Cervical Necrotizing Fasciitis--The Value of the Laboratory Risk Indicator for Necrotizing Fasciitis Score as an Indicative Parameter.

PURPOSE: Cervical necrotizing fasciitis (CNF) is uncommon, difficult to diagnose, and rapidly progressive. The objective of the present study was to determine the predictive value of the laboratory risk indicator for necrotizing fasciitis (LRINEC) score for CNF. MATERIALS AND METHODS: The LRINEC score for 16 consecutive cases of CNF and 595 cases of severe non-necrotizing neck infections was determined over a 6.5-year period in a single-center retrospective cohort study and case report. CNF was confirmed by histologic examination and operative report documentation. RESULTS: Using a cutoff score of 6, the LRINEC score had a sensitivity of 0.94 (95% confidence interval [CI] 0.92 to 0.96) and specificity of 0.94 (95% CI 0.70 to 1.00). The positive predictive value was 0.29 (95% CI 0.17 to 0.44), and the negative predictive value was 0.99 (95% CI 0.99 to 1.00). CONCLUSIONS: The LRINEC score can detect early cases of CNF. Patients with a LRINEC score of ≥6 must be carefully evaluated for the presence of CNF.

Reflux induces DNA strand breaks and expression changes of MMP1+9+14 in a human miniorgan culture model.

Gastroesophageal reflux disease has been implicated in the pathogenesis of adenocarcinoma of the oesophagus. The same applies to laryngopharyngeal reflux (LPR) and squamous cell cancer of the head and neck, but so far, this link has not been proven. The impact of low pH and bile acids has not been studied extensively in cells other than oesophageal cancer cell lines and tissue. The aims of this study were to investigate the pathogenic potential of reflux and its single components on the mucosa of the upper respiratory tract. We measured DNA stability in human miniorgan cultures (MOCs) and primary epithelial cell cultures (EpCs) in response to reflux by the alkaline comet assay. As matrix metalloproteinases (MMPs) are involved in extracellular matrix remodelling processes and may contribute to cancer progression, we studied the expression of MMP1, -9, and -14 in MOCs, EpC, UM-SCC-22B, and FADUDD. DNA strand breaks (DNA-SBs) increased significantly at low pH and after incubation with human or artificial gastric juice. Single incubation with glycochenodeoxycholic acid also showed a significant increase in DNA-SBs. In epithelial cell cultures, human gastric juice increased the number of DNA-SBs at pH 4.5 and 5.5. Artificial gastric juice significantly up regulated the gene expression of MMP9. Western blot analysis confirmed the results of gene expression analysis, but the up regulation of MMP1, -9, and -14 was donor-specific. Reflux has the ability to promote genomic instability and may contribute to micro environmental changes suitable for the initiation of malignancy. Further functional gene analysis may elucidate the role of laryngopharyngeal reflux in the development of head neck squamous cell carcinoma (HNSCC).

Motivation as a predictor of speech intelligibility after total laryngectomy.

BACKGROUND: It has often been argued that if patients' success with speech rehabilitation after laryngectomy is limited, it is the result of lacking motivation on their part. This project investigated the role of motivation in speech rehabilitation. METHODS: In a multicenter prospective cohort study, 141 laryngectomees were interviewed at the beginning of rehabilitation and 1 year after laryngectomy. Speech intelligibility was measured with a standardized test, and patients self-assessed their own motivation shortly after the surgery. Logistic regression, adjusted for several theory-based confounding factors, was used to assess the impact of motivation on speech intelligibility. RESULTS: Speech intelligibility 1 year after laryngectomy was not significantly associated with the level of motivation at the beginning of rehabilitation (odds ratio [OR], 1.3; 95% confidence interval [CI], 0.7-2.3; p = .43) after adjusting for the effect of potential confounders (implantation of a voice prosthesis, patient's cognitive abilities, frustration tolerance, physical functioning, and type of rehabilitation). CONCLUSIONS: Motivation is not a strong predictor of speech intelligibility 1 year after laryngectomy.

Primary extranodal Non-Hodgkin lymphoma of the orbital and paranasal region-a retrospective study.

PURPOSE: Primary extranodal lymphomas of the orbit and sinonasal region are rare and occur almost only as Non-Hodgkin lymphoma (NHL). The purpose of this study was to determine the frequency of different subtypes of NHL in these regions and to describe their radiological features. MATERIALS AND METHODS: Between January 2005 and January 2010, 567 patients with malignant immunoproliferative diseases (MID) were treated at our institution. Primary sinonasal and orbital manifestation was diagnosed in 36 cases. There were 13 women and 23 men with a median age of 67 years. CT and MRI were performed in 14 and 24 patients, respectively. Imaging was re-interpretated and histological subtypes were listed. RESULTS: Among all MID primary sinonasal and orbital NHL occurred with a frequency of 6%. Diffuse large cell lymphoma was identified in 11 cases (30%), marginal cell lymphoma in 6 (16%), and extranodal plasmacytoma in 5 (14%). Other subtypes were rare. On CT, lesions of soft tissue attenuation with homogeneous moderate contrast enhancement were seen in all cases. On T2-weighted fat saturated images 52% of the lesions were slightly hyperintense in comparison to unaffected musculature, 41% were isointense, and 7% slightly hypointense. On T1-weighted sequences most lesions (81%) were homogeneously isointense. After contrast administration marked enhancement was seen in 41%, moderate in 52%, and slight enhancement in 7%. CONCLUSION: The identified radiological features should be included in the differential analysis of lesions in the orbital and sinonasal regions, but they are not specific enough. For exact therapeutic planning histopathological diagnosis of the subtype is required.

Speech rehabilitation during the first year after total laryngectomy.

BACKGROUND: Gaining a new voice is one of the major aims after total laryngectomy. The objective of this study was to describe the process and results of speech rehabilitation during the first year after surgery. METHODS: Speech intelligibility was measured 6 months (n = 273) and 1 year (n = 225) after total laryngectomy. RESULTS: Objective (23.4 to 47.5 points, p < .0001) and subjective (51.6 to 64.7 points, p < .0001) speech intelligibility improved between 6 months and 1 year after total laryngectomy. Patients who used tracheoesophageal puncture (TEP) had the best results in speech intelligibility 6 months and 1 year after total laryngectomy. In all, 12% of the patients who used TEP initially no longer used it 1 year later. Patients who had received rehabilitation had better objective speech intelligibility than those who did not. CONCLUSIONS: Speech improves considerably between 6 months and 1 year after total laryngectomy. Nonattendance of rehabilitation is associated with a worse functional outcome in speech rehabilitation.

Clinical relevance of quality-of-life data in laryngectomized patients.

OBJECTIVES/HYPOTHESIS: Statistically significant differences in health-related quality of life (HRQL) are not always clinically relevant. It is also plausible that patients perceive other changes to be relevant than health professionals do. The objective of this study was to find thresholds for HRQL that laryngectomees consider to be clinically relevant 1 year after surgery, (i.e., the level of HRQL that patients rate as satisfactory). A second aim was to investigate how many laryngectomized patients reached those targets. STUDY DESIGN: Multicenter cross-sectional study. METHODS: A total of 28 patients 1 year following laryngectomy and 24 healthcare professionals (HCPs) defined target values for the QLQ-C30 and QLQ-H&N35. In another sample of 157 laryngectomized patients 1 year following laryngectomy, we determined what percentage of patients reached these thresholds. RESULTS: Patients are the most accepting of sensory impairments (56.5), coughing (53.6), and dyspnea (44.0), whereas constipation (9.1) and nausea/vomiting (10.7) were rated as being the most troublesome symptoms. HCPs assessed more of the studied complaints as being tolerable than patients did, especially in psychosocial domains. Between 34.5% (senses) and 86.5% (constipation) of the reference group hit the predefined targets at different scales. CONCLUSIONS: Symptoms caused by disease are easier for patients to live with than more general nonspecific symptoms. Taking into account that some adverse effects of disease or therapy are partially irreversible, target values additional to changes of HRQL can be helpful when interpreting data.

Update on necrotizing mediastinitis: causes, approaches to management, and outcomes.

Descending necrotizing mediastinitis (DNM) is one of the most feared and fatal forms of mediastinitis, occurring as a complication after odontogenic or cervicofascial infections or after cervical trauma. Delayed recognition, underestimation of the extent of disease, and insufficient therapy promote spread of infection. Primary treatment of DNM includes surgical eradication of the pharyngeal or odontogenic infection focus, and a concomitant major drainage applied to the neck and the mediastinum. However, the mortality rate of DNM remains high, even with the routine use of CT scanning, antibiotics, advancements in anesthesia and intensive care, and immediate surgical drainage. The present state of the optimal management of DNM is discussed controversially, in particular the question of whether thoracotomy should be performed routinely or if minimally invasive procedures (eg, video-assisted thoracoscopy) may be introduced. This review reports on the incidence and course of this disease and discusses management approaches to DNM.

Frequent promoter hypermethylation of tumor-related genes in head and neck squamous cell carcinoma.

Squamous cell carcinomas of head and neck (HNSCC) are a result of multiple genetic and epigenetic alterations. Epigenetic inactivation of tumor suppressor genes is an important event in head and neck carcinogenesis. Here we analyzed the promoter methylation of 15 genes (RASSF1A, p16, MGMT, DAPK, RARbeta, MLH1, CDH1, GSTP1, RASSF2, RASSF4, RASSF5, MST1, MST2, LATS1, LATS2) in 54 HNSCC and in matching 23 normal tissues. Methylation of these tumor-related genes (TRG) was significantly more frequent in HNSCC (42%) compared to normal samples (23%; p<0.05). Particularly, methylation of p16 (60%), MGMT (53%), DAPK (67%), RARbeta (75%), MLH1 (69%), CDH1 (43%), RASSF5 and MST1 (96%) was often found in HNSCC. Methylation of RASSF1A (18%), GSTP1 (4%), RASSF4 (13%), MST2 (4%), LATS1 (24%) and LATS2 (8%) was less frequently detected. A trend of increased TRG methylation in more advanced tumor stages and less differentiated HNSCC was observed. Methylation of p16 was significantly higher in poorly differentiated HNSCC (p=0.037) and RASSF5 methylation occurred preferentially in advanced tumor stages (p<0.05). Methylation of RASSF4 was higher in patients with recurrent HNSCC (23%) than patients without relapse (0%; p=0.033). Methylation of TRG in head and neck cancer cell lines was observed at similar frequency as in primary HNSCC. In summary, frequent hyper-methylation of tumor-related genes in HNSCC was detected and this epigenetic silencing event may have an essential role in head and neck carcinogenesis.

Retrospective analysis of titanium plate-retained prostheses placed after total rhinectomy.

PURPOSE: To report the use of a new platelike system (Titanium Epiplating System, Medicon, Tuttlingen, Germany) for rehabilitation of patients after total rhinectomy. MATERIALS AND METHODS: This retrospective study was conducted on all patients treated between August 2001 and July 2006 with total or subtotal rhinectomy. The clinical outcomes and satisfaction of patients receiving nasal prostheses were evaluated, and the success rate of the subperiosteal implants was determined. Quality of life (QOL) was evaluated with a standardized questionnaire. Patients who had experience with different retention methods responded to a five-point scale evaluating their current satisfaction. RESULTS: Eleven patients (four women and seven men) received nasal prostheses. The mean age was 63 +/- 12 years (range, 43 to 84 years). Nine patients were fitted with subperiosteal microplates and followed for a mean of 35 months. Two patients had subtotal rhinectomy and did not receive implants. In four patients immediate implant placement (concurrent with tumor resection) was performed; the other five patients received implants later. The implant success rate was 82%. There was no early implant loss, although one patient lost his implants after 3 years and another patient lost one implant after 1.5 years. QOL scores demonstrated high acceptance of implant fixed retention in comparison with other retention methods (P = .001). CONCLUSIONS: Implantation of anatomically prefabricated titanium plates has a high success rate in the nasal area, although late implant loss may occur. Patient perceptions of QOL show improvement when prostheses are retained by subperiosteal implants.

Micronucleus rate of buccal mucosal epithelial cells in relation to oral hygiene and dental factors.

Carcinogenesis of squamous cell carcinomas in the upper aero-digestive tract (UADT) is a multi-stage process. Since 1937, micronuclei (MN) have been considered a marker for genome damage in the initiation stage. By help of the micronucleus test, carcinogenic exposure can be proven in the mucosa area of the UADT. The hypothesis to be tested was that individual oral hygiene and the dental status, respectively - just like alcohol and tobacco abuse - are associated with the micronucleus rate in cytological preparations of the buccal mucosa. In a prospective clinical observation study, we determined in 100 probands the micronucleus frequency per 1000 mucosa epithelial cells. Study participants with a high number of missing teeth (M/T index, p=0.037), a below-average papillary bleeding index (PBI, p=0.032) and periodontal status, respectively (PSI, p=0.042) possessed a higher micronucleus number in comparison with restored dental conditions. Probands with composite restorations displayed a higher MN rate (p=0.006) compared to those with amalgam. However, we could not detect any significant relation with the prosthetic status (p> or =0.075). An adjustment was made according to alcohol and tobacco. We therefore conclude that subgingival plaque and synthetic dental materials in addition to chronic alcohol and tobacco consumption might have genotoxic relevance in the oral cavity.

The influence of oral hygiene on salivary quality in the Ames Test, as a marker for genotoxic effects.

Squamous cell carcinomas of the upper aerodigestive tract are a global health-political challenge. Accordingly, current research efforts are aimed towards the opportunities for early recognition of risk patients, and at the recognition of risk factors related to carcinogenesis. We determined the revertant number of the variety Salmonella typhimurium TA 98 and TA 100 after incubation, with saliva samples from 100 probands as a measure of a genotoxic environment within the oral cavity, depending on the dental status as measure of oral health. Beside chronic alcohol (p=0.032) and tobacco consumption (p<0.001), the dental status displayed in partial aspects (high plaque index, high number of decayed teeth, prosthetically not rehabilitated status, p or= 0.104). Therefore, it can be concluded that the polymicrobial supragingival plaque, as a possible independent factor, possesses a relevant mutagenic interaction with saliva, and that individual oral health is a co-factor in the development of carcinomas in the oral cavity.