A novel CD44 v3 isoform is involved in head and neck squamous cell carcinoma progression.

OBJECTIVES: CD44 comprises a family of isoforms involved in tumorigenesis. Here we investigate the role of CD44 isoforms in head and neck squamous cell carcinoma (HNSCC) progression. MATERIALS AND METHODS: HNSCC specimens underwent reverse transcriptase-polymerase chain reaction (RT-PCR) followed by Southern blot analysis. After surface biotinylation, FaDu (hypopharyngeal HNSCC) and CD44v3-transfected COS-7 cells were CD44 antibody-precipitated and compared by Western blot analysis. FaDu cells underwent double immunofluorescence staining and growth assays. RESULTS: Southern blot analysis suggested differential CD44v3 isoform expression in tumor and normal tissue. Cloning and sequencing revealed 2 novel CD44v isoforms. Western blot analysis suggested CD44v3 expression in COS-7 transfectants and FaDu. Double immunofluorescence staining revealed co-localization of CD44v3 and actin in FaDu projections. Anti-CD44v3 antibody decreased FaDu growth. CONCLUSION: HNSCC tissue and FaDu appear to express CD44v3 isoforms. These isoforms may promote tumorigenesis. CLINICAL SIGNIFICANCE: CD44v3 isoforms may be effective tumor markers and targets for HNSCC therapy.

Endoscopic sinus surgery in previously irradiated patients.

PURPOSE: Our purpose was to evaluate the safety and efficacy of endoscopic sinus surgery in irradiated patients with absolute indications for sinus surgery. PATIENTS AND METHODS: During 5 years at a tertiary referral center, more than 200 patients received irradiation to a field that included the paranasal sinuses. Complaints related to the sinuses are common in such patients and often include crusting and increased mucus drainage. Six patients presented with significant sinus infections in the absence of tumor recurrence and failed medical management. Additional problems included epiphora and nasal obstruction caused by cicatricial choanal stricture. Surgical interventions included ethmoidectomy, multiple osteotomies, debridement of scarred or devitalized tissue, and dacryocystorhinostomy. Outcome measures included intraoperative findings and complications, length of hospital stays, endoscopic assessments of the healing over 6 months post-operatively, and improvement or persistence of symptoms over 2 to 3 years of follow-up. RESULTS: Surgery can be technically difficult because of derangements of normal anatomy and dehiscence of important structures. Although bleeding problems, prolonged admission, and delayed healing were noted in certain cases, they did not result in long-term morbidity. CONCLUSIONS: Endoscopic sinus surgery has become an invaluable tool in the treatment of refractory sinusitis. Our literature review has revealed no information, however, regarding endoscopic sinus surgery in previously irradiated patients. Theoretically, such patients are at risk for healing problems and anatomic derangements, which could lead to complications. There is, nevertheless, a theoretical benefit to avoiding external approaches in patients who might heal poorly.

Sensory recovery in melolabial flaps used for oral cavity reconstruction.

Current literature advocates the use of complex reinnervated free flaps to re-establish oral sensation after resection of oral cavity cancers. It has been demonstrated that noninnervated flaps can also re-establish sensation. We assessed the return of sensation in local melolabial flaps used in oral reconstruction. Seven patients underwent sensory testing at intervals from 12 to 18 months after surgery. The ability to distinguish differences in temperature was present in all patients. Spontaneous return of sensitivity to touch was documented by clinical testing in 71% of the patients. Less return of sensation was seen in flaps used for defects of the buccal mucosa relative to the floor of mouth. We conclude that spontaneous return of flap sensation does occur with local melolabial flaps. Given the simplicity of these procedures, melolabial flaps represent a reasonable alternative in floor-of-mouth reconstruction for selected patients.

Octreotide scintigraphy for the detection of paragangliomas.

Paragangliomas are neuroendocrine tumors located primarily in the head and neck region, but they can also occur at other sites. Confirming the preoperative diagnosis and detecting synchronous tumors may be difficult in some patients. Octreotide is a somatostatin analog that, when coupled to a radioisotope, produces a scintigraphic image of tumors expressing somatostatin type 2 receptors. Paragangliomas, like many neuroendocrine tumors, have been found to have a high density of somatostatin type 2 receptors on the cell surface. This study compared the results of preoperative octreotide scintigraphy with the histopathology in 21 patients who underwent surgery for presumed head and neck paragangliomas. Octreotide scan findings were positive in 16 patients with paragangliomas and negative in 3 patients with other pathology. One false-positive and 1 false-negative result were obtained. Thus, this test had an accuracy of 90%, a sensitivity of 94%, and a specificity of 75%. Previously unidentified synchronous tumors were identified in 5 patients. On the basis of this series of patients, octreotide scintigraphy appears to be a reliable test to detect paragangliomas and may be quite helpful in preoperative planning.

Lateral arm microvascular flap in head and neck reconstruction.

OBJECTIVES: To report our results of a study of 28 patients who underwent sequential reconstructions of the head and neck using the lateral arm flap. To discuss the situations where we have found the procedure useful, report the complication rates, and delineate the advantages and disadvantages of using this flap. DESIGN: A clinical series of patients was followed up prospectively. The swallowing function of a subgroup that underwent oropharyngeal reconstruction was compared with that of a simultaneous control group that underwent reconstruction with the pectoralis major flap. SETTING: University medical center. PARTICIPANTS: Patients with malignant neoplasms of the head and neck who underwent resections and reconstruction with the lateral arm flap. INTERVENTIONS: Twenty-eight patients underwent head and neck reconstruction using lateral arm flaps. In 17 patients, the lateral arm flaps were used for pharyngeal and posterior oral cavity defects. Thirteen of these patients underwent reinnervation. Nine combined palatal and midfacial defects were reconstructed, and 1 lateral facial defect was reconstructed. Most cases were advanced malignant neoplasms and represented a selected minority of similar resections performed at our institutions. Three maxillary reconstructions were performed secondarily. All other reconstructions were performed at the time of tumor ablation. MAIN OUTCOME MEASURES: Data were collected regarding flap survival, return of sensation in flaps, complication rates, and the ability to feed orally. RESULTS: All flaps survived in their entirety. Of 7.5 tested flaps acquired sensation. Of 14 patients with large oropharyngeal defects, 8 resumed early oral feeding and all survivors eventually obtained nutrition orally. The ability to swallow was superior to the results obtained in a retrospective analysis of a group reconstructed using pectoralis major flaps. CONCLUSIONS: A unique feature of this flap is that it incorporates both thin skin from the proximal forearm and thicker skin from the upper arm. This is ideal for an oropharyngeal defect, where the thin malleable portion can be used in the posterior oral cavity or pharyngeal wall and the thicker portion in the tongue base. Either portion can be used alone as well. The availability of intermediate tissue bulk can also be advantageous for midfacial reconstruction. Sensation can be reliably reconstituted with this flap. We think that the lateral arm flap is versatile and has particularly low donor-site morbidity.

111In octreotide scintigraphy in the evaluation of head and neck lesions.

PURPOSE: To evaluate indium 111 octreotide scintigraphy for the detection of suspected neuroendocrine lesions of the head and neck. METHODS: After receiving 6 mCi of 111In octreotide, 22 patients with suspected lesions of the head and neck were examined with both planar and single-photon emission CT (SPECT). Static images, obtained at 4 hours, included the head/neck, chest, abdomen, and pelvis. Additional SPECT images were obtained at 4 or 24 hours. Studies were compared with available conventional radiologic examinations (12 CT, 11 MR, and three angiographic studies) as well as with clinical and pathologic findings. RESULTS: Eighteen of the 22 patients had abnormal findings at scintigraphy. Eleven paragangliomas were seen in 10 patients, metastatic medullary thyroid carcinoma in three patients, thyroid adenoma in two patients, and Merkel cell tumor, carcinoid, and plasmacytoma in one patient each. Surgical confirmation was available in 13 patients. The smallest lesion detected was 1.5 cm. There was one false-positive and one false-negative examination. CONCLUSION: 111In octreotide scintigraphy is a useful imaging tool for the detection of primary and metastatic neuroendocrine tumors of the head and neck that are larger than 1.5 cm. This technique enables distinction of glomus tumors from other masses (such as neuromas) and can be used in the postoperative setting to distinguish scar from recurrent paraganglioma. Since it is an examination of the entire body, it has great utility for detecting multicentric paraganglioma and for screening patients with familial paraganglioma.

Rehabilitation of cranial nerve deficits after neurotologic skull base surgery.

Damage to any one of these nerves results in sufficient morbidity to warrant therapy; however, most patients will compensate for isolated loss of function. It is with multiple nerve injuries, as often seen in glomus surgery with the resection of cranial nerves IX, X, and XII that the full efforts of the rehabilitation team are called on. After vocal cord medialization and palatal adhesion, younger healthier patients will eventually resume adequate oral intake. However, the time it requires to return to a reasonably enjoyable diet often extends up to 1 year postoperatively. A few never attain the goal of enjoyable intake and continue to struggle to maintain adequate nutrition. The latter situation is the rule, not the exception, in the elderly population. Our experience over the years has led us to a more conservative treatment of glomus tumors in the elderly debilitated patient.

Silastic medialization and arytenoid adduction: the Vanderbilt experience. A review of 116 phonosurgical procedures.

From April 1987 to April 1992, 116 phonosurgical procedures were performed to treat glottal incompetence. The initial numbers of these surgical procedures included the following: 29 primary Silastic medializations, 3 primary Silastic medializations with arytenoid adduction, 53 secondary Silastic medializations, 4 secondary Silastic medializations with arytenoid adduction, and 11 bilateral Silastic medializations. These procedures are useful in treating unilateral true vocal cord paralysis, scarring, bowing, or paresis, as well as bilateral true vocal cord bowing. Of the initial 100 patients, 16 later underwent a revision with either a larger implant's being placed or an arytenoid adduction. Primary Silastic medialization is the placement of an implant under general anesthesia in the same surgical setting in which laryngeal innervation is sacrificed. Secondary Silastic medialization is the placement of an implant under local anesthesia for a preexistent vocal cord malfunction. In either case, overall voice results for unilateral paralysis are very good. Primary Silastic medialization significantly decreases the postoperative rehabilitation period in skull base patients because of the immediate postoperative glottal competence and decreased use of perioperative tracheotomy. Bilateral implants yielded good results in 6 patients with presbylaryngis, but 6 other patients with bowing from other causes experienced only moderate improvement in speech quality. There were no implant extrusions; however, 1 implant was removed secondary to a persistent laryngocutaneous fistula in a patient who had previously undergone laryngeal irradiation. This was the only complication in this series.

Laryngoceles and saccular cysts in infants and children.

Laryngoceles and saccular cysts are an unusual cause of respiratory obstruction in infants and children. Laryngoceles in particular are less common in the pediatric population than in adults. They typically produce intermittent upper airway obstruction and hoarseness (due to episodic filling with air), and are, therefore, difficult to diagnose. Saccular cysts produce similar symptoms but are not episodic. While smaller anterior saccular cysts are readily managed by endoscopic excision, larger saccular cysts tend to recur repeatedly. Review of experience with 20 infants and children having saccular pathologic changes (17 saccular cysts and three laryngoceles) suggests that saccular lesions are more troublesome than is generally appreciated. The clinical course is typically a lengthy one, with multiple endoscopic procedures. Most patients required tracheotomy, some under emergent conditions. Three patients acquired subglottic stenosis; one was clinically significant. A fourth patient had a congenital subglottic stenosis. Saccular cysts can be managed endoscopically in many cases, but if persistent after two or three endoscopic procedures, a prolonged course can be anticipated. Complete excision, endoscopically or through an external surgical approach, may shorten the clinical course.