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Objectives/Hypothesis: To evaluate the treatment results of pleomorphic adenoma (PA) of the parapharyngeal space at a single institution during a 30-year period. Study Design: A retrospective review. Methods: This study was performed by examining the records and reviewing the pathology of 44 patients with PA of the parapharyngeal space treated at a single medical center from January 1975 to November 2005. Results: Of the 44 patients with PA, 35 patients underwent 38 excisions. Eleven men and 27 women were treated surgically. Follow-up varied from 24 months to 180 months. There were three recurrences in two patients. Recurrence rates at 5 and 10 years were equal at 7.9%. Gender, age, tumor volume, surgical approach, pathologic surgical margin status, and prior resections were evaluated for significant prognostic factors. Advanced age proved a poor prognostic indicator (P < .05). History of prior resection (P < .01) was significant for recurrence. Positive surgical margins (P = .69) proved a negative association. Conclusions: We report low recurrence rates in this patient population with two important prognostic indicators. History of prior resection is significant to predict recurrence. Interestingly, positive surgical margins are actually shown not to effect risk of recurrence. Local recurrence of the tumor is associated with further recurrence and less favorable prognosis. Laryngoscope, 2009

Objectives To evaluate the treatment results of adenoid cystic carcinoma (ACC) of the submandibular gland at a single institution during a 35-year period. Study design & setting A retrospective review was performed by examining the records and reviewing the pathology of 22 patients with ACC of the submandibular gland treated at UCLA Medical Center from June 1963 to December 1997. Results Seven men and 15 women with an age range of 23 to 85 years (median, 48 years) were treated. Surgical intervention was performed in 21 patients. All patients with advanced tumor size, perineural invasion, microscopically positive surgical margins, or regional neck metastases received postoperative adjunctive therapy, primarily radiotherapy. Follow-up varied from 6 months to 181 months (median, 67 months). Disease-free survival at 3, 5, and 10 years was 66%, 57%, and 41% respectively, whereas overall survival was 76%, 70%, and 37%, respectively (note: 5- and 10-year survival rates are not statistically conclusive due to the small sample size). Conclusions We report fairly high disease-free survival rates in this patient population and a number of prognostic trends are evident. Early diagnosis, wide surgical intervention, and postoperative radiation are associated with a favorable prognosis. Advanced tumor size, positive surgical margins, perineural invasion, and local recurrence of the tumor are associated with an unfavorable prognosis. EBM rating: C.

We have previously shown TP16 MTS1/CDK41 gene deletion in more than 50% of a cohort of squamous cell carcinoma of the head and neck (SCCHN) patients using polymerase chain reaction (PCR). We have performed fluorescence in situ hybridization (FISH) on paraffin-embedded SCCHN specimens from the same cohort to identify the deletion of TP16 MTS1/CDK41CDK41 gene. Twenty normal and 19 SCCHN specimens were studied. An α-satellite DNA probe specific for chromosome 9 and a cosmid probe for the TP16 MTS1/CDK41CDK41 gene were used. Of the 19 tumors examined by FISH, 6 had homozygous deletions, 7 were hemizygously deleted, and the remaining 6 showed no evidence of deletion of the TP16 MTS1/CDK41 gene. None of the normal specimens showed TP16 gene deletion. Data obtained from FISH highly correlated with the PCR results for the identification of TP16 MTS1/CDK41 gene deletions. Patients with deletion of the TP16 MTS1/CDK41 gene show a greater tendency toward the development of recurrence and metastasis.

Objectives/Hypothesis To demonstrate the efficacy of external beam radiation therapy as a primary treatment modality for the management of patients with advanced juvenile nasopharyngeal angiofibroma (JNA). Study Design Retrospective chart review. Methods The medical records of 130 patients with the diagnosis of JNA seen at UCLA Medical Center over a 41-year period (1960–2000) were retrospectively reviewed. Results One hundred thirty cases of JNA have been seen at UCLA Medical Center from 1960 to 2000. One hundred two were treated with surgical resection, 1 refused therapy, and the remaining 27 received radiation (3000–5500 cGy) as their primary mode of treatment. Fifteen percent (4 of 27) of the irradiated patients developed recurrent tumor 2 to 5 years later. Long-term complications occurred in 4 patients (15%) and consisted of growth retardation, panhypopituitarism, temporal lobe necrosis, cataracts, and radiation keratopathy. Conclusions External beam radiation therapy represents an effective mode of treatment for patients with advanced JNA. Although the latency period may be long, we think the likelihood of potentially fatal complications developing at the radiation dosages we recommend is less than the risk of significant morbidity and mortality associated with surgical intervention in these cases.

Objectives/Hypothesis Cyclin D1, a cell cycle regulator localized to chromosome 11q13, is amplified in several human tumors including head and neck squamous cell carcinoma (HNSCC). Amplification and/or overexpression of cyclin D1 have been correlated to a poor prognosis. Deletion of the p16 gene, localized to 9p21, has also been observed in a significant proportion of HNSCC. The p16 gene regulates cyclin D1-CDK4 activity and prevents retinoblastoma tumor suppressor gene phosphorylation, thereby downregulating cellular proliferation. Detection of cyclin D1 amplification and p16 deletion using a simple and sensitive method will be valuable for the development of effective treatment modalities for head and neck cancer. Study Design We have used fluorescence in situ hybridization (FISH) to study cyclin D1 amplification and p16 gene deletion in head and neck tumors. Both single- and dual-color FISH were performed. Methods Paraffin-embedded tissues from 103 patients with HNSCC were analyzed using genomic DNA probes for cyclin D1 and p16. Dual-color FISH was performed with chromosome 11 or 9 centromeric probes as a control. Twenty-eight of these samples were analyzed for p16 expression by immunohistochemistry. Results Cyclin D1 amplification was observed in 30% (31/103) of patients, and p16 deletion in 52% (54/103). Lack of p16 expression was observed in 64% (18/28) of patients. There was a good correlation between the deletion of p16 sequences and the loss of p16 expression (P = .008). Amplification of cyclin D1 had a statistically significant association with recurrence, distant metastasis, and survival at 36 months. There was a significant association between p16 deletion and the development of distant metastases. Cyclin D1 amplification and p16 deletion together correlated with recurrence, distant metastasis, and survival. Conclusions We demonstrate that FISH is a simple and sensitive method for detecting cyclin D1 amplification and p16 deletion in head and neck cancer. Our results suggest that these two genetic aberrations together portend a poorer outcome than either of the abnormalities alone in head and neck cancer.

Our objective was to review recent developments in diagnosis, staging, and treatment of esthesioneuroblastoma (ENB). A meta-analysis of publications between 1990 and 2000 was carried out, and studies were classified according to their main subject: origin/aetiology of ENB, histopathological diagnosis, and treatment. Data so far point to the basal progenitor cells of the olfactory epithelium as the origin of ENB. Histopathological diagnosis remains difficult and is based on results of antigen expression detected through a panel of antibodies by immunohistochemistry. RT-PCR of HASH expression could be a specific marker of ENB. Overall and disease-free survival at 5 years averaged 45% (SD 22) and 41% (SD 21) in the studies included in the meta-analysis. Survival in Hyams' grades I-II was 56% (SD 20) compared with 25% (SD 20) in grades III-IV (odds ratio 6.2). In patients with metastases in cervical lymph nodes (on average 5% of the total) survival was 29%, compared with 64% for patients with N0 disease (odds ratio 5.1). Survival according to treatment modalities was 65% for surgery plus radiotherapy, 51% for radiotherapy and chemotherapy, 48% for surgery, 47% for surgery plus radiotherapy and chemotherapy, and 37% for radiotherapy alone. The histopathological grading according to Hyams and the presence of cervical lymph-node metastases emerged as prognostic factors. A combination of surgery and radiotherapy seems to be the optimum approach to treatment. The exact role of chemotherapy in treatment protocols is still unclear. The role of elective neck dissection is unclear.

No single method of reconstruction has proven ideal for all patients with defects following vertical hemilaryngectomy. In this report, we detail a new technique for hemilaryngeal reconstruction involving the use of a pedicled buccal mucosa island flap supplied by the facial artery and vein. The buccal flap was used to resurface a transversely oriented sternohyoid myofascial flap. The reconstructive outcome was analyzed in 4 animals, 3 of which survived the early postoperative period. Videoendoscopy and stroboscopy were performed to analyze the laryngeal configuration and vibration. Each subject was decannulated and had a competent airway free of aspiration. After sacrifice of the animals, whole organ axial sections were made at multiple levels. Endoscopic and histologic findings documented that this technique produced an appropriate neocord position. Laryngeal stroboscopy in each animal showed bilateral mucosal traveling waves, with entrainment of the reconstructed neocord mucosa and native vocal cord mucosa. We conclude that the layered reconstructive technique described, compared to traditional methods of reconstruction, more closely replicates the structure of the excised tissue in hemilaryngeal reconstruction, potentially resulting in an improved voice outcome.

A retrospective review of 14 patients with adenoid cystic carcinoma of the tongue treated between 1955 and 1997 was performed. Treatment consisted of surgery (n = 2), radiotherapy (n = 2), chemotherapy (n = 1), or combination therapy (n = 9). The 2-, 5-, and 10-year absolute survival rates were 92%, 79%, and 63%, respectively. Seventy-five percent of the patients who died of cancer succumbed to distant metastases. However, long-term survival was common despite a high incidence of local and distant recurrence. The presence of positive surgical margins, the incidence of regional metastases, the incidence of perineural invasion, the initial stage of disease, and the eventual development of locoregional recurrence and distant metastases did not significantly alter the survival rate. Surgical extirpation combined with postoperative radiotherapy is advocated for the treatment of adenoid cystic carcinoma of the tongue. Given the indolent nature of this disease process, surgery should be directed toward conservation of speech and swallowing function.

Background Parathyroid adenoma is the most common cause of primary hyperparathyroidism (pHPT). Adenomas usually involve only a single gland, and the remaining glands are normal or suppressed. Multiple parathyroid adenomas have been reported to occur in as high as 11% of patients with pHPT. The significant incidence of multiple adenomas with histologic similarities to hyperplasia has raised the possibility that adenoma is a continuation of the hyperplasia state. To test this theory, we used molecular genetics to compare clonality and proliferative activity of parathyroid adenoma with its corresponding normal glandular tissue. Furthermore, we devised a scheme to definitively distinguish between the different parathyroid states on a molecular level, because histologic distinction is unreliable. Methods The study included three patients with a diagnosis of singular parathyroid adenoma and three with double parathyroid adenomas. Paraffin-embedded surgical specimens of both adenomas and normal glands were retrieved from each patient. Clonal analysis of the phosphoglycerolkinase (PGK) gene has suggested that parathyroid adenomas are monoclonal. Clonality of parathyroid adenomas and normal parathyroid glands was studied by polymerase chain reaction–based restriction fragment length polymorphic analysis for the PGK gene. Proliferative activity of the specimens was also analyzed using the immunohistochemical markers PCNA and Ki-67. Results All adenomas were monoclonal and all normal parathyroid glands were polyclonal for the PGK gene in both the single and double adenoma specimens. All adenomas stained positive for proliferative activity. In the three patients with singular adenoma, proliferative activity was not detected in the normal parathyroid tissue. However, in the double adenoma group, two of the three patients showed hyperproliferative activity in the normal glands. Conclusion Proliferative activity consistent with hyperplasia was present in some normal glands of multiple adenoma patients. Our observation supports the theory that multiple adenomas may be a continuation of the hyperplasia state. © 2001 John Wiley & Sons, Inc. Head Neck 23: 134–139, 2001.

The authors reviewed treatment results in patients with nasal and paranasal sinus carcinoma from a large retrospective cohort and conducted a systematic literature review.

Preoperative localization of parathyroid adenomas in patients with hyperparathyroidism currently relies on a combination of computed tomography, magnetic resonance imaging, ultrasound, (99m)Tc-sestamibi scintigraphy, and venous sampling of parathyroid hormone. No procedure is universally reliable, however, and in reoperation for missed parathyroid adenomas, development of an optimal preoperative localization strategy becomes especially problematic. We report the case of a patient with hyperparathyroidism who required reoperation for a missed parathyroid adenoma despite preoperative localization with (99m)Tc-sestamibi scintigraphy. (99m)Tc-sestamibi scintigraphy was done 2.5 hours before reoperation. On reoperation, a gamma-detecting probe (C-Track; Care Wise Medical Corporation, Morgan Hill, CA) introduced through a right neck incision was used to localize a 4-cm adenoma within 45 minutes. No significant radiation hazard existed, and no special handling of the specimen was required. The patient's hyperparathyroidism resolved within 24 hours postoperatively. Therefore, this intraoperative technique may prove to be a useful adjunct to preoperative localization studies of parathyroid adenomas, particularly in patients requiring reoperation for persistent postsurgical hyperparathyroidism.

The goal was to analyze the outcome of surgical therapy for buccal carcinoma.A retrospective chart review was done.The study took place in a major tertiary-care hospital.Twenty-seven patients received first-time surgical therapy for buccal carcinoma. Treatment was surgery alone in 15 and surgery followed by radiation therapy in 6 patients. Six additional patients received surgical salvage for radiation therapy failure. Composite resection of the tumor was performed in 16 patients (59%). Five-year observed actuarial survival rates were 100%, 45%, 67%, and 78%, and locoregional recurrence rates were 0%, 27%, 44%, and 0% for stages I to IV, respectively. The 5-year actuarial survival rates were 80% after surgery and 82% after surgery and postoperative radiation therapy. Patients who underwent surgical salvage after radiation therapy failure had a 1-year survival rate of 0%.Aggressive surgical treatment of buccal carcinoma may result in better survival rates.The article analyzes buccal carcinoma in regards to the patterns of presentation, treatments rendered, and patterns of failure.

In recent years endoscopically controlled laser-induced thermal therapy (LITT) has been increasingly accepted as a minimally invasive method for palliation of advanced or recurrent head and neck or gastrointestinal cancer. Previous studies have shown that adjuvant chemotherapy can potentiate endoscopic laser thermal ablation of obstructing tumors leading to improved palliation in advanced cancer patients. Eight patients with recurrent head and neck tumors volunteered to enroll as part of an ongoing phase II LITT clinical trial, and also elected to be treated with systemic chemotherapy (cisplatin, 80 mg/m2) followed 24 h later by palliative laser thermal ablation. Laser treatments were repeated in patients with residual disease or recurrence for a total of 27 LITT sessions. Four of the 8 patients treated with laser thermal chemotherapy remained alive after a median follow-up of 12 months. Of the 12 tumor sites treated, complete responses were located in the oral cavity (3), oropharynx (1), hypopharynx (1), maxillary sinus (1), and median survival for these patients was 9.5 months. This initial experience with cisplatinum-based laser chemotherapy indicates both safety and therapeutic potential for palliation of advanced head and neck cancer but this must be confirmed by longer follow-up in a larger cohort of patients.

This study was undertaken to determine whether brief periods of vocal cord paralysis might commonly occur as a result of tracheal intubation. The vocal cords of 100 patients were examined prior to and after intubation for operation. Although soft tissue trauma was observed in nearly all patients none had evidence of vocal cord paralysis.

Glandular carcinomas of the larynx are rare tumors that constitute less than 1 % of all laryngeal malignancies. A retrospective case review of 12 patients with glandular carcinomas of the larynx is presented to identify patient and tumor characteristics, therapeutic modalities, and treatment outcomes. Ten patients underwent surgical excision of the primary tumor, by either supraglottic laryngectomy, vertical partial laryngectomy, or total laryngectomy. Seven of these patients also received postoperative radiotherapy. After a median follow-up period of 23 months, 7 of the 12 patients (58.3%) died as a result of uncontrolled locoregional disease or distant metastases. The 5-year survival rate was 57% in patients who underwent combination therapy versus 50% for those patients who received surgery alone. Surgical resection is the primary treatment modality used in the majority of cases. Neck dissection is reserved for patients with clinically apparent adenopathy, adenocarcinoma, or high-grade mucoepidermoid carcinoma. Combination therapy with surgical resection and radiotherapy may be more effective in achieving tumor remission than is surgical resection alone.

Purpose: To show that a supraclavicular neck mass may be indicative of metastatic testicular carcinoma and to offer further insight into the treatment of residual neck disease. Method: We report six cases of testicular carcinoma metastatic to the neck. All were initially treated with radiation, chemotherapy, or a combination of both depending on histological type. Results: Neck masses persisted despite primary therapy. Three patients underwent subsequent modified neck dissection and remained free of disease; three others received nonsurgical forms of adjuvant therapy and ultimately died of their cancer. Conclusion: Metastatic testicular carcinoma may manifest as a supraclavicular neck mass and must therefore be considered in the differential diagnosis of a mass in this region. Surgical resection is indicated in the management of neck masses that persist after cytoreductive chemotherapy to remove residual foci of disease and potential source of spread.

An interesting case of a traumatic neuroma of the greater auricular nerve provides the impetus for a discussion of head and neck neuromas. Traumatic neuromas of the head and neck are relatively rare. Division of the greater auricular nerve during parotidectomy occasionally results in a traumatic neuroma. We report a case of a 73-year-old woman who presented with a traumatic neuroma nine years after undergoing superficial parotidectomy with dissection of the facial nerve for a mixed tumor. The patient had a 1.5 cm x 1.0 cm mass located below the old surgical site over the anteromedial border of the sternocleidomastoid muscle. The patient's past history was significant for Frey's syndrome, which is the result of abnormal neurologic growth. On first impression, the tumor was thought to be a recurrence of neoplastic disease; however, because of the evaluation, traumatic neuroma was suspected. An attempt at fine-needle aspiration of the mass was too painful to be carried out. At surgery, a whitish tumor was excised which, on final pathologic examination, revealed traumatic neuroma. The surgical literature is reviewed and the subject of head and neck neuromas, including their evaluation and management, is thoroughly discussed. Knowledge of this possible diagnosis may spare the patient and the surgeon needless worry, as well as unnecessary procedures, once tumor recurrence has been ruled out.

Basal cell carcinoma is the most common cutaneous neoplasm and involves the head and neck in more than 85% of cases. Metastatic lesions occur in less than 0.1% of cases. In this report, four cases of metastatic basal cell carcinoma of the head and neck are presented. Previous reports indicate that metastases typically arise from long-standing, large and deep locally invasive lesions that are refractory to surgical or radiation therapy. Although three of the four cases follow this pattern, one case demonstrates that a small but rapidly enlarging lesion also has the potential for metastasis. The relationship of metastasis to tumor growth, histologic subtype, and host immune function is discussed.

Background Granular cell tumor was first described by Abrikossoff in 1926. It is rare and usually presents as a benign solitary lesion. Multifocal and malignant forms are known to occur. Methods This presentation illustrates an additional case of granular cell tumor. Clinical and histological features to distinguish malignant and benign forms are presented. Results Tumor can develop years after therapy for the primary lesion. Treatment recommendations are presented. Conclusions Patients diagnosed with granular cell tumor require close follow-up. Radiographic evaluation for the presence of metastatic disease is necessary if a malignant variant is suspected. © 1997 John Wiley & Sons, Inc. Head Neck19: 634–637, 1997.

Thirty-nine patients underwent reconstruction of composite mandibular defects following resection for squamous cell carcinoma. Thirty-four underwent immediate reconstruction, while 5 were reconstructed secondarily. Twenty-one received soft-tissue reconstruction only with a pectoralis major myocutaneous flap, 14 underwent osteocutaneous free-tissue transfer, and 4 received a reconstruction plate with free-tissue transfer for soft-tissue coverage. The mandibular defects in the pectoralis major myocutaneous flap group tended to be posterolateral, while free-tissue transfer defects were more severe, usually involving the anterior mandible. Length of surgery and duration of intensive care unit care were significantly longer for free-tissue transfer patients, while flap complications were more common in the pectoralis major myocutaneous flap patients. Facial appearance scores were higher for the free-tissue transfer group by both patient and physician assessment. Social function, speech, and oral function did not differ significantly. Patients reconstructed secondarily with free-tissue transfer reported significant improvement in appearance, oral continence, and social function, with little change in speech intelligibility, deglutition, or diet tolerance. The cost of the main hospitalization was significantly higher in the free-tissue transfer group than in the pectoralis major myocutaneous flap group, although when the costs of subsequent hospitalizations are included, the difference in total cost narrows. Despite more adverse defects, free-tissue transfer provided more predictable aesthetic results and expeditious return to normal social function than did pectoralis major myocutaneous flap reconstruction. The fiscal impact of these complex reconstructions is, however, significant. Cost-containment issues are presented and recommendations are made.

Surgical stents have improved and simplified our ability to predictably restore maxillomandibular relationships after composite oromandibular resections. Bimaxillary relationships are optimized, the aesthetic result is enhanced, and successful dental rehabilitation follows.

Although computed tomography and magnetic resonance imaging have contributed to the ability to identify metastatic disease in head and neck cancer, inadequacies in evaluating lymphadenopathy still exist. This study was undertaken to estimate the accuracy of radiological criteria used to detect cervical lymph node metastases. The morphological characteristics of 957 lymph nodes from 36 neck dissections from patients with squamous cell cancer were examined microscopically. A large number of malignant nodes were found to have diameters of less than 10 mm. Extranodal spread also occurred in a substantial percentage of smaller nodes. Because the present radiological criteria for assessing cervical lymph node status are based largely on size, findings indicate major limitations in the capabilities of detecting metastatic disease. New modalities to improve the staging of head and neck cancer are discussed.

Objective: To characterize the otolaryngologic manifestations of amyloidosis; classify patients with amyloidosis by specific location and type of underlying disease; and compare disease presentation and long-term outcome in these patients. Design: Retrospective review of biopsy specimens recorded as amyloidosis. Setting: Tertiary care referral center serving a diverse patient base. Patients: Of 141 patients with biopsy-verified amyloidosis who met the inclusion criterion for the study, 27 (19%) had head and neck manifestations. Outcome Measures: Good functional outcome and survival of patients with amyloidosis. Results: The tongue was the most commonly affected site of the head and neck. Distinct differences exist in functional outcome and long-term survival in patients with the localized form of amyloidosis when compared with patients with systemic amyloidosis. Conclusion: Because amyloidosis often affects the head and neck, otolaryngologists need to be familiar with this disease. (Arch Otolaryngol Head Neck Surg. 1995;121:778-782)

Background. Histologic changes that may predict irreversible neoplastic transformation remain poorly defined for lesions of the larynx. To date, more than 20 schemes for the classification of laryngeal dysplasia have been proposed, yet no one system has gained wide acceptance. This has led to considerable confusion in defining the pathogenesis of this process and controversy in selecting the optimal management strategy of patients with premalignant changes of the larynx. Methods. A detailed and systematic review was made of 125 laryngeal biopsies from 62 patients with laryngeal squamous cell dysplasia who received long term follow-up (mean, 74 months). Various histopathologic parameters were assessed in an attempt to define the prognostic importance of each parameter for progression from atypia to invasive carcinoma. Results. Five parameters were found to be significantly different when comparing lesions that progressed to carcinoma with those that remained stable or resolved: abnormal mitotic figures, mitotic activity, stromal inflammation, maturation level, and nuclear pleomorphism. Surface morphology, nucleolar prominence, and koilocytosis were not significantly different when comparing the two groups. Surface keratin formation did not suggest improved prognosis for patients with lesions with other features of dysplasia. Conclusions. These findings suggest that within the laryngeal glottis, severe keratinizing dysplasia occurs more frequently than does classic carcinoma in situ, and both entities likely represent intraepithelial neoplastic transformation. Cancer 1995;75:457-63.

Imaging-guided, minimally invasive surgery is a new concept that uses ultrasound (US) and/or high-speed magnetic resonance imaging (MRI) to guide various energy sources such as lasers, radio frequency, ultrasonic, or cryotherapy devices for treatment of deep-seated tumors and to monitor tissue changes during energy deposition. This approach for treatment of cancer will become clinically useful only after development of high resolution methods for real time monitoring of energy deposition in tumors. Recent studies have shown the efficiency of US and MRI for real and/or near real time tumor and vessel identification as well as for monitoring and quantifying energy-induced tissue damage. We report our initial clinical experience with patients in whom US and/or MRI-guided interstitial tumor therapy (ITT) techniques were successfully applied for the treatment of recurrent, nonresectable, local, and/or metastatic head and neck carcinomas. Patients were treated on an outpatient basis either in the operating room or in an upgraded, specially equipped SIGNA 1.5 T magnetic resonance suite. Most patients tolerated these procedures well and were successfully palliated for periods ranging from 3 months to 6 years posttreatment. The clinical experience and steps that led to our current technique are reviewed.

Sarcomas of the nose and paranasal sinuses are rare malignancies. Key issues remain unresolved in the management of these tumors, particularly with regard to the role of radiotherapy. To help clarify these issues, 48 consecutive cases of nasal and paranasal sinus sarcomas treated at the University of California, Los Angeles, between 1958 and 1988 were retrospectively reviewed. Six of 16 patients managed initially with surgery alone were cured. All had negative surgical margins and 5 of the 6 had low-grade tumors. Of 5 patients with high-grade lesions treated with surgery only, 1 was rendered free of disease. Twelve patients with positive surgical margins were treated with adjuvant radiotherapy; 5 were cured with this approach. Grade and surgical margin status were found to be significantly related to outcome for sinonasal sarcoma. There were 14 patients with rhabdomyosarcoma; 3 were cured with modern combined-modality therapy. Patients with positive surgical margins should be treated with adjuvant radiotherapy. Surgical therapy is effective for low-grade lesions that are completely excised.

Malignant clear cell hidradenoma is an uncommon tumor of eccrine sweat gland origin that has a predilection for the head and neck. It is characterized by an indolent growth pattern yet frequently recurs following surgical excision and has a high incidence of regional and distant metastases. A case of recurrent malignant clear cell hidradenoma of the upper lip is presented. The lesion was treated with surgical excision followed by radiotherapy. The literature on this rare lesion is reviewed and treatment strategies discussed.

Radiographic studies were reviewed from a group of 24 patients with biopsy-proven inverted papilloma of the nasal cavity or paranasal sinuses. Thirty-two cases of computed tomography (CT), 17 cases of plain sinus radiography, four cases of polytomography, and three cases of magnetic resonance imaging (MRI) were retrieved for analysis. Although no preoperative MRI examinations were available for comparison, CT was the most helpful study for evaluation of primary, nonrecurrent inverted papilloma, demonstrating disease-related abnormalities in 90% of the cases. While no CT finding was pathognomonic, findings that helped to distinguish inverted papilloma from benign nasal polyposis included predominantly unilateral involvement (90%) and frequent unilateral bony remodeling (40%). Plain sinus X-rays were abnormal in 70% of cases of primary tumor, with all positive studies showing nonspecific unilateral opacification of the maxillary antrum. Both CT and MRI defined the extent of histologically proven recurrent disease, although it was impossible to radiographically distinguish recurrent disease from postoperative scar tissue or mucoperiosteal thickening.

Rhytidectomy is a safe and effective procedure for rejuvenation of the aging face. Reported complication rates vary between 2.5% and 28%, and with proper management, longterm sequelae are unusual. Injury to the spinal accessory nerve is a rare but potentially debilitating complication of rhytidectomy. Afflicted patients present with dull, constant pain in the shoulder region which can be severe in nature. In addition, there is weakness of shoulder abduction and cosmetic deformity related to trapezius atrophy. Measures for conservative management include analgesics and physical therapy to strengthen the shoulder girdle. Nerve exploration is indicated for cases with documented denervation that do not respond to conservative treatment. A review of the English literature identified two previous case reports of spinal accessory nerve injury sustained during rhytidectomy. In this report, we present two additional cases and review current concepts regarding diagnosis, management, and prevention of this unusual complication of rhytidectomy. © 1994 John Wiley & Sons, Inc.

The rehabilitation of patients with orofacial-mandibular defects has made great strides with our ability to reliably transfer composite tissues. Unimpeded soft-tissue healing and osseous union set the stage for reliable restoration of form and function. A multidisciplinary, carefully planned, and carefully executed approach is emphasized.

Between 1955 and 1990, 28 patients with angiosarcoma of the head and neck were seen at UCLA Medical Center, Los Angeles, Calif. Half the lesions arose on the scalp; the remainder occurred in the soft tissues of the face and neck. Nine patients presented with multifocal disease. Follow-up ranged from 3 to 159 months, with a median of 32 months. The overall prognosis was poor, with a 5-year disease-free survival of 26% (7/27 patients). Of 21 patients having recurrences after primary treatment, 90% (19/21 patients) had a component of local failure. Distant metastasis had developed in nine patients at last follow-up. Of patients treated initially with surgery alone, 8% (1/12 patients) remain disease free vs 67% (4/6 patients) who received postoperative radiation therapy, with or without chemotherapy. Only one (14%) of seven patients treated primarily with radiation therapy with or without chemotherapy was rendered disease free. Angiosarcoma usually presents with high-grade histologic features and frequently with multifocal disease. There is propensity for both local recurrence and distant metastasis. Our results and a review of the literature suggest that combined modality therapy offers the best chance for long-term control in patients with angiosarcoma of the head and neck.

Background. With improvement in survival after cancer treatment, it is becoming increasingly important to study treatment-related morbidity and mortality. Sarcoma can develop in the irradiated field after radiation therapy. The authors performed a study to estimate the risk, and compared the risk of sarcoma after radiation therapy with that of other treatment modalities used against cancer. Methods. Between 1955 and 1988, 229 patients with sarcoma of the head and neck were seen at the University of California, Los Angeles (UCLA), Medical Center. Of these, 13 (6%) had a previous history of radiation therapy to the head and neck. Results. Radiation doses were known in 10 of 13 patients and ranged from 30 to 124.4 Gy. The latency time from radiation therapy to the development of postirradiation sarcoma (PIS) ranged from 3 months to 50 years, with a median of 12 years. More than 2000 patients have received radiation therapy to the head and neck for various conditions at the UCLA Medical Center since 1955. Conclusions. The authors conclude that most head and neck sarcomas are not radiation related and that the risk of PIS after head and neck irradiation for other diseases is low. From a review of the literature comparing mortality risks of chemotherapy, general surgery, and anesthesia, the risk of PIS appears no worse. Given the large number of patients who can be cured or receive palliation with radiation therapy, concern about PIS should not be a major factor influencing treatment decisions in patients with cancer.

Purpose: Most cases of endoscopic sinus surgery are amenable to techniques using local anesthesia with monitored sedation. However, it is frequently the preference of the patient to have surgery under general anesthesia. One major drawback of general anesthesia is the increased bleeding encountered which can interfere with optimal visualization of the intranasal anatomy. In this study, an analysis was made to see if technique of general anesthesia has an impact on estimated blood loss in patients undergoing endoscopic sinus surgery. Methods: Twenty-five patients undergoing outpatient endoscopic sinus surgery under general anesthesia over a 1-year period were reviewed retrospectively to determine if anesthetic technique had an impact on estimated blood loss. Twelve patients were identified who received a continuous intravenous infusion of the nonbarbituate hypnotic agent propofol as the primary anesthetic agent, and 13 patients were identified who received anesthesia based on inhalational isoflurane. Results: There was no difference between the duration of surgery or the intraoperative mean arterial blood pressure when comparing the two groups. The average estimated blood loss in the propofol group was 101 mL compared with an average estimated blood loss of 251 mL in the isoflurane group ( P Conclusions: General anesthesia based on propofol infusion may have the advantage of decreased bleeding compared with conventional inhalation agents, making endoscopic sinus surgery technically easier and safer by improving endoscopic visualization of the surgical field. This anesthetic technique may have other applications in otolaryngology, where bleeding within a confined space frequently can interfere with visibility.

Inverting papilloma of the nose and paranasal sinuses is a benign disease with malignant potential. This disease is characterized by multiple recurrences, especially after minimal operative therapy. Controversy exists over the most appropriate treatment for this rare tumor. This review presents an update of the UCLA experience with inverting papilloma over the past four decades along with a review of the literature. A retrospective study of 61 patients seen at the UCLA Medical Center was conducted. The mean age at presentation was 63 years, with a male-to-female ratio of 2:1. The most common symptom at presentation was nasal obstruction (71%), followed by epistaxis (27%). Seventeen percent of the patients in this series either had concurrent squamous cell carcinoma of the nose or paranasal sinuses, or it developed. Patients treated with a lateral rhinotomy and medial maxillectomy had a recurrence rate of 30 percent. Those treated with a less aggressive operation had a recurrence rate of 71 percent. Despite a trend for a more conservative sinus operation in recent literature, we continue to advocate a lateral rhinotomy and medial maxillectomy as the treatment of choice for inverting papilloma of the head and neck.

Enophthalmos previously has been reported to be a rare complication of maxillary sinus mucoceles. We report three patients treated by the senior author (T.C.C.) over a 2-month period for enophthalmos or obvious deformity of the midface associated with complete opacification of the maxillary antrum. Most previous authors have stressed the role of chronic pressure necrosis or osteitis leading to bone destruction, with primary involvement of the orbital floor. No patients in this series had symptoms typical of maxillary sinus mucoceles. Two of our three patients presented with minimal symptoms of chronic infection. There was inward collapse of the anterior, superior, lateral, and medial walls of the maxillary sinus, with no radiographic or intraoperative confirmation of bone destruction. We speculate that this process may be the result of chronic maxillary hypoventilation with subsequent atelectasis of the antrum secondary to chronic negative pressure. All patients had obstruction at the osteomeatal complex and were treated by endoscopic enlargement of the natural maxillary ostium.

Chondrosarcoma of the head and neck is a rare tumor. In an attempt to clarify optimal treatment of these lesions, we reviewed the records and pathologic material of 18 consecutive cases of head and neck chondrosarcoma seen at our institution between 1955 and 1988. Follow-up ranged from 3 to 168 months with a median of 72. Absolute 5-year survival was 68% (11/16), with 9/16 (56%) patients surviving disease-free. Grade was the most important prognostic factor. Only one of 7 (14%) patients known to have high grade histology was rendered disease-free, as opposed to 9/10 (90%) with low-grade lesions. Tumor size and completeness of surgical resection were also important prognostic factors. Four of 10 patients managed initially with surgery alone achieved local control with greater than 5-year survival. All four had low-grade lesions. Five patients received surgery and radiation as primary treatment, and three are disease-free with greater than 5-year follow-up. Two of these were irradiated because of positive margins. One patient received radiation alone and has persistent disease. Two patients received combined chemotherapy and surgery because of high-grade lesions, and one is free of disease with greater than 5-year follow-up. Patients with incomplete resections should receive further surgery or postoperative radiation therapy. High-grade lesions should be treated aggressively.

Purpose Using a transnasal, transfacial, anterior skull base approach, we have removed olfactory neuroblastomas (OFN) obviating the need for a frontal craniotomy. The objectives were to present our surgical approach in achieving clear margins, to assess patient survival, and to recommend eligibility criteria. Materials and methods A retrospective chart review was done to identify patients diagnosed with OFN who underwent this surgical approach. Thirteen patients were identified who underwent our pictorially described approach. Postoperative assessment of pathologic margins, patient survival, and limitations of surgical approach was determined. Results Of the 13 patients, 12 (92%) had clear postsurgical margins. One patient had residual intracranial disease due to coagulopathy preventing further resection. Twelve patients remain alive with 10 patients remaining disease-free (follow-up ranging from 11 to 64 months). Three patients presented with recurrent disease initially, with 2 having had subsequent repeat local and regional recurrences, respectively; one of whom died recently of the rerecurrent disease. One patient had a postoperative cerebrospinal fluid leak repaired via the original surgical approach. Conclusions Although craniofacial resection remains an accepted approach for surgical treatment of OFN, we have adopted a transnasal, transfacial approach eliminating the need for a frontal craniotomy. This approach allows for adequate exposure of the cribriform plate, dura, and anterior skull base. Our technique minimizes dural defects and prevents many craniotomy-associated complications, including frontal lobe retraction. Long-term follow-up is needed to compare survival using this approach; however, our results to date are quite promising.

The authors reviewed 164 cases of head and neck sarcoma from adult patients seen at the University of California, Los Angeles (UCLA), between 1955 and 1988. The median follow-up was 70 months. Multivariate analysis demonstrated that tumor grade, size, and surgical margin status were the most important independent prognostic factors. Thirty-one percent (27 of 85) of patients with high-grade lesions were free of disease versus 81% (44 of 55) with low-grade lesions at last follow-up. Sixty-seven percent (50 of 76) of patients with lesions smaller than 5 cm were free of disease versus 38% (33 of 88) with lesions larger than 5 cm. In 16 patients, low-grade lesions, measuring less than 5 cm and with negative margins histologically, were controlled with surgery alone. For the 94 patients whose primary tumors were treated at UCLA, local control was achieved in 52% (26 of 50) of patients treated with surgery alone and 90% (20 of 22) with combined therapy (surgery and radiation therapy [RT] with or without chemotherapy). Seventy-five percent (6 of 8) of patients with positive surgical margins treated with postoperative RT achieved local control versus 26% (5 of 19) of patients receiving no additional treatment. In conclusion, surgery alone appears to be adequate treatment for small, low-grade tumors and negative surgical margins. Patients with incomplete resection or high-grade tumors should receive aggressive treatment--surgery and RT.

During a 26-year period (1961-1987), a total of 18 patients with primary non-Hodgkin's lymphoma (NHL) of the paranasal sinuses and nasal cavity received radiation therapy at (University of California at Los Angeles) UCLA Medical Center. At the time of diagnosis and using the available diagnostic methods, none of these patients had clinically detectable disease beyond the paranasal sinuses. All 18 patients were staged IE by the Ann-Arbor system. When the patients were staged according to the AJC staging system from epithelial tumors, half presented with advanced T3-4 disease. Diffuse histiocytic lymphoma was the most common histology (eight cases) and maxillary sinus, the most common site of origin (11 cases). All nine T1-2 tumors received radiation therapy alone, while radiation and chemotherapy was used in seven of nine advanced T3-4 staged tumors. The mean follow-up was 71 months. At last follow-up, eight of nine T1-2 patients were rendered disease-free. In contrast, only four of nine T3-4 patients had long-term disease-free survival. Seventy-five percent of the failure occurred within 2 years. Radiation therapy alone achieves high local control in small tumors (T1-2), while large tumors (T3-4) require aggressive combined treatment, i.e., radiation and chemotherapy.

To evaluate the treatment results of pleomorphic adenoma (PA) of the parapharyngeal space at a single institution during a 30-year period.A retrospective review.This study was performed by examining the records and reviewing the pathology of 44 patients with PA of the parapharyngeal space treated at a single medical center from January 1975 to November 2005.Of the 44 patients with PA, 35 patients underwent 38 excisions. Eleven men and 27 women were treated surgically. Follow-up varied from 24 months to 180 months. There were three recurrences in two patients. Recurrence rates at 5 and 10 years were equal at 7.9%. Gender, age, tumor volume, surgical approach, pathologic surgical margin status, and prior resections were evaluated for significant prognostic factors. Advanced age proved a poor prognostic indicator (P.05). History of prior resection (P.01) was significant for recurrence. Positive surgical margins (P = .69) proved a negative association.We report low recurrence rates in this patient population with two important prognostic indicators. History of prior resection is significant to predict recurrence. Interestingly, positive surgical margins are actually shown not to effect risk of recurrence. Local recurrence of the tumor is associated with further recurrence and less favorable prognosis.

A vertical partial laryngectomy (VPL) for salvage was performed on 25 patients with locally persistent or recurrent squamous cell carcinoma of the vocal cord(s) after high-dose radiotherapy at the UCLA Medical Center between 1969 and 1988. Patients were followed for a minimum of 2 years and a median of 4.4 years after VPL. Ninety-six percent of patients remained free of disease. Tumor was controlled in patients with impaired vocal cord mobility and involvement of the contralateral cord or false cord. The actuarial survival rate was 80% at 5 years. There were no serious wound healing problems. A permanent tracheostomy was required in one patient due to recurrent aspiration pneumonia. Swallowing and voice function were satisfactory in all other patients. These results indicate that the selection criteria for initial VPL can be applied to the salvage situation with similar success.

• Eighteen cases of osteogenic sarcoma of the head and neck were treated at our institution between 1955 and 1987. The patients' ages ranged from 5 to 73 years, with a median age of 28 years. The sex distribution was equal. Follow-up ranged from 1 to 276 months, with a median of 79 months. The primary site of the tumor was the mandible in nine cases, maxilla and paranasal sinuses in six, skull in two, and orbit in one. Six of 18 patients were free of disease with greater than 5 years of follow-up. Four of the six received combined surgery, radiation therapy, and chemotherapy as their primary treatment. Of the five patients treated with surgery alone, four suffered recurrences, one of whom was salvaged with further surgery and chemotherapy. Five patients were treated initially without surgery. They received radiation therapy with or without chemotherapy; all five developed local recurrence. We conclude that osteogenic sarcoma of the head and neck is an aggressive tumor, prone to both local and distant failure. Based on our series and from published experience involving the extremities, osteogenic sarcoma of the head and neck should be managed with multimodality therapy. (Arch Otolaryngol Head Neck Surg. 1991;117:761-766)

• Between 1955 and 1987, twenty-nine patients with the diagnosis of fibrosarcoma of the head and neck were seen at the UCLA Medical Center. Follow-up ranged from 15 to 192 months, with a median of 66 months. Absolute 5-year survival was 62% (13/21). Five of 17 patients treated initially with surgery alone achieved local control and long-term survival. All five had low-grade lesions. Five patients received postoperative radiation therapy because of positive surgical margins. Three were rendered disease free, and all had low-grade lesions. Radiation therapy was used as primary treatment in six patients, four of whom received additional chemotherapy. Of these six, two are disease free with longer than 5-year follow-up. Surgery with and without adjuvant therapy successfully salvaged 42% (5/12) of the patients with local recurrence. Eighty percent (12/15) of the patients with low-grade lesions were ultimately rendered disease free vs only 8% (1/12) of the patients with high-grade histologic features. Seventy-two percent (13/18) of the patients with local recurrence were known to have positive surgical margins. Sixty-eight percent (13/19) of the patients with recurrent disease had high-grade lesions and/or tumor size larger than 5 cm. Tumor grade is the most important prognostic factor followed by tumor size and surgical margin status. Patients with low-grade lesions and adequate surgical margins are treated well with surgery alone. Patients with high-grade lesions or positive surgical margins should receive adjuvant treatment. (Arch Otolaryngol Head Neck Surg. 1991; 117:396-401)

Massive defects of the scalp, cranium, and dura can be covered with local rotation, transposition scalp flaps. Five cases of massive defects of up to 300 square centimeters resulting from resection of scalp neoplasms were reconstructed by this technique. Excellent cosmetic and functional results were obtained in all cases. Although the emphasis in the recent literature has been on free flap coverage of these massive defects, our series demonstrates that these extensive scalp defects can be reconstructed using large local scalp flap transposition.

Tongue base resection plays an important role in the management of the patient with cancer of the posterior tongue. The considerable morbidity resulting from loss of functional tongue includes compromised deglutition, chronic aspiration, and altered speech articulation. The particular operative approach used dictates additional secondary morbidity, which may include cosmetic and functional defects of the mandibular arch, malocclusion, lip and chin scars, and postoperative changes in the oral cavity. Our recent experience with a transpharyngeal approach in 13 patients with tongue base cancer is reviewed. Adequate operative exposure was obtained in all cases. Persistent aspiration was not a problem, and all patients learned to swallow effectively. The transpharyngeal approach avoids unnecessary surgical trauma to the mandible and anterior oral cavity and minimizes cosmetic deformity. Our early experience with this approach is encouraging.

Objective To determine the incidence and causes of perioperative complications in patients who undergo microvascular free flap procedures for reconstruction of the head and neck. Setting Academic tertiary care medical center. Patients and Methods A total of 400 consecutive microvascular free flap procedures were performed for reconstruction of the head and neck, with 95% of the defects arising after the treatment of malignancies. Flap donor sites included radial forearm (n = 183), fibula (n = 145), rectus abdominis (n = 38), subscapular system (n = 28), iliac crest (n = 5), and a jejunal flap. Patient-related characteristics (age; sex; diagnosis; comorbidity level; tumor stage; defect site; primary vs secondary reconstruction; and history of surgery, radiation therapy, or chemotherapy) and the incidence of perioperative complications were recorded prospectively over a 7-year period. Results The perioperative mortality was 1.3%. Overall, perioperative complications occurred in 36.1% of all cases. Free flaps proved to be extremely reliable, with a 0.8% incidence of free flap failure and a 3% incidence of partial flap necrosis. Perioperative medical complications occurred in 20.5% of cases, with pulmonary, cardiac, and infectious complications predominating. Multivariate statistical analysis showed significant relationships between the incidence of perioperative complications and preoperative comorbidity level as indicated by American Society of Anesthesiologists (ASA) status ( P = .02). Conclusions The present study confirms that free flaps are extremely reliable in achieving successful reconstruction of the head and neck. The incidence of perioperative complications is related to preoperative comorbidity level.

Problem: To determine whether curcumin would trigger cell death in head and neck squamous cell carcinoma (HNSCC) cell lines CCL 23, CAL 27, UMSCC-1, and UMSCC-14 in a dose-dependent fashion. Methods: In-vitro studies included MTT assay and Annexin V-FITC flow cytometry of the HNSCC cells at 8 and 15 hours after treatment with curcumin. In vivo studies were done on HNSCC xenograft tumors grown in nude mice, using curcumin paste applied topically to the tumors daily for 4 weeks. Results: CCL23 cell lines had dose-dependent reduction in cell viability following treatment with curcumin, with nearly 100% cell survival at 100 μM and less than 5% survival at 300 μM. CAL27 cell lines showed reduction of cell viability beginning at 60 μM, and 0% survival at 300 μM. UMSCC-1 cell lines showed reduction in cell viability from 70% at 100 μM to 0% at 200 μM, at both 8 and 15 hours after treatment. UMSCC-14A cell lines showed similar sensitivity, with an average 40% reduction in viability beginning at 100 μM and 0% survival at 200 μM. Flow cytometry demonstrated early and late apoptosis with the curcumin-treated CCL23 and CAL27 cells. The xenograft tumors exhibited more than 50% decrease in size with the curcumin/saline paste. Conclusion: Curcumin has a direct effect on CCL23, CAL27, UMSCC-1, and UMSCC-14, reducing viability in both cell lines in a dose-dependent fashion. In addition, curcumin/saline paste had a significant suppressive effect on HNSCC xenograft tumors, confirming curcumin’s anti-tumor properties in vivo. Significance: To determine whether curcumin would trigger cell death in head and neck squamous cell carcinoma cell lines. Support: None reported.

Background. Desmoplastic malignant melanoma (DMM) is a rare variant of malignant melanoma with high local recurrence rate after surgical excision. We performed a retrospective review to address the role of radiation therapy in local control of this tumor. Methods. Between 1976 and 1997, 44 patients with the pathologic diagnosis of DMM were registered at our tumor registry. Fourteen patients received postoperative RT, and one patient received preoperative RT. Three of the irradiated lesions had gross residual or positive surgical margins. Doses ranged from 44 to 66 Gy. Results. Sixty-eight percent of DMM lesions occurred in the head and neck region. Forty-eight percent (21 of 44) of patients experienced a local recurrence after initial excision (mean time to recurrence, 12 months). Local failure in head and neck was 46% (14 of 30). Clark level, primary site, and neurotropism did not predict local recurrence; the Clark level predicted distant metastasis. No viable tumor was found in the surgical specimen of the patient who received preoperative RT. None of 15 patients who received adjuvant irradiation had any additional recurrences (mean follow-up, 64.7 months). By contrast, four of seven patients with history of recurrence who did not receive RT had local relapse (p =.005). The incidence of distant metastasis did not reach statistical significance between the irradiated and nonirradiated groups. Conclusions. The high rate of local recurrence of DMM after surgical resection is dramatically reduced by adjuvant radiation therapy. We recommend adjuvant postoperative radiation therapy as a part of treatment of DMM.