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When cancer spreads to both sides of the neck, as occurs in approximately 5 percent of head and neck cancers, it is considered an ominous sign. A bilateral neck dissection is often used as a means of controlling and, in some cases, curing the disease. In this surgical procedure the main muscles on the sides of the neck and the soft tissue, including the lymph nodes and the jugular veins, are removed in a single bloc of tissue. The main arterial supply, the carotid system, is left intact. Venous drainage, previously served by the removed jugular system, is conveyed by a complex interconnection of veins including those around the vertebral column. A case history describes a 49-year-old male with cancer of the larynx (voice box) that spread to the lymph nodes on both sides of the neck. The patient underwent a total laryngectomy (removal of the larynx). Following the operation his recovery was relatively normal, but four months later the disease had spread to the lymph nodes. A bilateral neck dissection was performed and the patient recovered well from the immediate effects of the surgery with the exception of severe facial swelling, which was great enough to close the patient's eyes. Examination of the eyes indicated increased pressure of the cerebral spinal fluid (CSF), but no signs of damage to the blood vessels of the retina was found. A spinal tap performed the following day confirmed the suspicion of elevated CSF pressure. The facial edema slowly resolved, and although the patient has become completely blind, he remains otherwise well. This case history suggests that the loss of sight was secondary to the elevated CSF pressure; it is hypothesized that the CSF pressure elevation may have been due to increased venous pressure within the skull (cavernous sinus) when venous blood was not adequately drained by the vertebral plexus of veins. The case points out that blindness is an infrequent, but truly devastating potential complication of bilateral neck dissection. (Consumer Summary produced by Reliance Medical Information, Inc.)

Abstract This is the first study quantitatively measuring tongue motion in 3D after in vivointraoperative neurostimulation of the hypoglossal nerve and its branches during a neck dissection procedure. Firstly, this study is performed to show whether this set-up is suitable for innervating different muscles or muscle groups with an identifiable corresponding motion pattern by stimulating the main stem and the visible branches and by performing an intra-patient comparison over the captured 3D trajectories. Secondly, an inter-patient comparison is performed to analyse if similar branches lead to comparable movements of the tongue tip. Our results showed the measurement set-up works, and that we are able to capture distinguishable trajectories for different branches. The inter-patient comparison showed a poor match in trajectories for similar branches, which could be an indication of the presence of several anatomical variations between individuals.

Recent innovations such as preoperative SPECT/CT, intraoperative imaging using portable devices and a hybrid tracer were evaluated in a multimodality approach for sentinel node (SN) mapping and biopsy in head and neck malignancies.

Primary prosthetic voice restoration by performing tracheoesophageal puncture (TEP) and immediate insertion of a voice prosthesis at the time of total laryngectomy (TLE) is presently the method of choice. This enables the easiest and most comfortable voice rehabilitation with the patient still under general anesthesia when the first prosthesis is inserted. Reconstruction of the pharynx with e.g. free revascularized or pedicled flaps does not preclude surgical prosthetic voice restoration. The TEP can even be done as a primary procedure after total laryngectomy and total pharyngectomy when the full circumference of the neopharynx has to be reconstructed, provided the esophagus is still present at the level of the trachea. Since indwelling devices may have a more robust construction, their device-life generally is longer than that of their non-indwelling counterparts. Indwelling devices have the unique advantage in that patient's dexterity plays a lesser role in the daily maintenance of the device. With a few refinements in the surgery of TLE several postlaryngectomy problems can be avoided or diminished such as hypertonicity of the pharyngoesophageal (PE) segment and a poor contour of the stoma. The combination of Heat and Moisture Exchanger (HME) and indwelling voice prosthesis contributes to a significant improvement of both pulmonary function and voice quality. The solution of the majority of prosthesis and TE-fistula related problems by the well trained physician, make prosthetic voice restoration a safe procedure.

Aims:To investigate the results of our treatment policy, we present our institutional experience in the management of regional neck node metastases of cutaneous head and neck squamous cell carcinoma (CHNSCC).

Aims: Cervical metastases of adenocarcinoma or undifferentiated large cell carcinoma (ULCC) (non-squamous cell carcinoma) of unknown primary origin are rare and often accompanied by distant metastases at multiple sites in the body. Nevertheless, in the past decades, several patients have presented in our clinic with isolated neck metastases of this type of malignancy. The aim of our study is to evaluate the clinical behaviour of these cases and to define the role of surgery and radiotherapy. Methods: Over the past 24 years, we selected 15 out of 270 patients (6%) with isolated cervical lymph node metastases of adenocarcinoma (six) or ULCC (nine) of unknown primary origin. Diagnosis was made either by histology or by fine needle aspiration cytology. Treatment consisted of (selective) neck dissection and/or radiotherapy. Results: The clinical presentation of isolated cervical metastases of adenocarcinoma compared with ULCC is equivalent, with an overall median survival time of 25 months (confidence interval 21–29 months). Combined therapy was correlated with an increased and persistent regional control and was associated with longer duration of survival. Conclusions: Patients with isolated cervical neck node metastases of adenocarcinoma or ULCC of unknown primary origin are rare and the diagnostic process to identify this subgroup requires a systemic work-up. In selected cases treatment should concentrate on (selective) neck dissection combined with radiotherapy to achieve a prolonged survival.

Tobacco smoking is a major risk factor for oral cancer; mouth floor and buccal mucosa are among the most and least cancer‐prone subsites, respectively, in the oral cavity. We investigated the applicability of immunohistochemistry of smoking‐induced DNA adducts in oral cells for assessing the exposure to carcinogens, and estimating the risk for oral cancer. Polycyclic aromatic hydrocarbon (PAH)‐DNA adducts were measured in mouth floor and buccal mucosa cells of smokers (n = 26) and nonsmokers (n = 22) by means of a semiquantitative immunoperoxidase assay. Smokers had elevated levels of PAH‐DNA adducts compared to nonsmokers in their mouth floor cells (0.045 ± 0.022 versus 0.022 ± 0.016, P= 0.0008 arbitrary units of immunohistochemistry) as well as in their buccal mucosa cells (0.058 ± 0.028 versus 0.028 ± 0.012, P= 0.001). Also, there was a correlation between the levels of PAH‐DNA adducts in mouth floor cells and those in buccal mucosa cells (r= 0.4, P= 0.01). Furthermore, PAH‐DNA adduct levels in both mouth floor and buccal mucosa cells were significantly related to current smoking indices (amount of tar and number of cigarettes consumed per day). Expectedly, the levels of PAH‐DNA adducts neither in mouth floor cells nor in buccal mucosa cells, both being short‐lived cells, were related to smoking history index (pack years). The levels of PAH‐DNA adducts, however, in mouth floor cells as the cancer prone cells were lower than those in buccal mucosa cells (0.037 ± 0.023 versus 0.044 ± 0.026, P= 0.04). We conclude that immunohistochemistry of PAH‐DNA adducts in oral cells can be used for exposure assessment of tobacco‐related carcinogens, however, it cannot be used for oral cancer risk estimation. Environ. Mol. Mutagen. 36:127–133, 2000. © 2000 Wiley‐Liss, Inc.

In previous studies investigating the influence of a heat and moisture exchanger on the respiratory and psychosocial problems of laryngectomized patients, the value of regular use of such a device could clearly be established. However, the compliance with the use of these devices was not optimal, mainly due to problems related to the plaster and to the often troublesome combination of these HMEs with a voice prosthesis. Therefore, a prospective, clinical trial was undertaken to investigate whether the use of a newly developed heat and moisture exchanger (HME, Provox® stomafilter) could improve the acceptibility of such a device. In total, 19 patients participated in this study, 13 men and six women. Vocal rehabilitation was achieved with a Provox® voice prosthesis in all patients. Each of the patients was provided with a supply of HMEs for a 3-week trial period. The results showed that all patients were clearly positive about the valve used for digital occlusion of the stoma. Voicing was considerably facilitated and the intelligibility improved. Problems experienced in previous studies related to the adhesive tape, such as skin irritation, inadequate adherence and loosening of the plaster by coughing or forced expectoration, could be solved by the availability of the different adhesives included in this system.

Patients with head and neck carcinoma show deficits of cellular immunity, probably due to low molecular mass factors (LMMFs) released by the tumour. Thymostimulin (TP1) restores the defective monocyte chemotaxis and dendritic cell clustering capability in the presence of the tumour when administered pre-operatively. In the present study we investigated these immune parameters in 39 patients treated with TP1 for 10 days pre- and 6 months post-operatively and in 22 patients who were not treated with TP1 for 6 months after operation. Removal of the tumour in non-TP1-treated patients also resulted in a restoration of monocyte and dendritic cell functions, while TP1 treatment gave no additional effect. LMMF levels in the blood of both TP1-treated and non-TP1-treated patients remained elevated even after removal of the tumour, and it is therefore concluded that it is unlikely that depression of cellular immunity is a direct effect of these LMMFS.

Aims: To assess the value of CT scanning for detection of lymph node metastases in the neck. Methods: The appearance and site of the metastases was studied, as well as the sensitivity and specificity of CT. Results: Nodal metastases did not always show a high contrast uptake and nodal density therefore cannot be used as a criterion for metastasis. Irregular contrast enhancement was seen in seven of the 21 tumour-positive necks. Frequently, metastases in the parotids, superficial nodes in the neck and in the posterior triangle were seen. The sensitivity and specificity of palpation and CT scanning were 87 and 100%, respectively. Conclusions: However, because small, clinically occult, melanoma metastases were frequently overlooked on CT, the role of this imaging modality in assessing occult metastases remains limited. Based on recent data from literature it is reasonable to speculate that ultrasound guided fine needle aspiration cytology (FNAC) will prove to be more effective than a non-invasive staging procedure of the neck in melanoma patients.

In this study, the immunoreactivity of several cytokeratin antibodies; 115 D8, a monoclonal antibody against MAM-6, an epithelial membrane antigen; and two vimentin antibodies, is examined in relation to the degree of morphologic differentiation in carcinomas of the head and neck. The results indicate that a relationship exists between the degree of morphologic differentiation and the expression of cytokeratin, MAM-6, and vimentin, as detected by polyclonal antikeratin, 115 D8 and anti-vimentin. Expression of cytoketatin and MAM-6 is reversely related to vimentin. Polyclonal antikeratin; CAM 5.2, a monoclonal antibody against cytokeratin 8, 18 and 19; and 115 D8, used in combination, were still able to identify the epithelial nature of undifferentiated/spindle cells. Since these immunohistochemical markers precede light microscopic detectable signs of epithelial differentiation, they can be used for the identification of the epithelial nature of undifferentiated/spindle tumors of the head and neck.