Survival and quality of life in oropharyngeal cancer patients treated with primary chemoradiation after salivary gland transfer.

OBJECTIVES: Salivary gland transfer surgery can reduce xerostomia in oropharyngeal squamous cell carcinoma patients undergoing primary chemoradiation. A potential drawback of salivary gland transfer is the treatment delay associated with the surgery, and its complications. This study aimed to determine whether the treatment delay affects patient survival and to evaluate patient quality of life after salivary gland transfer. METHODS: A retrospective analysis of 138 patients (salivary gland transfer group, n = 58; non-salivary gland transfer group, n = 80) was performed. Patient survival was compared between these groups using multivariate analysis. Salivary gland transfer patients were further evaluated for surgical complications and for quality of life using the head and neck module of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire. RESULTS: Salivary gland transfer and non-salivary gland transfer patients had comparable baseline clinical characteristics. Salivary gland transfer patients experienced a median treatment delay of 16.5 days before chemoradiation (p = 0.035). Multivariate analysis showed that this did not, however, correspond to a survival disadvantage (p = 0.24 and p = 0.97 for disease-free and disease-specific survival, respectively). A very low complication rate was reported for the salivary gland transfer group (1.7 per cent). Questionnaire scores for the item 'xerostomia' were very low in salivary gland transfer patients. CONCLUSION: The treatment delay associated with salivary gland transfer surgery does not negatively affect patient survival. Oropharyngeal squamous cell patients have an excellent quality of life after salivary gland transfer.

Merkel cell carcinoma of the head and neck: poorer prognosis than non-head and neck sites.

BACKGROUND: Merkel cell carcinoma is a rare, aggressive neurocutaneous malignancy. This study investigated whether patients with Merkel cell carcinoma in the head and neck had poorer outcomes than patients with Merkel cell carcinoma located elsewhere. METHODS: A retrospective study was performed of patients with Merkel cell carcinoma treated at the Jewish General Hospital in Montréal, Canada, from 1993 to 2013. Associations between clinicopathological characteristics and disease-free and disease-specific survival rates were examined according to the Kaplan-Meier method. RESULTS: Twenty-seven patients were identified. Although basic clinicopathological characteristics and treatments were similar between head and neck and non-head and neck Merkel cell carcinoma groups, disease-free and disease-specific survival rates were significantly lower in the head and neck Merkel cell carcinoma group (log-rank test; p = 0.043 and p = 0.001, respectively). Mortality was mainly due to distant metastasis. CONCLUSION: Patients with head and neck Merkel cell carcinoma had poorer survival rates than patients with non-head and neck Merkel cell carcinoma in our study. The tendency to obtain close margins, a less predictable metastatic pattern, and/or intrinsic tumour factors related to the head and neck may explain this discrepancy.

Computerized tomography based tumor-thickness measurement is useful to predict postoperative pathological tumor thickness in oral tongue squamous cell carcinoma.

BACKGROUND: Tumor thickness has been shown in oral tongue squamous cell carcinoma (OTSCC) to be a predictor of cervical metastasis. The postoperative histological measurement is certainly the most accurate, but it would be of clinical interest to gain this information prior to treatment planning. This retrospective study aimed to compare the tumor thickness measurement between preoperative, CT scan, and surgical specimens . METHODS: We retrospectively included 116 OTSCC patients between 2001 and 2013. Thickness was measured on computer tomography imaging and again surgical specimens. RESULTS: The median age was 66 years. 62.8 % of patients were smokers with a mean of 31.4 pack-years. Positive nodal disease was reported in 41.2 %. Mean follow-up time was 33.1 months. The correlation between CT scan-based tumor thickness and surgical specimens based thickness was significant (Spearman rho = 0.755, P < 0.001). CONCLUSION: Tumor thickness assessed by CT scan may provide an accurate estimation of true thickness and can be used in treatment planning.

A survey on pulmonary screening practices among otolaryngology-head & neck surgeons across Canada in the post treatment surveillance of head and neck squamous cell carcinoma.

BACKGROUND: Post treatment lung screening for head and neck cancer patients primarily focuses on the distant metastasis and a high rate of second primary can also be expected. The best screening tool and timing for this purpose is controversial. We sought out to assess the current practice and beliefs among Canadian Head and Neck Surgeons. METHODS: After Ethical Board approval, a nationwide survey was conducted through the Canadian Society of Otolaryngology (CSO) among head and neck surgeons regarding their practices for pulmonary screening in HNSCC patients. RESULTS: Our CSO survey among Otolaryngology-head and neck surgeons showed that 26 out of 32 respondents perform routine lung screen, out of which 23 (88%) feel that chest radiography should be preferred. The majority of respondents felt that lung screening could impact beneficially on mortality. For symptomatic patients, low-dose spiral CT was the preferred modality (48%), followed by PET/CT scan (14%) and sputum cytology (14%). In high-risk asymptomatic patients (current smoker, radiation exposure, family history and advanced HNSCC), 31% of respondents performed a CXR. The same percentage performed a low dose CT, while 19% relied on PET scan. A further 19% of respondents did not perform any screening in high-risk patients. Most respondents (77%) had more than 10 years practice since graduation from medical school and came from the provinces of Quebec, Ontario and Alberta. CONCLUSION: Chest radiography remains the preferred modality for lung screening and was believed to be impacting beneficially on lung mortality. The recent literature does not seem to be in agreement with those beliefs. Further studies to establish which modality is best and concurrent nation-wide education are warranted.

Narrow band imaging of nasopharynx to identify specific features for possible detection of early nasopharyngeal carcinoma.

BACKGROUND: Narrow band imaging (NBI) features of normal and early nasopharyngeal carcinoma (NPC) have not been clearly described. The main purpose of this study was to define NBI features in the nasopharynx in the detection of early NPC. METHODS: We conducted a prospective cohort study of 53 patients who underwent NBI endoscopy to describe its specific features. RESULTS: Among 19 normal patients, common NBI features were discrete brown spots (100%) and regular polygonal follicular pattern of nasopharyngeal mucosa (90%). The features of 15 patients with NPC were loss of normal polygonal follicular architecture of nasopharynx (100%), concentrated brown spots (93%), and pale pink areas (80%). In the 19 post-NPC radiation patients, common features were patches of intense brown-green spots (100%), loss of polygonal follicular pattern of nasopharyngeal mucosa (95%), and discrete microvasculature branches (95%). CONCLUSION: There are discernible NBI features between normal mucosa and an exophytic NPC mass. This can form the basis of a prospective screening program to detect early NPC using NBI.

Laryngotracheal rhinosporidiosis.

Rhinosporidiosis is a chronic granulomatous disease caused by Rhinosporidium seeberi. It usually affects mucous membranes of the nose, nasopharynx, and ocular conjunctiva. Cutaneous, laryngeal, tracheal, genital, and bony dissemination is rare. Laryngotracheal involvement poses many diagnostic and therapeutic challenges. A 45-year-old South Indian man presented with complaints of a mass in both nostrils for 2 years, associated with progressive hoarseness of voice and difficulty in breathing for 6 months. Rhinosporidial lesions were seen bilaterally in the nasal cavity. Telescopic and fiberoptic laryngoscopic examinations showed reddish, strawberry-like masses with whitish spots on their surface involving the larynx and trachea. Computed tomography of the head and neck revealed soft-tissue mass lesions involving the bilateral nasal cavities and nasopharynx, extending to the oropharynx and involving the larynx and trachea. A preliminary tracheostomy was performed, followed by direct laryngoscopic excision of the laryngeal lesions and rigid-bronchoscopy-guided excision of the tracheal lesions. The patient was prescribed dapsone and advised to take it for 2 years. At 2 years of follow-up, there was no recurrence.

Embryogenic cervico-thyro-piriform tract.

Branchial cleft fistulae are rare congenital anomalies that arise from the abnormal persistence of branchial remnants. Branchial arch anomalies are rare. They usually present as a lateral neck mass or abscess in the form of acute suppurative thyroiditis. A complete fistula of the third arch is extremely rare. We describe such a case in a 13-year-old girl who presented with a small opening in the left lower neck, from which a mucoid discharge had been present since birth. The fistula was accompanied by recurrent neck swelling. Computed tomography with contrast injection into the external skin opening revealed a continuous tract that extended to the base of the piriform sinus. Total excision of the tract up to the piriform sinus with a left hemithyroidectomy was performed. At follow-up 28 months postoperatively, the patient exhibited no evidence of recurrence.

Giant tracheocele with multiple congenital anomalies.

Tracheocele--an outpouching of tracheal mucous membrane--is an uncommon entity. It can occur as a congenital or acquired form. The congenital entity remains mostly dormant until adulthood, and then it typically presents as a herniation with multiple air-filled sacs. The acquired form develops as the result of blunt trauma, recurrent pulmonary infection, intubation, instrumentation, or surgery, and it typically presents as a single paratracheal cavity. We present an extremely rare case of a tracheocele associated with multiple congenital anomalies involving the face, limbs, and heart.

Retrospective case review of pyriform sinus fistulae of third branchial arch origin commonly presenting as acute suppurative thyroiditis in children.

OBJECTIVE: Abnormalities of the third branchial arch are less common than those of the second arch and usually present with left thyroid lobe inflammation. This paper describes 15 cases of pyriform sinus fistulae of third branchial arch origin usually presenting as recurrent thyroid abscess on the left side. METHOD: A retrospective review of 15 cases of third arch fistulae managed 2000 and 2008, diagnosed based on histopathology and radiological evidence of a fistulous tract, and treated with fistulectomy with left hemithyroidectomy. RESULTS: All patients (six boys and nine girls, aged three to 15 years) presented with recurrent low neck inflammation. Pre-operative ultrasound, computed tomography fistulography and barium swallow demonstrated a third arch fistulous tract, left-sided in all cases. The fistula was detected intra-operatively and pathologically in all cases. Surgery (successful in all cases) emphasised complete recurrent laryngeal nerve and ipsilateral pyriform sinus exposure, to facilitate tract excision, with left hemithyroidectomy. There was no recurrence over three to five years' follow up. CONCLUSION: Paediatric recurrent low neck inflammatory episodes, due to thyroidal abscess, especially left-sided, should raise suspicion of pyriform sinus fistulae.

Primary extranodal T-cell non-Hodgkin lymphoma of the tongue.

The most common sites of extranodal non-Hodgkin lymphoma (NHL) are the gastrointestinal tract and the head and neck region. Head and neck involvement accounts for 8 to 13% of all extranodal lymphomas. Primary NHLs of the oral cavity, especially in the tongue, are extremely rare, which makes it difficult to understand their biologic behavior. Extranodal NHLs of the tongue usually present as a nodular lesion of the B-cell type. The T-cell variant of tongue NHL with an ulcerated exophytic presentation is extremely rare. We report such a case in a 37-year-old woman.

Simultaneous occurrence of a thyroglossal duct cyst and a lingual thyroid in the absence of an orthotopic thyroid gland.

OBJECTIVE: We report an extremely rare case of the simultaneous occurrence of a thyroglossal duct cyst and a lingual thyroid in the absence of an orthotopic thyroid gland, in a seven-year-old girl from South India. METHOD: Case report and a review of the English language literature on the subject. RESULTS: The patient presented with a mass on the tongue that had been present for three years, and an anterior neck swelling that had been present for two years. Examination revealed a midline, pinkish, firm mass present on the posterior one-third of the tongue. The neck showed a midline cystic swelling in the infrahyoid position. Radiological imaging confirmed the clinical findings, revealing the absence of her thyroid gland in the normal location. Sistrunk's procedure was performed leaving behind a lingual thyroid. At 13-month follow up, the patient was euthyroid with no recurrence. CONCLUSION: To our knowledge the association of a lingual thyroid and a thyroglossal cyst has only been reported once in the literature. The presence of a lingual thyroid in the absence of a normally located thyroid gland or functioning thyroid tissue along the thyroglossal tract, confirmed by radionuclide and computed tomography imaging, may indicate the failure of the normal descent of the thyroid gland during embryonic development. This probable absence of the descent of the thyroid raises questions regarding the origin of thyroglossal duct cysts.

Development of hemangioma in a tongue harboring long-standing angiokeratoma circumscriptum.

Angiokeratoma is a very rare vascular lesion of the papillary dermis. It is characterized by vascular ectasia with overlying epidermal hyperkeratosis. The systemic form of angiokeratoma is associated with Fabry disease and fucosidosis. There are several localized forms. Tongue involvement is uncommon. Hemangiomas are tumors made up of capillaries; they grow by active endothelial proliferation as opposed to expansion of vascular spaces in vascular malformations. Lingual hemangiomas are usually indolent, but they can cause cosmetic deformities, recurrent hemorrhage, and functional problems with speaking, mastication, and deglutition. We report a case of angiokeratoma of the tongue with an underlying hemangioma in a 30-year-old woman. Angiokeratomas have been reported to develop over arteriovenous malformations and in the area of lymphangioma circumscriptum following repeated local trauma. To the best of our knowledge, the development of a lingual hemangioma in a patient with long-standing angiokeratomatous lesions has not been previously reported in the literature.

Primary frontal sinus carcinoma with extradural anterior cranial fossa involvement.

Paranasal sinus carcinoma is rare, with an estimated annual incidence of less than 1 per 100,000 population. Primary frontal sinus involvement is extremely rare, accounting for only 0.3% of all paranasal sinus malignancies. A frontal sinus cancer may be mistaken for a mucocele, pyocele, or osteomyelitis. We report the case of a 48-year-old woman with a carcinoma that originated in the frontal sinus. Computed tomography and magnetic resonance imaging demonstrated bony destruction with intracranial extension but no involvement of the bulbus. The patient underwent a frontal craniotomy, tumor excision, and postoperative radiotherapy. One year later, she remained symptom-free.

Microbiological profile with antibiotic sensitivity pattern of cholesteatomatous chronic suppurative otitis media among children.

INTRODUCTION: Chronic suppurative otitis media (CSOM) is the most common cause of childhood hearing impairment in the developing countries and atticoantral type is associated with increased incidence of intracranial and extracranial complications. This study was undertaken to define the microbiology of atticoantral type of chronic otitis media and the antibiotic sensitivity pattern, thereby reducing the potential risks of complications. MATERIALS AND METHODS: A retrospective study was done in the Department of Otolaryngology, JIPMER, Puducherry from the year August 2003 to October 2009 using the medical record department database to retrieve the patient details. During this study period, 223 children with atticoantral type CSOM consisting of 126 males and 97 females with an age range of 1-14 years were assessed. Patients with persistent otorrhea for more than 3 months with atticoantral type of chronic otitis media were selected. The exudates were collected under sterile conditions and inoculated onto culture media; bacterial growth and antibiotic sensitivity pattern were studied. RESULTS: Nine species of micro organisms were isolated from the middle ear aspirate, Pseudomonas aeruginosa being the most predominant isolate constituting about 32% (72 discharging ears) of the total isolates followed by Proteus mirabilis (20% of isolates) and Staphylococcus aureus (19% of isolates). Gram negative organisms accounted 58% of total isolates and gram positive organisms constituted 22% isolates. Candida albicans and methicillin resistant S. aureus were identified in 4% and 2% of isolates, respectively. 100% of Pseudomonas isolates showed susceptibility to ceftazidime and a high sensitivity (92% of isolates) to ciprofloxacin and 88% isolates were sensitive to amikacin. 100% of P. mirabilis isolated from inoculates showed sensitivity to ceftazidime and ciprofloxacin. It also showed 87-97% sensitivity to ceftriaxone, amikacin and ampicillin. All (100%) of the Staphylococcus isolates were sensitive to vancomycin and 84-86% were sensitive to ciprofloxacin and erythromycin. In general, gram negative organisms showed increased sensitivity to ceftazidime, ciprofloxacin and amikacin, while gram positive organisms to vancomycin, erythromycin and ciprofoxacin. CONCLUSION: Continuous and periodic evaluation of microbiological pattern and antibiotic sensitivity of cholesteatomatous CSOM is necessary to decrease the potential risks of complications by early institution of appropriate systemic and topical antibiotic alongside mastoid exploration. We believe that our data may contribute to an effective medical management of chronic suppurative otitis media with cholesteatoma. Since the most common organisms in our clinical set up being P. aeruginosa, P. mirabilis and S. aureus, which showed a percentage susceptibility of 100% to ceftazidime and vancomycin, thus making it an empirical antibiotic combination therapy of choice in the recent times.

Recurrent neck infection with branchial arch fistula in children.

OBJECTIVE: Acute suppurative neck infections associated with third or fourth branchial arch fistulas are frequently recurrent. Third and fourth branchial arch anomalies are much less common than those of second arch and usually present with left thyroid lobe inflammation. The authors present their experience with 15 cases of pyriform sinus fistulae (PSF) of third branchial arch origin and 3 cases of fourth arch origin, all of which presented as recurrent neck infection mainly on the left side. METHODS: A retrospective review of 18 cases of third and fourth arch fistulae treated at JIPMER from 2005 to 2010. This study includes 18 patients with PSF diagnosed by the existence of fistulous tract radiologically and intraoperatively with pathological correlation. Neck exploration with excision of tract and left hemithyroidectomy was performed in all cases. RESULTS: The patients consisted of 7 males and 11 females, and the ages ranged from 3 to 15 years. All of them presented with recurrent episodes of neck infection. Investigations performed include computed tomography (CT) fistulography, barium swallow and ultrasound which were useful in delineating pyriform sinus fistulous tract preoperatively. All cases were on the left side and the fistula was identified by barium swallow in 14 cases (80%), while intraoperative and pathologic confirmation of the tract was possible in all cases (100%). Neck exploration with an emphasis on complete exposure of the recurrent laryngeal nerve and exposure of the pyriform sinus opening to facilitate complete fistulous tract excision with left hemithyroidectomy was successful in all patients. A follow up period of 1-3 years showed no recurrence. CONCLUSION: Recurrent neck infection in a child should alert the physician to the possibility of an underlying pyriform sinus fistula of branchial origin and CT fistulography should be performed after the resolution of the neck infection to delineate the tract anatomically.

Rhinosporidiosis of the upper airways and trachea.

OBJECTIVE: We report an extremely rare case of rhinosporidiosis with involvement of both larynx and trachea, together with coexisting nasal, nasopharyngeal and oropharyngeal lesions, in a 32-year-old man. METHOD: Case report and review of the world literature concerning laryngotracheal and disseminated rhinosporidiosis. RESULTS: A 32-year-old, South Indian man presented with a nasal mass of four years' duration, with progressive hoarseness for one year. Strawberry-like rhinosporidial masses were seen in both nasal cavities. Fibre-optic laryngoscopic examination revealed reddish masses with whitish surface specks, involving the glottis, subglottis and trachea. Computed tomography revealed soft tissue opacities involving both nasal cavities and the nasopharynx and extending to the oropharynx, with involvement of the larynx and trachea. Direct laryngoscopy and rigid bronchoscopy guided excision of the laryngeal and tracheal lesions was performed. CONCLUSION: Rhinosporidiosis is a chronic, granulomatous disease which usually affects the mucous membranes of the nose and nasopharynx. Lower dissemination into the trachea is extremely rare. Laryngotracheal involvement poses many diagnostic and therapeutic challenges, due to the potential risk of bleeding and aspiration. In the presented case, local spread of rhinosporidiosis, due to direct spillage of spores from the nasopharynx into the larynx during episodes of bleeding or previous surgery, may have resulted in laryngotracheal involvement, although systemic spread cannot be excluded.

Longstanding malformation of right sided pinna in an elderly man.

The pinna is the second most common site for external ear vascular malformation in the head and neck. These malformations are relatively uncommon in adults and can pose difficult therapeutic challenges. We hereby present a case of a 69-year-old man with a congenital lesion in the right pinna consistent with an arteriovenous malformation. The lesion was complicated by ulceration and bleeding for 6 months prior to presentation. Resection of pinna was carried out, and satisfactory functional and esthetic results were obtained. There was no recurrence at 22 months of regular follow up.

Complete congenital third branchial fistula with left-sided, recurrent, suppurative thyroiditis.

OBJECTIVE: We report an extremely rare case of a complete congenital third branchial arch fistula in a nine-year-old boy. METHOD: A case report and a review of the English literature concerning third branchial arch fistula of congenital origin are presented. RESULTS: A nine-year-old boy presented with a history of a small opening in the middle third of the anterior neck since birth, with recurrent surrounding swelling. There was no history of surgical drainage or spontaneous rupture. Computed tomography with contrast injection into the external cervical opening revealed a patent tract from the neck skin to the base of the pyriform sinus. Complete excision of the tract up to the pyriform sinus with left hemithyroidectomy was performed. Follow up at 22 months showed no recurrence. CONCLUSION: To our knowledge, this case represents a very rare occurrence of the congenital variety of complete third branchial arch fistula at an unusual site. This case indicates that third branchial arch fistula can be complete, and may present in the anterior neck, an unusual site. In such cases, computed tomography fistulography and injection of dye into the pyriform sinus enables intra-operative delineation of the tract.

Giant congenital auricular arteriovenous malformation.

Arteriovenous malformation (AVM) is an uncommon vascular anomaly usually present in intracranial location, however may be present in other sites of the body, mostly in the head and neck region. The lesion may be present since birth or caused by trauma, but may become obvious during puberty or pregnancy. The diagnosis can be confirmed by selective angiography. Treatment usually includes super selective embolization followed by surgical excision within 48 h. We hereby present a rare case of a grotesquely disfiguring congenital auricular arteriovenous malformation in a 77-year-old elderly man, which has recently been complicated by ulceration, infection and hemorrhage in the past 6 months. The pinna showed a 15 cm x 8 cm pulsatile, erythematous, ulcerative hemorrhagic swelling which on angiography revealed tortuous superficial temporal and occipital arteries supplying the lesion. Complete auricular excision with split skin grafting was carried out. The option of preoperative embolization was not considered due to his renal dysfunction and the high dye load required for embolizing the fast flow arteriovenous malformation.