Search

Objective/hypothesis: Elevation of the superficial musculoaponeurotic system (SMAS) with or without fat graft interposition during superficial parotidectomy prevents a concave facial deformity and Frey's syndrome. Study Design: Retrospective, case-control study. Methods: Charts for 248 patients who underwent superficial parotidectomy were reviewed for pathologic, radiographic, clinical, and operative data. Sixteen patients who underwent SMAS elevation and 34 patients who underwent SMAS elevation with fat graft interposition were included in two study groups. Nonreconstructed controls were randomly selected from a pool of patients who had unilateral, superficial parotidectomy and were matched based on pathologic specimen volume. Patients were surveyed for their postoperative symptoms. Results: Patients undergoing SMAS elevation alone (n = 16) compared with controls (n = 19) had greater facial symmetry (12% vs. 32%, P = .147) and a lower incidence of symptomatic Frey's syndrome (6.3% vs. 18.6%, P = .382). Patients undergoing SMAS elevation and fat graft interposition (n = 34) compared with controls (n = 38) had less facial asymmetry (9% vs. 39%, P = .002) and a lower incidence of symptomatic Frey's syndrome (6% vs. 28%, P = .04). Complications among the study and control groups were comparable. Conclusions: Simultaneous reconstruction of a superficial parotidectomy defect using SMAS elevation with or without fat grafting may improve postoperative facial symmetry and decrease the incidence of symptomatic Frey's syndrome without increasing complications. [ABSTRACT FROM AUTHOR]

Keloids are an abnormal response to wound healing distinguished by an overproduction of collagen. Thickened bundles of collagen in the reticular dermis oriented haphazardly in relation to the overlying epithelium are found in keloids, in contrast to thinner collagen fibers in a more orderly arrangement that are found in normal scars. Previous clinical trials of intralesional interferon-gamma (IFN-G) injections by Larrabee et al. and Granstein et al. showed a decrease in lesion size. These findings led to a conclusion that IFN-G would be a useful adjunct to surgical excision of keloids to aid in preventing recurrence. We performed a double-blind, placebo-controlled trial in patients with two or more keloids treated with excision and subsequent local injections of IFN-G or placebo. [ABSTRACT FROM AUTHOR]

Purpose: To report on a prospective clinical trial of the use of daily kilovoltage cone-beam computed tomography (CBCT) to evaluate the interfraction and residual error motion of patients undergoing intensity-modulated radiotherapy for head-and-neck cancer. Methods and Materials: Patients were treated with intensity-modulated radiotherapy with an Elekta linear accelerator using a mounted CBCT scanner. CBCT was performed before every treatment, and translational (but not rotational) corrections were performed. At least once per week, a CBCT scan was obtained after intensity-modulated radiotherapy. Variations were measured in the medial-lateral, superoinferior, and anteroposterior dimensions, as well as in the rotation around these axes. Results: A total of 28 consecutive patients (1,013 CBCT scans) were studied. The average interfraction shift was 1.4 +/- 1.4, 1.7 +/- 1.9, and 1.8 +/- 2.1 mm in the medial-lateral, superoinferior, and anteroposterior dimensions, respectively. The corresponding average residual error shifts were 0.7 +/- 0.8, 0.9 +/- 0.9, and 0.9 +/- 0.9 mm. These data indicate that in the absence of daily CBCT image-guided radiotherapy, a clinical target volume to planning target volume margin of 3.9, 4.1, and 4.9 mm is needed in the medial-lateral, superoinferior, and anteroposterior dimensions, respectively. With daily CBCT, corresponding margins of 1.6, 2.5, and 1.9 mm should be acceptable. Subgroup analyses showed that larynx cancers and/or intratreatment weight loss indicate a need for slightly larger clinical target volume to planning target volume margins. Conclusion: The results of our study have shown that image-guided radiotherapy using CBCT for head-and-neck cancer is effective. These data suggest it allows a reduction in the clinical target volume to planning target volume margins by about 50%, which could facilitate future studies of dose escalation and/or improved toxicity reduction. Caution is particularly warranted for cases in which the targets are mobile (e.g., the tongue). [ABSTRACT FROM AUTHOR]

Background: Locoregional recurrence rates following parotidectomy for cancer remain as high as 20-30%. The auriculotemporal nerve (ATN) may allow parotid cancers to spread from the facial nerve (FN) toward the skull base, causing local recurrence., Methods: Retrospective review of 173 parotidectomies for malignancy. Preoperative and post-recurrence imaging were reviewed by a neuroradiologist for signs of tumor adjacent to the ATN., Results: Clinical and imaging signs of possible ATN involvement correlated with FN weakness and sacrifice. Eight patients had pathologically confirmed tumor from the ATN or V3. Forty-four percent of local recurrences had post-recurrence imaging showing tumor along the course of the ATN. Locoregional failure along the ATN was also associated with preoperative FN weakness, intraoperative FN sacrifice, and failure to complete recommended adjuvant therapy., Conclusions: Parotid cancers may invade the FN and spread to the skull base via the ATN. If not appropriately managed, this may lead to local recurrence., (© 2020 Wiley Periodicals LLC.)

Objective: To assess the pathological outcomes of surgically-managed human papillomavirus (HPV) positive oropharyngeal squamous cell carcinoma (OPSCC) using the 8th Edition of the American Joint Committee on Cancer Staging Manual (AJCC-8ed)., Materials and Methods: A retrospective review was conducted of 156 patients with previously untreated OPSCC who underwent primary TORS between March 2010 and February 2015 to evaluate the impact of the new AJCC-8ed pathologic staging system. Only patients who had complete pathologic staging with neck dissection and at least 2 years of follow-up records or disease recurrence within 2 years were included for analysis., Results and Conclusions: Of the 156 patients, 116 patients had neck dissections and adequate follow-up data. There were 10 total recurrences, including 2 regional recurrences and 1 local recurrence. Lymph node size, number of positive lymph nodes, and presence of any positive nodes were not associated with recurrence for HPV-positive patients. The presence of extranodal extension approached significance. Pathologic N-stage was not predictive of recurrence under the AJCC-7ed or the AJCC-8ed systems. Cancer staging under the AJCC-8ed, but not the AJCC-7ed system was significantly associated with recurrence. In conclusion, pathologic node status as defined in the AJCC-8ed pathologic staging system does not appear to drive prognosis for surgically managed patients. While the new AJCC-8ed staging is an improvement in prognostication, the use of T-stage alone is still a better predictor of recurrence. TORS with adjuvant therapy determined by pathologic findings provides excellent locoregional control for HPV-positive OPSCC., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Objectives: Bevacizumab (avastin) and erlotinib (tarceva) had shown early clinical activity against head and neck cancer (HNC). We initiated a phase I trial of induction cisplatin, docetaxel, 5-fluorouracil and erlotinib (TPF-E) followed by cisplatin, bevacizumab and erlotinib (PA-E) with radiotherapy (XRT) for advanced HNC. The goal was to determine maximum tolerated erlotinib dose., Methods: Eligible patients had stage IVA or higher HNC with good performance status, hematologic, and renal reserve. Two cycles of induction TPF-E were administered. XRT was administered with concurrent weekly cisplatin and bevacizumab every 2 weeks. Initial erlotinib dose was 50 mg daily from start of induction chemotherapy until radiotherapy completion. Erlotinib dose escalations to 100 and 150 mg were planned., Results: Thirteen patients with previously untreated locoregional disease (11 patients) or oligometastatic (2 patients) HNC were enrolled. Totally, 11 of 13 patients completed XRT as planned. Four of 8 patients in cohort 1 (erlotinib 50 mg), 3 of 4 patients in cohort 2 (100 mg), and 0 of 1 patients in cohort 3 (150 mg) completed the regimen. Two patients had significant gastrointestinal complications (bleeding and perforation), and 1 had dose-limiting diarrhea. Maximum tolerated dose was reached at 50 mg erlotinib. At median 23.4 months follow-up, 5 patients (38%) have no evidence of disease, and 2 (15%) have stable but measurable disease., Conclusions: Erlotinib in combination with induction TPF followed by erlotinib, cisplatin, and bevacizumab with XRT is active but toxic. Gastrointestinal toxicities partly caused high rates of study withdrawal. All doses studied in this protocol caused unexpected toxicities and we do not recommend advancement to phase II.

Objectives/hypothesis: To evaluate functional outcomes and complication rate after total laryngectomy (TL) for dysfunctional larynx with end-stage dysphagia., Study Design: Retrospective chart review., Methods: Chart review was performed on all patients who underwent TL from January 2008 to July 2016 at a single tertiary academic medical center. Patients who underwent TL for dysfunctional larynx without preoperative evidence of malignancy were included. Main outcome measures were post-TL functional swallowing and speech outcomes, and complication rate., Results: The study included 19 patients from a cohort of 278 consecutive patients. All patients were previously treated with radiotherapy (RT), whereas 13/19 (68%) previously received chemoradiotherapy. The median time from RT to TL was 10.98 years (range, 0.67-23.94 years). Aspiration was evident preoperatively in 17/19 (89%) patients, with 11 experiencing recurrent aspiration pneumonia. Seventeen of 19 (89%) patients were nil per os (NPO) requiring enteral nutrition. Six of 19 (32%) patients had surgical complications, including three (16%) pharyngocutaneous fistulas. At 3-month and 1-year postoperative follow-up, there was significant improvement in mean Functional Oral Intake Scale (FOIS) score and aspiration, recurrent pneumonia, enteral nutrition, and NPO status rates (P < .05). At 1-year follow-up, no patients were NPO, and only one patient required gastrostomy tube supplementation. Mean FOIS score increased from 1.3 to 6.1 (P = .001). Eight of 13 patients (62%) were actively using a tracheoesophageal prosthesis at 1-year follow-up., Conclusions: Laryngectomy for dysfunctional larynx eliminates the morbidity of aspiration while improving diet and reducing gastrostomy tube dependence with an acceptable complication rate., Level of Evidence: 4. Laryngoscope, 128:597-602, 2018., (© 2017 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: In many cancers, varying regions within the tumor are often phenotypically heterogeneous, including their metabolic phenotype. Further, tumor regions can be metabolically compartmentalized, with metabolites transferred between compartments. When present, this metabolic coupling can promote aggressive behavior. Tumor metabolism in papillary thyroid cancer (PTC) is poorly characterized., Study Design: Immunohistochemical staining of tissue samples., Methods: Papillary thyroid cancer specimens from 46 patients with (n = 19) and without advanced disease (n = 27) were compared to noncancerous thyroid tissue (NCT) and benign thyroid specimens (n = 6 follicular adenoma [FA] and n = 5 nodular goiter [NG]). Advanced disease was defined as the presence of lateral neck lymphadenopathy. Immunohistochemistry was performed for translocase of outer mitochondrial membrane 20 (TOMM20), a marker of oxidative phosphorylation, and monocarboxylate transporter 4 (MCT4), a marker of glycolysis., Results: Papillary thyroid cancer and FA thyrocytes had high staining for TOMM20 compared to NCT and nodular goiter (NG) (P < 0.01). High MCT4 staining in fibroblasts was more common in PTC with advanced disease than in any other tissue type studied (P < 0.01). High MCT4 staining was found in all 19 cases of PTC with advanced disease, in 11 of 19 samples with low-stage disease, in one of five samples of FA, in one of 34 NCT, and in 0 of six NG samples. Low fibroblast MCT4 staining in PTC correlated with the absence of clinical adenopathy (P = 0.028); the absence of extrathyroidal extension (P = 0.004); low American Thyroid Association risk (P = 0.001); low AGES (age, grade, extent, size) score (P = 0.004); and low age, metastasis, extent of disease, size risk (P = 0.002)., Conclusion: This study suggests that multiple metabolic compartments exist in PTC, and low fibroblast MCT4 may be a biomarker of indolent disease., Level of Evidence: N/A. Laryngoscope, 126:2410-2418, 2016., (© 2015 The American Laryngological, Rhinological and Otological Society, Inc.)

Background: Metabolism in the tumor microenvironment can play a critical role in tumorigenesis and tumor aggression. Metabolic coupling may occur between tumor compartments; this phenomenon can be prognostically significant and may be conserved across tumor types. Monocarboxylate transporters (MCTs) play an integral role in cellular metabolism via lactate transport and have been implicated in metabolic synergy in tumors. The transporters MCT1 and MCT4 are regulated via expression of their chaperone, CD147., Methods: We conducted a meta-analysis of existing publications on the relationship between MCT1, MCT4, and CD147 expression and overall survival and disease-free survival in cancer, using hazard ratios derived via multivariate Cox regression analyses., Results: Increased MCT4 expressions in the tumor microenvironment, cancer cells, or stromal cells were all associated with decreased overall survival and decreased disease-free survival (p < 0.001 for all analyses). Increased CD147 expression in cancer cells was associated with decreased overall survival and disease-free survival (p < 0.0001 for both analyses). Few studies were available on MCT1 expression; MCT1 expression was not clearly associated with overall or disease-free survival., Conclusion: MCT4 and CD147 expression correlate with worse prognosis across many cancer types. These results warrant further investigation of these associations.

Objectives: The role of positron emission tomography (PET) scans in the staging of head and neck cancer (HNC) is unclear. The National Comprehensive Cancer Network guidelines do not recommend routine metastatic workup beyond physical examination, chest x-ray, and laboratory tests. The purpose of this report is to examine the accuracy of staging PET scans for detecting distant metastatic disease in patients with HNC., Methods: Retrospective review of 182 consecutive newly diagnosed HNC patients who had a staging PET scan at Thomas Jefferson University Hospital between 2003 and 2007., Results: The overall incidence of confirmed distant metastatic disease in this population was 5.0%. About 26 of the staging PET scans had areas suspicious for a metastatic lesion(s). Of total, 23 patients were further evaluated with imaging and/or biopsy, revealing 9 (39%) true positives, and 14 (60%) false positives. Of the 156 negative PET scans, there was 1 false negative and 155 true negatives. Thus, the sensitivity of PET was 90% and specificity was 92%. Positive predictive value was 39% and negative predictive value was 99.4%. No patients with pre-PET clinical stage I or II cancer had confirmed distant metastases. The only statistically significant predictor for metastatic disease was clinical stage IV versus all other stages (P=0.03)., Conclusions: Given the marked differences in the treatment of locally advanced/nonmetastatic HNC versus metastatic HNC, we recommend PET for clinical stage IV disease. Although the sensitivity, specificity, and negative predictive value rates were acceptable, the positive predictive value was suboptimal. Patients found to have a PET scan "positive" for metastatic disease require confirmatory imaging or ideally biopsy.

An otherwise healthy 29-year-old woman presented with a complaint of odynophagia of several months' duration. On examination, she was found to have a broadly based, yellow, exophytic lesion on the right lateral pharyngeal wall. Findings on biopsy were consistent with amyloidosis. The patient underwent tonsillectomy with resection of the oropharyngeal lesion. Final pathology established a diagnosis of nodular non-AL-type amyloidosis. Localized amyloidosis of the oropharynx is exceptionally rare. Additionally, most cases of localized amyloidosis are of the AL type, not the AA (i.e., non-AL) type seen in this patient.

We sought to determine the prevalence and patterns of complementary and alternative medicine (CAM) use among head and neck cancer patients who were being treated at an academic otolaryngology practice in the northeastern United States from January 2005 through December 2006. During a 3-month period, we conducted an anonymous survey of 213 new and established patients regarding their use of CAM during their cancer treatment. According to the responses, only 13 of these patients (6.1%) were currently using CAM during treatment. With respect to the various products being taken, 9 patients (69.2% of all CAM users) were taking herbs or supplements. Only 7 patients (53.8%) who used CAM disclosed this fact to their physician during in-office encounters. The most common sources for obtaining CAM were health-food stores, where most patients spent approximately $25 per week. The most frequently cited reason for using CAM was that a particular product had been recommended by family or friends as being potentially helpful. No adverse effects of CAM were reported. We conclude that while CAM use was not very prevalent in this study, patients who did use it were employing modalities with biologic activity that may potentially interact with conventional therapies. Because patients' disclosure of CAM use is frequently not volunteered, otolaryngologists should routinely elicit this information in a highly specific fashion so that we may better serve our unique patient population.

Objective: To investigate whether a correlation between fine needle aspiration cytology and positron emission tomography (PET) exists in the preoperative screening, staging and diagnosis of head and neck cancer., Study Design: We retrospectively correlated fine needle aspiration biopsy (FNAB) and PET scan in patients with head and neck lesions., Results: There were 92 FNABs with corresponding PET scan in 83 patients. Mean standard uptake value (SUV) for benign lymph nodes was 5.05 (SD, 5.79), and 13.56 (SD, 6.38) and 16.99 (SD, 19.04) for squamous carcinoma and other malignancies, respectively. Ideal SUV cutoff value was determined to be 6.0. Of 66 malignant FNABs, 52 had an SUV > or = 6, 8 had an SUV < 6, and 6 were interpreted as "hypermetabolic." Of 26 benign FNAB (SUV was available for 17), 8 were interpreted as "hypermetabolic" and 1 as "not hypermetabolic." Of those with SUVs reported, 15 were < 6 while 2 were > or = 6., Conclusion: Lesions with SUV 6 are more likely to harbor malignancy, while lesions with repeatedly negative FNAB in the context of SUV > 6 should be considered for open biopsy. Further, lesions with SUV < 6 may harbor malignancy and therefore fine needle aspiration biopsy is also recommended.

Differentiated thyroid cancer is characterized by an excellent long-term prognosis, which unlike other head and neck carcinomas, is not influenced definitively by regional lymph node metastasis. The relative rarity of the disease, together with its tendency for delayed metastasis and its low mortality, makes a prospective randomized trial comparing treatment outcomes difficult. As a result, the effect of cervical lymph node metastases on survival is unclear, making meaningful recommendations for their management somewhat subjective. This article discusses guidelines for the management of the neck in differentiated.

Objective: To test the feasibility of contrast-enhanced ultrasound (CEUS)-guided sentinel lymph node biopsy (SNB) of the head and neck in a porcine model., Study Design and Setting: In this prospective, nonrandomized study, methylene blue and Sonazoid were injected into the lateral tongue or floor of mouth (FOM) of four swine. Real-time CEUS was used to identify contrast in the lymphatic channels flowing to the sentinel lymph node (SLN). Endoscopic or open SNB was performed. Neck dissection was then performed, and the residual nodal packet was examined for remaining contrast-enhancing or blue dye-stained nodes., Results: In all eight procedures, the SLN was visualized with ultrasound and blue dye. Seven procedures identified a single SLN, and one identified two SLNs. Subsequent neck dissections revealed no other nodes containing methylene blue or contrast in the nodal specimen or operative bed., Conclusion/significance: CEUS-guided SNB of the head and neck in swine is feasible, with success comparable to blue dye-guided SNB. This technique may offer several advantages over traditional techniques, and warrants further study.

Objective: Routine use of intraoperative pathologic examination (IOPE), including frozen section (FS) and scrape preparation cytology (SPC), during diagnostic thyroid lobectomy continues to be a source of controversy. We sought to better delineate the usefulness and cost-benefit ratio of IOPE in the context of cytologically diagnosed cellular follicular lesion (CFL) or follicular neoplasm (FN)., Design: Records of 205 patients who underwent thyroidectomy for cytologically diagnosed FN or CFL between 1997 and 2005 were retrospectively reviewed. IOPE results, patient demographics, and tumor characteristics were correlated to final histopathologic diagnoses. Sensitivity, specificity, predictive values, accuracy, and costs of IOPE were calculated., Main Outcome: IOPE correctly identified 3 of 16 follicular carcinomas and 9 of 36 papillary carcinomas. Sensitivity, specificity, and accuracy were 23%, 99%, and 78%, respectively. On univariate analysis, malignancy risk among follicular nodules did not correlate with age, gender, or nodule size. On multivariate analysis, nodule size was predictive of malignancy (p < 0.05). Over the entire patient series, routine IOPE resulted in a net cost savings of $74,304.33., Conclusions: IOPE reduced costs and limited the number of completion thyroidectomies necessary. IOPE is specific, cost effective, and of minimal additional risk when performed routinely for patients with CFL or FN.

Objective: To assess the feasibility of endoscopic sentinel node biopsy (SNB) using a tracer dye in a pig model., Study Design and Setting: This was a prospective, nonrandomized experimental study in Yorkshire pigs. The posterolateral tongues of three animals were injected with a one-to-one solution of carbon dye to methylene blue dye. Endoscopic SNB was performed and stained lymph nodes identified and retrieved, followed by an open dissection to recover any remaining nodes. Specimens were analyzed by a pathologist for staining, size, and structural integrity., Results: Six unilateral endoscopic SNBs were performed without complications. During endoscopic dissection, gross blue-staining of a sentinel node was noted in four of six dissections (66%). One of six sentinel nodes demonstrated histologic evidence of carbon staining. Structural integrity of all nodes was intact upon histological evaluation., Conclusion/significance: Endoscopic cervical SNB in pigs is feasible but has limitations based on lymph node size and reliability of tracer dyes. Further study is warranted to perfect tracer dyes and retrieval methods to improve this technique.

In this article we describe the first case of combined laryngotracheal and esophageal injury following blunt neck trauma in the otolaryngology literature and delineate appropriate management considerations. Successful reconstruction requires appropriate airway management, restoration of esophageal and laryngeal mucosal integrity, and reduction of tracheal and laryngeal fractures with appropriate stenting. Laryngotracheal separation following blunt neck trauma is rare and can be initially overlooked. After the airway is secure, injury severity dictates repair and postoperative care. Immediate reconstruction with restoration of the laryngotracheal framework and mucosal integrity enables patients to recover a patent airway, functional voice, and normal swallow.

Polymorphous low-grade adenocarcinoma (PLGA) is a malignant neoplasm that tends to follow a benign clinical course. Recurrences are uncommon. We report a case of recurrent PLGA of the paranasal sinuses that manifested as a large mass that filled the entire nasal cavity and left maxillary sinus. To our knowledge, this is the first reported case of a recurrent PLGA of the paranasal sinuses.

Objectives: To determine the feasibility of recurrent laryngeal nerve monitoring and stimulation during endoscopic neck surgery in an animal model., Study Design: Prospective, nonrandomized experimental investigation in a porcine model., Methods: Bilateral recurrent laryngeal nerve monitoring and stimulation was accomplished during endoscopic neck surgery in five domestic pigs. Each pig was intubated with an electromyography endotracheal tube. Recurrent laryngeal nerve function was monitored throughout the endoscopic neck surgery with a nerve integrity monitor system. An endoscopic surgical pocket was created in the neck using blunt dissection followed by low-pressure carbon dioxide insufflation. Under direct endoscopic visualization, the trachea, thyroid gland, and associated vasculature were identified. The recurrent laryngeal nerve was identified on each side of the animal and was successfully stimulated with a monopolar stimulator probe., Results: Ten of ten recurrent laryngeal nerves were successfully monitored and stimulated. No significant complications were encountered during the procedures., Conclusions: Recurrent laryngeal nerve monitoring and stimulation may be successfully accomplished during endoscopic neck surgery.

Objective: To evaluate the efficacy of fractionated stereotactic radiotherapy (FSRT) after surgery in the management of residual or recurrent nonfunctioning pituitary adenomas with respect to tumor control and the development of complications., Methods and Materials: The clinical records of patients with nonfunctioning pituitary adenomas who underwent FSRT were retrospectively analyzed. For newly diagnosed tumors, transsphenoidal surgery was performed, and, if residual tumor was identified at 3 months, FSRT was performed. If significant tumor volume persisted, transcranial surgery was performed before FSRT. We originally initiated FSRT with 2-Gy fractions to 46 Gy. We escalated the dose to 50.4 Gy thereafter. As a final modification, we dropped the daily dose to 1.8-Gy fractions delivered within 6 weeks. High-dose conformality and homogeneity was achieved with arc beam shaping and differential beam weighting. The radiographic, endocrinologic, and visual outcomes after FSRT were evaluated., Results: The 68 patients included 36 males and 32 females with an age range of 15-81 years. The median follow-up was 30 months (range, 2-82 months), and the median tumor volume was 6.2 cm(3). Of the 68 patients, 20 were treated to 46 Gy and 48 to 50-52.2 Gy. Most were treated to 50.4 Gy. Eleven patients had recurrent tumors, 54 had residual tumors, and no surgery was performed in 3 patients before FSRT. We noted no radiation-induced acute or late toxicities, except for radiation-induced optic neuropathy in 2 patients. At latest follow-up, the tumor had decreased in size in 26 patients and remained stable in 41 of the 42 remaining patients. Of the 68 patients, 4 (6%) developed hypopituitarism at 6, 11, 12, and 17 months after FSRT. Reviewing available serial Humphrey visual fields, visual fields were objectively improved in 28 patients, and remained stable in 24 patients, and worsened in 2 patients., Conclusion: The findings of this analysis support the use of surgery followed by FSRT as a safe, effective, and integrated treatment for nonfunctioning pituitary adenomas. Additional follow-up is needed to document the long-term tumor control rates, preservation rates for vision and pituitary function, and neurocognitive outcomes.

Thyroid surgeons are becoming increasingly more aware of a histologically distinct subset of thyroid carcinoma whose classification falls between well-differentiated and anaplastic carcinomas with respect to both cell differentiation and clinical behavior. This subtype of tumors has been categorized as poorly differentiated or insular carcinoma, based on its characteristic cell groupings. Although the differentiation of insular carcinoma from other thyroid carcinomas has important prognostic and therapeutic significance, relatively little about insular carcinoma has been published in the otolaryngology literature. In this article, we describe a new case of insular carcinoma and we discuss the findings of our review of the literature. We conclude that insular thyroid carcinoma warrants aggressive management with total thyroidectomy followed by radioactive iodine ablation of any remaining thyroid tissue.

In the past, bilateral vocal fold immobility (BVFI) occurred most commonly after thyroidectomy. However, no large series documenting the etiology of adult BVFI has been published within the past fifteen years. This study reviews the etiologic patterns of BVFI at our institutions. We compare BVFI from before and after 1980. We also review combined studies of unilateral vocal fold immobility (UVFI) to compare and unilateral versus bilateral etiologic trends. In comparison with previously published series, fewer cases of BVFI present today as a complication of thyroid surgery and more as the result of malignancies and nonsurgical trauma. Unfortunately, BVFI caused by malignancy is not usually an initial sign of local disease, but an ominous sign of recurrence or metastases. In comparing UVFI and BVFI we found that thyroidectomy causes a higher percentage of BVFI than of UVFI. Over one-third of UVFI cases were caused by neoplasm which further underscores the potential seriousness of immobile vocal folds and the need for careful investigation.

Objectives: The purpose of this study was to begin investigating the relationship between nodal yield in neck dissection and the likelihood of finding cervical metastases in T1 and T2 head and neck squamous cell carcinoma (HNSCC). No clinical implications are drawn from this preliminary work., Study Design and Setting: This study was a retrospective analysis of 564 patients with T1 and T2 HNSCC of the oral cavity, oropharynx, or hypopharynx from the National Cancer Institute Surveillance, Epidemiology, and End Results (SEER) Program registry. A multivariate analysis was performed to evaluate the relationship between nodal yield in neck dissection and the discovery of cervical metastases. Other independent factors included in the analysis were gender, age, race, and primary site of tumor., Results: Compared with nodal yield < 13, cervical metastases were more likely to be found for nodal yield 21-28 (P < 0.001, odds ratio [OR] = 3.68), 29-40 (P = 0.021, OR = 1.98), and >40 (P < 0.001, OR = 3.52). Increased age, male sex, and oropharynx and hypopharynx primaries were also associated with a significantly increased likelihood of finding cervical metastases., Conclusion: In T1 and T2 cases of HNSCC, nodal yield >20, increased age, male sex, and primary site correspond with an increased likelihood of finding cervical metastases.

We conducted a study to investigate whether taste buds are present on the human adult uvula. Our impetus was to determine whether surgical procedures that involve removal of the uvula can affect taste perception. Five human uvulae were removed via a modified carbon dioxide laser-assisted uvulopalatoplasty in an outpatient office setting. The uvulae were serially sectioned and stained with a solution specific for membrane-bound calcium-modulated adenosine triphosphatase, a high concentration of which is found in taste receptors. Examination of the stained sections under light microscopy failed to show that any taste receptors were present in any of the uvulae. This finding suggests that the taste disturbances noted after surgical procedures involving removal of the uvula are not attributable to a loss of taste receptors.

Objectives: Cyclooxygenases (COX) are enzymes that catalyze the conversion of arachidonic acid to prostaglandins. COX-2, unlike the constitutively expressed COX-1, is an inducible enzyme upregulated during cell proliferation and inflammation. More recently, COX-2 has been implicated in the development of numerous types of epithelial cancers. In addition, COX-2 is highly expressed in several inflammatory diseases. Because of its dual role in inflammation and cancer, we were interested in determining if COX-2 plays a role in the development of human thyroid carcinoma and Hashimoto's thyroiditis, an autoimmune condition frequently associated with thyroid malignancy., Materials and Methods: Twenty paraffin-embedded human tissue specimens, including normal, inflammatory, and neoplastic thyroid sections, were analyzed by immunohistochemical staining for expression of human COX-2. In addition, COX-2 protein expression was verified by Western blot in two specimens., Results: Immunohistochemical staining confirmed the presence of COX-2 in thyroid epithelial neoplasms, including papillary and follicular carcinomas. Moreover, COX-2 expression was observed in patients with Hashimoto's thyroiditis. COX-2 expression, however, was not observed in normal thyroid tissue, multinodular goiter, or anaplastic carcinoma., Conclusions: We have shown that cyclooxygenase-2 is expressed in thyroid carcinoma and thyroid epithelium from patients with Hashimoto's thyroiditis but not in normal thyroid. The expression of COX-2 in both of these thyroid pathologies may provide a basis for the relationship between carcinogenesis and autoimmunity.

Objectives: We studied the unilateral nodal yields for procedures reported as standard or modified radical neck dissection (RND) to determine their applicability in outcomes research., Methods: We analyzed the unilateral nodal yields for all procedures reported as RND for carcinoma of the oral cavity, pharynx, and larynx at our institution from 1985 to 1997 (n = 64, no prior treatment). These included both standard and modified techniques, encompassing levels I through V of the neck. Each side of a bilateral RND was treated as a separate case. This sample was compared with a similar population from the National Cancer Institute's Surveillance, Epidemiology, and End-Results (SEER) registry. Nodal yield was obtained for RND alone and for unspecified neck dissection with primary excision for the same diseases and time period (n = 1499)., Results: The mean nodal yield from 64 RND was 30 vs 27 in the SEER data. The standard deviation was 14.7 compared with 17.2 in the SEER data. Values ranged from 7 to 66 nodes whereas the SEER range was from 1 to 97 nodes. Although the SEER data contain nodal yields from regional or selective neck dissection, we corroborate our findings of large variance in nodal yield from our RND sample., Conclusions: Large variance in nodal yields from RND may have undefined effects on quality of life, cure rate, and survival. Until correlation of nodal yields with outcomes is examined, we cannot know how to relate RND to outcomes.

Xanthoma of the temporal bone is extremely rare; we describe only the fourteenth reported case. Our case is further remarkable because it is the first report of such an occurrence in a patient with familial type III hyperlipoproteinemia. Moreover, while otalgia, infection, hearing loss, and tinnitus were the most common initial symptoms in the previous 13 cases, our patient reported only diplopia, vertigo, and unstable gait. The patient underwent a simple mastoidectomy and debulking, and his diplopia, vertigo, and unstable gait resolved.

A ganglion cyst of the temporomandibular joint is a rare entity that commonly presents as a minimally tender, preauricular mass. This benign cystic lesion, which is lined by synovium and can be found in association with other joints, occasionally erodes adjacent bone to form an intraosseous ganglion. We discuss an unusual case of an intraosseous temporomandibular ganglion cyst that presented with bloody otorrhea. Examination revealed an external auditory canal mass with radiographic evidence of temporal bone erosion. The cyst was excised using a combined approach to the glenoid fossa and mastoid. The management principals of this case and a pertinent review of the literature are included.

Endoscopic repair of cerebrospinal fluid rhinorrhea is a promising alternative to traditional repair techniques. This article reports our experience with 21 cases (10 spontaneous, 8 iatrogenic, and 3 traumatic). Various diagnostic radiographic modalities were used, including computer-aided techniques. Most repairs were accomplished with a free fascial graft positioned in the epidural space. Postoperative lumbar drainage was used in 15 cases. Initial repair was successful in 18 cases (85.7%). In all 3 failures, the surgeon had difficulty with proper graft placement. Additionally, 2 of these cases were confounded by early inadvertent removal of the lumbar drain. All patients in whom the procedure failed underwent a second successful endoscopic repair. There were no major complications. In our experience endoscopic repair of cerebrospinal fluid rhinorrhea is a safe and effective approach that can be improved with computer-aided localization devices. Proper graft placement is critical, and lumbar drainage is an important adjunct in selected cases.

Human olfactory neuroepithelium (OE) is situated within the olfactory cleft of the nasal cavity and has the characteristic property of continually regenerating neurons during the lifetime of the individual. This regenerative ability of OE provides a unique model for neuronal differentiation, but little is known about the structure and biology of human olfactory mucosa. Thus, to better understand neurogenesis in human OE, we studied the expression of olfactory marker protein (OMP), TrkB and NeuroD in human nasal biopsies and autopsy specimens and compared these data with those obtained from normal and regenerating mouse OE. We show that NeuroD and TrkB are coordinately expressed in human OE. Thus, by using these markers we have been able to extend the known boundaries of the human OE to include the inferior middle turbinate. In normal mouse OE, TrkB and OMP expression overlap in cells closest to the superficial layer, but TrkB is expressed more strongly in the lower region of this layer. In contrast, NeuroD expression is more basally restricted in a region just above the globose basal cells. These characteristic expression patterns of OMP, TrkB and NeuroD were also observed in the regenerating mouse OE induced by axotomy. These results support a role of NeuroD and brain-derived neurotrophic actor (BDNF), the preferred ligand for TrkB, in the maintenance of the olfactory neuroepithelium in humans and mice.

Our research goal is to better understand the mechanisms controlling the initiation and progression of thyroid diseases. One such disease, papillary thyroid carcinoma (PTC), is the leading endocrine malignancy in the United States. Recently, a family of related fusion proteins, RET/PTC1-5, has been implicated in the early stages of PTC. Although all five members of this family have the c-RET proto-oncogene kinase domain in their COOH terminus, little is known about how these genes alter follicular cell biology. Consequently, to answer questions related to the mechanism of the RET/PTC fusion protein action, we have devised a molecular genetic strategy to study PTC using a mouse model of thyroid disease. A new member of this fusion oncogene family, RET/PTC3, which has been implicated in more cases of solid tumor carcinoma (79%) than PTC1 or PTC2 and predominates (80%) in radiation-induced thyroid cancer of children, was investigated in our study. We have generated transgenic mice expressing human RET/PTC3 exclusively in the thyroid. These mice develop thyroid hyperplasia, solid tumor variants of papillary carcinoma and metastatic cancer. This new transgenic line will be useful in deciphering the molecular and biological mechanisms that cause PTC and histological variations in humans.

Laser-assisted uvulopalatoplasty (LAUP) enlarges the oropharyngeal airway by reshaping the uvula, soft palate, and tonsillar pillars. In contrast to a uvulopalatopharyngoplasty performed in the operating room, LAUP is staged over several office visits, is less costly, is bloodless, and is not associated with velopharyngeal insufficiency or stenosis. Previous studies have documented the efficacy of LAUP in the treatment of snoring. We explore the efficacy of LAUP in the treatment of obstructive sleep apnea. Forty-eight patients comprised the study group. Each patient snored, exhibited >50% palatal collapse on Müller's maneuver, and had nocturnal polysomnography showing a respiratory disturbance index (RDI) >10. Each patient underwent LAUP until he or she reported that snoring had ceased. Of the 29 patients who underwent post-LAUP nocturnal polysomnography, 7 had RDIs <10, oxygen saturation >86%, and no cardiac arrhythmias. LAUP reduced RDI to <10 in patients with pre-LAUP apnea indexes <3 (P = 0.05) or pre-LAUP RDIs <30 (P = 0.01). The following variables did not correlate with the success of LAUP in treating obstructive sleep apnea: age, sex, pre-LAUP weight, pre-LAUP body mass index, perioperative weight change, perioperative body mass index change, pre-LAUP snoring, and post-LAUP snoring. We conclude that LAUP is an effective means of treating patients with RDIs <30.

Since its introduction, functional endoscopic sinus surgery (FESS) has demonstrated success rates of 76% to 98%. A small group of the patients in whom initial FESS and optimal medical therapy fail require revision endoscopic sinus surgery (RESS). This group has recently been studied by several authors, and we have evaluated a group of 90 RESS patients selected from 753 consecutive primary FESS patients. Patients were followed for a mean of 22.8 months. Extent of disease, history of polyps, allergy, previous traditional endonasal sinus surgery, male gender, chronic steroid use, and the presence of a deviated septum all appeared to adversely affect RESS outcome. The surgeon's knowledge of the sinus anatomy is critical, especially in revision sinus cases in which landmarks are distorted or absent. In our review, RESS was associated with a 1% major complication rate and was successful in 67% of patients. Computer-assisted endoscopic sinus surgery integrates preoperative imaging with realtime endoscopic visualization, augments the surgeon's knowledge of anatomy, and helps to minimize patient risk.

Objectives: To determine the dose-response characteristics and side-effects profile of Clostridium botulinum type A exotoxin (Botox) used to treat glabellar wrinkles and develop guidelines for patient selection based on the nature and severity of the treated wrinkles., Design: Prospective, nonrandomized pilot and electromyogram (EMG)-guided studies., Setting: Two ambulatory care clinics at university hospitals., Participants: For the pilot study, volunteer samples of 23 patients with glabellar wrinkles; for the EMG-guided study, volunteer samples of 57 patients with glabellar wrinkles., Interventions: For the pilot study, 23 patients were serially injected with up to 10.0 mouse units (MU) of Botox into each corrugator muscle; for the EMG-guided study, 57 patients were injected under EMG guidance with an initial dose of 10.0 MU of Botox into each corrugator muscle. Eleven patients with persistent corrugator activity were reinjected with 10.0 MU of Botox., Main Outcome Measures: For the pilot study, slide photographs were obtained before and 2 weeks after injection; for the EMG-guided study, slide photographs were obtained before and at 2 weeks and at 2 months after injection. Patients were asked to evaluate results numerically., Results: For the pilot study, injection of up to 10.0 MU of Botox into each corrugator muscle produced a satisfactory improvement in 12 patients; for the EMG-guided study, 43 patients were satisfied with improvement after full abolition of corrugator or accessory lateral brow muscle activity. Women were more likely to achieve satisfactory results than were men (80% [40/50] vs 43% [3/7]; P < or = .03). Improvement was not age related. No significant side effects or complications were observed., Conclusions: Glabellar wrinkles may be satisfactorily treated with Botox injection into the corrugator supercilii muscles. Improvement is temporary, dose dependent, and may not be seen in some patients even with successful denervation of the treated muscles. Clinicians may begin treatment with a dose of 10.0 MU of Botox into each corrugator muscle, and may select candidates for injection by determining the type of wrinkle to be treated and its spreadability (glabellar spread test).

Hashimoto's thyroiditis is an inflammatory disease of the thyroid gland with autoimmune etiology. Patients afflicted with Hashimoto's have a higher risk of thyroid malignancies such as papillary thyroid carcinoma. In the present study, we investigated the frequency of papillary thyroid carcinoma specific genes in patients diagnosed with Hashimoto's disease. The newly identified oncogenes RET/PTC1 and RET/PTC3 provide useful and specific markers of the early stages of papillary carcinoma as they are highly specific for malignant cells. Using a sensitive and specific reverse transcriptase-polymerase chain reaction (RT-PCR) assay, we found messenger RNA (mRNA) expression for the RET/PTC1 and RET/PTC3 oncogenes in 95% of the Hashimoto's patients studied. All Hashimoto's patients presenting without histopathologic evidence of papillary thyroid cancer showed molecular genetic evidence of cancer. These data suggest that multiple, independent occult tumors exist in these patients at high frequency.

Olfactory neuroblastoma is a rare malignancy of the olfactory mucosa that may be derived from the olfactory epithelium. To characterize this tumor, we cultured olfactory neuroblastoma cells in the presence or absence of growth factors (transforming growth factor alpha and basic fibroblast growth factor) known to affect olfactory tissue and assessed their responsiveness to known odorants by measuring changes in intracellular calcium. Untreated cells did not respond to odorants. Basic fibroblast growth factor treatment had cytotoxic effects, and treated cells did not respond to odorants. Transforming growth factor alpha treatment resulted in the induction of odor responsiveness in these cells. Cells responded to odorants at 100 nM to 100 microM concentrations and responded with both increases and decreases in intracellular calcium. Increases in intracellular calcium were mediated by a calcium influx and were reversibly blocked by compounds known to inhibit second messenger pathways in olfactory receptor neurons. The calcium responses of the olfactory neuroblastoma cells were thus specific to the odorants and similar to those found in olfactory receptor neurons. The results support the notion that olfactory neuroblastoma cells may be of olfactory origin and thus they can be used as a model cell line to study human olfaction.

Olfactory neuroblastoma (ONB) is a rare neuronal malignancy of the olfactory mucosal. Markers used in the diagnosis of ONB do not distinguish ONB from other neuronal tumors or tumors with neuroendocrine features thus making the diagnosis of ONB difficult. Using a modified RT-PCR technique, we show that the human homologue of the Drosophila achaete-scute gene HASH1 is expressed in 6 primary and one metastatic ONB specimens, whereas Olfactory Marker Protein (OMP) is not. Previous studies have shown that HASH1 is expressed in immature olfactory neurons and is required for their development. OMP, whose function is unknown, is expressed exclusively in mature olfactory neurons. Together, these data suggest that ONB is derived from immature olfactory neurons of neuroectodermal origin. Analysis of RNA expression in primary tumor specimens and in an established cell line make this an ideal system to study olfactory growth and differentiation. Furthermore, these studies represent the first molecular genetic analysis of this rare and unusual neuronal tumor.

We summarize etiologies of vocal fold paralysis and current treatments. The recent literature involving electrical stimulation of the larynx is reviewed. Four canines were involved in a study to test a new laryngeal pacemaker system. This system was used to stimulate both the lateral cricoarytenoid and thyroarytenoid muscles. The data are taken from two of these canines. One of the goals was to stimulate the paralyzed side of the larynx based on the activity of the normal (nonparalyzed) side of the larynx. The best stimulation parameters for full addition of the paralyzed vocal cord were 3-7 V, pulse duration of 0.5 ms at a frequency of 84-100 Hz. Principles for electrode design and electrophysiologic parameters pertaining to laryngeal pacing are discussed. We believe that unilateral vocal fold paralysis may someday be treated by stimulating the paralyzed lateral cricoarytenoid and thyroarytenoid muscles to move in synchrony with the normal, unparalyzed, lateral cricoarytenoid and thyroarytenoid muscles.

Giant cholesterol cyst (GCC) of the petrous apex is a rare clinical entity. This benign cystic lesion can cause neurologic deficits and vascular compromise by persistent growth and progressive bone destruction. Magnetic resonance imaging studies of GCC show the lesions to be hyperintense on T(1)-weighted sequences with progressively lower signal intensities on the first and second echoes of T(2)-weighted sequences. These findings are relatively specific for GCC, permitting a narrow differential diagnosis. The goal of surgery is to provide adequate drainage with the creation of a permanent fistula. The classic approaches to these lesions are the posterior fossa craniotomy and the middle fossa extradural craniotomy. The translabyrinthine approach provides wide exposure at the expense of cochlear and vestibular function. The transsphenoidal approach provides adequate drainage with hearing preservation and no craniotomy. The endoscopic, endonasal transsphenoidal approach to a 2.5 cm GCC of the petrous apex accomplished complete drainage with the creation of a fistula. Advances in endoscopic technique and instrumentation facilitated the addition of the approach to the surgeon's armamentarium. In selected cases, this approach provides adequate surgical exposure with minimal morbidity.