Small atypical cervical nodes detected on sonography in patients with squamous cell carcinoma of the head and neck: probability of metastasis.

OBJECTIVE: The purpose of this study was to assess the probability of metastasis of small atypical cervical lymph nodes detected on sonography in patients with squamous cell carcinoma (SCC) of the head and neck. METHODS: We reviewed, retrospectively and blindly, sonographic findings of 148 patients (118 men and 30 women; mean age, 58.2 years) who underwent curative neck dissection. Each lymph node was classified by using a 4-point scale: 1, definitely benign; 2, indeterminate (small [short-axis diameter <10 mm for levels I and II and <7 mm for levels III-VI] atypical node); 3, definitely metastatic; and 4, large (>3-cm) metastatic. Lymph nodes were considered atypical if they met at least 1 of the following criteria: a long- to short-axis diameter ratio of less than 2.0, absence of a normal echogenic hilum, and heterogeneous echogenicity of the cortex. These results were verified, on a level-by-level basis, with histopathologic findings. RESULTS: Small atypical nodes were found on sonography in 63 cervical levels of 48 patients, of which 18 (28.6%) were proved to have metastatic nodes. The probability of metastasis was significantly higher with than without a large (>3-cm) ipsilateral metastatic node (0.50 versus 0.20; P = .038) and marginally higher with than without an ipsilateral metastatic node (0.41 versus 0.16; P = .061) but not significantly associated with the T stage of the primary tumor (P = .238) or the presence of an ipsilateral tumor (P = .904). CONCLUSIONS: Metastasis was encountered in about 30% of small atypical cervical nodes on sonography in patients with SCC of the head and neck. Our results indicate that small atypical nodes must be interpreted with consideration of metastatic nodes in the ipsilateral neck.

Anatomical variations of the spinal accessory nerve and its relevance to level IIb lymph nodes.

OBJECTIVE: This study was conducted to identify anatomical variations of the spinal accessory nerve (SAN) in the upper neck, the landmark of the anterior and inferior border of level IIb, and to evaluate the nerve's effect on the border and the number of lymph nodes (LNs) in level IIb. STUDY DESIGN AND SETTING: Case series with planned data collection. SUBJECTS AND METHODS: A total of 181 neck dissections (NDs) were prospectively enrolled in this study. The relation between the SAN and adjacent structures (internal jugular vein [IJV], sternocleidomastoid muscle [SCM], cervical plexus) and the number of LNs in level IIb was investigated. RESULTS: The SAN crossed the IJV ventrally in 72 cases (39.8%) and dorsally in 104 cases (57.4%), and passed through the IJV in five cases (2.8%). The SAN ran along the inner surface of the SCM and sent branches to the SCM without penetration of the muscle in 83 cases (45.9%), whereas in 98 cases (54.1%) the nerve sent branches to the SCM by penetration. Cervical plexus contribution to the SAN was seen from C2 in 96 cases (53.1%), C2 and C3 in 69 cases (38.1%), and C3 in 16 cases (8.8%). The mean number of LNs of level IIa and level IIb was 6.5 and 8.2 in cases in which the SAN crossed the IJV ventrally, and 6.8 and 5.4 in dorsally crossing cases. LNs included in the neck level IIb in ventrally crossing SAN cases were significantly larger than the dorsally crossing cases (P < 0.05). CONCLUSIONS: Our results may help to minimize the incidence of injuring the SAN in the upper neck during ND. Neck level IIb would contain more LNs if the course of the nerve leans toward the ventral side.

CT, MR, US,18F-FDG PET/CT, and their combined use for the assessment of cervical lymph node metastases in squamous cell carcinoma of the head and neck.

The purpose of this retrospective study was to compare the diagnostic value of four different imaging methods-computed tomography (CT), magnetic resonance (MR) imaging, ultrasonography (US), and (18)F-fluorodeoxyglucose (FDG) positron emission tomography (PET)/CT-and their combined use for preoperative detection of cervical nodal metastases in head and neck squamous cell carcinoma (SCC). Sixty-seven patients (58 men and 9 women; mean age, 60.1 years) with head and neck SCCs underwent CT, MR, US, and PET/CT before surgery. First, each study was reviewed separately for the presence of nodal metastases. Then, the value of combined images was assessed based on a confidence rating score for each modality assigned by observers. These results were verified, on a level-by-level basis, with histopathologic findings. Histopathologic examination revealed nodal metastases in 74 of 402 nodal levels. The sensitivity, specificity, and accuracy were 77.0%, 99.4%, and 95.3% for CT and MR; 78.4%, 98.5%, and 94.8% for US; and 81.1%, 98.2%, and 95.0% for PET/CT, respectively. The comparison of these modalities showed no statistically significant difference among them (p > 0.05). The combination of CT, MR, US, and PET/CT improved sensitivity (86.5%), without loss of specificity (99.4%) and accuracy (97.0%), although the difference failed to reach statistical significance.

The prevalence and significance of incidental thyroid nodules identified on computed tomography.

PURPOSE: The purpose of this study was to assess the prevalence of incidental thyroid nodules (ITN) found on computed tomography (CT) of the neck and to determine whether CT characteristics could distinguish malignant from benign thyroid lesions. MATERIALS AND METHODS: We retrospectively reviewed CT scans in 734 patients without known thyroid disease (384 men and 350 women; mean age, 49.8 +/- 13.7 years). The CT findings of ITN such as size, shape (anteroposterior-transverse diameter ratio [AP/T ratio]), margin, peripheral enhancing rim, intralesional calcification, and attenuation characteristics were analyzed and correlated with ultrasonographic (US) findings. RESULTS: One hundred sixty ITNs were noted in 123 (16.8%) patients. Of 120 ITNs whose histological diagnoses were available, 15 (12.5%) were malignant. Malignant nodules more frequently showed nodular or rim calcifications (46.7% vs 13.3%; P < 0.0005), AP/T ratio of greater than 1.0 (33.3% vs 9.5%; P < 0.05), and mean attenuation value on contrast-enhanced scan of greater than 130 Hounsfield units (86.7% vs 49.5%; P < 0.05) than benign nodules. CONCLUSIONS: We found at least a 9.4% (15/160) prevalence of malignancy among ITN detected on CT. The further evaluation with US or biopsy should be performed, if an ITN shows CT features suggesting malignancy (calcification; AP/T ratio, >1.0; or mean attenuation value, >130 HU).

Comparison of sensory recovery and morphologic change between sensate and nonsensate flaps in oral cavity and oropharyngeal reconstruction.

BACKGROUND: Sensory recovery after oral cavity and oropharyngeal reconstruction is 1 of the most important goals of free flap reconstruction. The aim of this study was to compare sensory recovery of sensate and nonsensate free flaps and to evaluate the morphologic differences between sensate and nonsensate free flaps. METHODS: A total of 27 cases of radial forearm free flap reconstruction after oral cavity and oropharyngeal cancer resection were included in this study. Fifteen flaps were sensate flaps, and the other 12 flaps were nonsensate flaps. The sensory recovery was evaluated in 5 subjective senses: light tough, deep pressure, pain, warm, and cold senses. The 2-point discriminations were also recorded. For morphologic evaluation, the shapes of nerve fibers and nerve fiber bundles were observed and counted after immunohistochemical stains with S-100 protein and neuron-specific enolase and observed with transmission electron microscope. RESULTS: The scores of the 5 subjective senses in the sensate flaps and 2-point discrimination capabilities were significantly higher than those in the nonsensate flaps (p <.05). The number and the shape of the nerve fibers in the sensate flaps were more prominent (p <.05). CONCLUSION: There were significant differences in sensory recovery between sensate and nonsensate flaps in oral cavity and oropharyngeal reconstruction, and the nerve fibers were larger, better arranged, and more numerous in sensate than nonsensate flaps.

Facial canal dehiscence in the initial operation for chronic otitis media without cholesteatoma.

OBJECTIVE: To evaluate the risk of the facial nerve injury during operations for chronic otitis media without cholesteatoma by analysis of the intraoperative findings of the facial canal dehiscence. METHODS: We retrospectively reviewed operative findings of 152 patients who underwent tympanoplasty with mastoidectomy for chronic otitis media. We examined every segment of the facial canal from the geniculate ganglion to the mastoid segment. Facial canal dehiscence was confirmed by palpation with a Rosen pick after inspection with a surgical microscope. RESULTS: The rate of facial canal dehiscence was 8.6% (13 of 152 cases), and the tympanic segment was the most commonly found region at 84.6% (11 of 13 cases). Of the 11 cases of tympanic segment dehiscence, 9 cases were involved the lateral aspect of the facial canal in the oval window area. There was one case each of facial canal dehiscence in the geniculate ganglion and the mastoid segment, respectively. CONCLUSION: The rate of facial canal dehiscence of 8.6% is not a low incidence rate, so even though performing a routine chronic ear operation, surgeons may encounter facial canal dehiscence at any time and should be prepared for the emergence of such a situation.

Functional benefit after modification of radial forearm free flap for soft palate reconstruction.

OBJECTIVES: To compare the velopharyngeal function, swallowing and speech of the conventional and modified radial forearm free flap (RFFF) for soft palate reconstruction. METHODS: Retrospective clinical study. Twenty-eight patients who underwent oropharyngeal reconstruction with RFFF were divided into two groups: 10 patients had conventional folded RFFF and 18 patients underwent modified method. RESULTS: The average speech intelligibility score in modified RFFF group was 8.0+/-2.4, and 6.2+/-2.2 in conventional RFFF group (P<0.05). The nasalance was 27.4+/-7.8% in modified group and 38.6+/-2.7% in conventional group during no nasal passage reading and 43.6+/-7.3% in modified group, 55.2+/-7.6% in conventional group during high nasal passage reading (P<0.05). The subjective swallowing functional score was 2.8 in modified group and 2.1 in conventional group. CONCLUSION: The speech assessment and nasalance demonstrate a more favorable outcome in modified group than conventional group.

High mobility group HMGI(Y) protein expression in head and neck squamous cell carcinoma.

CONCLUSION: We conclude that increased expression level of the high mobility group I (HMGI(Y)) is closely associated with malignant transformation in head and neck squamous cell carcinomas (HNSCCs), and the measurement of HMGI(Y) levels in HNSCCs may be useful as a prognostic marker. OBJECTIVES: To investigate whether HMGI overexpression is observed in HNSCCs, and its value as a prognostic marker in HNSCCs. MATERIALS AND METHODS: HMGI(Y) expression was determined at the protein level by immunohistochemisty using a HMGI(Y)-specific antibody and RT-PCR in 10 surgically resected specimens of non-neoplastic tissue (normal palatal tissue) and 40 HNSCCs. We also evaluated the association of HMGI(Y) overexpression within clinicopathologic parameters, i.e. clinical stage, pathologic grade, status of cervical lymph node metastasis, recurrence rate. RESULTS: Expression of HMGI(Y) by immunohistochemical staining was observed in 35 of 40 (87.5%) HNSCC samples, whereas normal mucosa and/or the mucosa adjacent to the tumor tissue showed negative or weakly positive staining (p<0.05). Semi-quantification of HMGI(Y) by RT-PCR was 2.98+/-2.24 in cancer and 0.47+/-0.25 in normal tissue (p<0.001). High expression of HMGI(Y) was observed in recurrent cases, compared with non-recurrent cases (p<0.05). However, no significant correlation was observed between the levels of HMGI(Y) expression and other clinical factors such as clinical stage, pathologic grade, and status of cervical lymph node metastasis.

Multiple osteomas in the middle ear.

Osteomas in the middle ear are extremely rare and are generally solitary and small. We present a case of a 28-year-old female patient with multiple middle ear osteomas which arose from the promontory, epitympanum, and lateral semicircular canal. The osteomas were successfully removed by tympanomastoidectomy. This is the first reported case of a patient with middle ear osteomas arising from multiple sites.