Carcinoma of the tonsil: prognostic factors.

OBJECTIVES: This study was conducted to provide a review of the prognostic factors of tonsillar carcinoma. DESIGN: A retrospective analysis. SETTING/PATIENTS: Patients with squamous cell carcinoma of the tonsil, treated in Northern Alberta, at the Cross Cancer Institute from 1975 to 1995 were analyzed using a population-based, head and neck cancer registry. There were 102 patients, 73 male and 29 female, ranging in age from 35 years to 83 years, with a mean of 60 years. The clinical stages were T1: 5 patients; T2: 27 patients, T3: 33 patients; T4: 11 patients; and Tx: 3 patients. The nodal stages were N0: 33 patients, N1: 26 patients; N2: 34 patients, N3: 7 patients; Nx: 2 patients. METHOD: The patients were treated with various modalities: surgery alone: 2 patients; surgery plus radiation: 26 patients; radiation treatment alone: 61 patients; and others: 13 patients. Patients were classified according to the UICC TNM 1992 criteria. The overall 5-year Kaplan-Meier survival in our series was 39%. The cause-specific 4-year survival was 57%. Various prognostic factors and their impact on survival were studied. RESULTS: On univariate analysis, the following factors were found to be significant. Age < 50 vs. > 50 (p = .02); endophytic growth pattern vs. exophytic growth of the primary (p = .01); ulcerated lesions vs. nonulcerated lesions (p = .000); various T stages (p = .003); clinical extension vs. no extension of primary disease (p = .02); combined modality of treatment (surgery and radiation treatment) had the best chance of survival compared to radiation treatment alone (p = .03). Nodal stages N0 vs. N+ disease (p = .2); sex of the patient, female vs. male (p = .83); and dose of radiation treatment < 5000 cGy vs. > 5000 cGy (p = .41) were found not to be significant. When the above significant factors were stratified according to the stage of the disease, only two were significant; ulcerated lesions vs. nonulcerated lesions (p = .04), and the modality of treatment chosen (e.g., radiation alone vs. radiation plus surgery) (p = .02). CONCLUSIONS: In this series of patients, combined-modity approach using surgery and radiation treatment was found to be the best way to treat carcinoma of the tonsil. However, each treatment strategy should be individualized taking into account various prognostic factors.

Nasal T-cell lymphoma: a case presentation.

Nasal lymphoma represents 2.2 to 6.8% of extranodal lymphomas and presents a difficult diagnosis due to the variability of cell populations. Lesions may evolve de novo or may develop as a spectrum of midline lethal granuloma (MLG). The majority of extranodal disease is felt to be of B-cell origin, but there is evidence that those associated with MLG are of T-cell origin. We present a case of a 41-year-old Jamaican female with recurrent lesions of the nasal tip and vestibule beginning at age 16. Intensive investigation and review of the pathology continued to show nonspecific granuloma. However, at age 34, the lesion was diagnosed as T-cell lymphoma (HTLV-I related), and a later review of the slides suggests this may have been present as early as 8 years before diagnosis. She received 4000 cGy to the nose and nasopharynx over 25 treatments. Although the question of two small axillary nodes exists, the primary site has been disease free for 7 years.

Cherubism.

Cherubism is a rare inherited fibro-osseous disorder that affects the jaws, producing a characteristic facial appearance. Patients are normal at birth; however, by their second or third year of life they develop a fullness of the lower one half of their face and retraction of the lower eyelids that exposes a rim of sclera below the iris. The facial appearance is similar to a Renaissance cherub with its gaze toward heaven. A case of cherubism in a 19-year-old male, complicated by severe orbital compression resulting in diplopia, is presented. The patient was diagnosed at three years of age when he developed the characteristic cherub facies and severe dental anomalies that required surgical correction. At age 14, he underwent facial contouring surgery of his jaws. Orbital compression later developed due to lesions growing in the floor of his orbits. This was corrected by way of a subciliary approach to the orbit. The patient's facial appearance and visual function were markedly improved by the surgery. A review of the literature detailing this rare disease is discussed.

Superiorly based osteoplastic flap for frontal sinus disease.

The osteoplastic flap is a widely used technique as an approach to frontal sinus disease. All current textbooks describe the technique with basing the flap inferiorly along the orbital rim and across the naso-frontal suture line. Since 1977, we have had occasion to base the flap superiorly in eight cases with good results. We feel that the superiorly based flap is ideally indicated in unilateral disease, particularly in the balding male, where a coronal incision would be very obvious. It is also a more direct approach. The skin incision itself can be parallel to the brow or almost identical to a blepharoplasty incision. After the floor of the frontal sinus has been removed (as in a Lynch or Howarth approach), cuts in the anterior wall of the frontal sinus are made under direct vision, and the bone is fractured at the superior extent of the sinus. This is certainly quicker and simpler than the standard approach, where a template is required. The risks of CSF leak are greatly diminished. The surgeon has the option of obliterating the sinus, removing the intersinus septum, or creating a mucoperiosteal flap. Details of the technique and two illustrative cases are presented.

The malignant lymphoepithelial lesion of the salivary glands.

Malignant lymphoepithelial lesion (MLEL) is a rare neoplasm of the salivary gland which has an exceptionally high incidence in the Eskimo. Eighty-four cases have been previously reported. Seven additional cases in six Eskimos and one Filipino patient are reported in this paper. The etiology, treatment and prognosis of these lesions is then discussed.

Ankylosis of the temporomandibular joint from psoriatic arthritis.

A review of 27 cases of temporomandibular joint arthritis in patients with psoriasis reveals the main pathologic features to be condylar erosions, condylar osteoporosis, calcification of the articular disc, and subchondral cyst formation. We present another pathological process, temporomandibular joint bony ankylosis in a patient with psoriasis. Surgical management consisted of a high condylectomy, with a silastic implant to maintain the vertical dimension of the ramus. A very good functional result was obtained and 21/2 years later her incisive distance is 44 mm.

Case report: Chylous fistula following right radical neck dissection.

Two unusual cases of chylous fistulae following right radical neck dissection are presented. Treatment in the second case consisted of pressure dressing and replacing the regular blended tube feeding diet with one containing medium chain triglycerides to replace ordinary lipids (long chain triglycerides). Caloric intake was supplemented with parenteral protein and fat infusions. This resulted in prompt cessation of the leak. Other methods of controlling fistulae such as re-operation and oversewing the area or using muscle flaps, or direct packing of the wound often lead to other complications and frequently require considerable time to control the leak.