Intraoperative microwave processing of bone margins during resection of head and neck cancer.

OBJECTIVE: To develop an accurate method for performing histopathologic analysis for a full cross-section of cortical bone within 2 to 3 hours. METHODS: Microwave technology was used to augment and to more rapidly perform fixation and decalcification of cortical bone. RESULTS: Using the methods described, slides suitable for histopathologic analyses regarding the presence or absence of malignant tumor were prepared in 2 to 3 hours and, in 10 patients studied, had a 100% correlation with slides prepared in 7 days using the standard decalcification technique. CONCLUSION: Microwave technology allows accurate assessment of a full cross-section of cortical bone regarding the presence or absence of malignant tumor within the time limits required for resection of a malignant head and neck tumor and reconstruction of the surgical defect.

Isolated cervical recurrence of squamous cell carcinoma in the previously treated neck.

PURPOSE: Our study goal was to identify clinical factors associated with, and that might predict, treatment outcome for patients with an isolated cervical recurrence of squamous cell carcinoma in the previously treated neck (ICR-PTN). MATERIALS AND METHODS: We reviewed all patients with noncutaneous head and neck squamous cell carcinoma treated at our tertiary care center between 1987 and 1997, and identified 17 patients (2%) who later developed an isolated recurrence in a previously treated neck. These patients made up our study group, and their charts were thoroughly reviewed. Outcome of salvage therapy (surgery, radiation, or combined therapy) for these patients was compared with pooled clinicopathologic data using the Fisher exact test (one tail). RESULTS: Fifteen such ICR-PTN patients consented to salvage therapy. Six patients were without disease at last follow-up, and 3 were successfully palliated. A statistically significant association between the side of ICR-PTN relative to the primary tumor and outcome of salvage therapy (P =.026) was noted, with ipsilateral neck recurrence being a favorable prognostic factor. Trends that did not meet the standard for statistical significance were observed between a better outcome of salvage therapy and the following parameters: age of less than 60, nonsurgical initial treatment of the neck, and lack of a history of a recurrence before they developed the ICR-PTN. CONCLUSIONS: The current study showed that only the side of the ICR-PTN relative to the primary site is associated with outcome of salvage therapy. Based on our findings and a review of the literature, we have developed a summary of factors that might predict which patients with an ICR-PTN are most likely to benefit from aggressive salvage therapy.

Factors related to outcome of salvage therapy for isolated cervical recurrence of squamous cell carcinoma in the previously treated neck: a multi-institutional study.

OBJECTIVE: The goal was to identify factors associated with the outcome of salvage therapy for patients with isolated cervical recurrences of squamous cell carcinoma in the previously treated neck (ICR-PTN). STUDY DESIGN AND SETTINGS: A tumor registry search for ICR-PTN patients was performed at 7 participating institutions, and the charts were reviewed. Kaplan-Meier plots for survival and time until re-recurrence were used to evaluate the significance of associated variables. RESULTS: Median survival and time until re-recurrence were both 11 months. Survival was better in patients with the following characteristics: nonsurgical initial neck treatment, negative initial disease resection margins, no history of prior recurrence, ipsilateral location of the ICR-PTN relative to the primary, and use of surgical salvage. CONCLUSIONS: By pooling the experience of 7 US tertiary care medical centers, we have identified 5 factors that are associated with outcome of salvage therapy for ICR-PTN. SIGNIFICANCE: Consideration of these factors, as well as the reviewed literature, should facilitate patient selection for salvage protocols.

Endoscopic stapled diverticulotomy: treatment of choice for Zenker's diverticulum.

OBJECTIVE: To evaluate the efficacy and safety of endoscopic stapled diverticulotomy in the treatment of patients with Zenker's diverticulum. STUDY DESIGN: Cohort study. METHODS: Fourteen elderly patients (11 men and 3 women) with Zenker's diverticulum were evaluated in a community hospital setting from July 1996 to November 1999. Before surgery patients had significant dysphagia, regurgitation, cough, or aspiration pneumonia. The common septum between the diverticulum and cervical esophagus was visualized with a Weerda diverticuloscope. While using videoendoscopic monitoring, the septum was divided and the edges simultaneously sealed with a linear endoscopic stapler. Average operative time was 31 minutes. RESULTS: The operation was successfully performed in 11 of 14 patients. In the three unsuccessful cases, one patient's pouch was too small to staple and the other two patients had a septum that was difficult to visualize with the diverticuloscope. There was no significant postoperative morbidity or mortality. Patients started a liquid diet on the first postoperative day and resumed a soft diet a week later. They were usually discharged on the first postoperative day. Most patients reported significant improvement with resolution of dysphagia and regurgitation. CONCLUSIONS: Compared with the traditional open technique, the endoscopic stapled diverticulotomy technique is safe, quick, and effective and requires a shorter length of stay in the hospital. Therefore it has become our treatment of choice for elderly, high-risk patients with a large (>2 cm) hypopharyngeal (Zenker's) diverticulum.

Presentation and patterns of late recurrence of olfactory groove meningiomas.

The objective of this article is to present the recurrence pattern of olfactory groove meningiomas after surgical resection. Four patients, one female and three males, with surgically resected olfactory groove meningiomas presented with tumor recurrence. All patients underwent resection of an olfactory groove meningioma and later presented with recurrent tumors. The mean age at initial diagnosis was 47 years. All presented initially with vision changes, anosmia, memory dysfunction, and personality changes. Three patients had a preoperative MRI scan. All patients had a craniotomy, with gross total resection achieved in three, and 90% tumor removal achieved in the fourth. Involved dura was coagulated, but not resected, in all cases. Three patients were followed with routine head CT scans postoperatively, and none was followed with MRI scan. The mean time to recurrence was 6 years. Three patients presented with recurrent visual deterioration, and one presented with symptoms of nasal obstruction. Postoperative CT scans failed to document early tumor recurrence, whereas MRI documented tumor recurrence in all patients. Tumor resection and optic nerve decompression improved vision in two patients and stabilized vision in two. Complete resection was not possible because of extensive bony involvement around the anterior clinoid and inferior to the anterior cranial fossa in all cases. Evaluation of four patients with recurrent growth of olfactory groove meningiomas showed the epicenter of recurrence to be inferior to the anterior cranial fossa, with posterior extension involving the optic canals, leading to visual deterioration. This location led to a delay in diagnosis in patients who were followed only with routine CT scans. Initial surgical procedures should include removal of involved dura and bone, and follow-up evaluation should include formal ophthalmologic evaluations and routine head MRI scans.

Modified neck dissection for metastatic nonseminomatous testicular carcinoma.

OBJECTIVE: To examine the role of neck dissection in the treatment of metastatic stage 3 nonseminomatous germ-cell tumors (NSGCTs) of testicular origin. METHOD: A retrospective review was made of 45 patients with metastatic NSGCT who underwent 48 unilateral and 3 bilateral neck dissections. Only level III-VI nodes were dissected, often with concomitant or staged mediastinal dissection, thoracotomy, and/or retroperitoneal node dissection. Occasionally, resection of the clavicle, jugular vein, or subclavian artery, or a combination of these, was required to eradicate the disease. RESULTS: There were only four instances of recurrence in dissected necks. There was one case of dedifferentiation of mature teratoma to adenocarcinoma Patients who were followed for a mean period of 32 months had a disease-free survival of 72%. Prognosis for patients with stage 3 disease but negative preoperative tumor markers (alpha-fetoprotein and human chorionic gonadotropin) was excellent, with 97% of these patients having no evidence of disease at follow-up. Factors having a negative impact on survival included positive tumor markers, elements of germ-cell cancer in excised nodes, and a neck mass that represents late relapse of disease. CONCLUSION: Modified neck dissection has a demonstrated role in the treatment of metastatic NSGCT. It prevents reversion of mature teratoma to malignant germ cell tumor with minimal morbidity. Aggressive resection of disease is indicated, often in conjunction with thoracic surgery, to eradicate disease extending into the chest. There is an excellent prognosis in patients with negative preoperative serologic tumor markers.

Zenker's diverticulum: analysis of surgical complications from diverticulectomy and cricopharyngeal myotomy.

OBJECTIVE: To identify risk factors for postoperative complications in patients undergoing diverticulectomy and cricopharyngeal (CP) myotomy for Zenker's diverticulum. STUDY DESIGN: Retrospective. MATERIALS AND METHODS: A chart review was conducted of all patients with a Zenker's diverticulum who were treated with diverticulectomy and cricopharyngeal myotomy at three tertiary care centers in central Indiana between 1988 and 1998. RESULTS: Of the 24 patients identified, 9 developed postoperative complications (2 medical and 7 surgical). Statistical analysis of multiple potential risk factors revealed that only diverticulum size greater than 10 cm2 at surgery placed the patient at increased risk for postoperative surgical complications. To our knowledge, this is the first report that has specifically addressed diverticulum size as an independent risk factor for postoperative surgical complications following diverticulectomy and CP myotomy. CONCLUSIONS: Given our findings, we recommend considering diverticulopexy rather than diverticulectomy in a patient with a Zenker's diverticulum greater than 10 cm2 in size if a cervical approach is the selected treatment.

Radiologic percutaneous gastrostomy: results in 56 patients with head and neck cancer.

OBJECTIVE: The establishment of a direct enteral feeding route is critical in the overall treatment of many patients with head and neck cancer. Use of radiologic percutaneous gastrostomy (RPG), the newest technique for gaining enteral access, has not been studied in such patients extensively. This study evaluated the indications, technique, success rate, and complications associated with RPG in patients with head and neck cancer. STUDY DESIGN: Retrospective. METHODS: A comprehensive chart review was undertaken of 56 patients with head and neck cancer treated at a tertiary care institution who had undergone successful or attempted RPG at some point during their treatment course. RESULTS: Most study patients had advanced oropharyngeal squamous cell carcinoma. The most frequent indications for RPG were dysphagia/aspiration following tumor resection (n = 26) and dysphagia following completion of single- or combined-modality therapy (n = 22). The success rate of attempted RPGs was 98.2%. The overall complication rate for RPG was 12.7% (10.9% minor and 1.8% major). CONCLUSIONS: RPG is a valuable tool for establishing enteral nutrition in patients with head and neck cancer. Advantages of RPG include high success rate despite obstructing lesions, low complication rate, time efficiency and scheduling ease compared with intraoperative percutaneous gastrostomy (PEG) by a second team, no reported tumor seeding of the tube site, and the fact that postoperative RPG allows for more accurate selection of patients who require a gastrostomy tube.

Cable grafting of the spinal accessory nerve after radical neck dissection.

BACKGROUND: From January 1981 through March 1996, 20 patients with head and neck cancer underwent radical neck dissection with sacrifice of the spinal accessory nerve and immediate reconstruction of the nerve using a microsurgical technique and a cable graft of the great auricular nerve. METHODS: Postoperative shoulder function was assessed via a subjective questionnaire, objective strength testing, and/or postoperative electromyography. The latter was used to evaluate for the presence and amplitude of voluntary motor potentials, the presence of fibrillation potentials, and nerve conduction latency. The group of patients who underwent cable grafting of the spinal accessory nerve was compared with a group of patients who underwent modified radical neck dissection with preservation of the spinal accessory nerve and with another group of patients who underwent a classic neck dissection with sacrifice of the spinal accessory nerve and no reconstruction. RESULTS: In terms of shoulder function, the group of patients in whom the spinal accessory nerve was reconstructed occupied an intermediate position; ie, their postoperative shoulder function was better than that of the patients who underwent radical neck dissection without reconstruction but not as good as that of the patients who underwent modified neck dissection with preservation of the spinal accessory nerve. CONCLUSION: Cable grafting of the spinal accessory nerve that has been sacrificed during radical neck dissection results in improved shoulder function in the postoperative period.

The value of ultrasound with ultrasound-guided fine-needle aspiration biopsy compared to computed tomography in the detection of regional metastases in the clinically negative neck.

PURPOSE: Head and neck oncologists have not reached consensus regarding the role of contemporary imaging techniques in the evaluation of the clinically negative neck in patients with head and neck squamous cell carcinoma (HNSCC). The purpose of the present study was to compare the accuracy of ultrasound with guided fine-needle aspiration biopsy (UGFNAB) and computed tomography (CT) in detecting lymph node metastasis in the clinically negative neck. METHODS AND MATERIALS: Sixty-four neck sides of patients with HNSCC were examined preoperatively by ultrasound/UGFNAB and CT at one of five participating tertiary care medical centers. The findings were correlated with the results of histopathologic examination of the neck specimen. RESULTS: Ultrasound with guided fine-needle aspiration biopsy was characterized by a sensitivity of 48%, specificity of 100%, and overall accuracy of 79%. Three cases had nondiagnostic aspirations using UGFNAB and were excluded. CT demonstrated a sensitivity of 54%, specificity of 92%, and overall accuracy of 77%. UGFNAB detected two additional metastases not visualized on CT, whereas CT detected no metastases not seen on UGFNAB. The results of UGFNAB were similar between the participating centers. CONCLUSIONS: Approximately one half of the clinically occult nodal metastases in our patient group were identified by both CT and UGFNAB. Overall, UGFNAB and CT demonstrated comparable accuracy. The sensitivity of CT was slightly better than UGFNAB, but the latter remained characterized by a superior specificity. The results of CT and UGFNAB did not appear to be supplementary. The choice of imaging modality for staging of the clinically negative neck depends on tumor site, T-stage, and experience and preference of the head and neck oncologist. If CT is required for staging of the primary tumor, additional staging of the neck by UGFNAB does not provide significant additional value.

The pectoralis major myofascial flap: clinical applications in head and neck reconstruction.

PURPOSE: The pectoralis major myofascial (PMMF) flap, a simple variant of the pectoralis major myocutaneous (PMMC) flap, has been underemphasized as a reconstructive method in head and neck surgery. MATERIALS AND METHODS: In the present study, we review our experience using 18 PMMF flaps for a variety of reconstructive purposes in 15 head and neck cancer patients treated at a tertiary care hospital. Twelve of the study patients were undergoing surgical salvage of a recurrent cancer, and 10 had received previous radiation. RESULTS: The overall rate of flap complications in our series was 22%, and the incidence of major flap complications requiring surgical revision was 11%. CONCLUSION: In our experience, the use of the PMMF flap for a variety of reconstructive tasks in the head and neck has been associated with a high overall success rate with avoidance of some of the limitations of the PMMC flap.

Predictive factors for functional recovery after free tissue transfer oromandibular reconstruction.

BACKGROUND: Recovery of upper aerodigestive tract function after reconstruction of segmental oromandiblectomy defects is frequently incomplete. The purpose of this study was to quantitate postreconstruction function and define variables that predict functional outcome in this population. METHODS: A prospective study of 21 patients who underwent microvascular free tissue transfer reconstruction of segmental oromandibular defects was performed. Measures of swallowing, speech, bite, and oral intake were performed preoperatively and at 1, 3, 6, and 12 months postoperatively or until plateau. Preoperative versus maximal postoperative measures were compared and correlated with nine potentially predictive variables. Univariate and multivariate analyses were performed to determine the most significant predictive factors. RESULTS: Baseline function in the study population was abnormal. Postoperative bite force improved, but swallowing, speech, and oral intake were worse than preoperative. Significant (univariate) predictors of outcome included diagnosis of cancer, tongue resection, pharynx resection, and flap skin paddle area. Only tongue resection remained significant in multivariate analysis. CONCLUSIONS: Increasing need for oropharyngeal lining replacement, especially after tongue resection, is the most important predictor of functional outcome in reconstruction of segmental mandible defects.

Wound complications associated with brachytherapy for primary or salvage treatment of head and neck cancer.

Brachytherapy can be employed in the primary or salvage treatment of head and neck cancer. The advantage of brachytherapy is the stereotactic limitation of radiation exposure to noninvolved tissues. Wound complications associated with brachytherapy have been discussed only sporadically in the literature. This retrospective study examines 28 patients, 20 for initial treatment and eight for salvage, with varying site and stage head and neck cancer treated with brachytherapy in addition to external beam radiation therapy and/or surgery. The overall complication rate was 50% (14/28), with infection and minor flap breakdown being the most common problems. Tumor site in the primary treatment group was the only significant factor in wound complications. In the salvage group complications were minor and primarily related to flap coverage of brachytherapy catheters.

Comparison of ultrasound-fine needle aspiration and computed tomography in patients undergoing elective neck dissection.

BACKGROUND: Ultrasound of the neck with fine needle aspiration (US-FNA) of suspicious lymph nodes has potential advantages over other radiologic techniques as a screening method for the NO neck in head and neck cancer. METHODS: Twenty-five patients with head and neck cancer who underwent both US of the neck with FNA of any suspicious lymph nodes and neck computed tomography (CT) prior to elective neck dissection were studied. The majority of patients had squamous cell carcinoma (SCC) of the upper aerodigestive tract. Histopathologic results of the neck specimens were compared with each screening technique (palpation, US, US-FNA, CT). RESULTS: Computed tomography (87.9%) and US-FNA (84.9%) had similar overall accuracy in terms of screening the NO neck in our study and were superior to palpation (69.7%) and US alone (72.7%). Specificity was 100% for both CT and US-FNA, with a sensitivity of 60% for CT and 50% for US-FNA. Ultrasound-FNA and CT showed false-negative examinations on virtually the same cases. CONCLUSIONS: Overall, US-FNA was comparable to CT in screening the NO neck in our study. The choice of which modality to employ for imaging the clinically negative neck depends on a number of factors, including the location and clinical extent of the primary tumor as well as the experience and preference of the head and neck surgeon and radiologist.

Resorbable fixation plates in head and neck surgery.

A skeletal fixation system employing plates made of polylactic and polyglycolic acid has been employed at Indiana University Medical Center since July 1993 in 105 craniofacial reconstructions, 45 cases of maxillofacial trauma, 10 craniotomy flap repairs, and five cases involving reconstruction of the laryngotrachea. Because these plates eventually resorb, they offer significant theoretical advantages. No inhibition of structural growth should occur when using this system in children. Tissue tolerance of these plates has been excellent. The technical details of using heat to allow reshaping of the plates as well as the methods of fixation of the plates are discussed.

Apneic anesthesia with intermittent ventilation for microsurgery of the upper airway.

Apneic anesthesia with intermittent ventilation (AAIV) has been used in 250 procedures on the larynx and trachea at Indiana University Medical Center since October 1989. Initially employed for laryngeal papilloma removal in children, this anesthetic technique is now used for other procedures and in adult patients. The advantages of AAIV include improved visualization of the airway, absence of combustible material, and lack of vocal cord motion during surgery. No significant complications have occurred with AAIV. The high degree of safety for this anesthetic technique relates largely to the constant monitoring of oxygen saturation using pulse oximetry and the periodic measurement of end-tidal carbon dioxide (CO2) levels. Contraindications to AAIV are age less than 2 years, significant cardiopulmonary disease, and any hypermetabolic state. Relevant pulmonary physiology includes the unique aspects of oxygen and CO2 metabolism in children.

Carotid body tumors, inheritance, and a high incidence of associated cervical paragangliomas.

BACKGROUND: Current experience with carotid body tumors suggesting a high prevalence of associated cervical paragangliomas prompted this review. PATIENTS AND METHODS: An 8-year retrospective study of patients with carotid body tumors was undertaken, detailing presentation, diagnosis, and treatment. RESULTS: Eleven patients harboring 17 carotid body tumors were discovered. All patients had a neck mass. Seven patients (64%) had bilateral carotid body tumors. Six (55%) reported a positive family history-4 were first-generation relatives, 5 had bilateral tumors, and 3 had other head and neck paragangliomas. Angiography documented 4 associated vagal and 2 glomus jugulare paragangliomas in addition to the carotid body tumors. Precise surgical care limited blood loss to an average of 590 cc. The carotid artery was repaired during 5 resections (29%). Cranial nerve injury occurred in 3 cases, all following vagal body or glomus jugulare resection. Every patient is currently alive, stroke free, and functioning without major disability. CONCLUSIONS: Patients with carotid body tumors have a propensity for multiple head and neck paragangliomas. Angiography is diagnostic. The need for associated paraganglioma resection dramatically increases the risk of cranial nerve injury.

Laryngotracheal reconstruction using a Vitallium alloy miniplate.

When stenosis of the larynx and trachea involves loss to anterior support, this is usually corrected by an autograft of costochondral cartilage or of hyoid bone anchored with suture material. This paper describes an alternative technique employing a Vitallium alloy miniplate placed anterior to the airway as a means for providing support. This is placed over a fascial or auricular cartilage graft. Together, they provide a smooth scaffold for mucosal migration. Thirteen patients were treated at Indiana University Medical Center between 1991 and 1993 by means of this technique. Ten of the 13 patients (77%) achieved an adequate airway to allow decannulation. There have been no significant complications related to the use of the miniplate, and specifically, there have been no instances of infection or extrusion. It has been unnecessary to remove any of the miniplates. The Vitallium alloy miniplate offers unique advantages in laryngotracheal reconstruction in that it not only accurately approximates tissues, but it also provides external support to the airway.

Surgical management of pulmonary carcinoma secondary to recurrent respiratory papillomatosis.

Recurrent respiratory papillomatosis is a rare, but acknowledged, risk factor for pulmonary squamous cell carcinoma. Although previous reports suggest a poor prognosis for lung cancer associated with papillomatosis, we have successfully treated 1 such patient, who presented with three synchronous pulmonary malignancies, using parenchyma-sparing resection techniques.