entered into one of four experimental groupings: proximal IMA occlusion using platinum micro-coils (n = 6), mid-grade distal IMA occlusion with polyvinyl alcohol particulate (PVA) suspensions (300 to 500 microns, n = 5), high-grade distal IMA occlusion with polyvinyl alcohol particulate suspensions (50 to 150 microns, n = 5), and sham control (n = 2).

RESULTS

All embolizations resulted in acute decreases in average NBF from 120 mL/min per 100 g to 40 mL/min per 100 g (P < .05 for all groups). NBF returned to baseline in all three treated groups within 2 to 8 days after therapeutic embolization, depending on the level of occlusion (coils, 2 d; mid-grade PVA, 2-3 d; high-grade PVA, 8 d). Follow-up angiography showed recanalization and collateralization as possible methods of reestablishing NBF.

CONCLUSIONS

This study supports the rationale for performing distal IMA occlusion with transarterial particulate embolization, in order to provide a longer period of time of diminished NBF. This theoretically should promote hemostasis within an injured portion of the nasal mucosa by decreasing perfusion pressure within the capillary bed. However, the benefits of distal IMA embolization must be balanced against potential ischemic complications, as may be more commonly seen with high-grade particulate embolization.

Pigmented villonodular synovitis of the temporomandibular joint: diagnostic imaging and endovascular therapeutic embolization of a rare head and neck tumor

We report a case of pigmented villonodular synovitis involving the temporomandibular joint that presented as a rapidly growing tumor with extension through the skull base into the middle cranial fossa. The case is of interest not only because of the unusual extensive infiltration of this tumor but also because of the role modern diagnostic imaging and endovascular therapeutic techniques played in its diagnosis and management.

Intraoperative brachytherapy, laryngopharyngoesophagectomy, and gastric transposition for patients with recurrent hypopharyngeal and cervical esophageal carcinoma

OBJECTIVE

To evaluate the role of laryngopharyngoesophagectomy (LPE), intraoperative 125I brachytherapy (IOBT), and gastric transposition (GT) in patients with recurrent carcinoma involving the hypopharynx, or cervical esophagus.

METHODS

Between 1988 and 1994 a total of 21 patients were managed with LPE/IOBT/GT. All patients had documentation of recurrent disease at the hypopharynx or cervical esophagus and had previously been treated with external-beam radiation (EBRT) to a total median dose of 60 Gy. Median age was 67 years, with 17 male patients and four female. IOBT was performed in all cases with permanent 125I implantation. Medical records were retrospectively reviewed. Overall survival, local control, and complications were evaluated. Median follow-up was 6 months.

RESULTS

The median activity of 125I was 36 mCi, with a median dose of 80 Gy to the region at risk. Fifteen patients had lymph node dissections performed in conjunction with LPE, and 10 patients had nodal involvement on pathologic examination. Margins were microscopically positive in nine patients, and lymphvascular space invasion noted in 13. Actuarial survival at 1 and 3 years was 32% and 14%, respectively, with patients alive and with local control at 6, 24, 36, and 48 months (negative margins). Actuarial local control at 1 and 3 years was 63%. Complications included fistula in five patients, facial edema in four, protracted facial pain in two, cervical abscess in one, and mucosal hemorrhage in one.

CONCLUSION

Patients with recurrent carcinoma of the hypopharynx or cervical esophagus after EBRT have an extremely poor prognosis. LPE, IOBT, and GT may provide very good local control for all candidates and prolonged survival for a small percentage of patients with an acceptable risk profile.

Prognostic staging system for recurrent, persistent, and second primary cancers of the oral cavity and oropharynx

OBJECTIVE

To develop a practical staging system for predicting mortality of patients with recurrent squamous cell tumors of the oral cavity and oropharyngeal mucosa.

DESIGN AND SETTING

An inception cohort at an academic medical center.

PATIENTS

A total of 308 patients who had evidence of recurrent, persistent, or second primary tumors of the oral cavity and oropharynx between January 1, 1980, and December 31, 1991, of whom 162 (52.6%) met inclusion criteria.

MAIN OUTCOME MEASURE

One-year mortality.

RESULTS

The median survival time was 10 months. In bivariate analysis, the TNM stage of the recurrent tumor, invasion of pharyngeal constrictors and the floor-of-mouth muscles, weight loss, local and systemic symptoms, and eating function had significant effects on mortality. Multivariable analysis (done by conjunctive consolidation and Cox regression) identified constrictor invasion, the TNM stage of the recurrence, and weight loss as having a substantial effect on mortality. A composite 4-stage system using these 3 variables demarcated 1-year survival rates of 88.2% (30/34), 71.9% (23/32), 32.6% (16/49), and 4.2% (2/47).

CONCLUSIONS

The TNM status of recurrent tumors predicts mortality, but constrictor muscle invasion and weight loss also have major prognostic importance. The consolidation of these variables into a composite staging system successfully stratifies patients with widely divergent mortality rates. Improved staging of recurrent head and neck tumors can lead to more effective decisions about the comparisons and merits of additional treatment.

Tracheotomy tube occlusion status and aspiration in early postsurgical head and neck cancer patients

The purpose of the present study was to investigate tracheotomy tube occlusion status and prevalence of aspiration utilizing videofluoroscopy. A prospective study was done of 16 consecutive, early, postsurgical head and neck cancer patients with tracheotomy. Selection criteria included the ability to tolerate tracheotomy tube occlusion prior to and during the modified barium swallow procedure, oral and/or pharyngeal surgical resection, no history of neurological disease or stroke, and medical clearance to begin oral feeding. There was 100% agreement among the independent reviewers on ratings of the presence or absence of aspiration. It was found that occlusion status of the tracheotomy tube did not influence the prevalence of aspiration in the immediate postoperative period. No trends were observed when comparing bolus consistency, type of tracheotomy tube, or presence/absence of a nasogastric tube and the ratings of aspiration.

Percutaneous direct-puncture acrylic embolization of a pseudoaneurysm after failed carotid stenting for the treatment of acute carotid blowout

We report a difficult case of recurrent carotid blowout syndrome in a patient who had a rupture of the common carotid artery with formation of a large pseudoaneurysm. Conventional management of this emergency, consisting of composite occlusion of the internal and common carotid arteries, was not possible owing to prior clinical failure of balloon test occlusion. This led to an initial attempt to cover the site of rupture with overlapping self-expanding stents, which was only temporarily successful in controlling the hemorrhage. When a subsequent episode of carotid rupture with life-threatening hemorrhage occurred, percutaneous direct-puncture acrylic embolization with temporary flow arrest was used to successfully obliterate the pseudoaneurysm.

Fiberoptic endoscopic evaluation of dysphagia to identify silent aspiration

The traditional bedside dysphagia evaluation has not been able to identify silent aspiration because the pharyngeal phase of swallowing could not be objectively assessed. To date, only videofluoroscopy has been used to detect silent aspiration. This investigation assessed the aspiration status of 400 consecutive, at risk subjects by fiberoptic endoscopic evaluation of swallowing (FEES). Our study demonstrated that 175 of 400 (44%) subjects were without aspiration, 115 of 400 (29%) exhibited aspiration with a cough reflex, and 110 of 400 (28%) aspirated silently. No significant differences were observed for age or gender and aspiration status. The FEES, done at bedside, avoids irradiation exposure, is repeatable as often as necessary, uses regular food, can be videotaped for review, and is a patient-friendly method of identifying silent aspiration.

Bioreductive alkylating agent porfiromycin in combination with radiation therapy for the management of squamous cell carcinoma of the head and neck

Porfiromycin (methyl mitomycin C) has been shown in laboratory studies to have increased preferential cytotoxicity to hypoxic cells and therefore may provide enhanced therapeutic efficacy over mitomycin C when used in combination with radiation therapy (RT). The purpose of the two clinical studies reported here is to evaluate the concomitant use of porfiromycin with RT in the management of squamous cell carcinoma of the head and neck. Between October 1989 and July 1992, 21 patients presenting with locally advanced stage III/IV squamous cell carcinoma of the head and neck were entered into a phase I toxicity trial evaluating porfiromycin as an adjunct to RT. Patients were eligible if they had biopsy documented squamous cell carcinoma of the head and neck with a low probability of cure by conventional means. Patients were treated with standard fractionated daily RT to a total median dose of 63 Gy, with porfiromycin administered on days 5 and 47 of the course of RT. Upon completion of this phase I trial, a phase III trial was initiated in November 1992 randomizing patients with squamous cell carcinoma of the head and neck to RT with mitomycin C vs. RT with porfiromycin. There is no radiation only arm in this current trial. To date, 75 patients have been entered on this trial and acute toxicity data are available on 67 patients (34 porfiromycin, 31 mitomycin C) who have completed their entire course of treatment. Median follow-up of the 21 patients enrolled in the phase I porfiromycin trial is 58.5 months. Of the 21 patients, 5 were treated at a dose of 50 mg/M2, 4 at 45 mg/M2, and the final 12 at 40 mg/M2, which appeared to result in acceptable acute hematological and nonhematological toxicities. As of December 1995, 14 of the 21 patients have died with disease and 7 remain alive and free of disease, resulting in a 5-year actuarial survival of 32%. Of the patients enrolled to date in the phase III randomized trial of mitomycin C vs. porfiromycin, there have been no statistically significant differences between the two arms with respect to white blood cell count (WBC), platelet, or hemoglobin nadirs. Acute nonhematological toxicities including mucositis, epidermitis, odynophagia, and nausea have also been comparable. Two patients in this current randomized trial died during treatment, apparently of nondrug-related causes. We conclude that the bioreductive alkylating agent porfiromycin has demonstrated an acceptable toxicity profile to date. Final analysis of the phase I trial, which revealed a 5-year no evidence of disease survival rate of 32% in patients with locally advanced disease and a low probability of cure, appears encouraging. We anticipate completion of the current ongoing trial comparing mitomycin C to porfiromycin in the next 2 years. Further investigations, including large-scale multiinstitutional trials employing bioreductive alkylating agents or other hypoxic cell cytotoxins as adjuncts to RT, are warranted.

A prospective, double-blind, randomized study on the use of a topical anesthetic, vasoconstrictor, and placebo during transnasal flexible fiberoptic endoscopy

The purpose of the present study was to compare patient comfort levels following administration of a topical anesthetic, vasoconstrictor, placebo, or nothing to the nasal mucosa prior to flexible fiberoptic transnasal endoscopy. Using a prospective, double-blind, randomized design, 152 consecutive patients were randomly assigned to receive a topical anesthetic (N = 54), vasoconstrictor (N = 50), or placebo (N = 48). No significant differences were found among the three variables. An additional 50 consecutive patients had endoscopy performed without administration of any substance to the nares, and no significant differences were found among the four variables (N = 202). It was concluded that speech-language pathologists can perform independent and comfortable transnasal endoscopy without administration of any substance to the nasal mucosa. Flexible fiberoptic endoscopy, however, should be performed by experienced clinicians with care taken to examine visually the patency of both nares for ease and comfort of scope insertion.

True malignant mixed tumor (carcinosarcoma) of tonsillar minor salivary gland origin: diagnostic imaging and endovascular therapeutic embolization

We report a case of carcinosarcoma of the minor salivary glands of the left palatine tonsil, an especially rare location. Imaging characteristics assessed at CT, MR imaging, and angiography are presented. In addition, we describe our experience with preoperative therapeutic endovascular embolization of this hypervascular tumor.

Reconstruction of the head and neck

The collaboration of surgeons, radiation oncologists, chemotherapists, dentists, oral surgeons, prosthodontists, and speech therapists has led to major advances in the management of the difficult cancers of the head and neck area. The advent of myocutaneous flaps and the facilitation of microsurgical free flaps have ushered in an era of one-stage reconstructions to shorten the hospital stay and improve the overall therapeutic, functional, and cosmetic results.

Chemotherapy as an adjunct to radiation in the treatment of squamous cell carcinoma of the head and neck: results of the Yale Mitomycin Randomized Trials

PURPOSE

Two consecutive randomized trials were run at our institution using the bioreductive alkylating agent mitomycin as an adjunct to radiation therapy in an effort to improve outcome in patients with squamous cell carcinoma of the head and neck.

METHODS

Between 1980 and 1992, two consecutive randomized trials using mitomycin (trial 1) and mitomycin with dicumarol (trial 2) as an adjunct to radiation therapy in patients with squamous cell carcinoma of the head and neck were conducted at our institution. The patients were stratified by intent of therapy, extent of disease, and primary tumor site. Within each strata, patients were randomized to receive radiation therapy with or without mitomycin (trial 1) or mitomycin/dicumarol (trial 2).

RESULTS

A total of 203 patients were enrolled onto both trials, 195 of whom were eligible for analysis. Patients were equally balanced with respect to sex, age, extent of disease, primary site, radiation dose, and total duration of radiation treatment. Hematologic toxicities were more frequently noted in the drug-treated arms, but were acceptable with no drug-related treatment deaths. Nonhematologic toxicities were acceptable and not significantly different between the two arms. As of September 1995, with a median follow-up of 138 months, a statistically significant benefit occurred in the mitomycin arms with respect to cause-specific survival (0.74 +/- 0.05 v 0.51 +/- 0.05; P = .005), local recurrence-free survival (0.85 +/- 0.04 v 0.66 +/- 0.05; P = .002), and local regional recurrence-free survival (0.76 +/- 0.05 v 0.54 +/- 0.05; P = .003). No statistically significant difference in overall survival was obtained (0.48 +/- 0.05 mitomycin arms v 0.42 +/- 0.05 radiation alone).

CONCLUSION

The bioreductive alkylating agent mitomycin is a safe and effective adjunct to radiation therapy in the treatment of squamous cell carcinoma of the head and neck. The statistically and clinically significant improvement in local regional relapse and cause-specific survival obtained support the use of mitomycin as an adjunct to radiation therapy in the management of squamous cell carcinoma of the head and neck.

MRI evaluation of vocal fold paralysis before and after type I thyroplasty

Magnetic resonance imaging (MRI) is a useful modality for three-dimensional evaluation of laryngeal anatomy. The authors present data on patients with unilateral vocal fold paralysis both before and after type I thyroplasty for medialization. Videoendoscopic and acoustic measures were obtained. MRI was performed preoperatively and postoperatively. Three-dimensional descriptive parameters were established to assess implant location. As well, vocal and endoscopic assessment were used to determine a successful result. Magnetic resonance images of two patients with satisfactory results were compared with images and vocal analysis of two dissatisfied patients. Use of MRI after type I thyroplasty provides additional information about implant location that can help determine the cause of poor results.

Efficacy of transcutaneous computed tomography--guided fine needle aspiration biopsy in patients with laryngeal squamous cell carcinoma, probable failed radiation therapy, and negative transmucosal biopsies

For patients with suspected recurrent/persistent laryngeal squamous cell carcinoma (SCC) after external beam radiotherapy (EBRT), routine transmucosal biopsies obtained during direct laryngoscopy may fail to reveal active carcinoma. We evaluated transcutaneous computed tomography-guided fine needle aspiration (CTGFNA) in three consecutive patients who had a persistently fixed true vocal fold after EBRT that had been administered for laryngeal SCC and who had multiple negative transmucosal laryngeal biopsies. All three CTGFNA biopsies were positive, but final pathology confirmed invasive SCC in only one of the three patients. Despite its theoretical advantages, CTGFNA in its present form requires further assessment and/or modification.

Endovascular therapy for the carotid blowout syndrome in head and neck surgical patients: diagnostic and managerial considerations

PURPOSE

To review our institution's recent experience with patients with carotid blowout syndrome who were referred for emergency diagnostic angiography and endovascular therapy.

METHODS

Eighteen consecutive patients who had had surgery for cancer of the head and neck and in whom carotid blowout syndrome had occurred were referred to our service in accordance with a standardized protocol.

RESULTS

Twenty-three angiographic pathoetiologic conditions were diagnosed in the 18 patients; the majority of these were pseudoaneurysms involving various segments of the carotid system. Multiple lesions were detected in five patients. Most patients were treated by means of permanent balloon occlusion; in 8 patients with either multiple lesions or impending rupture requiring flap reconstruction, a composite permanent balloon occlusion of the affected carotid system was performed. Hyperacute hemorrhages were arrested in all cases. Hemorrhages reoccurred in 2 cases, and in 2 patients who had permanent balloon occlusion of the internal carotid artery, transient ischemic attacks occurred, which appeared to be related to temporary collateral reserve failure. No permanent neurologic complications ensued.

CONCLUSION

Our recent experience with carotid blowout syndrome suggests that this clinical diagnosis represents a heterogeneous group of angiographic pathoetiologies that the physician should evaluate carefully before proceeding with endovascular therapy. Specific endovascular approaches depend on the pathoetiologic mechanism of active or impending hemorrhage and the urgency with which intervention is required.

The extended lateral arm free flap for head and neck reconstruction: the Yale experience

The lateral arm free flap (LAFF) has been chosen by some head and neck reconstructive microsurgeons to be their fasciocutaneous free flap of choice. The qualities of this flap have been suggested to include its consistent vascular anatomy, its thin and pliable nature, and its reinnervation capabilities, as well as its low donor site morbidity and ease of closure. During the past year we have performed 14 head and neck reconstructions using the extended LAFF (ELAFF). We present our indications for its use and review its shortcomings. Although the ELAFF does have its limitations, including variability in its flap thickness and donor vessel size, it unquestionably is an important flap in head and neck reconstruction and is our flap of choice for soft tissue reconstruction.

Management of carotid artery rupture by monitored endovascular therapeutic occlusion (1988-1994)

The reported mortality (40%) and neurologic morbidity (25%) rates for carotid rupture remain unacceptably high. This study was conducted to assess the impact of endovascular detachable balloon occlusion and the changing characteristics of carotid rupture in head and neck surgery. Between January 1, 1988, and June 30, 1994, 18 carotid ruptures were identified in 15 patients. Etiologic factors included radical surgery, radiation therapy, wound complications, and recurrent or persistent carcinoma. In 15 of 18 instances of carotid rupture, patients survived without major neurologic sequelae. After the introduction of endovascular techniques in 1991, the 12 patients whose hemorrhage was definitively managed through permanent balloon occlusion survived without significant neurologic sequelae. Endovascular occlusion techniques in the monitored patient may significantly improve the outcome after carotid rupture.

Nonsurgical alternative therapy for bulky advanced head and neck tumors

OBJECTIVE

To rapidly induce symptomatic relief and local tumor control in bulky advanced head and neck tumors without surgery.

DESIGN

A retrospective analysis of the results with palladium 103-labeled or iodine 125-labeled brachytherapy (BT) and adjunctive external beam radiation therapy (EBRT); a survival analysis by the Kaplan-Meier method; and a comparison of results between the BT/EBRT and EBRT/BT (or BT alone) groups by the log-rank test. A nonsurgical alternative therapy was given to a total of 51 patients who presented with tumors of more than 100 cm3 in volume.

RESULTS

Moderate to complete symptomatic relief was observed in 31 (61%) of 51 patients. Seven (33%) of 21 patients in the BT/EBRT group and two (7%) of 30 in the EBRT/BT group were recurrence-free at 36 months. The difference was significant by the log-rank test. Cause-specific and overall 36-month survivals were 23% and 5%, respectively.

CONCLUSION

Cure rate by conventional therapy in bulky advanced head and neck tumors is dismal. The palladium 103- or iodine 125-BT/EBRT offers good symptomatic relief and an acceptable probability of recurrence-free survival.

The fate of the skin graft in laryngoplasty

In laryngoplasty procedures, laryngotracheal soft tissue defects are often repaired using skin grafts. While stenting is necessary to approximate and immobilize the graft, prolonged stenting causes increased bacterial counts, granulation tissue formation, tissue ischemia, and graft failure. Optimal time for stent removal has not been experimentally defined. Using the ferret animal model, 24 laryngoplasty procedures were performed. The subjects were stented by group for 0, 3, 7, 14, or 28 days. Analysis consisted of quantitative bacteriology, dye perfusion, and quantitative histologic assessment of graft viability. Tissue culture results revealed that by 3 days after the procedure all groups had 10(5) CFU of bacteria per gram of tissue. Graft viability in successful procedures was maximal in the 7-day group and statistically significant from the 3-day to the 28-day groups. In conclusion, while stenting is necessary for graft adherence, prolonged exposure to local tissue sepsis leads to progressive graft destruction.

Incidence, timing, and importance of tracheoesophageal prosthesis resizing for successful tracheoesophageal speech production

The Blom-Singer method of tracheoesophageal (TE) speech restoration is a proven alternative to esophageal and electrolaryngeal speech in patients with total laryngectomy. This retrospective study was undertaken to determine the incidence and timing of TE prosthesis resizing, amount of change in prosthesis length, etiologies associated with resizing, and importance of long-term professional follow-up for maintenance of successful TE speech production. Participants were 26 individuals with total laryngectomy and secondary TE puncture. Results indicated that all 18 participants available for long-term follow-up required TE prosthesis resizing, and multiple resizings were required in 87% of the routinely followed participants. In 14 participants the prostheses were resized shorter (sample mean [mean] = -0.7 cm); in 3, longer (mean = +0.5 cm); and in 1, from a duckbill to a low-pressure prosthesis of the same size. The mean number of days from initial measurement and fitting to first prosthesis resizing was 26. The importance of collaboration between the speech-language pathologist and otolaryngologist and need for long-term follow-up for successful maintenance of TE speech are stressed. Cost containment of rehabilitation services using the indwelling TE prosthesis is demonstrated.

Pathology of tumors of the cranial base

Tumors of the skull base are varied and can be categorized into benign and malignant neoplasms. This article outlines the types of tumors found in this surgically challenging anatomic location.