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Background Metastases from mucosal and cutaneous carcinomas can present in a delayed fashion, and this late presentation may confer a different prognosis after conventional treatment. Methods We present a series of patients in which there was a significant time delay between the treatment of a squamous carcinoma of the skin or mucosa of the midface and the detection of regional metastases in 12 of the 13 cases. Primary tumors were located on the lower lip and commissure (n = 3), nasal tip (n = 2), nasal ala (n = 1), columella (n = 1), nasofacial crease (n = 2), maxillary alveolus (n = 3), and mandibular alveolus (n = 1). Metastatic spread manifested by palpable perifacial or submandibular lymph nodes was not evident until greater than 11 months after the treatment of the primary site in 12 of 13 patients (range, 3–45 months). Nine of the patients were clinically staged as N1, whereas there was one each in the N2a, N2b, N2c, and N3 categories. Eleven of the 13 patients were initially seen with palpable disease involving the perifacial nodes within or around the submandibular gland. All patients were treated with neck dissection except one, who refused surgical treatment and underwent a second course of radiotherapy to the cervical region. The nine patients initially seen with clinical stage N1 disease underwent neck dissection with preservation of the sternocleidomastoid, internal jugular vein, and accessory nerve. Results Of 10 patients with perifacial node metastases who underwent neck dissection, 8 required sacrifice of the marginal mandibular nerve and overlying platysma to gain adequate margin. Extracapsular spread was present in 11 patients, (8 of 9 who were clinically N1). Postoperative radiotherapy was recommended to all patients with extracapsular spread, although only 7 of the 11 received radiotherapy. There were no regional recurrences after a minimum follow-up of 1 year (range, 12–65 months; mean, 31.4 months). Histologic grade appeared to have no influence on prognosis. Conclusions This cohort demonstrates the ability of midfacial squamous cell carcinoma to manifest regional metastatic disease over a delayed time. This delayed presentation appears to confer a more favorable response to treatment. For midfacial cancers, the perifacial nodes are at greatest risk for metastatic spread. For tumors in this region, primary treatment of the neck is probably not warranted, but careful extended follow-up for the potential of delayed cervical metastasis is prudent. © 1998 John Wiley & Sons, Inc. Head Neck 20:328–333, 1998.

Advances in imaging resolution have resulted in superior visualization of intracranial anatomy. Because of the inherent complexity of the surgical exposure of these lesions, intraoperative localizing techniques are required. Currently, C-arm fluoroscopy provides only two-dimensional localization for these anatomic structures. The recently described ACUSTAR I system, developed in conjunction with Codman and Shurtleff, Inc. (Randolph, Mass.), is an interactive, image-guided device that allows three-dimensional localization with a degree of accuracy previously unattainable. We assessed the clinical utility of the ACUSTAR I system for intraoperative spatial confirmation during transsphenoidal approaches to pituitary lesions.Eight patients underwent transsphenoidal approaches to pituitary lesions with the assistance of the ACUSTAR I system. The spatial relationships were clinically judged intraoperatively by the surgeon and by use of traditional C-arm fluoroscopy and then were compared with the ACUSTAR I system results.In all eight patients, the ACUSTAR I system correctly displayed the surgical orientation and provided localization to within less than 1 mm. In two patients, this facilitated the redirection of an errant approach. No complications were associated with the use of this image-guided device.The ACUSTAR I system is useful in displaying accurate, three-dimensional anatomic relationships during transsphenoidal approaches to pituitary lesions. This system provides critical information intraoperatively to redirect errant approaches and prevent significant morbidity.

Oromandibular reconstruction represents an exciting and growing area within head and neck reconstructive surgery. The advent and use of free tissue transfer have revolutionized the field. Combining these newer techniques with time-proven techniques presents the reconstructive surgeon with a wide array of reconstructive options in the oromandibular region. This article considers the more common and reliable methods for oromandibular reconstruction. The authors examine the anatomic basis of each option, highlight the literature concerning each technique, and make specific recommendations based on their experience.

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. Arch Otolaryngol Head Neck Surg. 1997;123:830-836

To understand the role of retinoids in chemoprevention, the authors examined the effects of 13-cis retinoic acid (cRA) on squamous cell carcinoma proliferation and adhesion to extracellular matrix proteins. The antiproliferative effects of cRA were first seen on day 11 (66% inhibition) and progressed through day 19 (96% inhibition). Using an adhesion assay, the authors then investigated the effects of cRA and transforming growth factor-beta1 (TGF-beta1) on cellular adhesion to purified type IV collagen, fibronectin, and laminin matrices. Cells treated for 4 days with TGF-beta1 increased adhesion by 15% to 29%, and cells treated with cRA increased adhesion by 19% to 39%. However, the use of cRA alone resulted in a decrease in adhesion when tumor cells were treated for 7 days (20% to 32%) and 15 days (25% to 40%). The authors also discuss how cRA acts as a differentiating agent on squamous cell carcinoma.

Background Head and neck oncologic surgery is a time-consuming specialty that requires extensive resources and manpower. Case mix index (CMI) is used in evaluating the complexity and economic impact of surgeons. Head and neck oncologic surgeons generate significant revenue for hospitals, yet compensation is relatively low. Methods Retrospective review of a tertiary hospital's case mix data for 605 otolaryngology admissions from 2009 to 2011 was performed. CMI comparison for head and neck oncologic surgeons versus general otolaryngology was performed. Results In an otolaryngology department of 9 surgeons; there was a significant difference (p 1) favoring head and neck oncologic surgeons. Conclusion Head and neck oncologic surgeons increase the CMI for hospitals and ultimately influence the hospital's reimbursement. There is a need for increased collaboration between hospitals and departments in fostering and furthering their head and neck surgical oncology programs by taking CMI into consideration. © 2013 Wiley Periodicals, Inc. Head Neck, 36: 1420–1424, 2014

Importance The present study addresses the survival benefit of aggressive surgical treatment of head and neck cancer involving the carotid artery. Objective To assess survival outcomes in patients treated for advanced squamous cell carcinoma involving the carotid artery using different treatment strategies. Design, Setting, and Participants Retrospective study at a tertiary care center of 44 consecutive patients with squamous cell carcinoma involving the carotid artery from 2005 to 2012 with a median follow-up of 12 months. The radiologist was blinded to the outcome of surgical procedures. Interventions Surgery with or without radiotherapy, and definitive chemoradiation. Main Outcomes and Measures Overall survival and rates of locoregional and distant failures. The hypothesis was formulated before data collection. Results Of 44 patients, 35 (80%) were treated with curative intent with surgery with or without adjuvant therapy (n = 27 [61%]) or definitive chemoradiation therapy (n = 8 [18%]), while 9 patients (21%) were treated in a palliative fashion. Patients treated with curative intent had improved overall survival (median survival, 13.5 months) compared with the palliative group (median survival, 3.6 months) ( P = .001). Of patients treated with curative intent, those with previously untreated disease (n = 14 [40%]) had an improved outcome relative to patients with recurrent or persistent disease (n = 21 [60%]), with median survival of 38.7 and 9.6 months, respectively ( P = .008). Patients were treated with curative intent using 3 different treatment strategies (ie, carotid artery resection with or without reanastamosis) (n = 6 [17%]), curative peeling with or without adjuvant therapy (n = 21 [ 60%]), and definitive chemoradiation therapy (n = 8 [23%]). Survival outcome was not significantly different between subgroups treated with curative intention ( P = .47). When reviewed by a head and neck radiologist in a blinded fashion (n = 30), preintervention imaging had a positive predictive value of 72.7% for resectability of cancer involving the carotid artery. In cases with almost circumferential involvement (>270°) and narrowing of the carotid artery, the disease was unresectable (n = 3). Conclusions and Relevance Advanced head and neck cancer involving the carotid artery can be treated with curative intent with favorable results in most patients. If disease burden merits, an aggressive approach involving resection with or without reanastamosis of the carotid artery can be used without significant added morbidity.

Human papillomavirus (HPV)-associated oropharyngeal squamous cell carcinoma (SCC) is associated with high cure rates and distant metastases are rare.We report a case of a 61-year-old man presenting with acute left-sided weakness. An enhancing dural mass was noted and resected. Histology revealed p16-positive SCC. Further workup revealed a p16-positive right tonsillar primary with ipsilateral nodal disease and was classified as T2N2bM1. The patient underwent whole brain irradiation and definitive chemoradiation with curative intent. Complete clinical response was achieved and the patient continues to be disease-free 6 months posttreatment.HPV-associated oligometastatic oropharyngeal SCC is a rare entity that may have a unique natural history and behavior. Given the excellent treatment response and prognosis of HPV-positive disease in general, these patients may be appropriate for definitive treatment approaches.

To investigate the effectiveness of salvage partial and total laryngectomy in the treatment of recurrent laryngeal cancer in the setting of initial nonoperative treatment failure and to identify factors influencing long-term survival.Case series with planned chart review.Tertiary medical center.Patients with recurrent squamous cell carcinoma of the larynx initially treated with either radiation or chemoradiation, who underwent salvage laryngectomy at the Cleveland Clinic Foundation from 1997 to 2011, were identified. The cohort was divided into an early-stage group and an advanced-stage group based on initial tumor staging. Survival outcome was evaluated separately in each group against tumor staging, methods of treatment, and nodal status. Secondary endpoints of speech and swallowing were also evaluated.A total of 100 patients were identified, with 72 patients in the early-stage group and 28 patients in the advanced-stage group. The overall postsalvage locoregional control rate was 70%, and the 5-year disease-specific survival was 70% and 55.2% in the early and advanced group, respectively (P = .39). The 5-year disease-specific survival was not significant in either group when compared with recurrent staging, initial treatment, salvage treatment, or nodal disease (P = ns). Using voice prostheses, good to excellent speech function was achieved postoperatively in most patients.Tumor staging, methods of initial and salvage treatment, and nodal disease were not significant predictors of survival. Both salvage partial and total laryngectomy were effective methods in the treatment of recurrent laryngeal cancer in carefully selected patients.

Objective To compare the clinical Allen test, preoperative Doppler ultrasonography, and intraoperative surgical Allen test with postoperative clinical findings in reconstruction of complex head and neck defects using radial forearm free flaps. Design, Setting, and Patients Retrospective review of 143 consecutive patients who underwent radial forearm free flap reconstruction from January 1, 1992, through December 31, 2006, at Vanderbilt University Medical Center. Results Flap survival rate was 96.4%. No patients experienced digital necrosis or other findings of acute ischemia. Two patients (1.9%) who had normal results of clinical and surgical Allen tests developed hand contracture and palmar nodule formation. Surgical Allen test findings were normal in all patients who underwent reconstruction. Eighty-two arms had documentation of clinical Allen testing and Doppler ultrasonography in the patients' medical records. Agreement between these measures was 92.7%. The clinical Allen test result was 100% sensitive and 75% specific in predicting an abnormal Doppler ultrasonographic finding. Conclusions The clinical Allen test is an appropriate preoperative evaluation before radial forearm free flap reconstruction. The addition of Doppler ultrasonography should be limited to patients with abnormal clinical Allen test results. The surgical Allen test provides reassurance but does not preclude the possibility of ischemic hand complications.

Head and neck oncologic surgery is a time-consuming specialty that requires extensive resources and manpower. Case mix index (CMI) is used in evaluating the complexity and economic impact of surgeons. Head and neck oncologic surgeons generate significant revenue for hospitals, yet compensation is relatively low.Retrospective review of a tertiary hospital's case mix data for 605 otolaryngology admissions from 2009 to 2011 was performed. CMI comparison for head and neck oncologic surgeons versus general otolaryngology was performed.In an otolaryngology department of 9 surgeons; there was a significant difference (p.01) in the CMI and a significantly greater chance to have a "good CMI" (CMI1) favoring head and neck oncologic surgeons.Head and neck oncologic surgeons increase the CMI for hospitals and ultimately influence the hospital's reimbursement. There is a need for increased collaboration between hospitals and departments in fostering and furthering their head and neck surgical oncology programs by taking CMI into consideration.

Literature on head and neck oncology continues to support the use of lasers in surgery of malignant and premalignant lesions of the oral cavity. This article explores the indications, techniques, results, and complications of laser use for surgery involving these lesions. Highlighted is the carbon dioxide laser, which is well suited for transoral resections of premalignant lesions and early carcinomas in the oral cavity. In this study the local control, the 5-year survival rates, and the postoperative function with the carbon dioxide laser are at least comparable with those obtained using other surgical methods. The neodymium:yttrium-aluminum-garnet laser, which has specific advantages in the treatment of large vascular malformations of the oral cavity because of its unique characteristics, is also discussed.

The rat model for a vascularized laryngeal allograft is duplicated with significant technical modifications. We report the addition of unilateral host-to-allograft recurrent laryngeal nerve anastomosis to this model. Long-term survival experiments determine the feasibility of reinnervation studies of the allograft larynx with this new model. A total of 59 transplants have been performed on histocompatible Munich Wistar rats, 36 with attempted unilateral allograft reinnervation. Because of the initially high operative mortality rates, additions and modifications of the original technique resulting in reproducibly enhanced survival are detailed. Factors critical to the functional study of this model with regard to reinnervation are elucidated. Preliminary data on allograft reinnervation are reported as confirmed by videodocumentation of vocal fold mobility, evoked and spontaneous electromyography, and glycogen-depletion Studies.

Importance Late toxic effects are common after definitive radiotherapy and chemoradiotherapy for oropharynx cancer and are considered a significant contributor to decreased quality of life for survivors. The incidence of severe late toxic effects may be reduced by modern narrow-margin image-guided intensity-modulated radiotherapy (IG-IMRT), current supportive care improvements, and the changing epidemiology of oropharynx cancer. Objective Assess the incidence of severe late toxic effects after modern definitive non-operative treatment for oropharynx cancer. Design, Setting, and Participants For this single-institution retrospective review, 156 patients with stage I-IVB squamous cell carcinoma of the oropharynx treated between April 2009 and February 2015 at a tertiary-referral academic multidisciplinary head and neck practice were recruited. Interventions Definitive narrow-margin IG-IMRT to a dose of 66 Gy (to convert milligray to rad, multiply by 0.1) or higher with or without concurrent cisplatin. Main Outcomes and Measures The primary outcome was the prospectively collected 2-year cumulative incidence of severe late toxic effects (Common Terminology Criteria for Adverse Events grade 3 or higher) occurring 3 months or more after radiotherapy. Toxic effect end points investigated included esophageal stricture requiring dilation, aspiration pneumonia hospitalization, vocal dysfunction, delayed feeding tube insertions, and osteoradionecrosis. Feeding tube dependence at 1 year was also considered a severe late toxic effect. Secondary outcomes collected include physician-reported grade 2 or higher neck fibrosis and xerostomia. The competing risks of recurrence and death were accounted for using the Gray method. Results One-hundred fifty-six patients (median [range] age, 58 [37-96] years) were identified; 130 patients (83%) were HPV positive. Concurrent cisplatin was delivered in 131 patients (84%) and 5 patients (3%) underwent an adjuvant neck dissection. The median (range) follow-up for survivors was 22 (4-73) months from diagnosis. The projected 2-year locoregional control was 93% (95% CI, 88.4%-97.6%) and overall survival was 88% (95% CI, 82.2%-94.0%). Thirty-eight patients (23%) required a feeding tube during treatment. The cumulative incidence of severe late toxic effects adjusted for competing risks at 2-year posttreatment was 2.3% (95% CI, 0%-5.6%). One patient required free-flap reconstruction for grade 3 osteoradionecrosis at 47 months. At 1 year, 2 patients (1%) experienced grade 2 neck fibrosis and 38 patients (23%) experienced grade 2 xerostomia. Conclusions and Relevance These results suggest that severe late toxic effects after modern definitive IG-IMRT, with or without cisplatin, for oropharynx cancer is likely uncommon. The importance of late toxic effect reduction in current and future investigational strategies, including clinical trials, should be considered.

6037Background: Definitive chemoradiation (CRT) has become an established organ preservation treatment for patients (pts) with locoregionally advanced laryngeal cancer. Although most pts will exper...

Objective: Tracheoesophageal prosthesis facilitates esophageal speech in postlaryngectomy patients. The vocal prosthesis can be placed either during tracheoesophageal puncture (TEP) or, more commonly, in a delayed fashion. Our objectives were to: 1) analyze the voice outcomes and 2) compare the pain and emergency care, following primary versus delayed prosthesis placement.Method: A 2011 cohort study. A tracheoesophageal puncture occurred in conjunction with, or within 3 months of, total laryngectomy. Nine patients underwent primary and 11 patients underwent delayed prosthesis placement. The primary outcome was voice production at the first postoperative appointment. Secondary outcomes included pain and perioperative emergency room visits.Results: All patients (100%) with prostheses placed at the time of the TEP had voice production at the first postoperative clinic visit, in comparison to only 45% (5/11) of patients with prostheses placed in delayed fashion. Significant pain with vocalization occurred in ...

Objective: To investigate the effectiveness of salvage partial laryngectomy (PL) and total laryngectomy (TL) in the treatment of recurrent laryngeal cancer in terms of disease control, postoperative course, survival, and functional outcomes, and to identify additional factors influencing the long-term survival and disease recurrence in patients receiving salvage laryngectomy.Method: Retrospective chart review of patients with recurrent squamous cell carcinoma (SCC) of the larynx receiving salvage laryngectomy at Cleveland Clinic from 1997 to 2011. Disease-specific survival (DSS), overall survival (OS), functional outcomes, recurrence rate, and postoperative course were evaluated against the methods of primary site and neck treatment.Results: The series is composed of 109 patients. The 5-year DSS and 5-year OS rates were 70.2% and 62.9%, respectively. Laryngeal preservation rate after PL was 80%, with 34% overall complication rate for all patients. No significant differences were noted in 5-year OS (P = .3...

Epistaxis following blunt facial trauma is usually self-limited and arises from the nasal mucosa, sphenopalatine, or anterior ethmoid arteries. Pseudoaneurysm of the intracavernous carotid artery (ICCA) occurs rarely with penetrating facial trauma, but is even more rare following blunt trauma. Rupture carries a greater than 50% mortality. Because rupture usually occurs after several episodes of epistaxis, recognition of subtle historic and physical findings is paramount to optimal management. Once suspicion is raised, definitive diagnosis and treatment is best accomplished with cerebral arteriogram and trapping of the pseudoaneurysm. We have noted that rupture may be precipitated by angiography, and, therefore, we advocate availability of emergent and definitive treatment equipment and personnel prior to performing cerebral arteriography. This should include an otolaryngologist, an interventional radiologist, and a neurosurgeon. A case of ICCA pseudoaneurysm is presented, and the key historic factors are discussed. Radiographic diagnosis and management options are discussed. © 1994 John Wiley & Sons, Inc.

Program Description: Although head and neck oncologic surgery (HNOS) is time consuming, requires an effective team, and needs allotment of precious resources, financial compensation for the surgeon is relatively low so that financial inducements for a surgeon to do HNOS are diminishing. However, HNOS can generate significant revenue for a hospital. This miniseminar provides information about costs, revenue, profit/ loss analysis of many aspects of HNOS. Parameters pertaining to HNOS that will be defined and discussed include the following: relative value units (RVU’s) contribution margins, case mix index, allocated expenses, opportunity costs, comparative profitability of various different treatment modalities, and the impact of diminishing reimbursements. In addition we will explain the ways that an otolaryngology department can utilize hospital financial data to justify the commitment of the varied resources that are needed to do major HNOS cases and to safely take care of the patients following surgery...

Castleman’s disease (CD) is an atypical lymphoproliferative disorder characterized by hyperplasia of lymphoid tissue that may develop at a single site or throughout the body. This disorder has frequently been associated with several systemic syndromes, including human immunodeficiency virus infection, polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy and skin changes (POEMS) syndrome and various connective tissue diseases. However there have been no previously reported cases of concomitant sarcoidosis and CD. In this report, the authors describe a young woman with an enlarging neck mass, biopsy of which showed histopathological features consistent with the hyaline vascular type of CD along with the presence of non-necrotizing granulomas and was deemed unresectable due to encasement of vital neural and vascular structures. Further studies revealed hypermetabolic generalized lymphadenopathy with pulmonary perilymphatic nodules. Bronchoscopic investigations demonstrated the presence of non-necrotizing granulomas within the lung parenchyma and mediastinal lymph nodes, a CD4 + T-lymphocyte predominant bronchoalveolar lavage and an elevated CD4/CD8 ratio consistent with a concomitant diagnosis of sarcoidosis. Institution of immunosuppression with prednisone and methotrexate led to reduction in size of the neck mass that allowed radical curative resection of the CD.

Recurrent or metastatic squamous carcinoma of the head and neck (RMSCHN) is a modestly chemoresponsive tumor; however, currently available agents have failed to improve survival. New active agents are needed for the treatment of this disease. Topotecan is a topoisomerase inhibitor that demonstrated initial promising activity in squamous carcinoma of the head and neck. The Eastern Cooperative Oncology Group conducted a phase II trial of topotecan to determine the efficacy and toxicity of a weekly treatment schedule in patients with RMSCHN. Patients with metastatic or locally recurrent squamous carcinoma of the head and neck were treated with topotecan 1.5 mg/m 2 X 24 hours by continuous infusion on days I, 8, 15, and 22 of each 35-day cycle. Patients were stratified in two cohorts: chemonaive and previously treated. Sixteen chemonaive and 16 previously treated patients were registered on study. Grade III/IV neutropenia and anemia occurred in 16% and 18% of patients, respectively. No responses were observed in either cohort. Median survival for previously untreated patients was 4.6 months and 3.2 months for previously treated patients.Topotecan failed to demonstrate efficacy in patients with RMSCHN. Further evaluation of this agent is not planned.

Synovial sarcoma is typically an aggressive malignant tumor of the soft tissues, usually in the extremities, that affects young adults. Tumors of the head and neck are rare. Reported head and neck sites have included the hypopharynx (the most common site), the oropharynx, the larynx, and the soft tissues of the neck; only 4 cases of orbital involvement have been previously reported. We describe a case of synovial sarcoma of the medial canthus, which we discovered during a review of a tumor registry. The patient, an 18-year-old woman, underwent conservative excision and postoperative radiation therapy. Long-term follow-up detected no evidence of recurrence. Because there is no established, consistent approach to the treatment of synovial sarcoma of the head and neck, we also present a consensus management plan based on our review of the literature.

Background— Recurrent head and neck squamous cell carcinoma (HNSCC) remains a difficultcancer to treat. Here, we describe a patient with HNSCC who had complete response tomethotrexate (MTX) after progressing on multiple cytotoxic agents, cetuximab, and AMG-479(monoclonal antibody against insulin-like growth factor-1 receptor [IGF-1R]). Methods— The clinical information was collected by a retrospective medical record review underan Institutional Review Board–approved protocol. From 4 tumors and 2 normal mucosal epithelia,global gene expression, and IGF-1R and dihydrofolate reductase (DHFR) protein levels weredetermined. Results— Effective target inhibition in the tumor was confirmed by the decreased protein levelsof total and phospho-IGF-1R after treatment with AMG-479. Decreased level of DHFR andconversion of a gene expression profile associated with cetuximab-resistance to cetuximab-sensitivity were also observed. Conclusion— This suggests that the combination of AMG- 479 and MTX or cetuximab may bea promising therapeutic approach in refractory HNSCC.

Microvascular free flaps have greatly advanced the field of head and neck reconstruction. This allows the transfer of vascularized tissue from distant sites to reconstruct postextirpative defects. Adding to the refinement of these techniques is the introduction of sensate flaps. These are essential in restoring function in the upper aerodigestive tract. In this review, we present a discussion on the importance of sensation for proper swallowing function. We also describe the techniques used for sensate free flap reconstruction.

Our previous study has shown that nuclear factor-kappa B (NF-kappaB)-signaling pathway was associated with a higher rate of recurrence in head and neck squamous cell carcinoma (HNSCC). The combination of bortezomib, an NF-kappaB inhibitor by inhibition of proteasomes, plus docetaxel was assessed for efficacy and toxicity.Patients with recurrent and/or metastatic HNSCC were enrolled on a phase II bortezomib/docetaxel trial (bortezomib 1.6 mg/m(2) and docetaxel 40 mg/m(2) on days 1 and 8 of a 21-day cycle). Response was assessed using RECIST. Tissue specimens were evaluated for the presence of human papillomavirus (HPV) and expression of NF-kappaB-associated genes.Twenty-one of 25 enrolled patients were assessable for response; one partial response (PR, 5%), 10 stable disease (SD, 48%) and 10 progressive disease (PD, 48%). Patients with PR/SD had significantly longer survival compared with patients with PD and the regimen was well tolerated. Only one of 20 tumors was positive for HPV. Patients with PD had higher expression of NF-kappaB and epidermal growth factor receptor-associated genes in their tumors by gene expression analysis.Further understanding of treatment resistance and interactions between bortezomib and docetaxel may provide novel approaches in managing HNSCC.

This prospective, randomized study assessed the clinical, microbiological, and patient comfort characteristics of two silver-based topical agents in the management of partial-thickness burn wounds. Pediatric patients were randomly assigned to treatment with either SilvaSorb Gel (Medline Industries, Munedelein, IL) or Silvadene silver sulfadiazine cream (King Pharmaceuticals, Bristol, TN) for up to 21 days or to the point of full reepithelialization of the wound. Inclusion criteria were patients ranging in age from 2 months to 18 years with TBSA ranging from 1 up to 40%. A total of 24 patients were enrolled and completed the study. Findings demonstrated that the use of SilvaSorb Gel was associated with less pain and greater patient satisfaction when compared with Silvadene. No statistically significant differences were found when assessing the rate of infection, time to reepithelialization, or the number of dressings changes required during treatment. The reduction of pain and improved overall patient satisfaction with the use of SilvaSorb Gel compared with Silvadene indicates an important role for SilvaSorb Gel in treatment of partial-thickness burns in a pediatric population.

Background. We describe the development and validation of the Vanderbilt Head and Neck Symptom Survey (VHNSS), which was designed to screen for tumor- and treatment-specific symptoms in patients with head and neck cancer undergoing concurrent chemoradiation (CCR). Methods. Using a 2-step card sort method, we identified high-impact and high-frequency toxicities in patients with head and neck cancer treated with CCR. This resulted in a 28-item questionnaire which scores symptoms on a 0 to 10 scale (none to severe). The tool was validated using data collected from 5 supportive care studies comprising a total sample of 332 patients with head and neck cancer. Results. Responses to the VHNSS items demonstrated a very consistent pattern (Cronbach's alpha = 0.943) with each item contributing substantially to the global index. Five symptom subscales were identified including “Nutrition,” “Pain,” “Voice,” “Swallow,” and “Mucous/Dry Mouth.” Each of the cluster scores demonstrated good internal consistency. The pattern of associations between the VHNSS and established tools indicated appropriate convergence and divergence. Comparison of global and subscale scores and objective measure were also in the expected direction providing further evidence of validity. Conclusions. The findings provide support that the VHNSS is a valid and reliable tool to assess head and neck–specific symptom burden and function loss. Further research to evaluate this screening tool as a part of a systems approach to supportive care is warranted. © 2009 Wiley Periodicals, Inc. Head Neck, 2010

• Interleukin 2–activated peripheral blood lymphocytes (lymphokine-activated killer [LAK] cells) have been shown to lyse tumor cells in a nonspecific fashion. Although the mechanisms involved in this cell-mediated lysis are unknown, previous work has shown that T-lymphocyte—mediated cytolysis is associated with massive fluctuations in the intracellular calcium concentration within target cells. Studies were undertaken to determine whether intracellular calcium concentration changes were associated with LAK-mediated cytotoxicity and to determine the effects of calcium channel blockade on in vitro cell-mediated cytotoxicity. Natural killer (NK) and LAK cell cytotoxicity in vitro were measured against head and neck squamous cell carcinoma (UMSCC-11a and UMSCC-38) and Daudi cell lines. Assays were performed in parallel with flow cytometry to measure changes in intracellular calcium concentration within the target cells. Compared with NK cells, LAK cells showed enhanced cytotoxicity against the UMSCC-11a and Daudi lines but not the UMSCC-38 cell line. Both NK and LAK cell cytotoxicity against all the target cell lines directly paralleled significant increases in calcium concentration in the target cells. The addition of verapamil hydrochloride inhibited the rise in intracellular calcium concentration in the sensitive target cells and significantly inhibited both NK and LAK cell cytotoxicity in all the cell lines. The NK cell activity was more sensitive than LAK cell activity to verapamil inhibition. These data suggest that changes in the target cell calcium concentration are early and important events in both NK and LAK cell cytotoxicity in vitro. ( Arch Otolaryngol Head Neck Surg . 1991;117:1281-1286)

Cricothyroidotomy as a method of elective airway management, previously shunned by Jackson, was reintroduced to the medical community in 1976. This article examines available data indicating the utility and complications of elective cricothyroidotomy for long-term airway management and defines its place with respect to tracheotomy.

Total or near-total esophageal stricture results from multiple processes. Traditional treatment with wire cannulation followed by serial dilation is often contraindicated due to poor visualization and the risk of perforation. We seek to demonstrate that combined antegrade and retrograde endoscopy are useful for treatment of total or near-total esophageal strictures. The gastrostomy tube is removed and the tract dilated. A standard endoscope is passed retrograde to the stricture. An antegrade endoscope is advanced until transillumination across the stricture is visualized. A biopsy forceps or needle is used to traverse the stricture in an antegrade fashion. The tract is cannulated with a stiff wire that is then brought out through the gastrostomy site. The stricture is serially dilated. The gastrostomy tube is replaced, and a nasogastric tube is left across the stricture for 3 to 4 weeks. The endoscope is withdrawn and an 18 or 20 Fr gastrostomy tube is left in place. A total of three patients with total esophageal strictures were treated using combined antegrade and retrograde esophagoscopy. All three patients regained the ability to swallow secretions. Importantly, there were no instances of esophageal perforation. This technique has broader application, including combination with minilaparotomy for patients without retrograde access. Further research is needed to determine durability of stricture dilation.

ProblemHead and neck squamous cell carcinoma (HNSCC) accounts for 4% of annual U.S. cancer deaths. In-vivo models exist using established HNSCC lines, but currently there is no such model that allows consistent growth of HNSCC from primary tumors.MethodsPrimary HNSCC tissue was obtained from 103 patients at biopsy/resection, disaggregated and seeded onto collagen-coated plates in keratinocyte growth media with 10% FBS, additives and antibiotics. After short-term growth in culture, cells were transferred to denuded rat tracheas and implanted subcutaneously in nude mice. Indirect immunofluorescent staining using antibodies specific to cytokeratin, vimentin and nuclear Ku was performed to determine cell lineage and origin.ResultsCultured cells exhibited morphology consistent with epithelial or stromal derivation. 80% of cultures had viable cells present at 10 days and 24% were maintained 30 days or longer. 5 cultures (5%) proliferated after multiple passages and thrived on uncoated plates in the absence of m...

The treatment paradigm for locally advanced head and neck cancers has evolved over the past two decades as the role of chemotherapy has been substantiated by clinical trials. Presently, concurrent chemoradiation is considered a standard treatment option for patients with resectable head and neck tumors desiring an organ preservation approach, as well as for patients with locally advanced nasopharyngeal cancers and patients in the postoperative setting who are at high risk for recurrence. The addition of a taxane to induction chemotherapy appears to improve efficacy over cisplatin and 5-FU. Targeted biologic therapies such as the monoclonal antibody Cetuximab has demonstrated efficacy with radiation that appear comparable to chemoradiation combinations and has a favorable toxicity profile. This review will discuss key clinical trials supporting the current standard of care. Emerging new technologies such as intensity modulated radiation therapy (IMRT) and image-guided radiation therapy (IGRT) will also be reviewed. Functional assessments and quality of life issues will be addressed.

Pediatric nasopharyngeal tumors are rare, and few clinicians possess more than anecdotal experience. The differential diagnosis includes a diverse group of benign and malignant tumors, but can be narrowed further based on the clinical and radiographic appearance of the mass. Nasopharyngeal angiofibroma has such characteristic angiographic and CT imaging that many authors suggest biopsy is not essential in the evaluation of this lesion. We present a case of a pediatric nasopharyngeal neoplasm with angiographic, CT, and clinical findings consistent with angiofibroma. We then discuss the preoperative evaluation of, operative approach to, and postoperative staging and treatment of the biopsy-proven embryonal rhabdomyosarcoma. A review of the literature pertinent to this case is presented, and recommendations made concerning biopsy of lesions resembling juvenile nasopharyngeal angiofibroma. We believe this report reaffirms the use of histologic study whenever possible, in addition to radiographic imaging, in the diagnosis of pediatric nasopharyngeal masses.