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The central compartment of the neck is a common site of local metastasis for thyroid carcinoma. Therefore, knowledge of the surgical techniques employed during a central compartment neck dissection is important to master for any surgeon who manages thyroid cancer patients. We review the anatomical boundaries of the central compartment of the neck as well as discuss the lymphatic drainage patterns of the thyroid gland. We advocate standardization of the surgical approach to the central compartment in order to minimize morbidity and ensure comprehensive removal of all lymph nodes when indicated, which can reduce the need for reoperative dissections., (Copyright 2008 S. Karger AG, Basel.)

Background: The aim of this study was to review our experience with reoperative thyroid bed surgery (RTBS) for recurrent/persistent papillary thyroid cancer (PTC), and present an algorithm for safe and effective RTBS., Methods: This is a retrospective study. Records of 33 consecutive patients who underwent RTBS for recurrent/persistent PTC in a previously operated thyroid bed, and were operated upon by the senior author (R.P.T.) July 2001 to January 2006 were reviewed. Reports of the pre- and post-RTBS serum thyroglobulin (TG) levels, the high-resolution thyroid bed ultrasound examination, pre-RTBS FNA cytopathology, as well as the post-RTBS final histopathology were reviewed. Recurrent laryngeal nerve (RLN) monitoring was used for all patients. Reports of the intra-RTBS condition of the RLN and any reported surgical complications were reviewed. In addition, reports of the pre- and post-RTBS fiberoptic laryngoscopy as well as pre- and post-RTBS serum calcium levels were reviewed., Results: In our study, 33 consecutive patients underwent RTBS for recurrent/persistent PTC with or without lateral neck dissection. In 30 patients, recurrent/persistent PTC was suspected because of rising serum TG levels, interpreted in conjunction with serum anti-TG-antibody titers by the endocrinology service at our institution. Three patients had serum anti-TG antibodies and their disease was detected and FNA confirmed by a regularly scheduled surveillance ultrasound examination. All patients underwent pre-RTBS high-resolution thyroid bed ultrasound examination and FNA for all suspicious masses. All patients had FNA-confirmed PTC in the thyroid bed. All patients had detailed diagrams localizing areas of FNA-confirmed PTC in the thyroid bed provided to the surgeon. In all study patients, post-RTBS histopathologic findings confirmed sites of recurrent/persistent PTC determined by pre-RTBS US guided FNA. All RLNs (53/53) that were at risk were successfully identified. In 3 patients, the RLN was electively resected because of the envelopment by a large paratracheal mass or tumor densely adherent to the RLN insertion point at the cricothyroid region. There was no incidence of unexpected RLN injury, permanent hypocalcemia, or any other surgery-related complication. Post-RTBS serum TG levels were significantly decreased or undetectable in most patients (2 patients had concurrent lung metastases), when compared with pre-RTBS levels. No patient exhibited thyroid bed recurrent/persistent PTC in the post-RTBS period based on semiannual high resolution neck ultrasound examination with a median follow-up of 2 years., Conclusions: Safe and effective RTBS is based on a multidisciplinary approach that enables the identification and localization of recurrent/persistent PTC. The surgical algorithm for RTBS described, provides a pathway that all endocrine-head and neck surgeons can comfortably utilize to treat this complex and challenging patient population.

Unlabelled: Various methodologies for (99m)Tc-sestamibi parathyroid scintigraphy are in clinical use. There are few direct comparisons between the different methods and even less evidence supporting the superiority of one over another. Some reports suggest that SPECT is superior to planar imaging. The addition of CT to SPECT may further improve parathyroid adenoma localization. The purpose of our investigation was to compare hybrid SPECT/CT, SPECT, and planar imaging and to determine whether dual-phase imaging is advantageous for the 3 methodologies., Methods: Scintigraphy was performed on 110 patients with primary hyperparathyroidism and no prior neck surgery. Of these, 98 had single adenomas and are the subject of this review. Planar imaging and SPECT/CT were performed at 15 min and 2 h after injection. Six image sets (early and delayed planar imaging, SPECT, and SPECT/CT) and combinations of the 2 image sets were reviewed for adenoma localization at 13 possible sites. Each review was scored for location and certainty of focus by 2 reviewer groups. Surgical location served as the standard. Sensitivity, specificity, area under the curve, positive predictive value, negative predictive value, and kappa-values were determined for each method., Results: The overall kappa-coefficient (certainty of adenoma focus) between reading groups was 0.68 (95% confidence interval, 0.66-0.70). The highest values were for dual-phase studies that included SPECT/CT. Dual-phase planar imaging, SPECT, and SPECT/CT were statistically significantly superior to single-phase early or delayed imaging in sensitivity, area under the curve, and positive predictive value. Neither single-phase nor dual-phase SPECT was statistically superior to dual-phase planar imaging. Early-phase SPECT/CT in combination with any delayed imaging method was superior to dual-phase planar imaging or SPECT for sensitivity, area under the curve, and positive predictive value., Conclusion: Early SPECT/CT in combination with any delayed imaging method was statistically significantly superior to any single- or dual-phase planar or SPECT study for parathyroid adenoma localization. Localization with dual-phase acquisition was more accurate than with single-phase (99m)Tc-sestamibi scintigraphy for planar imaging, SPECT, and SPECT/CT.

Objective: To determine the role of computed tomography (CT)-guided fine needle aspiration biopsy (FNAB) in surgical planning for parapharyngeal space (PPS) tumors., Design and Setting: Chart review of 49 consecutive patients with surgically treated PPS tumors from 1995 to 2005., Results: Twenty-nine patients had CT-guided FNAB. A cytopathologic diagnosis that was the same as final pathology was rendered in 14 (48%) patients; suggestive but not conclusive in 6 (21%) patients; discordant in 3 (10%) patients; and 6 (21%) patients had a nondiagnostic result. Fourteen of 15 patients who had a final histopathologic finding of pleomorphic adenoma had a correct or highly suggestive preoperative FNAB diagnosis. The positive predictive value for CT-guided FNAB to identify benign tumors is 90%, (18 of 20) but to identify malignant PPS tumors is 75% (3 of 4)., Conclusion: CT-guided FNAB of PPS tumors is helpful to predict the nature of the PPS tumors (especially benign), which allows the surgeon and patient to plan for treatment, accordingly.

The role of aberrant tumor suppressor gene methylation in the aggressiveness of papillary thyroid cancer (PTC) has not been documented. By showing promoter methylation-induced gene silencing in PTC-derived cell lines, we first demonstrated the functional consequence of methylation of several recently identified tumor suppressor genes, including those for tissue inhibitor of metalloproteinase-3 (TIMP3), SLC5A8, death-associated protein kinase (DAPK) and retinoic acid receptor beta2 (RARbeta2). We then investigated the role of methylation of these genes in the aggressiveness of PTC by examining the relationship of their aberrant methylation to clinicopathological characteristics and BRAF mutation in 231 primary PTC tumors. Methylation of TIMP3, SLC5A8 and DAPK was significantly associated with several aggressive features of PTC, including extrathyroidal invasion, lymph node metastasis, multifocality and advanced tumor stages. Methylation of these genes was also significantly associated with BRAF mutation in PTC, either individually or collectively in various combinations. Methylation of these genes, either individually or collectively, occurred more frequently in more aggressive classical and tall-cell PTC subtypes than in less aggressive follicular-variant PTC, with the latter known to infrequently harbor BRAF mutation. Several other tumor suppressor genes investigated were not methylated. These results suggest that aberrant methylation and hence silencing of TIMP3, SLC5A8, DAPK and RARbeta2, in association with BRAF mutation, may be an important step in PTC tumorigenesis and progression.

Head and neck surgeons often rely on imaging to determine if a neoplasm is resectable. Many of the critical issues are outlined in the American Joint Committee on Cancer Staging Manual, wherein T4a and T4b head and neck cancers are defined as resectable and unresectable, respectively. Even within the T4a advanced resectable classification, there are critical determinants that define whether the surgical option is such that major morbidity and mortality could be expected. This review article examines the imaging literature to determine the accuracy and diagnostic criteria of different modalities for evaluating these critical T4a and T4b factors, which include the following: 1) arterial encasement, 2) prevertebral fascia involvement, 3) mediastinal infiltration, 4) tracheal and esophageal extension, 5) laryngeal cartilage penetration, 6) pre-epiglottic fat involvement, 7) dural spread, 8) bone (mandible/maxilla and skull base) infiltration, 9) perineural spread, 10) orbital involvement, and 11) brachial plexus invasion. For the most part, the studies find MR imaging with higher sensitivity but lower specificity than CT. An ever-increasing role for PET/CT is suggested. Imaging is of great value in the determination of resectability issues listed previously for head and neck cancers, with the possible exception of prevertebral fascia involvement.

Objectives: To determine the incidence and presentation of synchronous thyroid lesions in a patient population undergoing open partial laryngectomy (OPL), and to determine whether routine preoperative evaluation of the thyroid gland prior to OPL is useful to identify synchronous thyroid lesions in order to reduce the need for reoperation in this complex patient population., Design: Retrospective medical chart review., Setting: Academic institution., Patients: Sixty-seven consecutive patients with laryngeal tumors who had undergone OPL from 1996 to 2005., Interventions: Charts of 67 consecutive patients with laryngeal tumors who underwent OPL in 1996 to 2005 have been reviewed for synchronous thyroid lesions. For all patients, reports of (1) complete preoperative examination findings, (2) inpatient course, (3) postoperative follow-up, and (4) postoperative final histopathologic findings were reviewed. For patients with synchronous thyroid lesions, reports of (1) thyroid evaluation and imaging and (2) preoperative (fine-needle aspiration), (3) intraoperative (frozen section), and (4) postoperative (final) histopathologic results for the thyroid lesions were reviewed., Main Outcome Measures: Incidence of synchronous thyroid lesions and laryngeal cancer in patients undergoing OPL., Results: Eight (11.9%) of 67 (95% confidence interval, 5.3%-22.2%) patients with laryngeal tumors who underwent OPL had evidence of synchronous thyroid lesions. All 8 patients had squamous cell carcinoma of the larynx and underwent either supracricoid or supraglottic laryngectomy. In these 8 patients, synchronous thyroid lesions were incidentally detected. Four patients had papillary thyroid carcinoma, 1 had squamous metaplasia, and 3 had follicular thyroid tissue that was negative for malignancy on final pathologic examination. In 2 patients, the thyroid lesions were detected preoperatively (prior to OPL); in another 2 patients, thyroid masses were detected intraoperatively; and in 4 patients, the thyroid disease was identified postoperatively on histopathologic examination of excised cervical lymph nodes. In 2 patients, thyroidectomy was performed as a second operation after the OPL, and 1 of them had transient vocal fold paralysis for 2 months. Thyroid ultrasonography was performed in 4 patients. In 3 patients, the ultrasonography was performed after the OPL final pathologic findings indicated the presence of metastatic thyroid disease in cervical lymph nodes. Ultrasonography revealed intrathyroidal lesions in all 3 patients., Conclusions: Patients with laryngeal tumors who will be undergoing OPL might have occult synchronous thyroid lesions. Thyroid surgery in patients with previous OPL may have an increased potential for complication owing to postsurgical changes in the central neck region. Routine preoperative evaluation of the thyroid gland, especially with ultrasonography, to screen for occult synchronous thyroid lesions is recommended for all patients with laryngeal tumors who will be undergoing OPL. Eradication of any thyroid cancer detected preoperatively by fine-needle aspiration should be performed at the same time as OPL. Pros and cons of total thyroidectomy for indeterminate thyroid nodules should be discussed with this patient population.

Background: Mucosa-associated lymphoid tissue (MALT) lymphomas account for less than 1% of all primary thyroid malignancies. They typically arise as neoplastic transformations within areas of autoimmune thyroiditis. Although they tend to have an indolent course, these lymphomas present a diagnostic challenge requiring a high level of suspicion in patients at increased risk of development., Methods: We retrospectively reviewed 3 cases of primary MALT thyroid lymphoma discovered in patients with a compressive goiter. This represents the experience at a single institution from 1996 to 2005. Hospital and clinic records were reviewed to identify the workup, treatment, and outcome., Results: One of 3 patients underwent preoperative fine-needle aspiration (FNA). All patients underwent total thyroidectomy to relieve compressive symptoms, and the final pathology revealed MALT lymphoma. Two patients subsequently underwent radiation therapy. All patients are alive without evidence of disease recurrence., Conclusions: These cases are notable for the unexpected presentation of MALT lymphoma within a compressive goiter.

Distant metastases to the larynx are rare. We describe the case of a 46-year-old man who was referred to our head and neck surgery clinic with a 6-week history of sore throat and otalgia. He was found to have a laryngeal lesion that was consistent with a primary myxoid liposarcoma that had been extirpated from a lower extremity earlier To the best of our knowledge, no case of myxoid liposarcoma metastatic to the larynx has been previously reported in the English-language literature.

Context: Serum DNA methylation markers may potentially be useful in diagnosing thyroid cancer and monitoring its recurrence., Objective: The objective of the study was to assess the utility of serum DNA methylation as a diagnostic test for patients with thyroid nodules and a monitoring test to detect thyroid cancer recurrence in previously treated patients., Design, Setting, and Subjects: Using real-time quantitative methylation-specific PCR, we analyzed the methylation status of five genes (CALCA, CDH1, TIMP3, DAPK, and RARbeta2) on 96 bisulfite-treated serum DNA samples isolated preoperatively from either solid thyroid nodule patients or patients in follow-up for history of treated thyroid cancer., Main Outcome Measure: Diagnostic sensitivity, specificity, and accuracy of serum DNA methylation marker for thyroid cancer were measured., Results: For the patients with thyroid nodules, when a positive result was defined by a serum methylation level above the appropriately chosen cutoff value for any one of the five genes, the preoperative diagnostic sensitivity for thyroid cancer was 68% (26 of 38), the specificity was 95% (18 of 19), and the overall preoperative diagnostic accuracy was 77%, with positive and negative predictive values of 96 and 60%, respectively. In a subset of patients with cytologically indeterminate thyroid nodules, serum DNA methylation testing could correctly diagnose eight of 11 (73%) cancers and four of four (100%) benign tumors, with a diagnostic accuracy of 80%. We also analyzed these serum DNA methylation markers in 39 previously treated thyroid cancer patients. Among the 10 patients proved to have recurrent disease by conventional measures, seven (70%) were positive on methylation testing. Among the 29 patients who had no corroboration of residual or recurrent disease by conventional studies, six (21%) were positive for serum DNA methylation markers., Conclusions: We have demonstrated the potential usefulness of serum DNA methylation markers as a novel tool for differential diagnosis of solid thyroid nodules and thyroid cancer recurrence monitoring.

Context: Use of BRAF mutation in papillary thyroid cancer (PTC) has the potential to improve risk stratification of this cancer., Objective: The objective of the study was to investigate the prognostic value of BRAF mutation in patients with PTC., Design, Setting, and Subjects: In a multicenter study of 219 PTC patients, data on their clinicopathological characteristics and clinical courses between 1990 and 2004 were retrospectively collected, and their tumor BRAF mutation status was determined. Associations of BRAF mutation with initial tumor characteristics and subsequent recurrence were analyzed., Main Outcome Measure: Relationships between the BRAF mutation status and clinicopathological outcomes, including recurrence, were measured., Results: We found a significant association between BRAF mutation and extrathyroidal invasion (P < 0.001), lymph node metastasis (P < 0.001), and advanced tumor stage III/IV (P = 0.007) at initial surgery. This association remained significant on multivariate analysis, adjusting for conventional clinicopathological predictors of recurrence excluding the histological PTC subtype, but was lost when the tumor subtype was included in the model. BRAF mutation was also significantly associated with tumor recurrence, 25 vs. 9% with and without mutation, respectively (P = 0.004), during a median of 15 (interquartile range, 3-29) months of follow-up. This association remained significant on multivariate analysis adjusting for conventional clinicopathological predictors of recurrence, even including the PTC subtype (odds ratio, 4.0; 95% confidence interval, 1.1-14.1; P = 0.03). BRAF mutation was even an independent predictor of recurrence in patients with stage I/II disease, 22 vs. 5% with and without BRAF mutation, respectively (P = 0.002). BRAF mutation was also more frequently associated with absence of tumor I-131 avidity and treatment failure of recurrent disease., Conclusions: In patients with PTC, BRAF mutation is associated with poorer clinicopathological outcomes and independently predicts recurrence. Therefore, BRAF mutation may be a useful molecular marker to assist in risk stratification for patients with PTC.

Background: A 6-ft Caldwell radiograph template and transillumination, typically, are used to elucidate the frontal sinus outline for osteoplastic frontal sinusotomy (OFS). These techniques can be fraught with imprecision. The consequences of imprecise OFS may result in significant complications. Computer-aided surgery may offer a safe and accurate alternative to these techniques in selected cases. Several disadvantages were noted with early computer-aided assistance. Current infrared and electromagnetic systems have eliminated many of these disadvantages. We describe our technique and experience with an infrared image-guidance system (The LandmarX Evolution; Medtronic Xomed, Jacksonville, FL) to create a precise OFS that maximizes exposure while minimizing morbidity., Methods: We describe the use of an infrared image guidance system, the LandmarX Evolution for OFS in three cases., Results: The LandmarX Evolution allowed for accurate placement of the OFS in each of the three cases and successful treatment of two symptomatic frontal sinus osteomas and a recurrent inverted papilloma. No complications were encountered., Conclusion: Image-guided OFS results in a confident and accurate entry into the frontal sinus. Image-guided OFS creation should be considered for select cases (i.e., complete opacification and altered anatomy) where performing an OFS by standard techniques may increase the complication rate. More experience with the technique and increased accessibility to image-guided equipment must be made possible before establishing this technique as a standard.

Knowing the surgical options for treating laryngeal carcinomas and the factors that are used to select patients for radiation therapy leads to a more valuable and relevant interpretation of neck scans in patients with laryngeal tumors. Critical factors include tumor volume; cartilaginous invasion; spread across supraglottic-glottic-subglottic boundaries; infiltration of preepiglottic, paraglottic, and pharyngeal planes; and nodal disease. MR imaging offers greater sensitivity to cartilaginous invasion than CT but shows a higher rate of false-positive studies. Direct coronal MR imaging is often valuable in assessing these issues.

Numerous biomolecular markers have been studied to improve the accuracy of fine needle aspiration biopsy (FNAB) in the diagnostic and prognostic evaluation of thyroid tumors, but none of them has yet become clinically useful. The recently discovered BRAF mutation, which occurs specifically in papillary thyroid cancers (PTC) with a high prevalence and is associated with poor clinicopathological outcomes, has the potential to be a useful diagnostic and prognostic marker for PTC. In the present study, we investigated whether detection of BRAF mutation on FNAB specimens was technically possible and could be used as an adjunct diagnostic tool with routine FNAB. Evaluation of a new colorimetric mutation detection method demonstrated 100% sensitivity and 100% specificity in comparison with conventional DNA sequencing as the "gold standard" in a large pool of DNA samples from various primary thyroid tumor specimens and cell lines. We found this novel technique even more sensitive in detecting BRAF mutation on FNAB specimens than conventional sequencing. In a series of 48 patients undergoing thyroidectomy, mostly for thyroid cancer or for suspicion of cancer, we performed preoperative FNAB and, using the colorimetric mutation detection method, identified BRAF mutation on the cytological specimens. Prospective analysis showed that 50% of the nodules that proved to be PTC on surgical histopathology were correctly diagnosed by BRAF mutation analysis on FNAB specimens; there were no false positive findings. Thus, we have demonstrated the usefulness of BRAF mutation detection on FNAB specimens that can help diagnose and identify those PTC patients who may need more aggressive surgical treatment and vigilant clinical monitoring.

Background: Fine needle aspiration (FNA) is routinely used in the preoperative evaluation of thyroid nodules, but subsequent patient management is often complicated by the inability to decisively recognize malignancy on cytologic grounds alone. Activating mutations of the BRAF oncogene commonly occur in papillary thyroid carcinomas (PTCs) but not in other types of benign and malignant thyroid lesions. Mutational analysis of FNAs could enhance selection of thyroid nodules for surgical removal., Methods: Ninety-five excised PTCs along with 49 corresponding FNAs were evaluated for BRAF mutations by a newly developed assay that uses a novel primer extension method (MutectorR assay) and by direct sequencing. An additional 42 FNAs from thyroid nodules that were excised based on a suspicion of malignancy were also evaluated., Results: BRAF mutations were identified in 36 of the 95 (38%) excised PTCs. By histological subtype, BRAF mutations were more common in conventional PTCs than in the follicular variant (67% versus 12%; P < 0.0001; chi(2)). Analysis of the preoperative FNAs accurately reflected BRAF status of the resected PTC in 46 of the 49 paired samples (94% concordance). In FNA samples grouped according to the preoperative cytologic findings (malignant, n = 25; benign, n = 11; and indeterminate, n = 55), a BRAF mutation confirmed the diagnosis of PTC in 72% of carcinomas within the malignant group, and it established the diagnosis of PTC in 16% of carcinomas within the indeterminate group. BRAF mutations were not detected in FNAs from 32 benign thyroid lesions. Direct sequencing and the MutectorR assay yielded completely concordant results., Conclusions: BRAF mutations are common in conventional PTCs, and they are specific for PTC. A BRAF mutation can be reliably detected in cells aspirated from a thyroid nodule suggesting a role for this marker in the preoperative evaluation of thyroid nodules.

Background: Odontogenic ghost cell carcinoma (OGCC), a malignant counterpart of the calcifying odontogenic cyst (COC), is exceedingly rare. Previous descriptions of this tumor were based on identification of malignant histologic characteristics such as infiltration, cellular pleomorphism, numerous mitoses, and necrosis concurrent with classical benign COC or its solid benign variant, the odontogenic ghost cell tumor., Methods: We present a case of a young Asian man who underwent multiple local excisions of a recurring maxillary COC. After one such excision, a rapid onset of painful swelling ensued, and the patient was referred to our institution for definitive surgery., Results: The patient underwent a right subtotal maxillectomy. Intraoperatively, a 5-cm tumor was found to be extending into the right maxillary sinus and nasal cavity. The excised tumor was diagnosed as an OGCC. The tumor was excised with clear margins, and no adjunctive radiotherapy was given. The patient was free of residual or recurrent disease 18 months after surgery., Conclusion: On the basis of this case and prior cases found in the literature, OGCCs show a spectrum of growth from slow growing locally invasive tumors to highly aggressive, rapidly growing, infiltrative tumors. Wide local excision with histologically clean margins is the recommended mode of treatment. We recommend close long-term surveillance of recurrent or long-standing benign COCs and OGCC., (Copyright 2003 Wiley Periodicals, Inc.)

The maxilla is an unusual site for an ameloblastoma, and certainly for an ameloblastic carcinoma. Ameloblastomas are considered as benign, yet locally aggressive neoplasms in the vast majority of cases. However, very rarely, these tumors demonstrate a clinical course of malignancy. Recently, a classification system was published differentiating between malignant odontogenic carcinoma variants. The two such forms include malignant ameloblastoma, and ameloblastic carcinoma. In the differential diagnosis, the designation of malignant ameloblastoma is reserved for lesions that, despite their benign histology, metastasize as well-differentiated cells. The diagnosis of ameloblastic carcinoma is reserved for tumors that demonstrate a malignant morphologic appearance, regardless of whether metastasis is a proven fact at the time of discovery and treatment. We discuss the presentation, pathology, and treatment of the 18th case of a maxillary ameloblastic carcinoma in the literature.

The open organ preservation surgical procedures are an important part of the head and neck surgeon's armamentarium for treating laryngeal cancer. The principles of organ preservation surgery as they apply to laryngeal cancer must be thoroughly appreciated and strictly applied for oncologic and functional success. The selection of eligible patients for these procedures is an art and requires a keen clinical acumen. The vertical partial laryngectomy and supraglottic laryngectomy have defined clinical applications that are relatively well accepted. The supracricoid laryngectomy continues gaining acceptance as a means of treating more extensive glottic and transglottic lesions while maintaining physiologic speech and swallowing without the need for a permanent tracheostoma. The inability to include and use the open surgical organ preservation approaches in the organ preservation paradigm for larynx cancer severely limits the patient's treatment options. Total laryngectomy and medical organ preservation protocols may not be acceptable to the patient from a quality-of-life standpoint. Therefore, it is incumbent upon the head and neck surgeon to have a thorough understanding of all the options available for treatment in the organ preservation paradigm for laryngeal cancer. These options must be skillfully evaluated as they relate to the patient's disease process and confidently used to provide the best oncologic and functional outcome.

Knowing the surgical options for treating laryngeal carcinomas and the factors that are used to select patients for radiation therapy leads to a more comprehensive interpretation of neck scans in patients with laryngeal tumors (Table 6). Critical factors include tumor volume; cartilaginous invasion; spread across supraglottic-glottic-subglottic [table: see text] boundaries; infiltration of preepiglottic, paraglottic, and pharyngeal planes; and nodal disease. MR imaging offers greater sensitivity to cartilaginous invasion than CT but leads to a high rate of false-positive studies, which decreases its overall accuracy. Thin-section CT with multiplanar capability is competitive with direct coronal MR scanning and benefits from high specificity and submillimeter section thickness, if multidetector units are employed. Overall, the head and neck radiologist plays an invaluable role in assessing the extent of disease and therefore influences the appropriate selection from the available treatment options.

Objective: Polypeptide growth factors have important influences on wound-healing and scar tissue formation. Specific growth factors or their inhibitors may potentially decrease scar tissue formation and prevent subglottic stenosis. Gene transfer using recombinant adenovirus may be an ideal method to mediate endogenous production of growth factors to inhibit fibrosis., Study Design: The study incorporated adenovirus-mediated transduction of normal and stenotic rat larynges and histologic analysis of the sequential expression of a beta-galactosidase marker gene over time., Setting: The study was conducted at the animal care facility of an academic children's hospital., Results: We report successful transduction in normal and injured rat larynx with peak expression of beta-galactosidase at 2 days after transduction and almost complete disappearance by 7 days. There appeared to be an early inflammatory response to the viral injection, but at 7 and 14 days after injection (transduction) the uninjured rat larynges resumed a normal histologic appearance. All distant sites stained negative for beta-galactosidase., Conclusion: Recombinant adenovirus-mediated gene transfer is feasible in the rat larynx with transient duration and limited toxicity., Significance: Adenovirus-mediated gene transfer has the potential to deliver growth factors that modulate wound healing and inflammation in the larynx by inhibiting fibrosis.

The sternocleidomastoid tumor of infancy (STOI) is a relatively uncommon condition. Typically, it presents as a firm, well circumscribed mass within the sternocleidomastoid muscle (SCM) in infants 1-8 weeks of age and may be associated with torticollis. This condition must be considered in any infant with a lateral neck mass. The diagnosis can often be made clinically, but unusual presentations may present diagnostic challenges. Although bilateral involvement is rare, it does occur. The second reported case, a 2-week old female with bilateral STOIs and torticollis, is reported. Although many of the characteristics of the masses suggested the condition, the bilateral nature added uncertainty to the clinical impression, and magnetic resonance imaging (MRI) was used to confirm the diagnosis. The clinical presentation and management of the STOI are reviewed, and the unusual features of this case are discussed.

Since 1992, 42 patients at the University of Pennsylvania have been treated for inverted papilloma (IP). Thirty-three patients were managed endoscopically with or without a Caldwell Luc approach (CLA) and retrospectively analyzed. The CLA, which involves a gingivobuccal incision for access to the maxillary sinus, is distinguished from a formal Caldwell Luc procedure. These 33 patients with histologically confirmed IP were without evidence of malignancy. They also did not have evidence of intracranial, orbital, or frontal sinus IP. Seventeen of 33 patients (17/33) were without prior treatment (primary). Sixteen of 33 (16/33) presented from an outside institution with recurrent IP (secondary). The recurrence rate using this method to treat primary IP was 6% (1/17), and for secondary IP was 25% (4/16). Scheduled postoperative endoscopic surveillance permitted early detection of recurrence and continued endoscopic control of IP. All 33 patients were endoscopically free of disease at the end of the study. These preliminary data are encouraging for the use of intranasal endoscopy with and without CLA as a means of managing and controlling IP in selected cases.

We reviewed our experience with sinonasal malignancies, which comprise less than 1% of all cancers, in order to determine the spectrum of disease and outcome after treatment. The medical records of 48 patients with sinonasal malignancies treated between 1990-1997 were reviewed for epidemiologic characteristics, tumor location and histology, treatment modalities, and tumor recurrence. Mean age was 58.5 years and 46% were male. Multiple sites of origin were common, including maxillary sinus (83%), ethmoid sinus (35%), and nasal cavity (40%). The histologic spectrum included squamous cell carcinoma (46%), adenoid cystic carcinoma (6%), and miscellaneous others (48%). Treatment included surgery and adjuvant radiotherapy (XRT) (58%), surgery alone (27%), XRT and chemotherapy (6%), surgery and chemotherapy (4%), and XRT alone (4%). Mean follow-up was 15 months (range 2-58). Recurrence was evident in nine patients (19%), 3 (33%) of whom had prior treatment before presenting to HUP. Of the six who recurred after initial treatment at HUP, five (83.3%) were treated with surgery and XRT and one (16.7%) was treated with surgery alone. Of the three that recurred after undergoing attempts at salvage (prior treatment and then treatment at HUP), one had received surgery alone followed by surgery and XRT, one had surgery and XRT followed by surgery and one had XRT followed by surgery alone. Our experience reveals surgery and XRT to be the modality of choice, particularly for advanced tumors, whereas surgery alone may be sufficient for small, well localized tumors. Neoadjuvant chemotherapy may offer improved local control; the future role of endoscopic surgery warrants further investigation.