Maxillofacial Skeleton and Facial Anatomy.

In this article, we discuss the anatomy and development of the face. One should become familiar with the layers, muscles, vessels, and nerves of the face. Embryologic development of the face and supporting structures is also discussed. Additionally, different clinical manifestation of facial paralysis is highlighted.

De-Escalated Adjuvant Therapy After Transoral Robotic Surgery for Human Papillomavirus-Related Oropharyngeal Carcinoma: The Sinai Robotic Surgery (SIRS) Trial.

BACKGROUND: Treatment of human papillomavirus-related oropharyngeal squamous cell carcinoma (HPVOPC) results in unprecedented high survival rates but possibly unnecessary toxicity. We hypothesized that upfront surgery and neck dissection followed by reduced-dose adjuvant therapy for early and intermediate HPVOPC would ultimately result in equivalent progression-free survival (PFS) and overall survival while reducing toxicity. METHODS: This study was a nonrandomized phase II trial for early-stage HPVOPC treated with transoral robotic surgery (TORS) followed by reduced-dose radiotherapy. Patients with previously untreated p16-positive HPVOPC and <20 pack years' smoking history were enrolled. After robotic surgery, patients were assigned to group 1 (no poor risk features; surveillance), group 2 (intermediate pathologic risk factors [perineural invasion, lymphovascular invasion]; 50-Gy radiotherapy), or group 3 (poor prognostic pathologic factors [extranodal extension [ENE], more than three positive lymph nodes and positive margin]; concurrent 56-Gy chemoradiotherapy with weekly cisplatin). RESULTS: Fifty-four patients were evaluable; there were 25 in group 1, 15 in group 2, and 14 in group 3. Median follow-up was 43.9 months (9.6-75.8). Disease-specific survival was 98.1%, and PFS was 90.7%. PFS probability via Kaplan-Meier was 91.3% for group 1, 86.7% for group 2, and 93.3% for group 3. There were five locoregional failures (LRFs), including one distant metastasis and one contralateral second primary. Average time to LRF was 18.9 months (9.6-59.0); four LRFs were successfully salvaged, and the patients remain disease free (11.0-42.7 months); one subject remains alive with disease. CONCLUSION: The results indicate that upfront surgery with neck dissection with reduced-dose radiation for T1-2, N1 stage (by the eighth edition American Joint Committee on Cancer staging manual) HPVOPC results in favorable survival with excellent function in this population. These results support radiation dose reduction after TORS as a de-escalation strategy in HPVOPC. IMPLICATIONS FOR PRACTICE: Transoral robotic surgery can provide a safe platform for de-escalation in carefully selected patients with early-stage human papillomavirus-related oropharyngeal cancer. In this clinical trial, disease-specific survival was 100%, over 90% of the cohort had a reduction of therapy from standard of care with excellent functional results, and the five patients with observed locoregional failures were successfully salvaged.

Rotation of the Ipsilateral Supraorbital Rim Around the Horizontal Axis in Unilateral Coronal Synostosis: A Craniometric Analysis of the Emergence Profile.

INTRODUCTION: Unilateral coronal synostosis (UCS) results in well-defined dysmorphic changes including sphenoid malposition yielding posterior displacement of the supraorbital rim. Although variation in the ipsilateral supraorbital rim emergence profile has been suggested, it has not been previously investigated. The authors sought to characterize the emergence profile of the ipsilateral supraorbital rim in UCS through craniometric analysis. METHODS: Thirty-five nonsyndromic UCS patients (0-18 months) with CT images obtained before operative intervention and 16 control patients (0-24 months, 32 orbits) were included. Craniometric measurements were performed to quantify the emergence profile of the ipsilateral supraorbital rim and locate the likely apex of rotation. RESULTS: The ipsilateral supraorbital rim was significantly rotated around the horizontal axis when measured in reference to the 0° vertical in UCS versus control patients by an average difference of 7.3° to 11.3° across age groups (P < 0.05). No significant effect modification was detected between age and UCS on ipsilateral supraorbital rim emergence profile (P > 0.05). Additional angles with vertices around the superior orbital circumference were then measured to locate the likely apex of rotation and revealed a significant decrease in the posterior orbital roof to 0° horizontal in UCS patients by an average of 9.3° to 22.1° in children under 1 year old (P < 0.01). CONCLUSION: Variation in the emergence profile of the ipsilateral supraorbital rim in UCS is quantified, and the apex of this rotation likely lies at the posterior orbital roof. The novel quantification and characterization of this deformity will better direct the operative approach and enable a more accurate correction.

Occult Nodal Disease and Occult Extranodal Extension in Patients With Oropharyngeal Squamous Cell Carcinoma Undergoing Primary Transoral Robotic Surgery With Neck Dissection.

IMPORTANCE: The historically reported rates of subclinical cervical nodal metastases in oropharyngeal squamous cell carcinoma (OPSCC) predate the emergence of human papillomavirus as the predominant causative agent. The rate of occult nodal disease with changing etiology of OPSCC is not known, and it is challenging to anticipate which patients will be upstaged postoperatively and will require adjuvant therapy. OBJECTIVE: To assess the rate of nodal upstaging and occult extranodal extension (ENE) in a multi-institutional population of patients with pathologic (p)T1-2 OPSCC treated by transoral robotic surgery and neck dissection. DESIGN, SETTING AND PARTICIPANTS: This retrospective, multicenter cohort study of 92 participants at 2 US institutions (Albert Einstein College of Medicine, Bronx, New York [n = 38], and Icahn School of Medicine at Mount Sinai, New York, New York [n = 39]) and 1 Canadian institution (Princess Margaret Hospital, Toronto [n = 15]) examined the rate of postoperative pathologic upstaging for 92 patients with pT1-2 OPSCC undergoing transoral robotic surgery with neck dissection from August 2007 to December 2016. A neuroradiologist at each site blinded to final pathologic diagnosis reviewed preoperative imaging; these findings were compared with operative pathology and applied for tumor staging using the eighth edition of the American Joint Committee on Cancer Cancer Staging Manual. The statistical analysis was performed on December 18, 2018. MAIN OUTCOMES AND MEASURES: Occult pathologic nodal disease and change in nodal category postoperatively. RESULTS: Of 92 patients who met the inclusion criteria, 76 (83%) were male, and they had a mean (SD) age at surgery of 59.5 (10.5) years; 70 patients (84%) with available p16 status were positive. Five of 18 patients (28%) who had no evidence of nodal disease on imaging had occult pathologic nodal disease. Seven of 32 patients (22%) presenting with no nodal disease or with a single metastatic node on imaging received pathologic upstaging because of multiple positive nodes, indicating implementation of additional adjuvant treatment not anticipated after a priori imaging. Changes included 12 patients (13%) who had pathologic nodal upstaging and 12 (13%) with pathologic nodal downstaging in the eighth edition of staging. In the cohort, 24 patients (27%) had pathologic ENE, and 5 of 39 patients (13%) had occult ENE in the absence of radiographic evidence. CONCLUSIONS AND RELEVANCE: Predicting pathologic staging preoperatively for patients with OPSCC undergoing transoral robotic surgery and neck dissection remains a challenge. Although nodal size, tumor size, and location do not help predict ENE, the presence of nodes on imaging and nodal category may help predict ENE. Our findings suggest a small proportion of patients might benefit from further adjuvant therapies not predicted by preoperative imaging based on occult nodal upstaging and ENE.

Occult contralateral nodal disease in oropharyngeal squamous cell carcinoma patients undergoing primary TORS with bilateral neck dissection.

BACKGROUND: Knowledge of the rate of occult contralateral nodal disease for oropharynx cancers (OPSCC) in the era of Human Papillomavirus-dominated disease would inform practitioners as to who may be a candidate for unilateral neck management. The objective of this study was to determine the rate of pathologic contralateral positive nodes in patients in OPSCC patients with pT1 and pT2 disease treated with TORS and bilateral neck dissections (BND). METHODS: Retrospective review of medical records was performed at Princess Margaret Cancer Center, Toronto; Icahn School of Medicine at Mount Sinai, New York City; and Montefiore Medical Center, New York City. Patients with pT1-2 N0-3 (AJCC 8th Edition) OPSCC disease treated with TORS and BND were included. RESULTS: Thirty-two patients met inclusion criteria. Twelve patients (37.5%) had a tonsil primary site, 19 (59.4%) patients had a base of tongue primary site, and 1 (3.1%) patient had a pharyngeal wall primary. Twenty-four (75%) patients were known to be p16+. Twenty-seven patients (84.4%) were radiographically negative in the contralateral neck preoperatively, and two of these patients had pathologic contralateral positive nodes. The occult pathologic contralateral nodal metastasis rate was 7.4% (2/27). The sensitivity, specificity, positive predictive value, and negative predictive value of suspicious contralateral nodes on preoperative imaging for pathologically positive nodes were 33.3%, 86.2%, 20% and 93% respectively. In the p16+ subgroup, the occult nodal positive rate in the contralateral neck was 5%. CONCLUSIONS: pT1-2 OPSCC patients undergoing TORS and elective contralateral neck dissection have a low rate of pathologic contralateral nodal positivity.

Prognostic value of radiographic extracapsular extension in locally advanced head and neck squamous cell cancers.

OBJECTIVES: We investigated associations between radiographic evidence of nodal extracapsular extension (rECE) and outcomes for locally advanced head and neck squamous cell cancers (LAHNC). MATERIALS AND METHODS: We conducted a single-institution retrospective study of 258 consecutive LAHNC patients with accessible pretreatment contrast-enhanced neck CT scans, who completed definitive or adjuvant radiation therapy. All scans were reviewed by an expert head and neck radiologist for evidence of rECE. Kaplan-Meier and Cox regression multivariate analyses (MVA) were performed to evaluate the impact of rECE on overall survival (OS), progression free survival (PFS), distant control (DC), and locoregional control (LRC). RESULTS: One-hundred forty patients were rECE-positive and 118 were rECE-negative. The rECE-positive cohort had more cN3 disease (11.6% vs. 0.8%) and heavier smoking histories (60.0% vs. 44.9% with ⩾10-pack-years). The rECE-positive cohort had significantly worse 3-year OS (64.3% vs. 82.8%, p=0.002), PFS (58.9% vs. 76.0%, p=0.001), DC (72.3% vs. 90.6%, p<0.001), and LRC (75.9% vs. 89.8%, p=0.002). On MVA, rECE independently predicted for worse OS, PFS, DC, and LRC for LAHNC overall. On subset analysis of HPV-positive oropharyngeal cancers, rECE was not a significant prognosticator. CONCLUSION: For all sites of LAHNC, except HPV-positive oropharyngeal cancers, presence of rECE independently predicts for worse disease control and survival. Further studies are needed to validate these findings and demonstrate whether rECE may be considered for risk-stratifying patients for clinical trial design and treatment decisions.

Radiographic Thrombus within the External Jugular Vein: Report of a Rare Case and Review of the Literature.

We are reporting a case of a 91-year-old male with a primary malignancy of the right parotid gland with radiographic thrombus extension within the right external jugular vein. He was treated with palliative radiation therapy to the right parotid mass with a marked clinical response. The rarity of this occurrence as documented in the review of the literature provides for uncertainty with regard to proper management. Radiographic evidence of thrombus in the absence of clinical manifestations, the role of anticoagulation, and the proper radiation target delineation were all challenges encountered in the care of this patient. Our case represents a rare occurrence with unique radiologic findings that has implications for management.

CT of Anatomic Variants of the Paranasal Sinuses and Nasal Cavity: Poor Correlation With Radiologically Significant Rhinosinusitis but Importance in Surgical Planning.

OBJECTIVE: The purpose of this study was to determine the incidence of sinonasal anatomic variants and to assess their relation to sinonasal mucosal disease. MATERIALS AND METHODS: A retrospective evaluation of 192 sinus CT examinations of patients with a clinical history of rhinosinusitis was conducted. The CT scans were evaluated for the presence of several anatomic variants of the sinonasal cavities, and the prevalence of each variant was calculated. Prevalences of all sinonasal anatomic variants were compared between patients who had minimal to no apparent imaging evidence of rhinosinusitis and those who had radiologic evidence of clinically significant rhinosinusitis. RESULTS: The most common normal variants were nasal septal deviation, Agger nasi cells, and extension of the sphenoid sinuses into the posterior nasal septum. We found no statistically significant difference in the prevalence of any of the studied anatomic variants between patients with minimal and those with clinically significant paranasal sinus or nasal cavity disease. CONCLUSION: Analysis of every routine CT scan of the paranasal sinuses obtained for sinusitis or rhinitis for the presence of different anatomic variants is of questionable value unless surgery is planned.

Imaging evaluation of lymphadenopathy and patterns of lymph node spread in head and neck cancer.

Accurate and consistent characterization of metastatic cervical adenopathy is essential for the initial staging, treatment planning and surveillance of head and neck cancer patients. While enlarged superficial nodes may be clinically palpated, imaging allows identification of deeper adenopathy as well as clinically unsuspected pathology and thus imaging has become an integral part of the evaluation of most head and neck cancers patients. This review will focus on the evaluation of cervical adenopathy, summarizing the currently used nomenclature and imaging approach for determining cervical lymph node metastases in head and neck malignancies. The imaging-based classification, which has also been adopted by the American Joint Committee on Cancer, will be presented, the morphologic characteristics used to identify metastatic nodes will be reviewed and the typical nodal spread patterns of the major mucosal cancers of the head and neck will be examined.

A contouring guide for head and neck cancers with perineural invasion.

PURPOSE: Perineural invasion (PNI) is a frequent pathological finding in head and neck cancers. When adjuvant radiation to cranial nerves at risk in head and neck cancers with PNI is considered, there is a need for consensus on which nerves are at risk and how to contour these nerves. This contouring guide attempts to address this need. METHODS AND MATERIALS: Representative patient diagnostic computed tomographic (CT) scans with contrast of the neck were used to create example contours. The cranial nerves V2, V3, VII, and XII, and sample primary tumor sites were initially delineated using the Varian Eclipse planning system by 5 radiation oncologists. All of the images were then reviewed with a diagnostic radiologist to establish consensus for delineating the cranial nerves. RESULTS: We provided detailed contouring and planning guidelines on a CT atlas, with figures to help illustrate internerve connections, based on clinical experience, literature-based patterns of failure, and established anatomic connections between cranial nerves. Tumor bed, cranial nerve, and elective target volumes are depicted. CONCLUSIONS: These planning guidelines and atlas provide anatomic, clinical, and technical recommendations for guiding radiation oncologists in the planning and delivery of intensity modulated radiation therapy for head and neck cancer with PNI.

Recurrent temporal bone tenosynovial giant cell tumor with chondroid metaplasia: the use of imaging to assess recurrence.

Tenosynovial giant cell tumor (TGCT) is a benign proliferative lesion of unclear etiology. It is predominantly monoarticular and involves the synovium of the joint, tendon sheath, and bursa. TGCT of the temporomandibular joint (TMJ) is rare and aggressive resulting in destruction of surrounding structures. The diagnosis may be suggested by imaging, mainly by the MR features and PET/CT, and confirmed by histopathology. We describe the case of a 50-year-old man who presented with right-sided hearing loss, tinnitus and TMJ pain. Pathology revealed tenosynovial giant cell tumor with chondroid metaplasia. Six years later he developed a recurrence, which was documented to our knowledge for the first time with CT, MR and FDG PET/CT imaging.

Mass-like and extensive secondary tumoral calcinosis in the neck and body of a patient on peritoneal dialysis.

We present a case of extensive tumoral calcinosis in a 42-year-old female with end-stage renal disease and secondary hyperparathyroidism on peritoneal dialysis. Periarticular calcified masses demonstrating fluid-calcium levels on computed tomography and containing chalky amorphous calcified material in the absence of neoplastic cells are the salient features of tumoral calcinosis. Although renal failure is the most common cause of secondary tumoral calcinosis, there are few reported cases of this condition occurring in patients on peritoneal dialysis. This case is also unusual due to the widespread and bulky nature of the disease with involvement of the neck and its quick onset and progression.

Improvement in the detection of locoregional recurrence in head and neck malignancies: F-18 fluorodeoxyglucose-positron emission tomography/computed tomography compared to high-resolution contrast-enhanced computed tomography and endoscopic examination.

OBJECTIVES/HYPOTHESIS: To compare the diagnostic efficacy of positron emission tomography (PET) with F-18 fluorodeoxyglucose (FDG-PET)/computed tomography (CT) to that of contrast-enhanced high-resolution CT (HRCT) and assess the value of a combinatorial approach in detection of recurrent squamous cell cancer of the head and neck (HNC) and to assess the efficacy of FDG-PET/CT with and without HRCT in comparison to standard-of-care follow-up--physical examination (PE) and endoscopy (E)--in determination of locally recurrent HNC. STUDY DESIGN: Retrospective study. METHODS: A total of 103 patients with HNC underwent FDG-PET/CT and neck HRCT. There were two groups of patients: Group A had an FDG-PET study acquired with low-dose CT, and group B had an FDG-PET study acquired with HRCT. The PET data obtained with or without HRCT were compared on a lesion and patient basis with the results of the PE/E. RESULTS: On a lesion basis, both groups combined had higher sensitivity and negative predictive value (NPV) than the HRCT. Specificity and positive predictive value (PPV) for group B were higher than for group A. On a patient basis, both groups combined had a higher sensitivity and NPV than PE/E, respectively, although specificity of PE/E was higher than that of either group. PET data obtained with either protocol directly influenced treatment. CONCLUSIONS: HRCT increases the specificity and PPV of PET/CT when acquired simultaneously with PET. FDG-PET/CT acquired with either LDCT or HRCT has higher accuracy than HRCT alone and increases the sensitivity and NPV of PE/E.

Imaging findings of atypical mycobacterial infection in the temporal bone.

Atypical mycobacterial (AM) infection of the temporal bone is rare, and its early diagnosis is critical for a good patient outcome. The imaging findings of AM infection have been only briefly reported. We present the computed tomographic and magnetic resonance findings of AM involvement of the entire temporal bone in an immunocompromised patient, and we discuss the differential diagnosis. The scattered areas of both bone sclerosis and erosion may help the radiologist suggest the diagnosis of an indolent process such as tuberculosis or AM and allow initiation of early treatment.

Toxicity profile and clinical outcomes in locally advanced head and neck cancer patients treated with induction chemotherapy prior to concurrent chemoradiation.

The use of induction chemotherapy prior to chemoradiation for locally advanced head and neck squamous cell carcinoma (LA-HNSCC) remains controversial. We explored whether toxicity from induction chemotherapy influenced the delivery of concurrent chemoradiation. Among 171 consecutive previously unirradiated patients with HNSCC treated with combined chemotherapy and radiation, we identified 66 patients with stage III-IVB head and neck carcinoma who were treated with induction chemotherapy prior to planned chemoradiation. The most common induction regimen was docetaxel, cisplatin and 5-FU (TPF; 80%) for 2 to 3 cycles. Mean radiation dose was 72 Gy (range, 36-75 Gy). Concurrent chemotherapy regimens included cisplatin (26%), cetuximab (5%) and 5-fluorouracil/hydroxyurea (65%)-based regimens. At a median follow-up of 27 months (range, 9-56 months), the 2-year locoregional control and distant control rates were 85 and 86%, respectively. The 2-year disease-free survival and overall survival rates were 74 and 80%, respectively. Although there were no grade 5 toxicities during induction chemotherapy, 26% of patients required hospitalization for adverse events, including 5% needing intensive care. The most common high grade adverse events were grade 4 neutropenia (21%) and neutropenic fever (17%). Six percent of patients were unable to tolerate concurrent chemotherapy. The 2-year disease-free survival was significantly higher in patients able to complete induction and concurrent chemoradiation as planned (83 vs. 27%, p<0.001). Induction chemotherapy followed by concurrent chemoradiation results in promising survival rates in our cohort of advanced head and neck carcinoma patients. Due to severe toxicities in a subset of patients, this strategy is only recommended in selected high-risk patients who are carefully followed by an experienced multidisciplinary team.

Cancers of the oral cavity and oropharynx: FDG PET with contrast-enhanced CT in the posttreatment setting.

The combined use of fluorine 18 fluorodeoxyglucose (FDG) positron emission tomography (PET) and contrast material-enhanced computed tomography (CT) for posttreatment monitoring of cancers of the oral cavity and oropharynx has steadily increased in recent years. FDG PET/CT offers many advantages for evaluating the effects of therapy, determining whether residual or recurrent disease is present, and assessing the extent of nodal disease. Because of the high negative predictive value of this imaging test, some have advocated the deferral of neck dissection in patients with negative findings at FDG PET/CT after chemotherapy and radiation therapy; positive findings may have a similarly heavy influence on the future course of treatment. Thus, the accuracy of image interpretation is crucial. However, the interpretation of posttreatment FDG PET images is challenging, with multiple potential pitfalls and limitations that could lead to an incorrect analysis. Accuracy depends on a detailed knowledge of the patient's treatment history and a thorough understanding of the kinds of changes that might result from treatment. Awareness of the principles underlying the selection of the optimal interval between the completion of treatment and the first follow-up FDG PET/CT examination is especially important, since an interval that is too short could lead to false-positive or false-negative findings. A period of 12 weeks or more is generally recommended, but the optimal waiting period depends on the extent of therapy and other factors. If recurrence or progression is suspected during the waiting period, contrast-enhanced CT or magnetic resonance imaging should be performed without FDG PET.

Phase 2 trial of concurrent 5-fluorouracil, hydroxyurea, cetuximab, and hyperfractionated intensity-modulated radiation therapy for locally advanced head and neck cancer.

BACKGROUND: The objective of this phase 2 study was to evaluate the tolerability and efficacy of incorporating cetuximab and simultaneous integrated-boost (SIB), intensity-modulated radiation therapy (IMRT) into a well described 5-fluorouracil (5-FU) and hydroxyurea (HU)-based chemoradiation regimen. METHOD: Patients with stage IVA and IVB or high-risk stage III squamous cell carcinomas of the head and neck were enrolled on a phase 2 trial. Prior organ-conserving surgery or induction chemotherapy was allowed off protocol. SIB-IMRT was prescribed to low-risk volumes (43.2 gray [Gy] to 48 Gy) and intermediate-risk volumes (54-63 Gy). A separate IMRT cone-down plan was targeted to macroscopic disease (72 Gy). The median radiation dose was 72 Gy (range, 60-72 Gy) administered in 1.5 Gy fractions twice daily during Weeks 1, 3, 5, 7 and 9. Concurrent systemic therapy consisted of 5-FU (600 mg/m²), HU (500 mg twice daily), and cetuximab (250 mg/m²). RESULTS: From January 2007 through April 2008, 33 patients were enrolled. At a median follow-up of 24 months, the 2-year rates of locoregional control, distant control, disease-free survival, and overall survival were 83%, 79%, 69%, and 86%, respectively. Grade 3 toxicity consisted of mucositis in 33% of patients, radiation dermatitis in 15%of patients, anemia in 18% of patients, leukopenia in 18% of patients, neutropenia in 12% of patients, and thrombocytopenia in 3% of patients. Most patients (64%) were able to tolerate treatment without a feeding tube, and there were no acute or late grade ≥4 adverse events. CONCLUSIONS: The current results indicated that concurrent 5-FU, HU, and cetuximab plus SIB-IMRT is a promising and reasonably well tolerated approach to incorporating molecularly targeted therapy into curative therapy for patients with locally advanced head and neck cancer.

FDG PET with contrast-enhanced CT: a critical imaging tool for laryngeal carcinoma.

Fluorine 18 fluorodeoxyglucose (FDG) positron emission tomography (PET) has evolved to be an essential imaging modality in the evaluation of laryngeal carcinoma. Although the modality has limited utility in assessing the extent of the primary tumor, FDG PET has proved to be superior to anatomic modalities in the detection of lymph node and distant metastases. The role of FDG PET in the evaluation of patients with laryngeal tumors that are clinically classified as N0 has not shown consistent usefulness because of the innate resolution limitations of the camera. In the posttherapy setting, however, FDG PET has consistently demonstrated a high negative predictive value in the identification of recurrent disease, both during the course of therapy and during long-term follow-up. In addition, contrast material-enhanced computed tomography (CT) in conjunction with FDG PET has demonstrated a complementary role by allowing for superior anatomic coregistration and therefore more definitive diagnosis. There is sufficient evidence that with further advances in PET technology, this modality will likely become more useful in the detection of small lesions and occult nodal disease, as well as in guiding the management of laryngeal carcinoma.