The palliative role of PDT in recurrent advanced nasopharyngeal carcinoma: case series.

We report on the application of photodynamic therapy in the management of recurrent advanced carcinoma of the nasopharynx. A selected cohort of 7 patients, only suitable for palliative therapy, was offered this modality to assess the palliative role of PDT. All 7 patients had at least 2 previous recurrences, which were managed with surgery and chemoradiotherapy but ultimately failed to respond. PDT was offered after careful discussion at a multidiscipline meeting. The photosensitiser "mTHPC" was introduced intravenously 96 h prior to delivering the light with nasoendoscopic guidance. Six patients' symptoms were reduced markedly post photodynamic therapy. Five patients have to had another round of treatment which was found to be as effective as the first round in terms of controlling disease progression as well as symptoms. Magnetic resonance images showed variable reduction of tumour volume with the majority of the patients having moderate to significant response. Photodynamic therapy was very successful palliative therapy for this small group of recurrent advanced nasopharyngeal cancer patients.

cTNM vs. pTNM: the effect of not applying ultrasonography in the identification of cervical nodal disease.

Accurate clinical staging of oral squamous cell cancer can be quite difficult to achieve especially if nodal involvement is identified. Radiologically-assisted clinical staging is more accurate and informs the clinician of loco-regional and distant metastasis.In this study, we compared clinical TNM (cTNM) staging (not including ultrasonography) to pathological TNM (pTNM) staging in 245 patients presenting with carcinoma of the oral cavity and the oro-pharyngeal region. Tumour size differences and nodal involvement were highlighted. US reports of the neck were then added to the clinical staging and results compared.Tumour size was clinically underestimated in 4 T1, 2 T2 and 2 T3 oral diseases. Also 20 patients that were reported as nodal disease free had histological proven N1 or N2 nodal involvement; while 3 patients with cTNM showing N1 disease had histologically proven N2 disease.Overall the agreement between the 2 systems per 1 site was 86.6% (Kappa agreement = 0.80), per 2 sites 90.0% (Kappa agreement = 0.68) and per 3 sites 90.5% (Kappa agreement 0.62).An accurate clinical staging is of an utmost importance. It is the corner stone in which the surgical team build the surgical treatment plan and decide whether an adjuvant therapy is required to deal with any possible problem that might arise. The failure to achieve an accurate staging may lead to incomplete surgical planning and hence unforeseen problems that may adversely affect the patient's survival.

Treatment of Kimura disease with photodynamic therapy: a case study.

We report on the application of photodynamic therapy (PDT) in the management of Kimura disease. A 58-year-old Asian male was offered this modality to assess the possibility to control disease progression. The patient was managed with surgery and the disease recurred and caused facial disfigurement. PDT was offered after careful discussion at UCLH multidiscipline meeting. The photosensitiser "mTHPC" was introduced intravenously 96h prior to delivering the light under ultrasound guidance. Magnetic resonance images showed moderate-significant reduction of the disease volume. Fourteen months post-PDT, the disease started re-growing and the patient subsequently underwent one further round of PDT which was as successful as the first round in reducing the facial disfigurement. Photodynamic therapy was very effective in controlling disease progression in this patient who suffers from Kimura disease.

Photodynamic therapy: The minimally invasive surgical intervention for advanced and/or recurrent tongue base carcinoma.

INTRODUCTION: The management of tongue base carcinoma continues to be a major challenge in head and neck oncology. Our aim in this prospective study was to evaluate the outcome following ultrasound-guided interstitial photodynamic therapy (US-iPDT) of stage IV tongue base carcinoma patients. Patients' reports on quality of life with clinical and radiological evaluation were the main end point parameters used to assess the outcome. MATERIAL AND METHODS: Twenty-one consecutive patients referred to the UCLH Head and Neck Centre for treatment of advanced and/or recurrent tongue base cancer were included in this study. Two-thirds of the referred patients had not been offered further conventional therapeutic options apart from palliative treatment. It was decided, by the multidisciplinary team, that the only available option was to offer US-iPDT under general anesthesia, using mTHPC (Foscan®) as the photosensitizing agent. Following treatment, patients were followed-up for a mean of 36 months (min. 21, max. 45). RESULTS: Nine of the 11 patients who presented with breathing problems reported improvement after treatment. Also, 19 of the 21 patients reported improvement of swallowing. Improvement of speech was reported by 11 of 13 patients. Clinical assessment showed that more than half of the patients had "good response" to the treatment and about a third reported "moderate response." Radiological assessment comparing imaging 6-week post-PDT to the baseline showed stable pathology with no change in size in four patients, minimal response in seven patients, moderate response in six patients, and significant response in two patients. Eight patients died; four of which due to loco-regional disease; and two from distant tumor spread. Kaplan-Meir survival curve was generated from the survival and follow-up data. CONCLUSIONS: Photodynamic therapy is a successful palliative modality in the treatment of advanced and/or recurrent tongue base carcinoma.

TMJ arthroscopy in patients with Ehlers Danlos syndrome: case series.

OBJECTIVE: The purpose of this report was to assess the outcome of temporomandibular joint (TMJ) arthroscopy in patients with temporomandibular disorders (TMDs) associated with Ehlers Danlos syndrome (EDS). STUDY DESIGN: This retrospective case series describes 18 patients with EDS who underwent arthroscopy for temporomandibular disorders. The patients' demographics were recorded, along with preoperative TMJ symptoms, Wilkes classification, mouth opening, and the presence of systemic involvement. The incidence of early and late postoperative complications and the final outcome were noted. RESULTS: All of the patients were females, with EDS Type III, and had a mean age of 34 years. A high proportion of the patients had joints other than the TMJ affected. Five patients were classified as stage II according to the Wilkes classification, 9 patients were stage III, 3 patients were stage IV, and only 1 patient was diagnosed with stage V Wilkes before intervention. Arthroscopy, followed by arthrocentesis and balloon dilatation of the affected TMJs was performed and intra-articular morphine injections were given to all patients. The main pre- and early postoperative complaint was pain, but this resolved in most cases. Improvement of mouth opening was noted from 23.4 +/- 4.2 to 27.8 +/- 5.1 mm after arthroscopy. Patients were followed for an average of 62 months and all were asymptomatic at their last review appointment. CONCLUSION: For patients where conservative measures of treating TMD are not effective, arthroscopy is a minimally invasive surgical procedure that has been shown to result in a satisfactory outcome, with no need to resort to open joint surgery. This case series is limited by its size and further research on surgical intervention on EDS patients with temporomandibular disorders is recommended.

Risk factors associated with injury to the inferior alveolar and lingual nerves following third molar surgery-revisited.

OBJECTIVE: Earlier reports, including a preliminary study within our unit, have shown that the surgeon's experience is one of the most influential factors in determining the likelihood of both permanent inferior alveolar nerve (IAN) and lingual nerve (LN) paresthesia, following third molar surgery. The effect of this and other factors influencing such prevalence are assessed in this study. STUDY DESIGN: This prospective study involved 3236 patients who underwent surgical removal of impacted third molars. Patients' demographics and radiological parameters were recorded along with the grade of the treating surgeon. The prevalence of inferior alveolar and lingual nerves paresthesia at 1 month, 6 months, and 18 to 24 months postoperatively were also traced. RESULTS: At 1 month postoperatively, the incidence of IAN paresthesia was 1.5% and the LN was 1.8%. These figures decreased over time and 18 to 24 months postoperatively, the incidence of permanent dysfunction of the IAN was 0.6% and LN was 1.1%. With regard to inferior alveolar nerve paresthesia, risk factors included the patient's age (26-30 years), horizontally impacted teeth, close radiographic proximity to the inferior alveolar canal (IAC), and treatment by trainee surgeons. With regard to the lingual nerve, risk factors included male patients, distoangular impactions, close radiographic proximity to the IAC, and treatment by trainee surgeons. CONCLUSION: One of the main risk factors of developing permanent sensory dysfunction in the distribution of these nerves is related to the surgical skills/experience of the operator. Other factors are associated with the type of impaction and the radiographic proximity of the tooth to the inferior alveolar nerve. Such long-term complications can affect the patient's quality of life; the impact on profession, education, and research is unknown.

Third molar surgery: the patient's and the clinician's perspective.

BACKGROUND: In this report, the problems of third molar surgery have been reviewed from the perspective of both patient and clinician; additionally an overall analysis of preoperative imaging investigations was carried out.Specifically, three main areas of interest were investigated: the prediction of surgical difficulty and potential complications; the assessment of stress and anxiety and finally the assessment of postoperative complications and the surgeon's experience. FINDINGS: In the first study, the prediction of surgical difficulty and potential injury to the inferior alveolar nerve was assessed. This was achieved by examining the patient's orthopantomograms and by using the Pederson Difficulty Index (PDI). Several radiological signs were identified and a classification tree was created to help predict the incidence of such event.In the second study, a prospective assessment addressing the patient's stress and anxiety pre-, intra- and postoperatively was employed. Midazolam was the active drug used against placebo. Objective and subjective parameters were assessed, including measuring the cortisol level in saliva. Midazolam was found to significantly reduce anxiety levels and salivary cortisol was identified as an accurate anxiety marker.In the third study, postoperative complications and the surgeon's experience were examined. Few patients in this study suffered permanent nerve dysfunction. Junior surgeons reported a higher complication rate particularly in trismus, alveolar osteitis, infection and paraesthesia over the distributions of the inferior alveolar and lingual nerves. In apparent contrast, senior surgeons reported higher incidence of postoperative bleeding. DISCUSSION: These studies if well employed can lead to favourable alteration in patient management and might have a positive impact on future healthcare service.

Management of deep-seated malformations with photodynamic therapy: a new guiding imaging modality.

Photodynamic therapy is an emerging technology and results from the interactions between a photosensitiser, oxygen and light. The delivery of light may either be by surface illumination or by interstitial application. We describe the first clinical application of ultrasound-guided interstitial photodynamic therapy (US-iPDT). A total of 23 treatments with meta-tetra-hydroxyphenyl chlorine (mTHPC) and ultrasound-guided interstitial photodynamic therapy were performed on 21 patients with various conditions at the Head & Neck Centre, University College London Hospital. The needles could be clearly identified during insertion in all 23 treatments, and it was possible to guide parallel needle insertions using ultrasound. Although the resolution of ultrasound is not as high as that of other imaging modalities [i.e. computed tomography (CT) and magnetic resonance imaging (MRI)] it was satisfactory in identifying the centre and the peripheries of the pathological lesions. Ultrasound is very easy to perform, non-invasive, relatively inexpensive, quick, convenient, non-ionising, suited to the imaging of soft tissues and does not cause any discomfort. Ultrasound can be used to guide 'real-time' photodynamic therapy in deep-seated tumours and other malformations and can augment the information from other imaging modalities without affecting the patient's treatment outcome.

Muscle disorders and dentition-related aspects in temporomandibular disorders: controversies in the most commonly used treatment modalities.

This review explores the aetiology of temporomandibular disorders and discusses the controversies in variable treatment modalities.Pathologies of the temporomandibular joint (TMJ) and its' associated muscles of mastication are jointly termed temporomandibular disorders (TMDs).TMDs present with a variety of symptoms which include pain in the joint and its surrounding area, jaw clicking, limited jaw opening and headaches. It is mainly reported by middle aged females who tend to recognize the symptoms more readily than males and therefore more commonly seek professional help.Several aetiological factors have been acknowledged including local trauma, bruxism, malocclusion, stress and psychiatric illnesses. The Research Diagnostic Criteria of the Temporomandibular Disorders (RDC/TMD) is advanced to other criteria as it takes into consideration the socio-psychological status of the patient.Several treatment modalities have been recommended including homecare practices, splint therapy, occlusal adjustment, analgesics and the use of psychotropic medication; as well as surgery, supplementary therapy and cognitive behavioural therapy. Although splint therapy and occlusal adjustment have been extensively used, there is no evidence to suggest that they can be curative; a number of evidence-based trials have concluded that these appliances should not be suggested as part of the routine care.Surgery, except in very rare cases, is discouraged since it is the most invasive alternative; recent studies have shown healthier outcome with cognitive behavioural therapy.

The application of photodynamic therapy in the head and neck.

UNLABELLED: Photodynamic therapy (PDT) is considered to be a minimally invasive treatment modality which shows great promise in premalignant and malignant conditions of the head and neck. This therapy can be applied before or after any of the conventional treatment modalities (ie surgery, radiotherapy or chemotherapy) and the treatment can be repeated as much as is needed at the same site. PDT uses photosensitizing drugs that are activated by exposure to light of a specific wavelength. Illumination of the suspected premalignant or malignant site by light at the activating wavelength results in cellular destruction by a non-free radical oxidative process. Most photosensitizers are administered systemically, although some can be applied topically in the treatment of skin cancer. Recent developments in photosensitizers and light delivery systems have substantially reduced treatment times and residual photosensitivity, while increasing the achievable depth of necrosis. Compared with standard approaches, PDT can achieve equivalent or greater efficacy in the treatment of premalignant and malignant lesions in the head and neck, with greatly reduced morbidity and disfigurement. The technique is simple, can commonly be carried out in outpatient clinics, and is highly acceptable to patients. It can be repeated to debulk large tumours progressively, and it can also be applied through interstitial light delivery to large solid tumours. CLINICAL RELEVANCE: Photodynamic therapy is now shown to achieve equivalent or greater efficacy than standard treatment of premalignant and malignant lesions in the head and neck, with greatly reduced morbidity and disfigurement.