The impact of a skilled nursing facility on the cost of surgical treatment of major head and neck tumors.

BACKGROUND: The finite resources available for health care and the proliferation of managed care in the United States have forced the head and neck surgeon to critically evaluate the cost of tumor treatment. OBJECTIVE: To determine whether the cost of treating patients with head and neck tumors would be reduced if the patients were to spend a portion of what would otherwise be acute care hospital days in a hospital-based skilled nursing facility (HB/SNF). DESIGN: Retrospective cost-benefit analysis. SETTING: Tertiary referral center. PATIENTS: Twenty-four consecutive hospital admissions for definitive surgical treatment of head and neck tumors were retrospectively reviewed. The postoperative day on which the patient theoretically could have been transferred to the HB/SNF was determined. The charges and cost of each patient's actual hospital stay were compared with the theoretical counterparts had the patient been transferred to the HB/SNF on the determined day. MAIN OUTCOME MEASURE: Cost savings. RESULTS: The total hospital stay for the 24 patients was 524 days. One hundred eighty-two of those days could have been spent in the HB/SNF. The total charge and cost savings with the use of an HB/SNF were $201,045 and $84,238, respectively (15% of the total charge and cost). This represents an average charge and cost savings of $8377 and $3510, respectively, per patient. The difference was statistically significant (P<.005). CONCLUSION: An HB/SNF could reduce the cost of head and neck tumor treatment without compromising patient care.

Tobacco cancer of the oral cavity and pharynx.

Cancer of the oral cavity and pharynx affects a significant number of individuals worldwide. The most important risk factor for development of oral cavity cancer is cigarette smoking. Tobacco in other forms and other types of smoking are also thought to be major risk factors. Co-factors, particularly alcohol consumption, are also important factors in oral cancer. Management of oral cancer requires a multidisciplinary team and has major implications for patient quality of life and for public health. Efforts are underway in many countries to reduce the incidence of oral cancer. These efforts always emphasize cessation of tobacco use and cancer screening. Local smoking cessation programs should be supported to improve the future of health care in West Virginia.

Role of screening chest computed tomography in patients with advanced head and neck cancer.

OBJECTIVE: The presence of pulmonary metastases significantly alters the treatment of patients with head and neck cancers. Currently, a chest radiograph (CXR) is used as a screening examination, although a chest CT (CCT) can detect smaller lesions. The aim of this study was to evaluate the benefit of CCT as a screening tool in patients with newly diagnosed advanced head and neck cancers. METHOD: New patients with stage III and IV head and neck squamous cell carcinomas were enrolled in this prospective study from August 1994 to December 1995. Twenty-five patients underwent CXR ($71) and CCT ($597) within 2 weeks of diagnosis of the index cancer. RESULTS: In 20 patients neither the CXR nor the CCT showed any evidence of pulmonary malignancy. Two patients had normal CXRs but possible metastases on CCT. Both the pulmonary lesions resolved on follow-up evaluation. Two patients had suspicious lesions on CXR, 1 of whom had a normal CCT. The second patient underwent CT-guided biopsy which was negative for malignancy. Both the CXR and CCT of the final patient, who had a bronchogenic carcinoma, were suspicious. CONCLUSION: In 2 patients CCT detected suspicious lesions missed on CXR, although neither revealed malignancy. Three patients with suspicious CXRs would have had CCTs anyway. Thus 22 of 25 CCTs done at the additional cost of $13,314 did not add to the sensitivity of the screening for pulmonary metastasis or second lung primary.

Allergic fungal sinusitis. A report of two cases with diagnosis by intraoperative aspiration cytology.

BACKGROUND: Allergic fungal sinusitis (AFS) is a newly recognized form of sinusitis characterized by opacification of the paranasal sinuses by "allergic mucin" (AM) admixed with scattered fungal organisms. AM consists of necrotic, or partially necrotic, eosinophils and Charcot-Leyden crystals suspended in lakes of laminated, mucinous material. AFS is characterized by the absence of bone or soft tissue invasion, purulent exudate or granulomatous inflammation. Clinically, it is important to differentiate AFS from both acute invasive fungal sinusitis and noninvasive mycetoma because the three diseases are treated with different modalities and have different prognoses. Although the radiologic features of AFS are often characteristic, occasionally it may be difficult to exclude neoplasia. CASES: Two cases of AFS, in which intraoperative diagnosis was made on the basis of the presence of both AM and fungal organisms, are reported. CONCLUSION: Cytologic diagnosis of AFS can be made from intraoperative sinus aspirates from the presence of AM and fungal elements. AM and fungi provide presumptive evidence for a noninvasive, allergic fungal disease and can help reassure clinicians intraoperatively and guide clinical management.

Smoking increases facial skin flap complications.

This study was undertaken to determine whether smokers have a higher risk of complications after reconstruction of facial skin defects. Ninety-one patients with facial skin defects reconstructed with local flaps were reviewed retrospectively. Thirty-eight (42%) were active smokers, 12 (13%) had not smoked for at least 1 year prior to surgery, and the rest were nonsmokers. Complications occurred in 23 patients (25%; 37% in smokers, 17% in ex-smokers, and 17% in nonsmokers; p < .03). All full-thickness skin losses and all cellulitis occurred in active smokers. We conclude that active smokers are at a higher risk for complications in facial skin flap surgery. That ex-smokers had a complication rate similar to that of nonsmokers suggests that part of smoking's adverse effect on skin flaps may be an acute phenomenon, and that smoking cessation for shorter (<1 year) periods of time before surgery may have a beneficial effect.

Combined Epstein-Barr virus and human papillomavirus infection in nasopharyngeal carcinoma.

Epstein-Barr virus (EBV) has been shown to be a likely etiologic agent in nasopharyngeal carcinogenesis. Human papillomaviruses (HPVs) have previously been identified in numerous upper aerodigestive tract carcinomas. This pilot study was undertaken to investigate the prevalence of combined EBV and HPV infection in 17 patients with nasopharyngeal carcinoma (NPCA) using polymerase chain reaction (PCR). The primary goal was to determine if the presence of HPV could be correlated with molecular, histologic, or clinical parameters. There were seven patients with undifferentiated NPCA (World Health Organization [WHO] type III) and 10 patients with squamous cell carcinoma (WHO type I). All 17 patients had stage IV disease at presentation. EBV was identified in 15 patients (88.2%), and HPV subtypes were identified in samples from nine patients (52.9%). All HPV-positive cases were also EBV positive. Western blot analysis of six samples showed a high level of expression of c-myc and cdc2 kinase and a low level of p53 protein in NPCAs that contained both HPV and EBV (n = 3). Increased expression of c-myc and cdc2 kinase was seen in the cases that contained EBV only, but to a lesser extent (n = 2). These findings indicate an effect of the virus on cellular proliferation and differentiation. Similarly, an elevated level of Rb protein was found only in the HPV-containing NPCAs. Moderate differentiation (keratinization) occurred in four of eight HPV-negative and none of the nine HPV-positive NPCAs. (All HPV-positive cases were poorly differentiated or undifferentiated.) This difference is statistically significant for this sample size (P < 0.03). There was a trend for the group that was HPV positive to have WHO III histology and for the HPV-negative group to have WHO I. The presence of HPV could not be correlated with any clinical parameters in this small group of patients with advanced disease; however, these data suggest that coexistence of EBV and HPV infection may be a factor in the pathogenesis of NPCA and may have an effect on regulation of cellular proliferation and differentiation.

The clavipectoral osteomyocutaneous free flap.

Microvascular free tissue transfer has revolutionized head and neck reconstruction and currently is considered the most successful and reliable method of primary oromandibular reconstruction. This study was designed to assess the feasibility of full thickness free vascularized transfer of the clavicle based on the clavicular branch of the thoracoacromial artery and the soft tissue component associated with the thoracoacromial axis. Forty dissections of the pectoral region were performed on 26 cadavers. The anatomic relations of the region and the thoracoacromial arterial and venous systems were documented in detail. Selective ink injections of the thoracoacromial arterial branches were also performed on fresh cadavers. The clavicle was supplied mainly by the clavicular artery (medial three quarters), with minor contribution from the deltoid artery (lateral quarter). An average of 16.1 cm (range of 12 to 20 cm) was obtained with total clavicular harvest and the clavicle had sufficient width and height to support dental implants. Two soft tissue donor sites were associated with the thoracoacromial artery: the sternocostal head of the pectoralis major muscle, with the overlying skin supplied by the pectoral artery, and the clavicular head of the pectoralis major muscle, with the overlying skin supplied by the deltoid and clavicular arteries. Sensory innervation of the upper chest was supplied through the supraclavicular nerves, whereas the lateral pectoral nerve supplied motor innervation to both heads of the pectoralis major muscle. The anatomy of the clavipectoral donor site and the first case of full thickness free clavicular transfer for mandibular reconstruction in the English literature are presented. The donor site is an excellent source of well vascularized, thin, pliable, hairless, potentially innervated (motor and sensory) soft tissue, along with up to 20 cm of clavicular bone. The surgical anatomy is familiar to the head and neck surgeon. The harvesting does not require repositioning of the patient and is amenable to a two-team, simultaneous approach. The functional and cosmetic donor site morbidity is minimal even with clavicular harvest. The major disadvantage of this flap is the relatively short pedicle. The authors conclude that the thoracoacromial system provides a free flap with osseous and soft tissue components that are well suited for oromandibular reconstruction.

QT interval changes following neck dissection. A stratified prospective study.

Studies from Europe have suggested that neck dissection, especially right radical neck dissection, causes a dangerous prolongation of the QT interval. Sudden cardiac arrest due to QT prolongation has been reported following right radical neck dissection. We investigated the prevalence of QT interval prolongation following neck dissection. Electrocardiogram tracings from 45 patients who underwent different combinations of neck dissection were studied. Preoperative and postoperative tracings were interpreted by a cardiologist blinded to the patient identification of each tracing. There were 28 unilateral neck dissection patients and 17 bilateral neck dissection patients eligible for analysis. There were 7 patients in the classic right radical neck dissection group, and only 3 of these had no neck dissection on the left. Comparisons of preoperative versus postoperative corrected QT interval for all subjects did not indicate a significant change. Stratification by neck dissection type (radical, modified or selective, and carotid artery resection) or by side dissected (left, right, or both) also showed no significant differences. No malignant arrhythmias were encountered. Thus, in contrast to the European experience, our findings show no significant predictable change in the QT interval after any of the combinations of neck dissection. Head and neck surgeons should be aware of the possibility of postoperative QT interval prolongation following neck dissection, although in the absence of other risk factors it appears to be a rare occurrence.

Gene expression of zinc-alpha 2-glycoprotein in normal human epidermal and buccal epithelia.

Zinc-alpha 2-glycoprotein (Zn alpha 2gp) is almost ubiquitous in body fluids. We have found it to be also present in stratified epithelia. We compare its mRNA expression in cells from human epidermis and buccal mucosa cultured in media of graded differentiation potential (attained by varying calcium ion concentration and adding serum). The Zn alpha 2gp gene is upregulated in both epithelia with differentiation and further with exposure to interferon gamma or transforming growth factor beta 1. The upregulation by these agents increases with differentiation in epidermal cells, but peaks in the low-differentiation medium in buccal epithelia. We compared gene expression levels of Zn alpha 2gp with those of characteristic cytokeratins of stratified epithelia (k5 for basal cells, K10 for epidermal suprabasal cells, and K13 for mucosal suprabasal cells). This pattern correlation associates Zn alpha 2gp cell-type dependently with late differentiation, i.e. with keratin K10 in epidermis and with K13 in buccal epithelium.

Communication after laryngectomy. An assessment of patient satisfaction.

OBJECTIVES: To determine the satisfaction of patients with their current method of alaryngeal communication. To focus primarily on the patients' perception of their own speech. DESIGN: A retrospective review of patients who underwent total laryngectomy for malignancy identified 4 groups of patients. A survey using a mailed questionnaire was used to compare groups. SETTING: Tertiary care university hospital, University of Texas Medical Branch at Galveston. PATIENTS: Forty-seven patients underwent total laryngectomy for cancer and survived. Thirty-one of the 47 patients responded to the survey. Patients were divided into 4 groups by their current method of communication: (1) tablet writers; (2) esophageal speech; (3) electrolarynx; and (4) tracheoesophageal speech. MAIN OUTCOME MEASURES: Satisfaction with communication, satisfaction with speech quality, ability to communicate over telephone, limitation of interaction with others, and satisfaction with quality of life. RESULTS: Patients in group 4 were significantly more satisfied with their speech (P < .001), perceived their speech to be of better quality (P < .001), had improved ability to communicate over the telephone (P < .001), and had less limitation of their interactions with others (P < .004). Patients in group 4 also rated their overall quality of life higher (P = .23). CONCLUSION: Although many studies in the past have demonstrated the objective superiority of tracheoesophageal speech compared with other methods of alaryngeal communication, most studies have focused on the intelligibility of speech judged by listeners. This study demonstrates that patients who use tracheoesophageal speech rate their own speech significantly higher than patients who use other methods and most likely have an overall superior quality of life.

Osteosarcoma of the head and neck: meta-analysis of nonrandomized studies.

To assess the role of adjuvant therapy in the treatment of osteogenic sarcoma of the head and neck, treatment and survival information from 173 patients with osteosarcoma of the head and neck was entered into a database. A meta-analysis of the data was attempted with primary emphasis on the effect of adjuvant therapy on disease outcome. The overall 5-year survival was 37%. Patients with mandibular and maxillary tumors had similar survival rates; both groups fared significantly better than patients with extragnathic tumors (P<0.001). Treatment with surgery alone was associated with significantly longer survival rates (P<0.03) than surgery with adjuvant therapy. In the majority of patients reported, information about surgical margins was not available. For this reason, the differences may not adequately represent the effect of adjuvant therapy. While there have been encouraging results with adjuvant treatment protocols for long bone osteosarcoma, the ultimate role of radiation and chemotherapy in the management of osteosarcoma of the head and neck remains unproven. Nevertheless, we recommend that adjuvant therapy be considered due to the poor prognosis in osteosarcoma of the head and neck.

Allergic fungal sinusitis.

Allergic fungal sinusitis is a non-invasive disease, first described in the early 1980s. We review our experience with 25 patients treated at the University of Texas Medical Branch, Galveston. All patients were treated surgically, using endoscopic techniques in 17, and combined endoscopic and external procedures in eight. Histological evidence of tissue invasion was absent in all 25 patients, in spite of extensive destruction of the skull base in four. Dematiaceous fungi were the most common cultural isolate. Fifteen patients were available for more than 6 months post-operative follow-up. None of the eight patients who developed recurrent disease had been treated with post-operative systemic steroids. Four of the seven patients who remained disease-free had received steroids. Clinical trials to test the efficacy of systemic steroids in the prevention of disease recurrence are clearly warranted.

Chondrosarcoma of the nasal septum: skull base imaging and clinicopathologic correlation.

Chondrosarcoma arising in the head and neck and craniofacial region is an uncommon lesion. The nasal septum is a particularly rare site of origin, with approximately 30 cases previously reported in the English literature. We present six new cases of chondrosarcoma arising in the nasal septum. Each of these tumors required cranial base surgical approaches for removal. Current imaging techniques allow a very accurate diagnosis to be made before biopsy. The characteristic ring-forming calcifications seen on computed tomography scans can be correlated with the histologic pattern of calcification. Magnetic resonance imaging techniques allow precise definition of tumor extent, which is particularly important because the disease is best treated with primary surgery. Advances in imaging and surgical techniques allow a much more complete tumor removal. It is hoped that this will increase the likelihood of cure in these patients. Surgical management and indications for adjuvant therapy are discussed.

Allergic fungal sinusitis with cranial base erosion.

BACKGROUND: Allergic fungal sinusitis (AFS) usually follows a slow, nonaggressive course. However, massive bone destruction can occur, with extension of the disease process outside of the confines of the sinuses. METHODS: Our series of 28 cases of AFS was reviewed. We identified 6 cases of AFS with definite radiographic evidence of skull base erosion. RESULTS: Histologic diagnostic criteria for AFS were present in all 6 cases. All patients were managed with surgery, most recently conservative endoscopic surgery. An earlier patient underwent dural resection. Antibiotics were used in all patients, but no antifungal agents were administered. No patient has had a permanent neurologic complication, although one was seen with abducens palsy. There have been no cerebrospinal fluid (CSF) leaks. All 6 cases also had orbital bone erosion, but none has had permanent ophthalmologic sequelae. All patients were initially suspected to have a neoplastic disease. CONCLUSIONS: We propose a new diagnostic entity, "skull base allergic fungal sinusitis" (SBAFS), which incorporates the histologic diagnostic criteria of AFS with the computed tomographic (CT) criteria of bone erosion. Biopsy is necessary to rule out invasive fungus or tumor. Otolaryngologists, ophthalmologists, and neurosurgeons should be familiar with SBAFS so that systemic antifungal agents, craniotomy, and dural resection-which might initially appear necessary-can be avoided. Endoscopic surgical debridement and drainage combined with topical steroids can lead to resolution of disease, even in the presence of marked bone erosion and cranial neuropathy.

Skull base allergic fungal sinusitis with abducens palsy in the third trimester.

Allergic fungal sinusitis (AFS) usually follows a slow course, but bone erosion including that of the skull base can be seen. Patients may present with intracranial extension mimicking a cranial base neoplasm. We describe a 21-year-old pregnant female initially seen at 27 weeks gestation with a complete right sixth nerve paralysis. MR imaging showed an apparent nasopharyngeal neoplasm invading both temporal lobes. Further evaluation revealed typical findings of fungal sinusitis on both CT and MR images. Biopsy results fulfilled the diagnostic criteria of AFS, and after endoscopic treatment the sixth nerve palsy quickly resolved. Although abducens palsy has been reported with acute bacterial sinusitis and with mucocele, and limitation of eye motility has been described with orbital involvement by AFS, we are unaware of any prior reports of true cranial nerve palsy associated with proven AFS. Our patient had no evidence of mucocele or of bacterial infection. The palsy in this case was presumably the result of compression of the cavernous sinus. The patient's pregnancy made decision making regarding imaging and surgical intervention complex. Mother and child are alive and well 31 months after surgery.

Free flap options for common head and neck defects.

A summary of first, second, and uncommon or new free flap options is shown in Table 1. It serves as a general guideline for head and neck defects.