Osteoradionecrosis of the subaxial cervical spine following treatment for head and neck carcinomas.

OBJECTIVE: To study MRI and positron emission tomography (PET)/CT imaging of osteoradionecrosis (ORN) of the subaxial cervical spine, a serious long-term complication of radiation therapy (RT) for head and neck cancers that can lead to pain, vertebral instability, myelopathy and cord compression. METHODS: This is a single-institution retrospective review of patients diagnosed and treated for ORN of the subaxial cervical spine following surgery and radiation for head and neck cancer. RESULTS: We report PET/CT imaging and MRI for four patients, each with extensive treatment for recurrent head and neck cancer. Osteomyelitis (OM) and discitis are the end-stage manifestations of ORN of the subaxial spine. CONCLUSION: ORN of the subaxial spine has variable imaging appearance and needs to be differentiated from recurrent or metastatic disease. Surgical violation of the posterior pharyngeal wall on top of the compromised vasculature in patients treated heavily with RT may pre-dispose the subaxial cervical vertebrae to ORN, with possible resultant OM and discitis. MRI and PET/CT imaging are complimentary in this setting. PET/CT images may be misinterpreted in view of the history of head and neck cancer. MRI should be utilized for definitive diagnosis of OM and discitis in view of its imaging specificity. ADVANCES IN KNOWLEDGE: We identify the end-stage manifestation of ORN in the sub-axial spine on PET/CT and MRI to facilitate its correct diagnosis.

Curative radiotherapy for anterior commissure laryngeal carcinoma.

There is continuing controversy surrounding the most effective treatment of glottic carcinoma involving the anterior commissure (AC). Surgery has been the preferred method of treatment, since studies previously indicated early tumor invasion of the thyroid cartilage at the AC, thereby assuming less curability by radiotherapy (RT). Subsequent laryngeal anatomic studies and refinement of RT techniques have brought into question the ineffectiveness of curative irradiation. A retrospective review of 174 patients with early-stage glottic carcinoma treated with standard fractionation curative RT revealed 34 patients with T1 and T2 lesions involving the AC. Allowing for a follow-up of at least 3 years, we observed only a 12% (4 of 34 patients) local recurrence rate after RT alone, with excellent voice quality and no major complications related to the irradiation. The 4 local recurrences were controlled by total laryngectomy, although 2 patients developed distant metastatic disease. Radiotherapy represents an effective method of treating T1 squamous cell carcinoma of the glottis with AC involvement. The small number of T2 glottic carcinomas in this study prevents a meaningful conclusion concerning treatment of these lesions.

Treatment of the clinically negative neck in oral squamous cell carcinoma.

OBJECTIVE: To define the most effect treatment plan of patients with oral cavity squamous cell carcinoma with clinically negative (NO) neck staging. STUDY DESIGN: Retrospective review of 54 patients with NO neck staging who underwent resection of an oral cavity primary tumor with or without elective neck dissection between January 1982 and December 1992 and with a minimum follow-up of 3 years. METHODS: The records of 54 patients with previously untreated oral cavity squamous cell carcinoma and NO neck staging were retrospectively reviewed to determine the impact of elective neck dissection on patient outcomes including regional recurrence and overall survival. RESULTS: All patients underwent surgical resection of their oral cavity tumors, with 33 patients undergoing "watchful waiting" observation for the development of neck disease while 21 patients had elective neck dissections. The most controversial group of patients were those with intermediate-sized (T2 and T3) primary tumors. Eighteen of these patients underwent elective neck dissection, with two patients developing recurrent neck disease and an ultimate prognosis of 72%. Twelve patients had observation of their necks, with five of these patients subsequently requiring neck dissection. An additional seven patients did not undergo neck dissection, and this group had four survivors free of disease. The prognosis was 42% in patients not having elective neck dissections. CONCLUSIONS: T1 tumors do well with neck treatment other than careful observation. The data suggest that patients with T2 and T3 oral squamous cell carcinoma should undergo surgical resection of their primary tumor site and elective neck dissection. Patients with T4 oral cavity lesions should routinely undergo neck dissection.

Evaluation and treatment of head and neck venous vascular malformations.

Congenital venous vascular malformations of the head and neck are low-flow, nonproliferative lesions that should be distinguished from hemangiomas. The characteristic history and clinical findings can establish the diagnosis. Direct percutaneous puncture and contrast injection at the time of treatment delineate the lesion and its drainage pattern. Treatment must be individualized according to lesion extent, patient tolerance and physician experience. Sclerotherapy with ethanol has proved to be a successful treatment modality for these lesions, as demonstrated in this study of 57 patients. Surgery is used for treatment of clinically significant residual disease. A multidisciplinary approach to evaluation and treatment is key to successful management.

Corniculate-cuneiform flap for reconstruction in the extended vertical partial laryngectomy.

The extended vertical partial laryngectomy involves removal of the vocal cord and adjacent arytenoid cartilage. Arytenoid sacrifice predisposes the patient to postoperative aspiration, since adequate laryngeal closure during swallowing cannot be accomplished. Various techniques have been previously described for reconstruction of this defect. We present five patients who had reconstruction of this area with a local, mucosally based corniculate-cuneiform flap. All patients were decannulated, had no long-term aspiration, maintained socially acceptable voice quality, and had no tumor recurrence with a minimum of 3 years of follow-up. Our preliminary data suggest that this flap can be used in previously irradiated patients. The corniculate-cuneiform flap is an effective method of reconstruction in patients undergoing an extended vertical partial laryngectomy.

Sphenoid cranial base defects in siblings presenting with cerebrospinal fluid leak.

Two sisters presented to our medical center with nontraumatic cerebrospinal fluid (CSF) fistulas from left sphenoid sinocranial junction defects. One sister had recurrent meningitis over a 20-year period that prompted a skull base evaluation. Four years later, her younger sister presented with profuse CSF rhinorrhea. Transethmoid sphenoidotomy with sinus obliteration and lumbar-subarachnoid temporary CSF diversion successfully treated one sister, while the other required reoperation and permanent lumbar-peritoneal shunting. In both cases the skull base defect was identically located in the posterolateral left sphenoid sinus. Embryological considerations, evaluation and management are presented.

Perioperative complications of transseptosphenoidal excision for pituitary adenomas.

Although complications of transseptosphenoidal (TSS) pituitary surgery have been discussed in the literature, there has not been an analysis of complication rates related to clinical features and the nature of the tumor. A retrospective review of 366 TSS procedures (354 patients) for excision of pituitary adenomas evaluated the incidence and management of perioperative complications. The mortality rate was 0.82%. The most frequently encountered complications were transient diabetes insipidus (8.74%) and cerebrospinal fluid (CSF) rhinorrhea (4.10%). Other complications included exacerbation of visual acuity and visual field defects, hemorrhage, hydrocephalus, and meningitis. The factors evaluated were gender, age, tumor size, hormone secretory status, and any history of prior pituitary surgery.There was a significantly higher incidence of transient diabetes insipidus in patients with hormone-secreting tumors. Minor and total complication rates were significantly increased in microadenomas, hormone-secreting tumors, in female patients, and in patients less than 60 years of age reflecting the increased incidence of transient diabetes insipidus in young female patients with hormone-secreting tumors. Observed intraoperative CSF leaks predisposed to postoperative CSF rhinorrhea. There were no identifiable risk factors for major complications.

Metastatic basal cell carcinoma of the head and neck.

Metastases are occasionally associated with cutaneous squamous cell carcinoma but only rarely with basal cell carcinoma. There are approximately 200 cases of metastases from basal cell carcinoma reported in the world literature. We describe 6 additional cases. All of our patients demonstrated recurrence at the primary site before they developed their metastases. Metastases presented in subcutaneous tissue, cervical lymph nodes, bone, and lung between 1.5 and 14 years after initial treatment of the primary lesion. The long interval seen in these patients between the initial treatment of the primary and the development of metastases underscores the need for long-term follow-up in what is often thought to be a nonaggressive, nonmetastasizing malignancy.

Reconstruction of the ligated external carotid artery for embolization of cervicofacial arteriovenous malformations.

PURPOSE: Until recently, the accepted management of life-threatening complications of unresectable cervicofacial arteriovenous malformations (AVMs) has been ligation of the major feeding vessels, usually the branches or the main trunk of the external carotid artery. Rapid enlargement of collateral vessels around the ligature is usually associated with an early return of symptoms. Percutaneous transcatheter embolization of the nidus of the arteriovenous malformation is now the preferred treatment for symptomatic AVMs that cannot be excised. Previous ligation of the main feeding vessels prevents catheter access and embolization therapy of the lesion. The purpose of this report is to describe our experience with the treatment of patients with symptomatic unresectable cervicofacial AVMs and previous external carotid artery ligation. METHODS: Six patients with symptoms from cervicofacial arteriovenous malformations required surgical reconstruction of their previously ligated external carotid artery with the anticipation of catheter embolization therapy to the branch vessels feeding the malformation. Saphenous vein was used in five reconstructions; a polytetrafluoroethylene graft was used in one. RESULTS: After successful arterial reconstruction, massive swelling of the tongue and perioral tissue developed in two patients, which necessitated tracheostomy in one patient; and embolization therapy before extubation could be safely performed in the other patient. In all, four patients underwent successful embolization therapy. One refused subsequent treatment. In one patient with severe epistaxis, external carotid artery revascularization led to the healing of the nasal ulcers without need for embolization therapy. CONCLUSIONS: For patients with previous ligations of the external carotid artery and symptomatic AVMs, revascularization of the external carotid artery is an important step in treatment. The surgery must be carefully coordinated with the interventional radiologist for possible emergency postoperative embolization therapy. External carotid artery ligation only complicates the treatment of patients with cervicofacial AVMs, and should no longer be used in the treatment of these individuals.

Refinement of the transpalatine exposure of the nasopharynx.

The intrasulcular incision provides excellent transpalatine exposure of the nasopharynx with a viable palatal flap. There is less chance for naso-oral fistula formation since the resulting suture line is always over underlying bone. This safely allows extensive removal of the hard palate. Additionally, the continuous sling suture allows excellent flap reapproximation using the teeth as anchors for the replaced palatal flap. Patients tolerate oral feedings within 24 hours of their operations and require minimal postoperative analgesics. The extended intrasulcular incision offers many advantages over other methods for transpalatine exposures to the nasopharynx.

Squamous cell carcinoma in older patients without risk factors.

Ten patients over sixty years of age with no history of tobacco or alcohol use were treated for squamous cell carcinoma of the upper aerodigestive tract between 1979 and 1991. Nine of these ten patients were women with lesions confined to the oral cavity and oropharynx. Modes of treatment included surgery, radiation, or a combination of surgery and radiation. Followup from 1 to 10 years revealed two deaths from local and distant spread, and eight patients with no evidence of disease. Recurrences after treatment were aggressive and occurred within the same region as the primary lesion. Although most patients with upper aerodigestive squamous cell carcinoma are men with alcohol and/or tobacco exposure, this study demonstrates findings consistent with field cancerization in a group of older women with no risk factors.

Extracranial repair of cerebrospinal fluid otorhinorrhea.

Forty-eight patients with cerebrospinal fluid leaks comprise this retrospective study. There were 39 traumatic and 9 spontaneous leaks. Nine patients were initially managed with bed rest and spinal drainage, but 3 patients in this group ultimately required surgical intervention for repair of their persistent leaks. Thirty-nine patients had surgery as initial therapy, with 33 extracranial repairs, 2 intracranial repairs, and 4 combined approaches. The extracranial approach was used in 36 of 42 patients, with an initial success rate of 86%.

Computed tomography of the clinically negative neck.

Members of the New York Head and Neck Society conducted a multi-institutional review correlating preoperative computed tomography (CT) of the neck with postoperative pathology in 59 patients with squamous cell carcinoma of the oral cavity, pharynx, and larynx, without palpable lymphadenopathy. All underwent CT followed by surgery that included partial or complete cervical lymphadenectomy. Sixteen (28%) patients had occult cervical metastases including 6 (17%) of 36 patients with "early stage" (T1 and T2) primary tumors and 10 (44%) of 23 patients with "advanced" (T3 or T4) lesions. There was agreement of CT scan findings with presence or absence of metastatic disease in 41 (69%) of 59 studies, with sensitivity 38%, and with specificity 81%. Findings of central lucency and nodal confluence were highly reliable indicators of malignancy, whereas nodal size bore a less direct relationship. Intravenous contrast medium was useful for anatomical delineation, but not for identification of malignancy. Review of films by a single radiologist did not produce greater diagnostic accuracy than the original interpretations. The authors conclude that while it is not possible to identify all instances of cervical node involvement, employment of CT in addition to physical examination and prognostication based on primary tumor stage will facilitate appropriate selection of patients for elective treatment of the neck.

Embolization in the treatment of epistaxis after failure of internal maxillary artery ligation.

Internal maxillary artery ligation is effective in treating epistaxis. Occasionally a patient may continue to hemorrhage after this procedure. Evaluation of postoperative angiograms reveals several factors accounting for the failure of internal maxillary artery ligation. These factors include incomplete ligation of vessels, alternative dominance of vessels, and reconstitution of flow through collaterals. Eleven such patients have been successfully treated with angiography and embolization. There was one complication of skin slough in the region of the columella. Embolization is a useful modality in the management of these difficult cases.

Epiglottitis in AIDS patients.

Adult epiglottitis in patients with acquired immunodeficiency syndrome has not been previously reported. A pale, floppy epiglottis with supraglottic edema, cervical lymphadenopathy, a normal to low white blood count without a shift to the left, and rapidly progressive airway obstruction characterize this entity. In this small series of patients, conservative medical management was not successful, and aggressive airway intervention with appropriate intravenous antibiotic therapy was necessary.

Cystic parotid lesions in patients at risk for the acquired immunodeficiency syndrome.

Twenty-three patients at risk for the acquired immunodeficiency syndrome presented with cystic lesions of the parotid gland. Fourteen patients had unilateral parotid cysts and nine had bilateral enlargement. Ten patients were positive for antibodies to the human immunodeficiency virus (HIV), three were negative for antibodies to the human immunodeficiency virus, and ten refused testing. Fine-needle aspiration cytology and computed tomography were helpful in making the diagnosis of benign lymphoepithelial cyst. Superficial parotidectomy confirmed the diagnosis. Concurrent malignancy (Kaposi's sarcoma) was diagnosed in one patient from a parotid specimen. Follow-up has ranged from four months to five years.

Benign lymphoepithelial parotid cysts and hyperplastic cervical adenopathy in AIDS-risk patients: a new CT appearance.

The contrast material-enhanced computed tomographic (CT) scans of 18 patients at risk for acquired immunodeficiency syndrome (AIDS) who had painless facial swelling were reviewed. All scans demonstrated parotid cysts and diffuse homogeneous cervical adenopathy. The cysts were bilateral in all but three cases. Eleven of 13 patients tested had antibodies to the human immunodeficiency virus (HIV), and two of the five untested patients later developed AIDS. The authors believe that the CT findings of multiple parotid cysts and cervical adenopathy suggest that the patient may be infected with the HIV virus, and the radiologist should alert the referring physician so that appropriate precautions and treatment may be initiated.

Trans-septal sphenoidotomy approach for cystic lesions of the clivus.

Destructive lesions of the clivus produce symptoms related to adjacent anatomic structures. Radiographic evaluation of a patient presenting with cranial neuropathies revealed a cystic lesion of the clivus, and surgical and histologic findings established a diagnosis consistent with a mucocele. There have been no previous reports in the literature describing a primary mucocele of the clivus. Appropriate treatment for these fluid-filled structures is marsupialization or exteriorization into the sphenoid sinus. A trans-septal sphenoidal approach was used in this case and is advocated as an effective means of managing cystic lesions in this area.