Frontal sinus schwannoma: case report and review of literature.

Although schwannomas are frequently found in the head and neck region, sinonasal tract involvement is extremely rare, especially those of the frontal sinus. We report a patient with an incidentally found right frontal sinus lesion. The patient underwent resection of the tumor via a right craniotomy. The histological diagnosis was consistent with a schwannoma. There has been no radiographic recurrence on 2-year follow-up.

Functional and oncologic results following transoral laser microsurgical excision of base of tongue carcinoma.

OBJECTIVE: The study objective was to determine survival and functional results in patients who underwent transoral laser excision of base of tongue squamous cell carcinoma. STUDY DESIGN: This was a case series with chart review. SUBJECTS AND METHODS: Patients with biopsy-proven base of tongue squamous cell carcinoma primarily treated with transoral laser excision and followed for at least 24 months were included. Disease-specific and overall survival data were determined. Quality-of-life data were obtained using the University of Washington Quality of Life instrument. RESULTS: Of the 71 patients treated, one (1.4%), nine (12.7%), seven (9.9%), and 54 (76.1%) were stage I, II, III, and IV, respectively, at diagnosis. At 24 months, overall survival was 90 percent; disease-specific survival was 94 percent. Locoregional recurrence occurred in 10 percent. Given the low number of deaths, no significance was detectable between survival and gender, overall stage, tumor size, nodal status, or adjuvant therapy. Quality-of-life data, obtained for 46 patients, revealed the majority of patients had mild or no pain, minimally impaired to normal swallowing, and normal speech. CONCLUSION: Transoral laser excision offers an acceptable treatment approach in terms of survival and quality of life for patients with base of tongue squamous cell carcinoma.

Glossopharyngeal schwannoma of the suprahyoid carotid space: case report and discussion of the relationship to the carotid artery.

BACKGROUND: The distinction between lesions of the deep parotid space and those of the carotid space has been greatly facilitated by cross-sectional imaging, particularly magnetic resonance imaging (MRI), due to 1) good assessment of parapharyngeal fat displacement, and 2) reliable and consistent identification of the carotid artery. While masticator space masses consistently displace the carotid artery posteriorly, it is generally assumed that carotid space masses, particularly schwannomas, displace the carotid artery anteriorly. We report on a patient with a rare glossopharyngeal schwannoma of the carotid space that caused posterior displacement of the carotid artery. METHODS: A 38-year-old female presented with headaches and a pharyngeal sensation of a foreign body without dysgeusia and dysphagia. Computed tomography (CT) and MRI showed a left carotid space mass, suggestive of a schwannoma, although the internal carotid artery was displaced posteriorly. The mass was hypovascular at angiography. The patient underwent surgical excision of her lesion via a left cervical-parotid approach. RESULTS: In our patient with a carotid space mass, all imaging features suggested a schwannoma, except for posterior displacement of the carotid artery. A glossopharyngeal nerve schwannoma was found at surgery. Schwannomas of the glossopharyngeal nerve are uncommon, and those originating from the extracranial course of the nerve are extremely rare. CONCLUSIONS: Schwannomas of the suprahyoid carotid space most commonly arise from the vagus nerve and have a typical pattern, which includes anterior displacement of the carotid artery. A rare exception to this has been reported in schwannomas of the sympathetic nerve, which may displace the carotid artery posteromedially. Our patient had a schwannoma of the extracranial glossopharyngeal nerve, which caused posterolateral carotid displacement.

Primary tumor thickness as a risk factor for contralateral cervical metastases in T1/T2 oral tongue squamous cell carcinoma.

OBJECTIVES/HYPOTHESIS: Contralateral cervical metastases represent an avoidable source of failure in squamous cell carcinoma (SCCa) of the oral tongue. We sought to identify risk factors for the development of contralateral cervical metastases in T1/T2 oral tongue SCCa. STUDY DESIGN: Retrospective review. METHODS: We reviewed the medical records of 50 sequential cases of Stage I/II SCCa of the oral tongue treated with surgery between 1983 and 2003 at Loyola University Medical Center and Hines VA Hospital. Clinical staging, primary tumor thickness, results of neck dissection, adjuvant treatment, site and date of recurrence, and final outcome were recorded. Follow-up ranged from 0.2 to 17 years, with a mean of 5 years. Data were analyzed using multivariate logistic, Cox regression analysis, and a classification and logistic regression tree analysis. RESULTS: The odds ratio for risk of developing contralateral neck metastasis was 5% for each 1 mm increase in tumor thickness (P = .68). The risk did not change when controlling for the presence of ipsilateral metastasis. There was a significant relationship between contralateral cervical metastases and the development of recurrent disease at any site (P = .005). Classification tree analysis determined the risk for contralateral metastases and was greatest for patients with tumors > 3.75 mm thick and < or = 9.5 mm thick. CONCLUSIONS: This report is the first to our knowledge that evaluates thickness as a risk factor for contralateral cervical metastasis in oral tongue SCCa. We recommend consideration be given to treating the contralateral neck in cases where the primary tumor is > 3.75 mm thick.

Peripheral ameloblastoma of the maxilla: a case report and literature review.

Peripheral ameloblastoma is a rare, benign, extraosseous neoplasm of the odontogenic epithelium. We report a case of peripheral ameloblastoma, detail our surgical therapy and review important elements in the pathological diagnosis and treatment of this unusual neoplasm.

Intratemporal Grafting of the Facial Nerve following Lateral Skull Base Tumor Resection.

UNLABELLED: Intratemporal skull base tumors may invade the facial nerve in the horizontal (tympanic) or descending (vertical) segments, while parotid malignancies typically infiltrate the facial nerve at the stylomastoid foramen. This article will describe our results following intratemporal facial nerve grafting in 44 patients. METHODS: This was a retrospective analysis of 44 patients requiring intratemporal facial nerve repair following lateral skull base tumor resection at our tertiary care, academic medical center. RESULTS: Tumor histology included 17 parotid cancers, 13 temporal bone malignancies, 9 glomus tumors, 3 facial neuromas, and 2 endolymphatic sac tumors. The greater auricular nerve was used in 25 patients and the sural nerve was used in 19 cases. Forty patients were available for facial function assessment at 2 years. Using the House-Brackmann (H-B) recovery scale, the breakdown of patients by facial function was as follows: Grade I, 0 patients; Grade II, 4 patients; Grade III, 29 patients; Grade IV, 4 patients; Grade V, 3 patients; and Grade VI, 0 patients. CONCLUSIONS: Facial paralysis may occur from intrinsic or external lateral skull base invasion of the facial nerve. Intratemporal interposition grafting resulted in favorable facial function (H-B II or III) in 33 of the 40 (82.5%) patients at the 2-year assessment.

Impact of mandibular condyle preservation on patterns of failure in head and neck cancer.

OBJECTIVE: To determine the role of native condyle preservation in local recurrence after segmental mandibulectomy in patients with head and neck squamous cell carcinoma. METHODS: Retrospective chart review with main outcome measuring local control of cancer. RESULTS: Between 1994 and 2003, 72 patients (48 men, 24 women) with an average age of 73.5 years without previous treatment underwent segmental mandibulectomy. Fifty-four cases (n = 54) involved the mandible posterior to the mental foramen and are the subject of this review. In 36 patients, the condyle was preserved and mandibular continuity was restored. In 18 patients, condyle and ramus were resected without mandibular reconstruction. Reconstructive modalities included primary closure (3), split-thickness skin graft (3), pedicle flap (19), and free tissue reconstructions (29). Overall local-regional recurrence rate was 22 percent (12 of 54); no recurrences were identified in patients who underwent condylar resection. Recurrences were observed in patients with mandibular reconstruction by both plate and pedicle flap (5 of 9) or (osteo) myocutaneous free flap (7 of 27). CONCLUSION: Condylar preservation may predispose patients to local recurrence after segmental mandibulectomy. This does not translate into overall reduction in survival.

Lacrimal sac melanoma.

A 48-year-old woman presented with a 5-month history of unilateral epiphora and progressive growth of a left-sided medial canthus mass. CT revealed a nonenhancing soft tissue mass of the left lacrimal sac with widening and erosion of the nasolacrimal canal. The tumor was resected and pathologically confirmed to be malignant melanoma. Despite wide resection and adjuvant radiotherapy, the patient developed metastases to the chest wall. The patient currently is receiving combined immunotherapy and chemotherapy. The clinical course and treatment strategies are reviewed for this highly aggressive and rare neoplasm.

Life after total laryngectomy: a measure of long-term survival, function, and quality of life.

OBJECTIVES: To analyze postoperative clinical, functional, and quality-of-life (QOL) outcomes in patients after total laryngectomy (TL) and to determine the effect of preoperative variables (including age, sex, comorbidities, prior chemotherapy or radiation therapy, and tumor site and stage) on long-term survival and quality of life. DESIGN: We performed a retrospective cohort follow-up study of patients who underwent TL for cancer between July 28, 1994, and August 11, 2005. SETTING: University tertiary care facility. PATIENTS: One hundred forty-three patients who underwent TL were identified, and their hospital medical records were reviewed. Ninety-one patients (63.6%) underwent TL for primary carcinoma and 52 (36.4%) for recurrent cancer. At follow-up, 58 patients (40.6%) were alive. MAIN OUTCOME MEASURES: Baseline characteristics and preoperative clinical variables were collected. Follow-up data on function and QOL were collected from patients who were alive at the time of study via the Head and Neck Cancer Inventory, a previously validated questionnaire. Survival was estimated using the Kaplan-Meier method. Univariate and multivariate analysis was used to determine factors significant for survival. RESULTS: The overall median survival for the cohort was 23.0 months (mean +/- SD, 50 +/- 29 months). On univariate analysis, the following 5 factors were significant predictors of long-term survival: cancer site in the larynx, T3 stage, N0 to N1 stage, presence of no more than 2 comorbidities, and absence of cardiovascular comorbidities at the time of cancer diagnosis (P<.05). On multivariate analysis, only T stage maintained significance as a predictor of survival (P =.04), while cancer site was nonsignificant at P =.07. For patients alive at the time of study, functional and QOL outcomes for 5 domains (speech, eating, social disruption, aesthetics, and overall QOL) ranged from intermediate (score, 31-69) to high (score, 70-100) categories. Pretreatment patient-related factors that correlated with notably better functional and QOL outcomes in at least 1 domain were age older than 65 years at diagnosis, presence of no more than 2 comorbidities, no history of previous chemoradiation therapy, and primary tracheoesophageal puncture placement. CONCLUSIONS: Pretreatment clinical variables (including primary tumor site, tumor stage, regional metastases, and number and type of comorbidities) have an effect on long-term survival after TL. Despite common belief, many patients who have undergone TL maintain a good QOL overall. This study sheds light on which patient-related factors may affect health-related QOL outcomes after TL. These findings may be used to select patients who are good candidates for TL based on anticipated functional and QOL outcomes.

Contemporary management of tumors of the salivary glands.

Management of tumors of the salivary glands requires a detailed understanding of the anatomy and pathologic processes affecting these glands. Salivary glands give rise to benign and malignant neoplasms and are affected by a variety of systemic diseases. CT remains the most common primary imaging study; magnetic resonance imaging and ultrasound have also been explored. Fine-needle aspiration as part of the diagnostic evaluation remains controversial due to varying sensitivities and specificities. Surgical extirpation is the primary modality for management of tumors of the salivary glands. Parotid surgery carries a potentially high morbidity with possible unsightly scarring and facial nerve damage. Nontraditional surgical approaches and instrumentation, as well as facial nerve monitoring, can decrease the morbidity of a parotidectomy. In specific instances, malignant salivary gland tumors warrant cervical lymphadenectomy. Adjuvant therapy is primarily accomplished with radiation. Chemotherapy continues to play a palliative role in salivary gland malignancies; however, newer trials are investigating the therapeutic role of chemotherapy.

Combined anterior and anterolateral approaches to the cranial base: complication analysis, avoidance, and management.

OBJECTIVE: During the past decade, applications of anterior and anterolateral cranial approaches for both benign and malignant pathologies have expanded in frequency and application. Complications associated with these procedures impact significantly on patient outcome. The primary aim of this study is to detail the strategies for complication management and avoidance developed from experience with 120 patients who underwent anterior and anterolateral cranial base procedures during the past 14 years. METHODS: Between July 1990 and February 2004, 62 male and 58 female patients underwent 120 combined (neurological surgery and otolaryngology joint participation) anterior and anterolateral cranial base procedures. Fifty-four percent had malignant pathology, and 46% had benign pathology. The approaches taken were transfacial (10%), extended subfrontal (33%), lateral craniofacial (23%), and anterior craniofacial (35%). Thirty-day morbidity and mortality were analyzed. RESULTS: Twenty (17%) patients experienced at least one complication. Malignancy and reoperation, regardless of histology, appeared to affect the complication rate. A decline in complications occurred with experience, in part because of changes in management that reflected the complication experience (25% in Patients 0-31, 18% in Patients 32-70, 10% in Patients 71-120). Methodology is detailed for avoidance and management of retraction injury, infection, tension pneumocephalus, cerebrospinal fluid leak, pericranial flap failure, free flap sizing, dural banding, intracranial hypotension, and cerebrovascular events. Individual patient analysis, complications timing, and strategy for management are discussed. CONCLUSION: Improved patient outcomes for anterior and anterolateral cranial base surgery are, in part, directly related to the ability to avoid and manage associated complications. Experience, avoidance, and interdiction are key factors in complication management.

Recurrent pleomorphic adenoma of the parotid gland.

OBJECTIVES: To assess the long-term results in the management of 42 patients with recurrent pleomorphic adenoma of the parotid gland. STUDY DESIGN: A retrospective analysis of 42 patients who underwent parotidectomy for recurrent pleomorphic adenoma was performed to study presenting clinicoradiographic features, surgical technique, facial nerve management, and the long-term risk of recurrence. RESULTS: All 42 patients had multi-focal, nontender recurrent nodules following one to four prior surgical procedures and 6 patients underwent prior radiotherapy. Surgical procedures included subtotal parotidectomy in 12 patients, total parotidectomy in 18 patients, parotidectomy with facial nerve resection in 7 cases, and subtotal petrosectomy with facial nerve resection in 5 individuals. The 2 patients with malignant transformation died of disseminated lung and bone metastasis. Twenty-nine of the remaining 40 patients had no recurrent disease. Seven patients developed local parotid bed or cutaneous recurrent disease, 2 patients died of unrelated causes, and 2 patients were lost to follow-up. CONCLUSIONS: All 7 patients with recurrent disease underwent subtotal parotidectomy with "negative" surgical margins. Total parotidectomy or subtotal petrosectomy with facial nerve resection in selected cases may reduce the risk of multiple episodes of pleomorphic adenoma recurrence. Two of 42 patients were found to have carcinoma ex-pleomorphic adenoma, both of these patients underwent prior radiotherapy, and both died of metastatic disease.

Closure of complex lateral skull base defects.

OBJECTIVE: To discuss surgical reconstructive options and complications in patients with extensive lateral skull base defects. STUDY DESIGN: Retrospective case review. SETTING: Tertiary referral center. PATIENTS: Eligibility criteria included patients seen between July 1999 and July 2003 with malignant neoplasms of the lateral skull base requiring surgical therapy, with resultant surgical defect not amenable to primary closure. INTERVENTION: Surgical extirpation of malignant skull base neoplasm requiring free tissue transfer or rotational flap closure. MAIN OUTCOME MEASURE: Closure and healing of surgical defect, intraoperative and postoperative complications, patient survival. RESULTS: There were 11 patients, 8 males and 3 females, with an average age of 65 years. Eight patients required trapezius flap reconstruction, whereas one patient required temporalis rotational flap closure, and two patients required rectus abdominus free tissue transfers. There was one perioperative death secondary to cardiac disease. There were no immediate wound complications. One patient developed a delayed partial trapezius flap failure successfully treated with a rectus abdominus flap. CONCLUSIONS: The trapezius rotational flap is a reliable means of closing complex lateral skull base defects with minimal morbidity.

Why do patients with head and neck squamous cell carcinoma experience distant metastases: can they be prevented?

PURPOSE OF REVIEW: This article will examine recent publications that enhance our understanding of this process, and current areas of investigation for therapeutic intervention in preventing and treating metastatic disease. RECENT FINDINGS: Recent investigations have led to insights into the mechanisms of cellular adhesion, invasion, and angiogenesis. E-cadherin, integrins, and selectins are all pivotal in cell-cell adhesion and communication. Recent advances in the area of tumor angiogenesis have led to our discovery of endostatin, an anti-angiogenic peptide that has potential in treating metastatic head and neck cancer. Current trials looking at sentinel node mapping may allow us to evaluate the nodal status of early head and neck cancer and identify a subset of patients at risk for distant metastasis. SUMMARY: As our understanding of metastatic disease increases, so will our ability to intervene in the various pathways involved in metastatic evolution. Metastatic cells are likely to respond differently to chemotherapeutic agents. Agents inhibiting specific aspects of invasion, adhesion, and angiogenesis will need to be combined to intervene at these key steps. Continued investigation into the biology of the epidermal growth factor receptor has led to an increased understanding of the mechanisms of abrogation of apoptosis, increased cellular motility, and metastasis. Inhibition of the epidermal growth factor receptor pathway with the monoclonal antibody C-255 has been shown to inhibit these processes and will likely be effective in reducing the development of distant metastasis.

Modulation of Th1 and Th2 cytokine profiles and their association with advanced head and neck squamous cell carcinoma.

OBJECTIVE: Plasma cytokine concentrations from patients with head and neck squamous cell carcinoma (HNSCC) were measured to determine whether the potential modulation of host Th1 vs Th2 immune responses are associated with advanced clinical disease. STUDY DESIGN AND SETTING: The concentrations of IL-4, IL-6, IL-10, and IL-12 were measured in the plasma of 58 patients with histologically proven HNSCC. These data were examined with respect to the histologic size (T-stage) of the primary tumor, and presence of nodal metastasis. RESULTS: The concentrations of IL-12 were greater from patients without nodal metastasis, and with T(1)/T(2)-stage tumors. IL-10 levels were greater from patients with nodal metastasis, and with T(3)/T(4)-stage tumors. The concentrations of IL-6 were greater from patients with T(3)/T(4)-stage tumors. CONCLUSIONS: Using parameters of primary tumor size and presence of nodal metastasis, patients with advanced HNSCC have significantly less plasma IL-12 levels, and greater plasma IL-10 and IL-6 levels. SIGNIFICANCE: Patients with advanced HNSCC have a potentially diminished Th1 immune response, and a stronger potential Th2 immune response when compared to that of patients with less advanced disease. EBM RATING: D-5.

Mandible fracture patterns: a suburban trauma center experience.

PURPOSE: Mandible fractures are among the most frequently seen injuries in the trauma center setting. Recent shifts in the mechanism and age distribution of patients sustaining these injuries are well documented. This study attempts to define current, predictable patterns of fracture based on patient characteristics and mechanism of injury. MATERIAL AND METHODS: The charts of 134 patients with 225 mandible fractures treated over a 7-year period by the Otolaryngology-Head and Neck Surgery, Plastic and Reconstructive Surgery and Oral-Maxillofacial Surgery services, our institution, were retrospectively reviewed. Patients were categorized based on age, mechanism of fracture, and anatomic location of fracture. Multivariate analysis of data was performed to determine significant relationships among groups. RESULTS: Violent crimes such as assault and gunshot wounds accounted for the majority of fractures (50%) in this study, with motor vehicle accidents less likely (29%). Overall, parasymphyseal fractures were most frequent (35%), whereas angle and body fractures were also common (15% and 21%, respectively). There was a statistically significant association of motor vehicle accidents with parasymphyseal fractures (45%), and gunshot wounds with body fractures (36%), whereas assault victims had a higher than predicted frequency of angle fractures (27%) and fewer parasymphyseal fractures (19%). Patients aged 17 to 30 were more likely to suffer from gunshot wounds, whereas older adults (age 31-50) were more likely to be assault victims. Patients over age 50 suffered fractures from falls at a higher than expected rate. Although children and young adults seemed to suffer more parasymphyseal fractures and older adults body fractures, these correlations failed to show statistical significance. Parasymphyseal fractures were most frequently associated with fractures at other sites within the mandible, ipsilateral body fractures being the most common. CONCLUSIONS: Updated data on the association of patient age and mechanism of injury with fracture pattern can guide treating physicians in anticipating and diagnosing traumatic mandible fractures.

Posterior marginal mandibulectomy in the management of cancer of the oral cavity and oropharynx.

OBJECTIVE: To review a single institution's experience with posterior marginal (ramus) mandibulectomy for mandibular preservation in the management of patients with squamous cell carcinoma of the retromolar trigone or oropharynx. To review the history and surgical technique with emphasis on functional as well as oncologic outcomes. STUDY DESIGN AND SETTING: Retrospective review at a tertiary care academic referral center from 1996 to 2002. RESULTS: Between 1996 and 2002, 382 patients with squamous cell carcinoma of the oral cavity and oropharynx were surgically treated at the Loyola University Medical Center. Medical records were reviewed and 152 patients were identified who had some form of mandibular procedure (segmental resection, marginal resection, or mandibulotomy) performed in conjunction with their tumor resection. Eighteen posterior marginal mandibulectomies were performed for primary cancers of the retromolar trigone, tonsillar fossa, and/or base of the tongue. All patients received adjuvant radiotherapy. Bone invasion of the marginal mandibulectomy specimens by squamous cell carcinoma was observed in 2 cases, neither of which developed a local recurrence. Mean and median overall survivals were 41.4 and 37.5 months, respectively. Functional outcomes were determined by administering the University of Washington Quality of Life instrument administered at 12 months. Patients reported significant alterations in chewing, but all were able to maintain satisfactory oral intake and no patient required a gastrosotomy tube. CONCLUSIONS: A posterior osteotomy of the mandibular ramus is a useful adjunct in the surgical treatment of cancer of the retromolar trigone or oropharynx. Negative surgical margins can be obtained even with focal invasion of mandibular bone. The loss of bone in this area does not significantly affect patients' appearance. Patients report deterioration in chewing following this procedure but are able to maintain a diet of solid food.