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Postoperative speech function may be influenced by a number of treatment variables. The objective of this study was to examine the relationships among various treatment factors to determine the impact of these measures on speech function. Speech function was tested prospectively in 142 patients with surgically treated oral and oropharyngeal cancer 3 months after treatment. Each patient's speech was recorded during a 6- to 7-minute conversation and while performing a standard articulation test, producing speech outcome measures of percent correct consonant phonemes and percent conversational understandability. Correlational analyses were used to determine the relationships among the speech outcome measures and 14 treatment parameters. Speech function was mildly to moderately negatively correlated with most surgical resection variables, indicating that larger amounts of tissue resected were associated with worse speech function. Overall measures of conversational understandability and percent correct consonant phonemes were related to extent of oral tongue resection, floor of mouth resection, soft palate resection, and total volume of tissue resected. These relationships varied depending on the method of surgical closure. Method of surgical reconstruction had a profound impact on postoperative speech function 3 months after treatment and was an important factor in determining how oral tongue resection influenced articulation and intelligibility. The combination of closure type, percent oral tongue resected, and percent soft palate resected had the strongest relationship with overall speech function for patients with surgically treated oral and oropharyngeal cancer 3 months after treatment. [ABSTRACT FROM AUTHOR]

Optimal management of advanced neck metastases as part of an organ preservation treatment approach for head and neck squamous carcinoma (HNSC) is unclear. Since 1989, our management paradigm for patients on organ preservation was modified to incorporate planned early neck dissection before radiation therapy for patients who did not achieve a complete response (CR) of neck nodes after induction chemotherapy (IC). The purpose of this study was to determine if planned early neck dissection is a safe and effective approach in the management of advanced nodal disease as part of organ preservation. Fifty-eight consecutive patients with advanced HNSC who were entered in organ preservation trials using induction chemotherapy and radiation with surgical salvage were studied. Median follow-up was 26 months. Of the 58 patients, 71% were stage IV. Patients were grouped by nodal response to chemotherapy and N class, and were analyzed with respect to patterns of recurrence, complications, and survival. Overall, the rate of CR of neck nodes was 49%. Fifty-one percent had less than a complete response of neck nodes after IC and required planned early neck dissection. There were no significant differences in patterns of recurrence, complications, interval time to start of radiation, recurrence, or survival rates between the CR and less than CR groups. These data suggest that planned early neck dissection for patients with less than CR in the neck after IC is not detrimental with respect to neck relapse or overall survival. We believe that planned early neck dissection can be safely incorporated into future organ preservation treatment protocols for patients with advanced head and neck carcinoma. [ABSTRACT FROM AUTHOR]

Diffuse reflectance spectroscopy (DRS) is a powerful tool for quantifying optical and physiological tissue properties such as hemoglobin oxygen saturation and vascularity. DRS is increasingly used clinically for distinguishing cancerous lesions from normal tissue. However, its widespread clinical acceptance is still limited due to uncontrolled probe-tissue interface pressure that influences reproducibility and introduces operator-dependent results. In this clinical study, we assessed and validated a pressure-sensing and automatic self-calibration DRS in patients with suspected head and neck squamous cell carcinoma (HNSCC). The clinical study enrolled nineteen patients undergoing HNSCC surgical biopsy procedures. Patients consented to evaluation of this improved DRS system during surgery. For each patient, we obtained 10 repeated measurements on one tumor site and one distant normal location. Using a Monte Carlo-based model, we extracted the hemoglobin saturation data along with total hemoglobin content and scattering properties. A total of twelve cancer tissue samples from HNSCC patients and fourteen normal tissues were analyzed. A linear mixed effects model tested for significance between repeated measurements and compared tumor versus normal tissue. These results demonstrate that cancerous tissues have a significantly lower hemoglobin saturation compared to normal controls ( p < 0.001), which may be reflective of tumor hypoxia. In addition, there were minimal changes over time upon probe placement and repeated measurement, indicating that the pressure-induced changes were minimal and repeated measurements did not differ significantly from the initial value. This study demonstrates the feasibility of conducting optical spectroscopy measurements on intact lesions prior to removal during HNSCC procedures, and established that this probe provides diagnostically-relevant physiologic information that may impact further treatment.

Diffuse reflectance spectroscopy (DRS) represents a quantitative, noninvasive, nondestructive means of assessing vascular oxygenation, vascularity, and structural properties. However, it is known that such measurements can be influenced by the effects of pressure, which is a major concern for reproducible and operator-independent assessment of tissues. Second, regular calibration is a necessary component of quantitative DRS to account for factors such as lamp decay and fiber bending. Without a means of reliably controlling for these factors, the accuracy of any such assessments will be reduced, and potentially biased. To address these issues, a self-calibrating, pressure-controlled DRS system is described and applied to both a patient-derived xenograft glioma model, as well as a set of healthy volunteers for assessments of oral mucosal tissues. It was shown that pressure had a significant effect on the derived optical parameters, and that the effects on the optical parameters were magnified with increasing time and pressure levels. These findings indicate that not only is it critical to integrate a pressure sensor into a DRS device, but that it is also important to do so in an automated way to trigger a measurement as soon as possible after probe contact is made to minimize the perturbation to the tissue site.

Background and Purpose: Workup of incidental thyroid nodules detected on CT imaging could be contributing to the increased diagnosis of small thyroid cancers. The purpose of this study was to evaluate recent trends in the incidence of thyroid cancer, and to determine the relationship between annual CT imaging volume and rate of thyroid cancer diagnosis., Materials and Methods: This retrospective cohort study used data bases for thyroid cancer and CT imaging volume. Thyroid cancer data from 1983-2009 were obtained from the Surveillance, Epidemiology, and End Results data base. National Council of Radiation Protection and Measurements Report No. 160 provided data on hospital and nonhospital CT imaging volume for 1993-2006. Trends in thyroid cancer were modeled for overall incidence on the basis of patient age, tumor histologic features, and tumor size and stage. Linear regression analysis was performed to evaluate the strength of the relationship between annual CT scan volume and the incidence of thyroid cancer by tumor size and histologic type., Results: In 2009, the incidence of thyroid cancer was 14 per 100,000, which represented a 1.9-fold increase compared with 2000. The growth in incidence was exponential compared with a minimal linear increase in thyroid cancer mortality rate. The subgroup with the greatest change was subcentimeter papillary carcinoma, with doubling in incidence approximately every 6.2 years. The linear relationship between annual CT scan volume and the incidence of subcentimeter papillary carcinoma was very strong (R(2) = 0.98; P < .0001)., Conclusions: The incidence of subcentimeter papillary carcinoma is growing at an exponential rate without significant change in mortality rate. The strong linear relationship between new cases of subcentimeter papillary carcinomas and the number of CT scans per year suggests that an increase in CT scans may increase the detection of incidental thyroid cancers.

Background and Purpose: Thyroid nodules are common incidental findings on CT, but there are no clear guidelines regarding their further diagnostic work-up. This study compares the performance of 2 risk-categorization methods of selecting CT-detected incidental thyroid nodules for work-up., Materials and Methods: The 2 categorization methods were method A, based on nodule size ≥10 mm, and method B, a 3-tiered system based on aggressive imaging features, patient age younger than 35 years or nodule size of ≥15 mm. In part 1, the 2 categorization methods were applied to thyroid cancers in the SEER data base of the National Cancer Institute to compare the cancer capture rates and survival. In part two, 755 CT neck scans at our institution were retrospectively reviewed for the presence of ITNs of ≥5 mm, and the same 2 categorization methods were applied to the CT cases to compare the number of patients who would theoretically meet the criteria for work-up. Comparisons of proportions of subjects captured under methods A and B were made by using the McNemar test., Results: For 84,720 subjects in the SEER data base, methods A and B each captured 74% (62,708/84,720 and 62,586/84,720, respectively) of malignancies. SEER subjects who would not have met the criteria for further work-up by both methods had equally excellent 10-year cause-specific and relative survival of >99%. For part 2, the prevalence of ITNs of ≥5 mm at our institution was 133/755 (18%). The number of ITNs that would be recommended for work-up by method A was 57/133 (43%) compared with 31/133 (23%) for method B (P < .0005)., Conclusions: Compared with using a 10-mm cutoff, the 3-tiered risk-stratification method identified fewer ITNs for work-up but captured the same proportion of cancers in a national data base and showed no difference in missing high-mortality cancers.

Objectives/hypothesis: To determine whether vocal cord fixation precludes nonsurgical management of T3/T4 laryngeal carcinoma., Study Design: A retrospective chart review., Methods: Between 1989 and 2005 patient records with T3/T4 squamous cell carcinoma of the larynx with vocal cord fixation at presentation were reviewed. All were treated with a concomitant cisplatin-based chemoradiotherapy protocol and were part of the institutional head and neck cancer chemoradiotherapy registry. Only patients with adequate pre- and post-treatment fiberoptic evaluations were included. Charts were reviewed for demographics and tumor characteristics; return of vocal cord function; local, regional, or distant recurrence after treatment; and need for salvage surgery. The Kaplan-Meier method was used to estimate outcomes, and the log-rank test was used to compare those patients whose vocal cords remained fixed to those with recovery of function., Results: Twenty-three patients met the inclusion criteria, 19 males and 4 females. The median age was 59 years (range, 39-73). Fourteen patients had T3 and nine had T4 tumors. Twelve patients recovered full range of mobility, three had partial recovery, and eight did not recover motion. The median follow-up was 68 months (range, 34-191). Comparing patients with post-treatment partial or fully mobile cords to those with persistent fixation revealed the following: A projected five-year overall survival of 100% versus 25%, (P < .001), freedom from recurrence of 86.7 versus 25% (P < .001), local control without surgery of 86.7% versus 30% (P = .003), and survival with functional larynx of 86.7% versus 25% (P = .008), respectively., Conclusions: Nonsurgical therapy in patients with pretreatment vocal cord fixation is feasible. However, persistence of vocal cord fixation after definitive chemoradiotherapy is a poor prognostic sign and early surgical intervention should be considered. Laryngoscope, 2009.

Radiotherapy and concurrent chemotherapy (CRT) is superior to radiotherapy alone for the treatment of locally advanced, nonmetastatic squamous carcinoma of the head and neck (HNC). Three issues affect the use of CRT as primary treatment for advanced HNC. The first issue is the definition of advanced stage and the initial therapeutic choice of surgery or CRT and the role of post-CRT neck dissection. Function preservation considerations should guide the choice between surgery and CRT for patients with resectable disease. Fluorodeoxyglucose-positron emission tomography scanning may identify patients who require adjuvant neck dissection. The second issue is optimization of radiotherapy and chemotherapy schedules. Ideally, concurrent chemotherapy should be incorporated into radiotherapy (RT) regimens that would constitute optimal therapy were RT to be administered as single-modality treatment. Modified fractionation schemes constitute optimal single-modality RT. Platinum schedules other than bolus dosing every 3 to 4 weeks are effective and may be less toxic. The third issue is integration of biologically targeted therapy into CRT treatment programs. Epidermal growth factor receptor blockade enhances the effectiveness of RT alone. Its role and that of angiogenic blockade in CRT are under investigation.

Background: Microcystic adnexal carcinoma (MAC) is a rare, locally aggressive tumor. Treatment for this neoplasm typically requires extensive local excision leading to morbidity. Therefore, the temptation to use alternative treatment options remains high., Methods: We report one case of a nasal dorsum MAC treated with external beam radiation secondary to the patient's poor health status and preference., Results: After initial dramatic clinical resolution, the tumor recurred in a clinically more extensive and histologically more aggressive form., Conclusion: On the basis of this case and several detailed in the literature, we therefore hypothesize that radiation therapy is not only an ineffective treatment for MAC, but evidence exists that this modality may induce conversion to a histologically and clinically less favorable neoplasm., (Copyright 2003 Wiley Periodicals, Inc. Head Neck 25: 251-254, 2003)

Background: Conventional angiography has been recommended for imaging of the leg prior to fibular-free flap harvest. Magnetic resonance angiography (MRA) offers a similar level of accuracy at no risk to the patient and at a lower cost., Methods: Thirty-two patients who were considered for fibular-free flap were retrospectively reviewed. Preoperative MRA of the lower extremities was performed on all patients and used to evaluate vessel patency. The decision of free flap donor site was based upon MRA findings., Results: The choice of side harvested was changed in four (12.5%) patients and the fibula was excluded as a donor site in three patients (9%). Flap design was altered in one patient found to have abnormally short peroneal arteries. The usual correlation between palpable distal pulses and proximal patent arteries was found to be unreliable. All 29 patients underwent successful free flap reconstruction with no ischemic complications., Conclusions: Preoperative MRA is useful when choosing the side of fibular harvesting and in excluding patients from the fibula as a donor site. We feel that the cost of obtaining preoperative imaging is outweighed by avoiding potential ischemic complications and additional operating room time with no risk to the patient's health., (Copyright 2001 John Wiley & Sons, Inc. Head Neck 23: 844-850, 2001.)

Objective: To determine if selective reinnervation of the cricothyroid muscle could be achieved with muscle-nerve-muscle neurotization., Design: Case series., Setting: Tertiary referral center., Patients: Three consecutive patients with high vagal lesions that resulted in unilateral laryngeal paralysis., Interventions: Patients underwent laryngeal reinnervation with ansa hypoglossi to recurrent laryngeal nerve anastomosis. In addition, patients underwent selective cricothyroid muscle reinnervation by muscle-nerve-muscle neurotization technique., Main Outcome Measures: Objective and subjective improvement in voice quality and electromyographic evidence of selective reinnervation of the cricothyroid muscle., Results: All patients recovered normal or near-normal speaking voice and had normal objective measures of voice quality. They also showed electromyographic evidence of cricothyroid muscle reinnervation., Conclusion: The muscle-nerve-muscle neurotization technique was successful in providing selective reinnervation of the cricothyroid muscle in our 3 patients.

Objectives/hypothesis: Early glottic squamous cell carcinoma can be effectively treated with either radiation or surgical intervention. We evaluated our experience treating early glottic cancer with primary radiation therapy and our vertical hemilaryngectomy (VHL) salvage experience., Study Design/methods: Retrospectively, patient records between January 1986 and December 1994 were reviewed and 45 patients with early glottic squamous cell carcinoma who received full-course radiation therapy at the Cleveland Clinic Foundation were identified., Results: Local control after radiation therapy was 80% overall, 87.5% for T1 lesions, and 75% for T2 lesions. Four patients underwent VHL for salvage after local recurrence; 1 was successfully salvaged with VHL. Five patients underwent total laryngectomy salvage after radiation therapy; all were successful. Only 1 of the 6 patients who were originally candidates for VHL before radiation therapy was successfully salvaged with the larynx preserved., Conclusions: Our local control rates using primary radiation therapy are consistent with prior published series, but voice sparing salvage is poor.

Ischemia/reperfusion injury is often the final and irreversible factor causing flap failure in microvascular surgery for head and neck defects. This paper begins with a detailed review of flap physiology and ischemia/reperfusion injury at the cellular level. Subsequently, the pharmacotherapeutic agents used clinically and experimentally to avoid or reverse ischemia/reperfusion injury are discussed. The goal of this review is to provide a framework for understanding the expanding body of literature relevant to ischemia/reperfusion injury in microvascular surgery., (Copyright 2000 John Wiley & Sons, Inc.)

Objective: To evaluate the feasibility and toxic effects of systemic adoptive T-cell immunotherapy in patients with unresectable squamous cell carcinoma of the head and neck (SCCHN)., Design: Nonrandomized phase 1 clinical trial., Setting: Academic tertiary care hospital., Patients: Between April 1, 1996, and September 30, 1998, 17 patients with confirmed recurrent and metastatic SCC of the upper aerodigestive tract were enrolled. Two patients did not receive T cells because of poor vaccine response. Fifteen patients were successfully treated with T-cell immunotherapy., Intervention: Patients were vaccinated on the thigh with irradiated autologous tumor cells admixed with granulocyte-macrophage colony-stimulating factor (GM-CSF) followed by 3 additional daily injections of GM-CSF at the vaccination site. Eight to 10 days later, tumor cell vaccine-draining inguinal lymph nodes were resected, and lymph node lymphocytes were activated with staphylococcal enterotoxin A and expanded in interleukin 2 in vitro. Resulting cultured cells were infused into patients peripherally on an outpatient basis., Results: Toxic effects of infusion were limited to grade 2 reactions in 3 of 16 treatments. One patient required overnight hospitalization for fever and emesis. Median cell expansion was 37 times (range, 4-416 times), and median cell dose was 7.5 x 10(9) (range, 1.3 x 10(8) to 4.2 x 10(10)). Infused cells were predominantly CD3+ (>97%), being a mixture of CD4+ and CD8+ cells. Three patients demonstrated stabilization of previously progressive disease. Two patients experienced favorable clinical courses after adoptive T-cell transfer, including 1 patient with no evidence of disease 4 years after surgical resection of a vertebral body metastasis., Conclusions: Adoptive immunotherapy is a technically feasible and safe treatment with low toxicity and may demonstrate therapeutic activity in patients with unresectable SCCHN.

We performed a prospective masked animal study to determine whether virtual bronchoscopy, a noninvasive computed tomography technique, can accurately measure upper airway stenosis. Virtual bronchoscopy creates a 3-dimensional endoscopic image from spiral computed tomography data. Laryngotracheal stenosis was endoscopically induced in 18 dogs. The excised larynges were examined by endoscopy, virtual bronchoscopy, and macrodissection. Measurements were made of the anteroposterior (A-P) diameter, the left-right (L-R) diameter, the full length of stenosis in the sagittal plane, and the length of the tightest stenotic segment. Each measurement method was performed independently. All investigators were unaware of measurements made by others. The measurements obtained through virtual bronchoscopy and actual endoscopy were compared to those made at dissection by interclass correlation coefficients (ICCs). Endoscopy was better than virtual bronchoscopy in measuring the A-P diameter (ICC = .79, p < .0001; ICC = .42, p = .01). Both were equally effective in measuring the L-R diameter (ICC = .53, p = .0062; ICC = .52, p = .0064). The endoscopes could not assess the full length of the stenosis, whereas virtual bronchoscopy measured it fairly accurately (ICC = .72, p = .0001). Virtual bronchoscopy relatively accurately measured the length of the tightest stenotic segment (ICC = .68, p = .0002), whereas endoscopy produced measurements in only 11 of 18 larynges, and the measurements were less accurate (ICC = .45, p = .0068). Virtual bronchoscopy can provide good measurements of stenotic lesions in the airway. It is more accurate than actual endoscopy in determining the length of stenosis. It may therefore be useful as an adjunct imaging method in preoperative planning for reconstructive surgery.

Unilateral vocal fold paralysis is a common clinical problem which frequently causes severe dysphonia. Various treatment options exist for this condition, with the type I thyroplasty being one of the more commonly performed surgical procedures for vocal rehabilitation. The Voice-Related Quality of Life (V-RQOL) Measure is a validated outcomes instrument for voice disorders. This study measured the V-RQOL of patients with unilateral vocal fold paralysis who had undergone a type I thyroplasty and compared these scores to those of patients with untreated and uncompensated unilateral vocal fold paralysis and to normals. Treated patients had significantly higher domain and overall V-RQOL scores than untreated patients, but also scored lower than normals. These differences were true across gender and age. Patients who were more distant from surgery had lower V-RQOL scores than those who had more recently been treated. It is concluded that type I thyroplasty leads to a significantly higher V-RQOL for patients with unilateral vocal fold paralysis. This study also demonstrates further the utility of patient-oriented measures of treatment outcome.