Long-term speech and swallowing function after primary resection and sentinel node biopsy for early oral squamous cell carcinoma.

OBJECTIVES: Analysis of long-term speech and swallowing function and subjective quality of life (QOL) after primary resection and sentinel node biopsy (SNB) in patients with early stage (cT1/T2) oral squamous cell carcinomas (OSCC). MATERIAL AND METHODS: Eighty-one consecutive patients treated primarily by transoral resection without flap reconstruction and SNB for a cT1/T2 OSCC were included. Completion neck dissection (CND) was indicated in case of occult disease in the sentinel nodes. Adjuvant radiation (aRT) was administered according to the ultimate lymph node status. All patients showed no evidence of disease at time of analysis. Speech and swallowing function were assessed using standardized clinical examinations (11-item, articulation test) and validated questionnaires on subjective QOL (MDADI, FIGS). Median follow-up was 60 months (range 13-159 months) after initial treatment. RESULTS: In all assessments for speech and swallowing, the entire study cohort achieved very high scores, with mean values located in the highest 10% of the scales. Neither tumor size nor site, age, pN-category, CND, and aRT had significant impact on functional outcomes and subjective QOL with the exception of lower scores in the global and physical scores of MDADI after CND or aRT, and articulation in the population over 60 years of age. CONCLUSION: Transoral resection without reconstruction and SNB for early OSCC achieves excellent outcome with regard to speech, swallowing and subjective QOL.

No benefit for regional control and survival by planned neck dissection in primary irradiated oropharyngeal cancer irrespective of p16 expression.

The aim of the study was to assess regional control and survival in primary irradiated oropharyngeal cancer patients with advanced neck disease (≥cN2a) receiving planned neck dissection (PND) irrespective of the nodal response compared to salvage neck dissection (SND) in case of regional persistence or reccurence in relation to tumoral p16 overexpression. 96 consecutive patients treated at the University Hospital of Zurich, Switzerland were included. Tissue microarray-based scoring of p16 expression was obtained. 5 years overall (OS) and disease-specific survival (DSS) in the PND and SND cohort were 70 vs. 57 % (p = 0.20) and 80 vs. 65 % (p = 0.14), respectively. Regional control in PND and SND achieved 95 vs. 87 % (p = 0.29), respectively. There was no statistically significant impact of neck treatment (PND vs. SND) on regional control or survival among patients with p16-negative tumors (5 years OS 59 vs. 50 %, p = 0.66; 5 years DSS 59 vs. 57 %, p = 0.89) nor among patients with p16-positive tumors (5 years OS 84 vs. 67 %, p = 0.21; 5 years DSS 95 vs. 81 %, p = 0.24). The type of neck dissection after primary intensity-modulated radiotherapy (IMRT) had no impact on regional control and survival even in human papillomavirus (HPV)-associated disease. Therefore we are convinced that based on the accuracy of newer diagnostic modalities the surveillance of a radiologically negative neck after primary chemoradiation (CRT) is oncologically safe irrespective of p16 expression of the tumor.

High sex determining region Y-box 2 expression is a negative predictor of occult lymph node metastasis in early squamous cell carcinomas of the oral cavity.

BACKGROUND: The transcription factor sex determining region Y (SRY)-box 2 (SOX2) (3q26.3-q27) has been recently identified as a recurrently activated major oncogene in squamous cell carcinoma of various sites. Its prognostic value in head and neck squamous cell carcinoma (HNSCC) is currently unclear. AIM: To correlate SOX2 protein expression with the occurrence of occult lymph node metastasis and relapse free survival in early oral SCC. METHODS: SOX2 expression in 120 T1/T2 oral SCC patients was evaluated using a tissue microarray technique. Intensity of SOX2 expression was quantified by assessing the Intensity/Reactivity Scores (IRSs). These scores were correlated with the lymph node status of biopsied sentinel lymph nodes and recurrence. Log rank univariate and Cox regression multivariate analysis was used to determine statistical significance. RESULTS: Twenty-six of 120 primary tumours (21.7%) showed high SOX2 expression. High expression levels of SOX2 significantly correlated with negative lymph node status in univariate (p=0.001) and multivariate analysis (p=0.003). Sensitivity was found to be 95.6% with a negative predictive value of 92.3%. Specificity was 32% with a positive predictive value of 45.7%. CONCLUSION: SOX2 up-regulation is frequent in early SCC of the oral cavity and associated with decreased risk of lymphatic metastasis. SOX2 immunohistochemistry may be used as a predictor for lymph node metastasis in squamous cell carcinoma of the oral cavity.

Relevance of sentinel node procedures in head and neck squamous cell carcinoma.

The management of the clinically and radiologically negative neck (cN0) in patients with early oral and oropharyngeal squamous cell carcinoma (OSCC) is still a matter of debate, though most centers favor an active policy and perform END for staging of the neck and removal of occult disease. In the past decade SNB has been successfully implemented in early stage head and neck carcinomas. A large number of validation studies have shown an excellent safety profile with good sensitivity for the identification of occult neck metastases. The status of the neck is more accurately assessed by step-serial sectioning (SSS) and immunhistochemistry (IHC) of the sentinel lymph nodes (SN) compared to routine histopathologic work up of a comprehensive lymph node dissection specimen. Gain in experience as well as technical developments have lead to a wider use of SNB even in the complex lymphatic system of the Head and Neck region. First observational trials have documented its oncological accuracy and safety with success rates in controlling the neck comparable to END. The role of small tumor deposits only detectable by the extensive histopathologic work-up of the SNB-protocol is controversial. The overview comprises an introduction of the sentinel node procedure and indications in the head and neck region. The methodology as well as the histological work up and reporting of SNB is described. Finally, the clinical application, prognostic significance and future perspectives of SNB are summarized.

The value of (18)F-FDG PET/CT for the detection of distant metastases in high-risk patients with head and neck squamous cell carcinoma.

The aims of this study were to assess a cohort of patients with head and neck squamous cell carcinoma (HNSCC) for: (1) the prevalence of synchronous distant metastases (DM) as detected by the initial staging by using (18)F-FDG PET/CT, (2) the prevalence of metachronous DM, and (3) the validity of published risk factors with special emphasis on the maximum standardized uptake value (SUV max) for the prediction of DM. Two hundred and ninety nine patients with advanced HNSCC were included. Following risk factors at the time of diagnosis and during follow-up were analyzed: advanced T/N stage, poor histological differentiation, level IV/Vb lymph nodes, primary site in the larynx/hypopharynx, and SUV max. The prevalence of DM at initial staging and during follow-up was 10% and 11%, respectively. At initial staging, primary site in the larynx/hypopharynx and neck nodes in level IV/Vb, and during follow-up only level IV/Vb nodes achieved statistical significance. The sensitivity for (18)F-FDG PET/CT with regard to the detection of DM was 96.8%, the specificity 95.4%, the positive predictive value (PV) 69.8%, and the negative PV 99.6%. Patients without DM showed a significantly better overall survival (OS) than patients developing DM (p<0.001). There was no significant difference in OS with regard to the time of diagnosis of DM. The prevalence for synchronous and metachronous DM in advanced HNSCC is considerable. (18)F-FDG PET/CT is highly accurate for initial staging and follow-up. DM carries a bad prognosis regardless of the time of diagnosis.

Joint practice guidelines for radionuclide lymphoscintigraphy for sentinel node localization in oral/oropharyngeal squamous cell carcinoma.

Involvement of the cervical lymph nodes is the most important prognostic factor for patients with oral/oropharyngeal squamous cell carcinoma (OSCC), and the decision of whether to electively treat patients with clinically negative necks remains a controversial topic. Sentinel node biopsy (SNB) provides a minimally invasive method for determining the disease status of the cervical node basin, without the need for a formal neck dissection. This technique potentially improves the accuracy of histologic nodal staging and avoids overtreating three-quarters of this patient population, minimizing associated morbidity. The technique has been validated for patients with OSCC, and larger-scale studies are in progress to determine its exact role in the management of this patient population. This document is designed to outline the current best practice guidelines for the provision of SNB in patients with early-stage OSCC, and to provide a framework for the currently evolving recommendations for its use. Preparation of this guideline was carried out by a multidisciplinary surgical/nuclear medicine/pathology expert panel under the joint auspices of the European Association of Nuclear Medicine (EANM) Oncology Committee and the Sentinel European Node Trial (SENT) Committee.

Evaluation of topography and vascularization of cervical paragangliomas by magnetic resonance imaging and color duplex sonography.

The management of cervical paragangliomas (PGs) depends on their specific type and their relation to adjacent vessels. The purpose of this study was to evaluate the potential of magnetic resonance imaging (MRI) and color duplex sonography (CDS) to classify PGs according to topography and vascularization. Sixteen patients harboring 22 PGs were studied retrospectively. With digital subtraction angiography as reference, the topographic relation of the tumors to the carotid arteries and the internal jugular vein and the patterns of vascularization were assessed. On MRI and CDS the typical feature of 15 carotid PGs was splaying of the carotid bifurcation, with the external carotid displaced anteriorly and the internal carotid artery and internal jugular vein located posteriorly. In five vagal PGs both modalities showed unidirectional anterior displacement of the external and internal carotid arteries. Two jugular PGs were found to extend within the lumen of the internal jugular vein. CDS completely depicted carotid body tumors but failed to delineate the high cervical portion of vagal and jugular PGs. MRI allowed us to assess the entire extent of all PGs. Nineteen lesions showed flow voids corresponding to abundant flow signal on CDS: three carotid body tumors appeared hypovascular on CDS and MRI. On CDS, intratumoral flow was directed cranially in carotid and inferiorly in vagal and jugular PGs. CDS and MRI are suitable for classification of cervical PGs as carotid, vagal or jugular PGs based on the topographic relation to the carotid arteries and internal jugular vein. Visualization of the intrinsic tumor vasculature proved an additional distinguishing criterion on CDS.

Sentinel lymph node evaluation in squamous cell carcinoma of the head and neck.

OBJECTIVE: The aim of our study was to assess the feasibility of sentinel lymph node (SLN) radiolocalization in N0 neck in squamous cell head and neck carcinoma and its predictive value for occult metastasis. STUDY DESIGN: Nineteen patients of an open prospective trial. SETTING: After peritumoral injection of a 99m Tc labeled radiocolloid, the SLN was localized preoperatively by lymphoscintigraphy and intraoperatively through the intact skin by a hand-held gamma-probe. The histology of the SLN and the nodes of the elective neck dissection were compared. RESULTS: Localization of the SLN by lymphoscintigraphy was possible in 18 of 19, and with the hand-held gamma-probe in all 19 patients. Six SLN revealed occult metastatic disease. No skip metastasis were found in the 13 neck specimen with negative SLN. CONCLUSION: SLN evaluation in N0 neck in squamous cell carcinoma of the head and neck is accurately feasible and seems to adequately predict the presence of occult metastasis.

Evaluation of the anatomical and functional properties of deglutition with various kinetic high-speed MRI sequences.

We evaluated various fast MR sequences for obtaining anatomical and dynamic functional information during deglutition. Seven healthy volunteers underwent MRI of the oropharynx during swallowing of an oral positive-contrast agent. Single-slice imaging was performed in the median sagittal plane while subjects were in a supine position. Twenty serial images were obtained using EPI, FLASH, and turbo-FLASH sequences. The dynamic (movement-related) information and the anatomical resolution of the soft tissues were evaluated during deglutition. The FLASH sequence provided high-quality images at rest. During swallowing, however, the images were significantly degraded by movement artifacts and had inferior temporal resolution. The EPI evidenced better temporal resolution, but was degraded by strong distortions and movement artifacts. The turbo-FLASH sequence provided the best temporal resolution and sufficient spatial resolution during motion. This sequence proved optimal for the investigation of swallowing function, and is expected to be of value for the documentation of functional disturbances in patients with oropharyngeal pathology.

Quality of life after treatment for early laryngeal carcinoma.

Radiotherapy and surgery for early laryngeal cancer achieve comparably good results in patient survival, and the choice of treatment between them is being influenced increasingly by the expected voice quality and quality of life (QoL). The superiority of vocal function after radiotherapy has been shown in previous objective voice assessment studies. This study compared the QoL of long-term survivors after endoscopic laser surgery or radiotherapy for early laryngeal carcinoma. QoL was evaluated with two validated questionnaires: the global EORTC QLQ-C30 and the head- and neck-specific EORTC QLQ-H&N35. A total of 62 patients were included. Among 56 patients completing the questionnaires (90% completion rate) 40 were treated by endoscopic CO2 laser surgery and 16 with radiation therapy. All 56 patients showed a good global QoL with no significant difference between the two treatment modalities. The head- and neck-specific evaluation revealed significantly better scores for surgically treated patients in questions about swallowing of solid food, xerostomia, and tooth problems, but no difference in questions about voice quality. Both treatment modalities achieve good QoL after treatment of early laryngeal tumors. Irradiated patients mainly complain about xerostomia related problems. In contrast to objective measurements long-term survivors after surgery do not rate their voice poorer than irradiated patients. The EORTC questionnaires are validated and useful tools in assessing QoL and should further be used in prospective trials.

Role of routine panendoscopy in cancer of the upper aerodigestive tract.

Patients with squamous cell carcinoma of the aerodigestive tract routinely undergo panendoscopy to detect possible synchronous second primary tumors. The aim of our study was to assess the incidence of synchronous and metachronous second primary tumors and to refine the role of panendoscopy. The charts of 358 patients evaluated by means of panendoscopy during work-up of a first primary squamous cell carcinoma of the upper aerodigestive tract were reviewed. The incidence of a second primary tumor was 16.2%, with 6.4% being synchronous and 9.8% being metachronous. In only 3.1% of all patients, a synchronous tumor was clinically silent and only revealed by means of the panendoscopy. The synchronous tumors were mainly in the oral cavity, pharynx, or larynx (61%), whereas the metachronous tumors were most likely in the lung (57%). Despite the low incidence of synchronous second primary tumors, we still recommend panendoscopy for assessment of the primary tumor and as a training field for residents.

Evaluation of eardrum laser doppler interferometry as a diagnostic tool.

OBJECTIVES: Laser Doppler interferometry (LDI) of the eardrum allows noncontact optical analysis of its vibrations in response to sound. Although LDI has been widely used in research, it has not yet been introduced into clinical practice as an adjunctive test for otological workup. The aim of this study was to evaluate LDI as a diagnostic tool in the clinical sphere. STUDY DESIGN: Prospective. METHODS: A measurement system was developed based on a commercially available scanning He-Ne laser Doppler interferometer. The study included 129 eardrums of 79 subjects that were divided into 3 groups: 1) normal subjects and 2) patients with sensorineural and 3) conductive hearing loss (HL). All the patients suffering from conductive HL underwent ossiculoplasty, which allowed confirmation of the final diagnosis, and patients were assigned accordingly to the subgroups malleus fixation, incus luxation, and stapes fixation. RESULTS: The modified LDI system allowed bilateral evaluation of a subject within 30 minutes. No significant difference between normal subjects and patients having sensorineural HL were found. However, it was possible to distinguish between normal subjects and patients with conductive HL. Furthermore, the system had the ability to differentiate between various middle ear diseases. These groups differed statistically significantly in terms of manubrium vibration amplitude and resonance frequency. In malleus fixation significant differences in tympanic membrane movement patterns were found. CONCLUSIONS: Our LDI is applicable in clinical otological practice and serves as a valuable addition to the routine audiological investigations for preoperative evaluation of the mobility and integrity of the ossicular chain.

Intraoperative assessment of stapes movement.

A method is described that allows, for the first time, intraoperative vibration modes assessment of the acoustically stimulated stapes by means of scanning laser Doppler interferometry (LDI). The study was designed to answer the following questions: 1) Is LDI practical for taking measurements during surgery? 2) Are the results comparable to the findings in temporal bone preparations? and 3) Do the vibration characteristics of the stapes change after the posterior incudal ligament is detached from the incus? Seven patients with profound bilateral hearing loss who were undergoing cochlear implantation were included in the study. The measurement system was easily applicable for intraoperative measurements and allowed contact-free analysis with very high accuracy. No major differences in the results from the live human subjects and temporal bone preparations were observed. The stapes movement was predominantly pistonlike at the lower frequencies and became complex at higher frequencies. Sacrificing the posterior incudal ligament had no statistically significant effect on stapes vibration.

Salvage surgery after failure of nonsurgical therapy for carcinoma of the larynx and hypopharynx.

BACKGROUND: For larynx preservation, radiotherapy is gaining popularity for primary treatment of laryngeal and hypopharyngeal cancer, reserving surgery for salvage. OBJECTIVE: To analyze the outcome of salvage surgery after failure of primary radiotherapy. DESIGN: Nine-year retrospective outcome analysis. SETTING: University referral center. PATIENTS: Fifty-four patients with squamous cell carcinoma of the larynx (n = 39) or hypopharynx (n = 15). RESULTS: For laryngeal cancer, mean interval from radiation to detection of recurrence was 14.5 months (range, 2-66 months). Twenty-three patients (59%) presented with a more advanced tumor stage after radiation than at the initial evaluation. Total laryngectomy was needed in 36 patients (92%). Disease-specific 5-year survival rate was 63%. Survival of patients with small recurrent tumors was statistically significantly better than those with advanced tumors (P =.004). For hypopharyngeal cancer, mean interval from radiation to detection of the recurrence was 10.6 months (range, 3-40 months). Total laryngopharyngectomy was needed in 8 of 9 patients with local recurrrence; neck dissection, in 6 patients with regional recurrence. Disease-specific 5-year survival rate was only 20%. Recurrent tumor and node stages did not influence the outcome. Patients with regional recurrences did no better than those with local ones. CONCLUSIONS: Salvage surgery in laryngeal cancer achieves good results, especially for small recurrences. Because of tumor progression, larynx preservation is seldom possible at the time of salvage. Salvage surgery in hypopharyngeal cancer shows poor survival regardless of tumor stage and despite radical surgical procedures, and can be recommended only for carefully selected patients. Arch Otolaryngol Head Neck Surg. 2000;126:1473-1477

Objective evaluation of normal facial function.

The aim of this investigation was the assessment of normal facial movements using the objective computer-assisted OSCAR method. Computerized black-and-white video images of 20 healthy volunteers were recorded with the face at rest, maximal wrinkling of the forehead, forced eye closure, and forced smiling. The mean regional symmetry index was found to be 91% (SD 6%; range 80% to 99%) for wrinkling of the forehead, 93% (SD 5%; range 82% to 100%) for forced eye closure, and 91% (SD 5%; range 79% to 98%) for maximal smiling. Clinical weighting gave a global symmetry index of 92% (SD 3%; range 88% to 96%). The presented results show that the physiological dynamic asymmetry of the normal face is 7% to 9%. No dominant facial side could be found. The comparison of the results obtained with the OSCAR method with those of the subjective House-Brackmann and Fisch grading systems showed that the physiological asymmetry of facial movements can only be accurately determined with a computer-assisted objective method.

Percutaneous tracheostomy: a comprehensive evaluation.

Percutaneous tracheostomy (PT) is an ancient procedure that has recently attracted increasing interest. While there are numerous publications in the literature, there remains confusion due to the large variety of techniques and instruments with which it has been performed and the wide disparity in clinical outcome. This study evaluates the international literature on over 1,500 cases, classifies the techniques that have been used, analyzes the safety of each method, and reports a prospective outcome and cost analysis of 130 cases undergoing what we determined to be the safest method. We found that PT performed with the correct instruments and technique under bronchoscopic surveillance has a lower incidence of complications than open tracheostomy (OT). Cost estimation demonstrated that PT may be significantly more expensive than bedside OT. While we recommend PT as a relatively safe and expedient method of tracheostomy for selected intubated patients in an intensive care unit, it does not offer an advantage for patients who must be taken to the operating room, and should not deprive house officers of necessary experience in OT in this setting.

A prospective randomized double-blind trial of fibrin glue for pain and bleeding after tonsillectomy.

OBJECTIVES: The notable morbidity of tonsillectomy includes considerable postoperative pain and a rate of postoperative bleeding that have remained largely uninfluenced by modern surgical techniques or medication. Fibrin glue is known to have a hemostatic effect in some settings, and there is research suggesting it may also reduce postoperative pain. The objectives of this study were to evaluate the effect of fibrin glue on pain and bleeding after tonsillectomy. STUDY DESIGN: A prospective randomized double-blind study was performed on 50 consecutive adult patients undergoing tonsillectomy for chronic tonsillitis. METHODS: After removal of both tonsils the tonsillar fossa randomly assigned to the treatment protocol was coated with fibrin glue. The other side was left unaltered. The patient was then monitored for postoperative bleeding and wound healing, and a patient-based pain assessment instrument was used to evaluate symptoms every 8 hours for 10 days after surgery. RESULTS: Detailed evaluation of the pain scores allowed the authors to create a pain profile for what the typical patient experiences over the first 10 postoperative days, as well as during the course of a single day. The pain remains relatively constant for the first 7 days and begins to decrease only on the eighth postoperative day. During a single day there is increased pain in the morning compared with noon and evening. However, no statistically significant difference was detected in postoperative pain, bleeding, or healing between the wounds treated with fibrin glue and controls. CONCLUSIONS: The patient-based pain evaluation data should aid the physician in preoperative outcome counselling and targeted prescription of pain medication. However, contrary to previous indications, the authors cannot substantiate a significant beneficial effect of fibrin glue in postoperative pain control. Furthermore, we did not find its action as a hemostatic agent clinically applicable in this setting, and thus find no indication for the routine use of fibrin glue in tonsillectomy.

Persistent bilateral hearing loss after shunt placement for hydrocephalus. Case report.

Transient hearing decrease following loss of cerebrospinal fluid (CSF) has been reported in patients undergoing lumbar puncture, spinal anesthesia, myelography, and/or different neurosurgical interventions. The authors present the first well-documented case of a patient with persistent bilateral low-frequency sensorineural hearing loss after shunt placement for hydrocephalus and discuss the possible pathophysiological mechanisms including the role of the cochlear aqueduct. These findings challenge the opinion that hearing decreases after loss of CSF are always transient. The authors provide a suggestion for treatment.

A clinical and histologic comparison of percutaneous dilational versus conventional surgical tracheostomy.

To directly compare percutaneous dilational tracheostomy (PDT) with conventional surgical tracheostomy, a prospective study was performed in 83 patients requiring tracheostomy for prolonged mechanical ventilation in the intensive care unit or after surgery for a large tumor in the upper respirodigestive tract. Median follow-up was 355 days after PDT and 338 days after conventional tracheostomy. The overall morbidity rate was significantly lower with PDT than with conventional tracheostomy (6.4% vs 36.1%; P < 0.001). Compared with conventional tracheostomy, PDT was also associated with a significantly lower incidence of postoperative bleeding (2.1% vs 13.9%; P < 0.05) and postoperative wound infection (0% vs 22.2%; P < 0.001). There were no clinical signs of laryngotracheal stenosis in either group. In conclusion, PDT is a simple, fast, safe bedside procedure that is associated with significantly lower morbidity than standard surgical tracheostomy.