Swallowing dysfunction is a common sequelae after chemoradiation for oropharynx carcinoma.

INTRODUCTION: A retrospective review of all patients with advanced oropharynx cancer from a single institution was performed. METHODS: Sixty-seven patients with stage III/IV oropharynx cancer were treated with definitive radiotherapy with or without concurrent chemotherapy from 1990 to 2004. Follow-up ranged from 6 to 91 months with a median of 32 months. RESULTS: Patients treated with concurrent chemotherapy had a statistically significant benefit for control above the clavicles, primary control, disease-free survival, and overall survival but no difference in distant control at 3 years. Cox proportional regression model demonstrated the use of concurrent chemotherapy to be the only independent variable that reached significance for control above the clavicles, primary control, and overall survival. Complete dysphagia for solids and/or gastrostomy tube dependence was observed in more patients who were treated with chemoradiation than those treated with radiation alone; 18% and 0%, respectively (P = 0.04). CONCLUSIONS: Concurrent chemotherapy decreases the recurrence at the primary site and above the clavicles. The most notable difference in sequelae between the 2 groups was the increase in swallowing dysfunction with concurrent chemotherapy.

Radiographic complete response on post treatment CT imaging eliminates the need for adjuvant neck dissection after treatment for node positive head and neck cancer.

OBJECTIVE: The primary purpose of this study was to correlate radiographic response in the neck to clinical outcomes for patients with node positive head and neck cancer. METHODS: One hundred three patients with stage III/IV node positive cancer were treated with definitive radiotherapy or chemoradiation at a single institution from 1990 to 2004. Follow-up ranged from 8 months to 144 months with a median of 42 months. Posttreatment CT scans were called complete radiographic response (rCR) or partial radiographic response. RESULTS: Actuarial 36 month rates of survival, control above the clavicles, and nodal control were 66%, 74%, and 90%, respectively. Patients, who had rCR on posttreatment CT scan, who had a neck dissection had a nodal control rate of 94% compared with those without neck dissection of 97%. Patients with partial radiographic response who were treated with neck dissection had a nodal control rate of 94% compared with those without neck dissection of 73%. CONCLUSIONS: Based on this data, there was no suggestion that neck dissection improved outcome for patients with rCR on posttreatment imaging 4 to 6 weeks after radiation.

Radiofrequency turbinate reduction: a NOSE evaluation.

BACKGROUND: The symptoms and treatments for nasal obstruction are numerous and common. Yet, a consensus on a surgical approach or, even more importantly, how to define the success of any approach is lacking in the literature. A disease-specific outcomes instrument recently developed by the American Academy of Otolaryngology, known as the Nasal Obstruction Symptom Evaluation (NOSE) scale, has allowed for a validated, uniform method to compare different treatments for nasal obstruction. METHODS: Using the NOSE scale, we prospectively compared the use of bilateral radiofrequency inferior turbinate reduction (BRITR) only with that of BRITR with septoplasty in the treatment of nasal obstruction caused by the combination of septal deviation and turbinate hypertrophy. NOSE scores were obtained pretreatment and at 3 month and 6 month follow-up. RESULTS: Our data demonstrated significant improvement from baseline after 6 months for the NOSE scores in both the BRITR (P < .001) and BRITR/septoplasty groups (P = .023). No statistical difference was noted in the amount of postoperative improvement between the two treatment groups (P = .304). Both groups did demonstrate a large, clinically important effect using a distribution-based assessment of clinical change. Despite equal clinically effective results, estimated costs for each treatment option differed significantly, with the office-based BRITR only group providing significant cost savings compared with the hospital-based BRITR/septoplasty group. CONCLUSIONS: This study suggests that BRITR should be considered as an initial treatment option for nasal obstruction rather than a septoplasty with turbinate reduction in patients with the clinical findings of both a septal deviation and turbinate hypertrophy after failure of medical therapy.

Laryngopharyngeal abnormalities in hospitalized patients with dysphagia.

OBJECTIVES: To determine the prevalence of laryngopharyngeal (LP) abnormalities in hospitalized patients with dysphagia referred for flexible endoscopic evaluation of swallowing (FEES). STUDY DESIGN: Retrospective, blinded review by two otolaryngologists of 100 consecutive FEES studies performed and video-recorded by a speech-language pathologist (SLP). METHODS: Two otolaryngologists reviewed videos of 100 consecutive FEES studies on hospitalized patients with dysphagia for the presence of abnormal LP findings. RESULTS: Sixty-one male and 38 female patients comprised the hospital dysphagia cohort. The mean age was 62. One subject could not be evaluated because of the severity of the retained secretions, leaving 99 subjects in the cohort. Seventy-six percent had been previously intubated, with a mean intubation duration of 13 days. The overall prevalence of abnormal LP findings was 79%. Forty-five percent of the patients presented with two or more findings, which included arytenoid edema (33%), granuloma (31%), vocal fold paresis (24%), mucosal lesions (17%), vocal fold bowing (14%), diffuse edema (11%), airway stenosis (3%), and ulcer (6%). There was a significant difference in LP findings between those individuals who had or had not been intubated. CONCLUSIONS: Hospitalized patients with dysphagia are at high risk for LP abnormalities, particularly if they have been intubated, and may benefit from either 1) an initial joint examination by the SLP and otolaryngologist or 2) an otolaryngologist's review of the recorded examination conducted by the SLP. Such otolaryngology involvement could identify airway stenosis patients at an earlier stage, initiate granuloma treatment sooner, enable earlier biopsy of unexpected lesions, and allow follow-up of mucosal and neuromuscular findings that do not respond to medical management.

Squamous cell carcinoma of the subglottis.

STUDY DESIGN: A retrospective study over a 25-year period of patients with laryngeal carcinoma treated by the Department of Otolaryngology at Wake Forest University. METHODS: The boundaries of the subglottis were defined as 5 mm below the free edge of the true vocal folds extending to the inferior border of the cricoid cartilage. All were staged according to American Joint Committee on Cancer: stages I and II were considered early and stages III and IV as late. Patients were grouped by treatment modality of surgery alone, surgery and radiotherapy, radiotherapy alone, and radiotherapy with surgical salvage. RESULTS: Fifteen patients represented 1.4% (15/1098) of laryngeal cancers diagnosed within that period. All patients had squamous cell carcinoma of the subglottis of which 20% (3/15) had early-stage disease (T1-T2) and 80% (12/15) had late-stage disease (T3-T4). Overall 3-year survival was low (25%) and is attributed to a high incidence of advanced-stage disease with a high rate of extralaryngeal spread and/or metastasis, especially to the lungs and paratracheal nodes. CONCLUSIONS: To improve earlier detection by primary care physicians and otolaryngologists and to improve treatment outcome, awareness of subglottic carcinoma and its appropriate evaluation is critical in the patient presenting with hoarseness and/or stridor. Radiation therapy treatment to include the low and upper mediastinal compartments to cover local/regional extralaryngeal involvement is advocated as well as paratracheal lymphatic neck dissection and thyroidectomy in surgically treated lesions.

Neck masses secondary to heterotopic salivary gland tissue: a 25-year experience.

OBJECTIVES: The aim of this study is to review salivary tumors arising from heterotopic salivary inclusions in the periparotid and cervical lymph nodal tissues over a 25-year span. METHODS: A retrospective chart review revealed 24 patients with asymptomatic neck masses treated between 1976 and 2001, whose pathology demonstrated heterotopic salivary tissue or neoplasms arising from heterotopic salivary tissue. RESULTS: Nine cases were benign periparotid lymph nodes with heterotopic salivary inclusions, 3 of which had multimodal involvement. Fifteen cases of heterotopic salivary tumors were identified. The benign tumors were predominantly Warthin's tumor (8) with 1 pleomorphic adenoma. Malignant tumors included mucoepidermoid (3), acinic cell (2), and adenocarcinoma (1). Patients were treated by a superficial parotidectomy, neck dissection, or simple excision depending on site and preoperative workup. Adjuvant radiation therapy was included for high-grade malignancies. Among the 15 tumor patients, follow-up ranged from 1 month to 17 years. Nine patients are alive and disease-free, 5 are deceased, and 1 was lost to follow-up. CONCLUSIONS: Heterotopic salivary tissue in periparotid and upper cervical nodes is a more common occurrence than historically recognized. Tumorigenic changes arise from heterotopic nodal inclusions, and although infrequent, should be considered in the differential diagnosis for isolated neck/periparotid masses and parotid Warthin's tumor. Suggested management, after a thorough clinical exam/needle aspiration biopsy, includes an imaging survey of the parotid gland and neck lymphatics with an appropriate resection to include a simple excision, parotidectomy, neck dissection, and/or irradiation as indicated. Isolated low-grade malignant lesions/benign lesions are adequately managed by excision or parotidectomy alone. High-grade malignant lesions require more extended surgery with possible irradiation.

Can post-RT neck dissection be omitted for patients with head-and-neck cancer who have a negative PET scan after definitive radiation therapy?

PURPOSE: A prospective, single institution study was conducted to evaluate the role of positron emission tomography with fluoro-deoxyglucose (FDG) before and after definitive radiation therapy for patients with head-and-neck cancer. Correlation with CT or MRI imaging and pathologic findings at the time of planned neck dissection was made. METHODS AND MATERIALS: Twelve patients with AJCC Stages III-IV cancer of the head and neck received CT or MRI and PET imaging before treatment with definitive radiation therapy. One month after completion of treatment, repeat CT or MRI and PET imaging was obtained. All images were reviewed independently by radiologists who were blind to the results of the other modality. Patients then underwent planned neck dissection. Pathologic correlation with posttreatment scans allowed calculation of the sensitivity, specificity, negative predictive value, and the positive predictive value for both CT/MRI and PET. RESULTS: Comparison of CT/MRI to PET obtained before definitive RT revealed both primary tumor and nodal disease were detected by both modalities in all cases where primary tumor was known. After RT, comparison of CT/MRI imaging to findings of neck dissection revealed a sensitivity of 90%, specificity of 100%, positive predictive value of 100%, and negative predictive value of 50%. Comparison of PET imaging with pathologic findings demonstrated sensitivity of 45%, specificity of 100%, positive predictive value of 100%, and a negative predictive value of 14%. CONCLUSIONS: In this small series of patients, the presence of a positive PET 1 month after RT accurately indicated the presence of residual disease in all cases; however, a negative PET indicated absence of disease in only 14%. Further investigation is warranted before FDG-PET should be used to determine whether post-RT neck dissection should be omitted.

Second head and neck cancers and tobacco usage.

OBJECTIVES: To examine the relative incidence of second primary carcinomas in patients who continued smoking compared with those who had ceased smoking. METHODS: This is a retrospective study based on review of the Wake Forest University-Baptist Medical Center Tumor Registry for the years 1985 through 2000. Ninety-one patients who had had an index head and neck tumor and who developed a second independent head and neck primary tumor, were identified. These cases were grouped into synchronous (different sites within 6 months) and metachronous (different site after 6 months or same site after 3 years) second tumors and were examined with respect to smoking history-specifically whether smoking had continued or ceased after the diagnosis of the index tumor. RESULTS: Of the 91 patients identified with double head and neck tumors, 88 were tobacco users. Comprising the group of 54 patients with metachronous second primaries were 51 smokers-25 who had continued and 26 who had ceased tobacco use. Of the 26 patients who had quit smoking but had developed a second primary, 13 had stopped smoking even before the index primary had been diagnosed. The remaining 13 had stopped when the index primary was treated. CONCLUSIONS: A review of 91 patients with double head and neck primary tumors indicate no difference in the frequency of second tumors developing in a group of patients who continued to smoke after diagnosis of their index cancers relative to patients who stopped smoking. This finding suggests a critical cellular level of cumulative and persistent damage. Methods to reverse this genetic alteration are hypothesized to be potentially more significant than smoking cessation efforts in preventing subsequent head and neck cancers.

Intraparotid facial nerve neurofibromas.

OBJECTIVES: To provide an awareness of intraparotid facial nerve neurofibroma as a cause of parotid masses and to describe their characteristics and management considerations. STUDY DESIGN: Case report with literature review. METHODS: The medical records of three patients with intraparotid facial nerve neurofibromas are reviewed, and data concerning the patient's presentations, treatment, and disease course are presented with a review of the world's literature on intraparotid facial nerve neurofibromas. CONCLUSIONS: Tumors arising from the extratemporal course of the facial nerve are quite rare. The tumors arise from Schwann cells and include the schwannoma and the neurofibroma. The overwhelming benign nature of these lesions necessitates a conservative course of treatment. Histological diagnosis should be followed by a limited tumor excision with emphasis on retaining normal facial nerve function. Malignant lesions require wide excision with facial nerve grafting or facial nerve reanimation.

Otolaryngology retirement profile in the southeastern United States.

OBJECTIVE: To document retirement-related issues and trends among otolaryngologists. STUDY DESIGN: Survey of 438 retired members in the Southern geographical region of the American Laryngological, Rhinological and Otological Society, Inc. METHODS: A questionnaire was mailed to retired members, completed anonymously, and returned to the author. RESULTS: A total of 138 (31.5%) surveys were received. Respondents' average age at retirement was 63.2 years; approximately half had retired in the last 5 years. Since 1995, most had left either a group practice (45%) or a solo practice (41%). The majority of respondents (40%) retired for previously planned or personal reasons. Two thirds of respondents reported that they were more satisfied with retirement than expected. This greater satisfaction was seen in those with a higher average income after retirement. The most common advice for colleagues still practicing was to save more money and invest more money. CONCLUSIONS: Although these results are biased because of a self-selected group of respondents, they illustrate that for this group of retired otolaryngologists, although retirement is being planned for, it is not occurring earlier than in previous years. The experience of retirement was largely positive for these respondents.

Surgical management of choanal atresia: improved outcome using mitomycin.

OBJECTIVE: To evaluate the intraoperative use of mitomycin to improve the surgical outcome and reduce the rate of soft tissue restenosis in children undergoing choanal atresia repair. DESIGN: Retrospective chart review of all patients surgically treated for congenital choanal atresia by the senior author (W.F.M). SETTING: Tertiary children's hospital. PATIENTS: Eight consecutive patients with bony choanal atresia (6 unilateral and 2 bilateral) were compared with 15 historical controls (6 unilateral and 9 bilateral). All study and historical control patients were treated with soft plastic postoperative stenting. INTERVENTION: At the completion of the surgical repair of the choanal atresia, 0.4 mg/mL of topical mitomycin was applied to the posterior choanae for 3 minutes. MAIN OUTCOME MEASURE: The success rate of the repair of the choanal atresia as determined by the postoperative need for dilation or revision surgical procedures was compared with that of the historical controls. RESULTS: All 8 children with intraoperative use of mitomycin were treated with a mean +/- SEM of 0.375 +/- 0.183 dilations per patient. The 15 children in the control group received a mean +/- SEM of 3.667 +/- 0.583 postoperative dilations for soft tissue restenosis. The difference in the number of postoperative dilations between the study and control group was statistically significant (P =.006) using a t test. CONCLUSIONS: Mitomycin is an effective and reliable treatment for improving the surgical outcome for choanal atresia repair. This may obviate the need for postoperative dilations and may potentially eliminate the need for surgical stenting.

Avoiding intubation in the injured subglottis: the role of heliox therapy.

Intubation in the child presenting with severe viral tracheobronchitis or prior subglottic injury can be detrimental to the child and the subglottis. Intubation may lead to further mucosal ischemia, scar, subglottic stenosis, or failed extubation requiring a tracheotomy. Heliox is a combination of helium and oxygen that produces less-dense gas exchange. Its use leads to a decrease in turbulent airflow, which may obviate the need for intubation. Here we report our experience using heliox as initial therapy in 14 consecutive children presenting with severe airway distress and the need for intubation. (Five had viral tracheobronchitis, 5 had inflammatory exacerbation of subglottic stenosis, and 4 had acute iatrogenic subglottic injury.) In 10 of the 14 children, intubation, which can lead to mucosal injury and scarring, was avoided by the use of heliox therapy. Of the 4 children in whom heliox therapy failed, 3 had a prior history of subglottic stenosis. Heliox is a relatively safe and reliable alternative to intubation of children with severe subglottic edema or injury. Heliox should be considered before intubation for selected children with subglottic inflammation and severe airway distress.

Laryngospasm and diaphragmatic arrest in immature dogs after laryngeal acid exposure: a possible model for sudden infant death syndrome.

Laryngopharyngeal reflux has been proposed as a possible cause of sudden infant death syndrome (SIDS). We investigated the efferent laryngeal and diaphragmatic responses to acid exposure on the laryngeal mucosa using a neonatal canine model. Electromyographic (EMG) recordings from the thyroarytenoid muscle and the diaphragm were measured with hooked-wire electrodes. Reproducible laryngospasm responses occurred in all animals after laryngeal exposure to hydrochloric acid at pH 2.0 or less. Laryngospasm occurred in combination with tachypnea and increased diaphragmatic activity in most of the animals. Laryngospasm was associated with prolonged apnea and total cessation of diaphragmatic EMG activity in 1 animal, and in another, initial tachypnea was followed by erratic diaphragmatic activity and brief apnea. Laryngeal acid exposure (below pH 2.0) causes laryngospasm and may result in paradoxical apneic events in neonatal dogs. Acid-induced, laryngospasm-associated apnea may represent a potential cause of SIDS, and the immature dog appears to be an excellent model for further investigations.

Endovascular treatment of hemorrhage after tonsillectomy in children.

SUMMARY: Endovascular therapy for hemorrhage after tonsillectomy or adenoidectomy is an important adjunct to the definitive treatment of this life-threatening occurrence. We report two cases of hemorrhage after tonsillectomy and/or adenoidectomy and describe the endovascular management of this complication in children.

Elective extracorporeal membrane oxygenation: an improved perioperative technique in the treatment of tracheal obstruction.

The surgical management of children with tracheal stenosis and obstruction is complicated by the perioperative needs of pressure ventilation and indwelling endotracheal tubes. These factors predispose to surgical failure and anastomotic breakdown, restenosis. and pneumomediastinum. The use of extracorporeal membrane oxygenation (ECMO) to manage ventilation during tracheal repair allows better visualization at the surgical site and obviates the need for indwelling endotracheal tubes and high-pressure ventilation. Six children were treated with elective ECMO at a tertiary care hospital. All 6 underwent successful surgical repair, and 4 of the 6 were ultimately extubated. There were no significant complications at the surgical site. There was 1 death from postoperative complications, and 2 patients required tracheotomy. One tracheotomy was performed for upper airway obstruction secondary to retrognathia, and this patient was subsequently decannulated. Medical complications were confined to 2 patients and included sepsis, hyperbilirubinemia, seizure disorder, renal failure, intracranial hemorrhage, and hydrocephalus. Elective ECMO provides a reliable perioperative technique for airway management of children with tracheal stenosis or obstruction. This technique offers the advantage of improved visibility at the operative site and eliminates the need for high-pressure ventilation, thereby likely reducing the risk of perioperative morbidity.

Autosomal dominant inherited hearing impairment caused by a missense mutation in COL11A2 (DFNA13).

OBJECTIVE: To analyze the phenotype in a 5-generation DFNA13 family with a missense mutation in the COL11A2 gene that causes autosomal dominant, presumably prelingual, nonsyndromic sensorineural hearing impairment. DESIGN: Family study. SETTING: University hospital department. PATIENTS: Twenty mutation carriers from a large American kindred. METHODS: Cross-sectional analysis using pure-tone threshold measurements at 0.25, 0.5, 1, 2, 4, and 8 kHz. The audiometric configuration was evaluated according to an existing consensus protocol. The significance of features relating to audiometric configuration was tested using 1-way analysis of variance. Progression was evaluated with linear regression analyses of threshold-on-age. RESULTS: Most individuals showed midfrequency (U-shaped) characteristics. The mean threshold in generations IV and V was 44 dB at 1, 2, and 4 kHz (midfrequencies); it was 29 dB at the other frequencies (0.25, 0.5, and 8 kHz). There was no significant progression beyond presbyacusis. CONCLUSION: The trait in this family can be characterized as autosomal dominant, nonprogressive, presumably prelingual, midfrequency sensorineural hearing impairment.

Serial positron emission tomography scans following radiation therapy of patients with head and neck cancer.

BACKGROUND: A single institution study was undertaken to evaluate the role of positron emission tomography (PET) scans with fluorodeoxyglucose (FDG) prior to radiation and following radiation. METHODS: Forty-five patients with head and neck cancers were evaluated with FDG-PET scans as well as either CT or MRI prior to treatment with definitive radiation (RT). These same scans were obtained following completion of RT at 1 month (36 patients), 4 months (28 patients), 12 months (19 patients), and 24 months (15 patients). Standard uptake values (SUV) normalized for blood glucose and lean body mass were calculated on the initial and 1-month post-treatment PET scans. RESULTS: Fifteen patients are alive without evidence of disease at 24 to 52 months following RT. Initial SUVs were calculated on the primary tumor site and ranged from 2.5 to 28.5. These values did not have any correlation with local control when examined for the entire group, primary site, or T stage. One-month post-RT SUV ranged from 1.8 to 6.24. Of the 36 1-month post-RT PET scans, six were interpreted as positive for residual disease and were confirmed by biopsy. Four of the five scans, which were interpreted as equivocal, were positive on biopsy. Seven of the 25 scans, which were interpreted as negative for tumor, were positive on biopsy. Four-month scans were more accurate for disease with disease noted in 0 of 18 negative scans, 6 of 7 positive scans, and 2 of 3 equivocal scans. CONCLUSIONS: PET is useful for initial imaging of head and neck cancers. SUV does not appear to be useful for predicting outcome following treatment with RT. One-month post-RT scans were inaccurate for predicting the presence of cancer. Four-month post-RT scans were a better predictor for the presence of cancer.

Velocardiofacial syndrome: incidence of immune cytopenias.

BACKGROUND: Velocardiofacial syndrome (VCFS) is associated with a broad clinical spectrum that frequently overlaps the DiGeorge syndrome. Both have been linked to chromosomal microdeletions of chromosome 22 (22q11.2). DiGeorge syndrome is associated with T-cell dysfunction. What is the incidence of immune cytopenias in children with VCFS? OBJECTIVES: To (1) identify, (2) characterize, (3) quantify, and (4) follow up the immunologic deficits in children initially seen in our institution with VCFS. DESIGN: Prospective clinical evaluation of patients with the features of VCFS. PATIENTS: Twenty consecutive children with the clinical diagnoses of VCFS. SETTING: Tertiary care children's hospital. MAIN OUTCOME MEASURES: All 20 children had genetics evaluation with chromosomal analysis. Immunologic evaluations included serum immunoglobulin concentrations, lymphocyte studies, and mitogen and antigen stimulation studies. RESULTS: Five (25%) of 20 children were noted to have T-cell dysfunction with a clinical presentation marked by recurrent upper respiratory tract infections. Three of these 5 children had resolution of the T-cell dysfunction over a 2-year period. The 2 children with persistent cytopenias combined with immunoglobulin dysfunction required intravenous IgG infusions to control their infections. CONCLUSIONS: Velocardiofacial syndrome is associated with an increased incidence of immune cytopenias and, thus, warrants evaluation in any child with the clinical diagnosis of VCFS. This immune deficit may be transient and depends on the age of the evaluation of the child.