Resection of cancer of the tongue base and tonsil via the transhyoid approach.

OBJECTIVE: To assess whether transhyoid resection of the tongue base and tonsil lesions is an effective approach to tumors involving this region compared with more traditional anterior surgical approaches that arbitrarily involve either segmental resection or division of the mandible. STUDY DESIGN: Retrospective review. METHODS: Since 1988, we have used a combined transhyoid and transoral approach to resect lesions involving the tongue base, tonsil, or both. Forty-one patients were identified who underwent surgical resection of lesions involving this region via this combined approach during this period. A stage-matched group of 41 patients was also identified in which patients underwent resection via traditional composite or mandibulotomy approaches and was used as a basis for comparison. Factors assessed included status of surgical margins, postoperative complications, degree of postoperative dysphagia, and long-term outcome. RESULTS: Comparison between the two groups revealed similar rates of negative surgical margins. Levels of postoperative dysphagia, notably severe primarily in patients with either T4 or recurrent disease, were also similar between groups. Complication rates, especially with regard to fistula occurrence and mandible-healing problems, were significantly lower in the transhyoid group. Analysis of long-term outcome revealed similar patterns with regard to disease status in both groups. CONCLUSIONS: The combined transhyoid and transoral approach is an effective surgical option for a number of lesions affecting the tongue base, tonsil, or both. Although similar to other approaches with regard to postoperative function and disease outcome, the transhyoid approach is associated with decreased postoperative morbidity. However, tumors that extend to involve the mandible or pterygoid musculature or skull base are probably best suited for traditional approaches that involve division of the mandible.

Influence of tobacco and alcohol on the stage of laryngeal cancer at diagnosis.

OBJECTIVE: This study sought to examine the influence of cigarette smoking and alcohol consumption on the stage of laryngeal cancer at diagnosis. STUDY DESIGN: A retrospective review of 499 laryngeal cancer patients diagnosed between 1978 and 1997 was conducted. METHODS: Parameters that included smoking history, history of alcohol consumption, and the tumor stage and location at diagnosis were analyzed using the proportional odds model, correlation coefficient, and Student t test. RESULTS: Three hundred sixteen patients met the inclusion criteria, and 180 (56%) had advanced-stage disease at the time of presentation. The statistical model demonstrated a small but significant relationship between tobacco and alcohol on the stage of laryngeal cancer at diagnosis. Patients diagnosed with an advanced-stage tumor (stage III or IV) smoked a significantly greater amount and were more likely to be heavy drinkers than those diagnosed with a localized laryngeal cancer. CONCLUSIONS: Our results demonstrate that for every incremental increase in pack years of smoking, there is a small but measurable increase in the odds that a patient's laryngeal cancer will be stage III or IV at diagnosis. Likewise, being a "heavy" drinker as opposed to a "social" drinker raises the likelihood of an advanced tumor. Given the preventable nature of these risk factors, the moderation of alcohol consumption and cessation of smoking is prudent advice that should be conveyed to all patients.

Salvage treatment for recurrent squamous cell carcinoma of the oral cavity.

BACKGROUND: Squamous cell carcinoma (SCCA) of the oral cavity recurs with a frequency of 25%-48%, a fact that usually portends a poor prognosis. Recent studies have reported salvage cure rates as high as 67%. Investigators have also claimed that restaging recurrent tumors provides useful prognostic information, although this has not been demonstrated with tumors of the oral cavity. The purposes of this study were: (1) to report the patterns of recurrent SCCA of the oral cavity; (2) to examine the benefit of restaging oral cavity tumors, and (3) to compare different treatment modalities in the management of recurrent SCCA of the oral cavity. Materials and Methods Thirty-eight patients who developed recurrent SCCA of the oral cavity were reviewed. Salvage treatment consisted of surgery, chemotherapy, radiation therapy, or a combination of these modalities. Survival analysis was based on the stage of the primary and recurrent tumors and the type of salvage treatment received. RESULTS: The overall recurrence rate was 28%. Local recurrence was most common (58%) followed by locoregional (27%) and regional recurrence (16%). Patients who recurred more than 6 months after completion of their primary treatment had improved survival compared with those who recurred within 6 months of initial treatment. Individuals with stage I-II primary tumors had significantly improved salvage time and total survival time compared with those with stage III-IV primary tumors (p < 0.005 and p < 0.001). Conversely, the stage of the recurrent tumor was not predictive of either improved salvage time or total survival time. Patients who underwent salvage surgery had significantly improved salvage time and total survival time compared with those who received chemotherapy and/or radiation therapy (p < 0.001 and p < 0.002). The overall salvage cure rate was 21%. Neither the stage of the primary or recurrent tumors nor the type of salvage treatment received significantly correlated with an improved cure rate. However, the group of patients who underwent salvage surgery approached a statistically significant improvement in cure rate (p = 0.08). CONCLUSIONS: Squamous cell carcinoma of the oral cavity is most likely to recur at the primary site. The stage of the primary tumor is significantly correlated with survival even after recurrence, but the stage of the recurrent tumor is not significantly correlated with survival. Patients most likely to benefit from retreatment are those who (1) have primary tumors stage I-II, (2) recur greater than 6 months after their initial treatment, and (3) develop recurrences that are amenable to salvage surgery.

Well-differentiated thyroid carcinomas: p53 mutation status and microvessel density.

BACKGROUND: Risk-stratification schemes exist for well-differentiated thyroid carcinoma and include prognostic factors such as age, sex, extent of tumor, size of tumor, and presence of metastasis. Controversy continues, however, over the aggressiveness of initial surgical intervention because of anecdotal experiences of poor clinical outcomes in low-risk patients. Our objective is to determine the prognostic significance of two biologic tumor markers, the p53 gene mutation and CD34 microvessel density (MVD) count, in well-differentiated tumors of thyroid gland. METHODS: We selected 38 patients with well-differentiated thyroid carcinomas from the University of Illinois Tumor Registry. Patients had an average clinical follow-up of 10 years. Paraffin-embedded tumor specimens were available for all patients. Immunohistochemistry was performed to identify mutations of the p53 gene (Ab 1801) and to determine the MVD count (CD34). RESULTS: There were significant increases in MVD counts within thyroid tumor tissue, when compared with surrounding, normal thyroid tissue. There was no significant correlation noted, however, between increased MVD and histology or recurrence rates. There was a trend toward higher MVD counts in tumor specimens of patients initially seen with metastatic lymphadenopathy. The incidence of p53 mutation expression was 28%, and there was no correlation between p53 status and histology, sex, recurrence rate, or survival. CONCLUSIONS: This study supports the concept of tumor neovascularization but fails to correlate MVD with clinical behavior or pathologic features in well-differentiated thyroid carcinoma. Furthermore, we found that the p53 mutation status was not an independent prognosticator of tumor behavior in these lesions.

Human papillomavirus expression and p53 gene mutations in squamous cell carcinoma.

OBJECTIVES: To determine the incidence of human papillomavirus (HPV) infection and p53 gene mutation expression in squamous cell carcinomas (SCCs) of the oral cavity and tonsils, to correlate the presence of HPV and p53 gene mutation with known clinical and pathological features of SCC, and to determine whether infection with HPV or the presence of p53 gene mutations are independent prognosticators of patient survival. DESIGN: To accomplish this goal, 58 patients with SCCs of the oral cavity and 42 patients with SCCs of the tonsils were randomly examined. The cases examined met the criteria of 5-year clinical follow-up, availability of complete staging information and treatment history, and the presence of paraffin-embedded tumor specimens. Immunohistochemical tests were performed to identify the mutant p53 protein. Human papillomavirus identification was accomplished with polymerase chain reaction, with confirmation via restriction fragment length polymorphisms. RESULTS: The incidence of p53 gene mutation expression for this series was 66%. Human papillomavirus infection was found in 11 patients (11%). There was a trend toward increased p53 gene mutation expression with advancing stage of tumor in the oral cavity cancer group, although this was less evident in the tonsil cancer population. The p53 gene mutation status was found not to correlate with the histological grade of the tumor, patient age or sex, recurrence rates, or survival status. Like p53 expression, there were no correlations found between the presence of HPV and age, sex, histological grade, or recurrence rates. However, a correlation did exist between HPV and survival status in the tonsil cancer group, with improved survival noted among patients with tonsil cancers infected with HPV compared with those not infected with HPV. A significant correlation existed with both p53 gene mutation status and HPV status with respect to alcohol and tobacco use. The presence of the p53 gene mutation positively correlated with increased tobacco and alcohol use, whereas infection with HPV predicted a significantly lower rate of alcohol and tobacco consumption. CONCLUSIONS: Human papillomavirus infection is an independent risk factor for the development of oral cavity and tonsil SCCs in those patients with a relatively low alcohol and tobacco use history. Conversely, there is a strong association between heavy alcohol and tobacco use and mutation of the p53 gene. Neither p53 gene mutation nor HPV infection serve as prognosticators of tumor behavior in SCCs of the oral cavity or tonsils, with the exception of improved survival noted among patients with tonsil cancers infected with HPV.

Negative-pressure pulmonary edema in the otolaryngology patient.

It is estimated that 11% of all patients requiring active intervention for acute upper airway obstruction develop negative-pressure pulmonary edema. This pathologic process typically has a benign and rapidly resolving clinical course with the prompt use of mechanical ventilation and positive end expiratory pressure. A review of the literature, however, has revealed a morbidity and mortality rate of 11% to 40% in reported series. During the years 1991 through 1993, six patients were identified in whom negative-pressure pulmonary edema developed after various otolaryngologic procedures. Five (84%) of the six patients had complete resolution of the pulmonary edema within 24 hours, and the sixth patient progressed to prolonged mechanical ventilation and eventual death. In an effort to further understand the pathophysiology of this disease, a cardiac evaluation was performed by use of echocardiography on all six patients. In three of the six patients, studies revealed an underlying cardiac anomaly not previously identified by history or physical examination. Findings included one case of hypertrophic cardiomyopathy and two cases of pulmonary and tricuspid valvular insufficiency. This 50% incidence of cardiac anomalies is striking, in contrast to the less than 1% incidence of these anomalies in the general adult population. To our knowledge, this is the first study to implicate an underlying cardiac cause for the generation of negative-pressure pulmonary edema. On the basis of this study, we recommend that echocardiography be a part of the routine evaluation of all patients who manifest negative-pressure pulmonary edema.

Inflammation in the uvula mucosa of patients with obstructive sleep apnea.

This study was conducted to determine whether inflammation is present in the uvula mucosa of patients with obstructive sleep apnea (OSA). Uvulas were obtained by uvulopalatopharyngoplasty in 21 patients with moderate OSA (mean apnea/hypopnea index and standard error of the mean: 32 +/- 4) and by autopsy in 5 individuals not known to have OSA. Using point counting in five randomly selected high-power microscopic fields (X100), the authors found that the number of leukocytes in the lamina propria of the uvula mucosa was significantly higher in patients with OSA than in the controls (179 +/- 12 cells vs. 71 +/- 4 cells, respectively; P < .05). This was due to a significant increase in the number of plasma cells in patients with OSA as compared with controls (89 +/- 15 cells vs. 21 +/- 5 cells, respectively; P < .05). The thickness of the lamina propria (an index of interstitial edema) was also significantly increased in patients with OSA compared with controls (0.99 +/- 0.12 mm vs. 0.27 +/- 0.02 mm, respectively; P < 0.05). The authors conclude that inflammation, characterized by plasma cell infiltration and interstitial edema, is present in the uvula mucosa of patients with moderate OSA. They also suggest that soft palate inflammation contributes to upper airway occlusion observed during sleep in these patients.

Long-term follow-up of tracheoesophageal puncture results.

Since its introduction by Blom and Singer in 1980, tracheoesophageal puncture with a voice prosthesis has become the most frequently recommended choice for speech rehabilitation of total laryngectomies. Many studies have reviewed the initial speech acquisition success rates following tracheoesophageal puncture; however, long-term follow-up in these initial successes has been lacking. In addition, factors predictive of long-term success with tracheoesophageal speech have not been defined. Over a 10-year period, we retrospectively reviewed all total laryngectomy patients, including those who have undergone primary or secondary tracheoesophageal puncture, at the University of Illinois Hospital and Clinics and the Westside Veterans Administration Hospitals. Survival in the total laryngectomy cohort of 202 patients ranged from 35% to 50%. Forty of these patients underwent tracheoesophageal puncture, in whom survival was 75%. Short-term success with tracheoesophageal speech was approximately 70% for our patients, while long-term success was achieved in 66%. Despite low socioeconomic status and relatively high alcoholism rates, successful maintenance of tracheoesophageal speech was achieved in the majority of cases. Tracheoesophageal speech should therefore be considered as a primary method of vocal rehabilitation in all patients undergoing total laryngectomy.

Comparison of rigid and flexible esophagoscopy in the diagnosis of esophageal disease: diagnostic accuracy, complications, and cost.

Rigid esophagoscopy has been used by otolaryngologists for evaluation of the esophagus for over 100 years. Few studies have examined the diagnostic accuracy of rigid esophagoscopy in patients with carcinoma of the head and neck. The goal of our study was to compare the diagnostic accuracy, complication rate, and costs of rigid esophagoscopy and flexible fiber-optic endoscopy in the evaluation of the esophagus in patients with head and neck carcinoma. We retrospectively reviewed the records of 195 patients with head and neck carcinoma who underwent both rigid esophagoscopy and flexible fiber-optic endoscopy within a 6-month period. We discovered 10 cases with discordant findings, of which 5 (50%) were esophageal carcinoma. The estimated cost was less for flexible endoscopy. No complications were reported in either procedure. Our study suggests that flexible fiber-optic endoscopy should replace rigid esophagoscopy in the evaluation of the esophagus in patients with head and neck carcinoma.

MR imaging of squamous cell carcinoma of the larynx and hypopharynx.

Despite recent diagnostic advances, the laryngopharynx remains an area where accurate assessment of tumor size and extent is difficult. Computed tomography has proven helpful in delineating lesions in these areas, yet significant limitations exist. In an attempt to more accurately evaluate laryngopharyngeal neoplasms, MR imaging was performed in 25 consecutive patients with squamous cell carcinoma of the larynx and hypopharynx. Mr imaging was analyzed for its utility in clinical staging, assistance in selection of candidates for conservation, Laryngeal surgery, and ability to reliably predict cartilage invasion. MR imaging improved the accuracy of tumor staging by 40% and was valuable in the selection of candidates for conservation surgery. In addition, MR imaging was able to predict cartilage invasion in 6 of 6 patients with pathologic confirmation with a single false-positive case. MR imaging appears to be a reliable indicator of tumor size and location and should be judiciously incorporated into the staging and pretreatment planning of patients presenting with laryngopharyngeal malignancies.

Incidence of cervical metastasis from uveal melanoma: implications for treatment.

BACKGROUND: Although the literature has focused on the propensity of uveal melanoma to metastasize to the liver, little attention has been directed to its spread in regional, cervical lymph nodes. METHODS: We reviewed records of 77 patients who underwent primary resection of uveal melanoma during a 15-year period at our institution. RESULTS: A total of only 6.5% of patients developed cervical metastasis. Factors such as age, race, sex, tumor location, and histology were not influential in identifying these patients. Tumor size and local orbital recurrence were, however, associated with a higher risk of cervical lymphadenopathy (p < 0.05). Cervical metastases were also associated with the presence of distant metastatic disease. CONCLUSION: Neck dissection should be reserved for patients with clinically demonstrable lymphadenopathy only after distant disease has been excluded.

Management of patients with positive surgical margins after vertical hemilaryngectomy.

OBJECTIVE: To evaluate the significance of positive surgical margins after vertical hemilaryngectomy for squamous cell carcinoma of the larynx. DESIGN: A retrospective review of patients undergoing hemilaryngectomy over a 20-year period. SETTING: A major academic medical center. PATIENTS: Fifty-six consecutive patients who underwent hemilaryngectomy between 1970 and 1990. Seventeen patients were excluded because of insufficient data or because they received postoperative radiation therapy. RESULTS: Eleven (28%) of 39 patients had cancer involvement of at least one margin. Two (8%) of 28 patients with negative margins and six (55%) of 11 patients with positive margins had recurrence. This difference in tumor recurrence is statistically significant. The mean disease-free interval prior to recurrence was 25 months, with no significant difference between the two groups. The mean follow-up periods for patients with positive vs negative margins were not statistically significant. There were no significant differences in survival estimates between patients with positive margins and those with negative margins. CONCLUSIONS: Despite a sevenfold increase in tumor recurrence rates for patients with positive margins after hemilaryngectomy, there was no adverse effect on overall survival when these patients were managed with close follow-up and salvage surgery with or without postoperative radiation therapy for tumor recurrence.

Superior laryngeal nerve injury from thyroid surgery.

BACKGROUND: Injury to the recurrent laryngeal nerve is a well-recognized complication of thyroid surgery. Injury to the superior laryngeal nerve is less documented, perhaps due to the difficulty in recognizing its manifestations. This study was designed to document the incidence of injury to the superior laryngeal nerve in a series of patients who underwent thyroidectomy. METHODS: Twenty consecutive patients with thyroidectomy during a 9-month period underwent evaluation for superior laryngeal nerve injury 3 months postoperatively. Methods for evaluation included laryngeal videostroboscopy, laryngeal electromyography, and a subjective interview. RESULTS: One patient (5%) was diagnosed with unilateral superior laryngeal nerve injury. CONCLUSIONS: The risk of injury to the superior laryngeal nerve during thyroidectomy is significant, and the result may be devastating to those patients who rely on their voices professionally. Laryngeal videostroboscopy and electromyography may be necessary to diagnose superior laryngeal nerve injury.

Transhyoid resection of tongue base and tonsil tumors.

Advanced lesions of the oropharynx are known to have increased survival with surgical excision combined with radiation therapy. Traditional surgery involves either a mandibular resection or, more recently, a mandibular sparing approach primarily through a lip-splitting incision. At our institution posterior oropharyngeal lesions are approached via a combined intraoral and transhyoid technique. Nineteen sequential procedures using this approach were compared with a similar number of previous, stage-matched controls in an attempt to obtain valid comparable information. No significant difference between the groups was noted with respect to surgical margins. A significant difference was, however, seen with respect to the need for flap closure with none required in the transhyoid group and five in the mandibulotomy group. Furthermore, a statistical difference was observed with respect to the presence of significant complications in favor of the transhyoid group. These results indicate that similar cure rates can be achieved with lower morbidity by use of a transhyoid pharyngotomy approach to tumors of the oropharynx.

Tracheal reconstruction using an epithelial equivalent.

The application of a rapidly vascularized epithelial equivalent that inhibits wound contraction would have great potential in the prevention and repair of tracheal stenosis. An animal model was developed to simulate the effects of circumferential tracheal injury and an autologous epithelial equivalent was created from a fibroblast-collagen matrix and subsequently implanted in the traumatized site in an attempt to prevent stenosis. Postinjury physiologic and histologic evaluation revealed near-normal mucosal flow analysis in the treated sites and an area of less than 20% stenosis versus 95+% in controls. This study's findings indicate that tracheal stenosis can be limited by the use of an epithelial equivalent.

Analysis of air flow patterns in the human nose.

The nasal cavity is the main passage for air flow between the ambient atmosphere and the lungs. A preliminary requisite for any investigation of the mechanisms of each of its main physiological functions, such as filtration, air-conditioning and olfaction, is a basic knowledge of the air-flow pattern in this cavity. However, its complex three-dimensional structure and inaccessibility has traditionally prevented a detailed examination of internal in vivo or in vitro airflow patterns. To gain more insight into the flow pattern in inaccessible regions of the nasal cavity we have conducted a mathematical simulation of asymmetric airflow patterns through the nose. Development of a nose-like model, which resembles the complex structure of the nasal cavity, has allowed for a detailed analysis of various boundary conditions and structural parameters. The coronal and sagittal cross-sections of the cavity were modeled as trapezoids. The inferior and middle turbinates were represented by curved plates that emerge from the lateral walls. The airflow was considered to be incompressible, steady and laminar. Numerical computations show that the main air flux is along the cavity floor, while the turbinate structures direct the flow in an anterior-posterior direction. The presence of the turbinates and the trapezoidal shape of the cavity force more air flux towards the olfactory organs at the top of the cavity.