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Background: Immunosuppression in patients with head and neck cancer is well recognized. Previous investigations have demonstrated graded immunosuppression that becomes more pronounced as lymphocyte activity is measured closer to the primary neoplasm. In fresh tumors, a soluble factor has been identified that may partly account for the observed graded immunosuppression., Objective: To examine the effect of soluble factors produced by head and neck sqamous cell carcinoma cell lines on the generation of lymphokine activated killer cell cytotoxicity and peripheral blood lymphocyte proliferation induced by interleukin 2, concanavalin A, and phytohemagglutinin., Design: Conditioned supernatant fluids were generated in a 4-day incubation period, using 5 head and neck squamous cell carcinoma cell lines, and were assayed for the ability to inhibit the generation of lymphokine activated killer cell cytotoxicity and naive peripheral blood lymphocyte proliferation induced by interleukin 2, concanavalin A, and phytohemagglutinin., Results: All conditioned supernatant fluids significantly inhibited the generation of lymphokine activated killer cell cytotoxicity relative to controls, and this inhibition was dose dependent. In contrast, supernatant fluids from a myelogenous leukemic tumor cell line, K562, and an ovarian epithelial cell line, SKOV-3, failed to inhibit cytotoxicity. Supernatant fluids conditioned with head and neck squamous cell carcinoma cell lines also profoundly inhibited the naive peripheral blood lymphocyte proliferation induced by interleukin 2, concanavalin A, and phytohemagglutinin., Conclusions: These studies demonstrate that the cell lines of head and neck squamous cell carcinoma produce soluble factors that inhibit lymphocyte function. Furthermore, these experiments suggest that the inhibition previously observed with enzymatically disaggregated fresh tumors is due to factors produced by the tumor cells rather than by other cells within the tumor matrix.

Transforming growth factor-beta is known to be a potent autocrine growth inhibitor produced by a wide variety of cells, including cells of the immune system. Other investigators have noted that the growth of nontransformed keratinocytes is inhibited by transforming growth factor-beta, whereas various carcinoma cell lines are resistant to these effects. Head and neck squamous cell carcinoma cells are known to have surface receptors for this cytokine. We thus assessed the effect of transforming growth factor-beta on the growth of head and neck squamous cell carcinoma cell lines. Four head and neck squamous cell carcinoma cell lines were incubated with varying concentrations of transforming growth factor-beta, and cytotoxicity was evaluated with a methylene blue colorimetric assay. After culturing in transforming growth factor-beta for 4 days, inhibition of growth was detected in CAL-27 (maximal inhibition at 5.0 ng/ml), UMSCC-1, and UMSCC-19 (maximal inhibition at 50 ng/ml) cell lines. One other cell line, UMSCC-8 was found resistant to the inhibitory effects of transforming growth factor-beta. Kinetics analysis experiments revealed minimal inhibition before day 2 of incubation, at which time inhibition increased linearly to day 4. Assessment of double-stranded DNA fragmentation suggested that DNA fragmentation occurs before significant cytotoxicity. Electron microscopic analysis and gel electrophoresis of extracted DNA revealed morphologic features consistent with apoptotic cell death. Our findings indicate that transforming growth factor-beta significantly inhibits the growth of head and neck squamous cell carcinoma cell lines by inducing apoptotic cell death.

Sebaceous carcinoma is uncommon, with fewer than 400 cases reported. Usually, lesions arise in the meibomian glands of the eyelid; however, extraocular lesions within the head and neck have been reported. Regardless of the location, sebaceous malignancies must be considered aggressive neoplasms with a potential for regional and distant metastasis. Diagnosis may be difficult, given the low incidence and inconsistencies in histopathologic classification. Recently, needle aspiration cytologic characteristics have been delineated, with this procedure becoming increasingly useful in establishing the diagnosis. Treatment requires wide surgical excision with removal of involved regional lymph nodes. Opinions are divided regarding the use of postoperative irradiation or chemotherapy. Records of all patients with sebaceous carcinoma of the head and neck treated at UCLA Medical Center, Los Angeles, over the last 35 years were reviewed. The clinical and pathologic features are discussed, and the literature is summarized.

A database of questions and answers has been developed to assist residents in reviewing current topics in otolaryngology-head and neck surgery. Each question/item has an associated answer, general category, specific category, and reference that allows cross-referencing on the computer system. The user can search the database for categories of interest and obtain a specific subset of questions. This allows an efficient means of knowledge acquisition and review for Board examinations. Additional data entry is also facilitated to expand the database as desired. Currently there are more than 2300 items in the database.

Patients with head and neck squamous cell carcinomas (HNSCCs) manifest defects in cell-mediated immune function. Previous studies in this laboratory have demonstrated regional alterations in the immunocompetence of draining lymph nodes (LNs) in HNSCC patients. In this investigation, we studied functional activity of lymphocytes from lymph nodes in different locations in the radical neck dissections (RNDs) from patients undergoing operations for HNSCC. Lymphocytes from nodes close to the primary tumor ("near" lymph nodes or NLN) exhibited a significant decrease in interleukin-2 (IL-2)-activated cytotoxicity when compared to lymphocyts from distant nodes ("far" lymph nodes or FLN). In addition, co-culture experiments suggested the existence of a soluble regulatory factor, produced by lymph nodes, that inhibited the development of lymphokine-activated killer (LAK) cells in vitro. Further experiments with conditioned supernatants from the lymph node cells confirmed the presence of this soluble inhibitory factor. The inhibitory effect is significantly greater in NLNs than in FLNS. This hierarchical phenomenon suggests a regional network of immunosuppression in HNSCC patients. It is likely that tumor- and lymph node-induced suppression plays a role in limiting the efficacy of current immunotherapy protocols in human beings. A greater understanding of mechanisms of local inhibition of immune function will aid in improving adoptive immunotherapy for treatment of cancers in human beings.

Incubation of human peripheral blood lymphocytes (PBL) in the presence of interleukin-2 results in the generation of lymphokine-activated killer (LAK) cells that are highly cytotoxic to a variety of autologous and allogenic tumor targets. We have identified a noncytotoxic, soluble factor, produced by human squamous cell cancers of the head and neck, that profoundly inhibits the generation of LAK cytotoxicity. Inhibition of the generation of cytotoxicity was demonstrated with coculture of PBL and freshly disaggregated tumor cells in a Transwell two-chamber system. Alternatively, inhibition occurred when LAK cells were generated in the presence of tumor-conditioned supernatants alone. These effects were not observed with conditioned supernatants from autologous or allogenic lymphocytes, human fibroblasts, or the erythroleukemia cell line K562. The presence of this inhibitory factor(s) was not required during the entire period of LAK generation. Suppression of cytotoxicity, measured after 4 days of LAK generation, could also be demonstrated when the conditioned tumor supernatant was present in only the last 24 hours of incubation. Suppression is mediated by a heat-labile factor with a molecular weight of greater than 75 kd. These results suggest that LAK cytotoxicity may be significantly impaired by soluble immunoregulatory factors present within the tumor milieu of squamous cell carcinomas of the head and neck. Further characterization of these factors may lead to the development of more rational and effective forms of immunotherapy.

While metastatic tumors to the nose and the paranasal sinuses overall are unusual, metastasis to the sphenoid sinus is exceedingly rare. Presented are 26 cases of metastasis to the sphenoid sinus. Seven were treated at UCLA between 1955 and 1988, and 19 additional cases were discovered from a search of the medical literature. The patients ranged from 14 months to 79 years of age. The most common tumor sites from which sphenoid metastases arose were the prostate and the lung. In 11 of the 26 cases, the sphenoid sinus metastasis was the first presentation of malignancy. Patients manifested signs and symptoms that were indistinguishable from those from primary tumors of the sinus. They included headache, facial pain, visual changes, and single or multiple cranial neuropathies. While cure of patients with sphenoid metastasis has not been reported, significant palliation with resolution of morbidity is possible in many patients with radiation therapy. Although metastasis to the sphenoid sinus is an uncommon entity, when present, signs and symptoms relating to this metastasis are frequently the first presentation of disease. As such, patients with sphenoid sinus symptoms suggestive of sphenoid sinus malignancy should be vigorously evaluated for the possibility of primary as well as metastatic tumor of the sinus.

Plummer-Vinson syndrome (PVS) is characterized by iron deficiency anemia, upper esophageal stricture, cervical dysphagia, and glossitis. The precise role of iron deficiency in PVS has yet to be defined and remains a subject of much debate. A 29-year-old woman with PVS is presented. The patient had a 4-year history of severe iron deficiency anemia, a 2-year history of progressive dysphagia and weight loss, and a greater than 90% benign upper esophageal stricture. Iron therapy alone resolved her dysphagia and anemia, and a follow-up esophagram 1 year later showed a residual stenosis of less than 30%. The development of severe iron deficiency anemia in this patient 2 years before the onset of dysphagia, as well as the response of the stricture to iron repletion, supports the theory that iron deficiency can cause dysphagia and upper esophageal strictures. The occurrence of glossitis, gastritis, and esophagitis in iron deficiency demonstrates the adverse effects of iron depletion on the rapidly proliferating cells of the upper alimentary tract.

Ameloblastomas are benign tumors derived from the odontogenic apparatus. Of these tumors, 80% originate in the mandible, while 20% originate in the maxilla. Six cases of maxillary ameloblastoma treated at the UCLA hospitals are presented; four of these cases showed extensive and destructive tumor growth involving vital structures, including the orbit, base of skull, and parasellar structures. Two of four patients with extensive disease died of their tumors, one, with extensive involvement of the base of the skull, became unavailable for follow-up, and, one year after diagnosis, one is alive with middle cranial fossa disease. A review of the medical literature provides further evidence of the locally aggressive behavior and potentially lethal nature of this tumor. No effective treatment has evolved for extensive ameloblastomas of the maxilla that have invaded surrounding vital structures. When tumor-free surgical margins are not possible, radiation therapy may offer palliation of disease.

Interleukin-2-(IL-2)-activated lymphocytes have been shown to kill a variety of continuously cultured allogeneic (nonself), natural killer cell-sensitive and resistant cell lines, and some autologous (self) tumor cells. Lymphokine-activated killer (LAK) cytotoxicity of autologous head and neck squamous cell carcinoma (HNSCC) cells has not been previously demonstrated, and efforts to demonstrate this have been hampered by the lack of a reliable and reproducible method of obtaining satisfactory tumor targets. In this study, fresh tumor cells were enzymatically dissociated, enriched by adherence to plastic, and used in a 3-hour chromium-51 cytotoxicity assay. Peripheral blood lymphocytes (PBLs) were incubated for 3 days with or without added IL-2. IL-2-activated PBLs showed significant cytotoxicity against autologous and allogeneic targets, while only low levels of tumor lysis occurred with unstimulated PBLs. These findings suggest the possible use of IL-2-activated lymphocytes in the adoptive immunotherapy of HNSCC patients.

Malignant salivary gland tumors of the base of the tongue are unusual lesions and optimal treatment has not been established. As a group, these tumors tend to be diagnosed at an advanced stage, and consequently carry a grave prognosis. Fourteen patients were treated at UCLA between 1954 and 1984. Twenty-three percent of the patients have survived longer than ten years, although only one patient is free of disease. Eight of 14 patients developed distant metastases. Salivary tumors in this location are difficult to completely excise and surgical margins are frequently positive. Treatment using a planned combined approach is advocated.

The successful use of the tracheoesophageal voice prosthesis for speech rehabilitation of the total laryngectomy patient has lead to common application of this device. Although the creation of a tracheoesophageal fistula is a simple procedure, it is not without complications. A review of 104 patients who underwent this procedure indicated a complication rate of 25%. Complications were related primarily to the fistula and included migration and progressive enlargement of the puncture, persistent or recurring infection of the fistula site, aspiration pneumonia, and death. Other problems included aspiration of the prosthesis, vertebral osteomyelitis, and tracheal stomal and esophageal stenosis. Many of these patients required hospitalization, intravenous antibiotics, and major surgical procedures to treat these complications. Guidelines for early identification and management of these problems as well as methods to prevent complications are discussed.

This study evaluated peripheral blood lymphocyte and lymph node lymphocyte natural killer (NK) cell activity in 22 patients with head and neck squamous cell carcinoma and eight patients undergoing surgery for nonmalignant conditions who served as controls. A novel mixed-model analysis of variance was used to analyze the results because of the inherent difficulties in data interpretation among heterogeneous groups when several concurrent variables impinge upon the results. The peripheral blood lymphocyte NK activity of cancer patients was significantly less than controls. In contrast, lytic activity from uninvolved draining lymph nodes of cancer patients was comparable to the activity of control nodes. However, if the node contained a small focus of metastatic tumor, NK activity was significantly diminished relative to uninvolved nodes from cancer patients or to control nodes. The mixed-model analysis of variance was particularly helpful in confirming this finding. Finally, NK lysis by tumor-infiltrating lymphocytes, purified from grossly metastatic nodes, was severely depressed. These data indicate that a spectrum of NK suppression exists in draining lymph nodes of head and neck squamous cell carcinoma patients, and that the level of activity depends upon the degree of nodal tumor involvement.

Acute carotid artery rupture is frequently heralded by prodromal arterial bleeding. This warning signal provides the physician with a brief interval in which to hemodynamically stabilize a patient, electively occlude the carotid, and consequently improve the patient's chance of survival. For three years, we have employed an initial nonoperative approach to patients with impending carotid rupture. A trial of endovascular balloon occlusion followed by detachable balloon embolization of the carotid artery has been utilized. Patients unable to tolerate temporary occlusion underwent a vascular bypass procedure followed by embolization. Six patients have undergone this approach, and all had permanent cessation of bleeding. None died as a result of the procedures. One patient developed permanent neurologic deficits. Balloon embolization offers improved results over elective ligation and should be considered as an alternative treatment for patients in this dire predicament.

Treatment of the paralyzed face remains a challenging surgical problem. When facial nerve damage is irreparable or facial nerve grafting has failed, static and dynamic techniques must be considered. A two-staged modification of the dynamic muscle transfer using ipsilateral temporalis muscle is described. Initially, a free temporalis fascia graft, harvested from the contralateral scalp, is placed around the oral commissure of the paralyzed side of the face through an incision in the nasolabial crease. Several weeks later, an ipsilateral temporalis muscle and fascia transfer is made to the anterior face and attached to the previously placed fascia graft. Oral commissure grafting, as a first step, provides for a secure anchoring point for the temporalis flap, and achieves a more satisfactory correction of the oral commissure.

In a review of 141 patients with thyroglossal duct cysts between 1961 and 1981, 28 patients were found to have surgical treatment for recurrent cysts and sinuses. Recurrent disease following surgical failure results in a high incidence of fistula formation. In the operative treatment of recurrent disease, all patients had a segment of hyoid bone excised. The dissection was extended to include a core of the base of the tongue in 20 of the 28 patients. There have been no surgical failures in this population of patients treated for recurrent thyroglossal duct cysts. We are currently treating patients with recurrent cysts and sinuses with en bloc anterior neck dissections, a modification of the classic Sistrunk procedure.

The clinical and histologic features of five homosexual men with acquired immunodeficiency syndrome (AIDS) who developed extranodal non-Hodgkin's lymphomas of the head and neck region are presented. The primary sites of these malignant neoplasms include the larynx, palate, alveolar ridge, nasal vestibule, and skin overlying the mastoid tip. In all cases, the patients' lymphomas followed an aggressive clinical course with frequent central nervous system involvement. Although, to our knowledge, this is the first report of head and neck lymphomas in patients with AIDS, this malignant neoplasm has been demonstrated to occur at other anatomic sites in such patients with an incidence far greater than that found in the general population. A high index of suspicion for lymphomas and other unusual malignant neoplasms is required on the part of the otolaryngologist and head and neck surgeon when evaluating patients with AIDS.

The bcl-1 locus on chromosome 11 at band q13 has been shown to be rearranged in some chronic B lymphoid malignancies with the t(11;14)(q13;q32). Chromosome 11 abnormalities also occur in squamous cell carcinomas including tumors from the head and neck region. In this investigation, we analysed the arrangement, copy number and expression of this locus in 23 fresh head and neck cancers and six established head and neck squamous cell carcinoma cell lines. Bcl-1 was found to be amplified two- to 10-fold in eight fresh tumors and two cell lines, UM-SCC-8 and UM-SCC-22A. Moreover, amplification was more frequently observed in poorly differentiated fresh tumors. None of the fresh tumors or cell lines showed rearrangement of bcl-1. In addition, these tumors and cell lines did not contain amplification of the c-myc or Ha-ras oncogenes.

Natural killer (NK) cells are a subpopulation of lymphocytes involved in host defense against tumor cells. Although a great deal of clinical research has focused on the role of NK cells in the blood of patients with cancer, very little has been done to determine what role they may play at the regional or lymph node level. One hundred seven lymph nodes from 22 patients with head and neck cancer and eight control patients were assayed for NK cell cytotoxicity against the human erythroleukemia cell line K562. Six of these nodes contained a discrete intracapsular focus of metastatic tumor. Lymphocytes from these focally positive nodes exhibited a significant depression of NK cell cytotoxicity compared with all other nodes. These data suggest that the presence of metastatic tumor inhibits NK cell function at the regional level in patients with head and neck squamous cell carcinoma.

Lymphokine-activated killer cells are thought to be important mediators of host tumor defense. In the present study, the cytotoxic potential of lymphokine-activated lymphocytes against different head and neck squamous cell carcinoma cell lines was investigated. Lymphokine-activated killer cells were derived from peripheral blood lymphocytes. Effector peripheral blood lymphocyte cell suspensions were incubated in the presence or absence of recombinant interleukin-2. Cytotoxicity of incubated cells or fresh peripheral blood lymphocytes was determined in a 3-hour chromium 51 release assay. Target cell lines included K562 (a natural killer-sensitive target) and the following head and neck squamous cell carcinoma cell lines: Cal 27, UMSCC-1, UMSCC-8, UMSCC-16, UMSCC-19, and UMSCC-22a. Fresh peripheral blood lymphocytes and peripheral blood lymphocytes cultured in the absence of added interleukin-2 demonstrated minimal cytotoxic effects against the squamous cell carcinoma targets. In contrast, these fresh and incubated lymphocytes showed significant cytotoxic effects against K562. Cells preincubated in the presence of interleukin-2 demonstrated a statistically significant increase in cytotoxic effects against K562 and all squamous cell carcinoma targets. These investigations support the possible role of lymphokine-activated killer cells in host defense against squamous cell carcinoma. In vitro natural killer cell activity against head and neck squamous cell carcinoma cell lines is low; however, significant lymphokine-activated killer cell cytotoxicity is present.