Search

Background: Stage T4a cancers are associated with a 5-year survival of 21.6-59.0%. Adequate resection of these tumors is a critical factor in maximizing survival. Tumors invading bone pose a unique challenge to intraoperative bone margin assessment. Due to processing limitations, there had been no formal standardized protocol for intraoperative bone sampling at the QEII Health Sciences Centre. These resections often involve extensive reconstruction, making salvage surgery difficult if positive margins are detected post-surgically. The purpose of this study was to assess the accuracy and frequency of intraoperative bone margin assessment during the study period and to determine survival and recurrence rates associated with positive final bone margins., Methods: A retrospective chart review was conducted including patients with stage T4a head and neck cancer involving bone that underwent primary surgical resection in Nova Scotia between 2009 and 2019. Eligible patients were identified through the Cancer Care Nova Scotia registry. Exclusion criteria included patients with stage T4a tumors involving bone that did not receive primary surgical treatment with curative intent and patients with stage T4a tumors that did not invade bone., Results: Of 67 patients included, 50 were amenable to intraoperative bone margin sampling while 18 had intraoperative sampling. Four patients had positive intraoperative margins and one had final positive bone margins. The incidence of final bone margin positivity was 7.5%. Median survival following surgery was 4.56 years for patients with final negative bone margins (n = 62) and 3.98 years for patients with positive final bone margins (n = 5). All patients with final positive bone margins received adjuvant radiation therapy. Of patients with negative final bone margins, 16.1% received no adjuvant therapy, 61.3% received adjuvant radiation therapy and 21.0% received adjuvant chemoradiation therapy., Conclusion: Intraoperative bone margin sampling occurred in 26.8% of all cases and 36.0% of amenable cases. Median survival of patients with positive final bone margins was 0.58 years lower than those with negative final bone margins, although this difference did not reach statistical significance. This will provide baseline data for comparison of the standardized intraoperative bone margin sampling protocol implemented at the QEII Health Sciences Centre., (© 2023. The Author(s).)

Background: Laryngeal cancers of glottic origin comprise a large proportion of head and neck malignancies. Transoral laser microsurgery (TLM) and radiation therapy are mainstays in the treatment of early stage glottic cancer, but debate persists as to which modality is functionally superior. Furthermore, there is a paucity of North American data related to functional and oncological outcomes in T1a glottic cancer. Here, we assessed oncological and functional outcomes of T1a glottic squamous cell carcinoma (SCC) with TLM to supplement evidence from jurisdictions outside North America., Methods: This study is a retrospective cohort study performed from a prospectively collected tertiary center institutional TLM database. Patients who were diagnosed with T1a glottic SCC and underwent TLM as their primary treatment were included. Functional outcomes were analyzed using the Voice Handicap Index-10 (VHI-10) questionnaire. Ultimate control with TLM only was considered to be those patients with locoregional control with repeat TLM procedures, but without addition of other modalities. Student's t-test was used to test significance and Kaplan-Meier survival analysis was used to assess oncological outcomes., Results: 48 patients met study criteria. The mean follow-up time was 74 months. The 5-year locoregional, ultimate control with TLM only and laryngeal preservation rates were 83.2%, 90.4% and 100%, respectively. The overall survival and disease-specific survival were 87.2% and 100%, respectively. VHI-10 scores were available for 13/48 patients and mean scores improved non-significantly from pre-op (mean: 11.23; range: 2 to 30; median: 10) and post op (mean: 7.92; range: 0 to 18; median: 8) scoring (p-value = 0.15). Sub-stratification of voice data revealed a significant improvement between pre and post-operative scores (mean difference - 10.6, 95% CI: - 0.99 to - 20.21, p-value = 0.035) for patients with abnormal pre-operative scores (VHI > 11)., Conclusion: To our knowledge, the current work represents one of the first North American studies to report both functional and oncologic outcomes for TLM treatment of T1a glottic SCC. The oncologic and functional outcomes presented here add to existing evidence in favor of TLM as a safe and effective primary treatment option for early staged T1a glottic cancer., (© 2022. The Author(s).)

Objective: To evaluate the oncologic and functional outcomes of transoral laser microsurgery (TLM) for glottic cancers in patients ≥80 years., Study Design: Prospectively collected case series., Setting: QEII Health Sciences Centre, Halifax, Canada., Methods: This case series used a prospectively collected glottic cancer database to examine consecutive elderly patients (≥80 years old) undergoing TLM. Kaplan-Meier analysis was used to evaluate rates of disease-free, disease-specific, and overall survival as the primary end points of oncologic control. Secondary functional outcomes included voice function, length of hospital stay, and time to readmission., Results: From 2005 to 2017, 17 octogenarian patients underwent TLM for glottic cancer. Median follow-up was 4.19 years (interquartile range, 0.71-6.95). Kaplan-Meier estimates of 5-year survival were 78.4% (disease free), 92.9% (disease specific), and 81.9% (overall). The median length of hospital stay was 1 day (range, 0-8). There was only 1 readmission within 30 days of surgery. No patients in this study developed significant surgical or postoperative complications requiring unplanned readmissions. Patient-perceived voice function improved to normal after treatment in 62.5% of patients., Conclusion: The results of this study suggest that TLM is a safe and effective treatment modality for glottic cancer in patients aged ≥80 years, providing good oncologic control and satisfactory functional outcomes., (© The Authors 2021.)

Cancer causes substantial emotional and psychosocial distress, which may be exacerbated by delays in treatment. The COVID-19 pandemic has resulted in increased wait times for many patients with cancer. In this study, the psychosocial distress associated with waiting for cancer surgery during the pandemic was investigated. This cross-sectional, convergent mixed-methods study included patients with lower priority disease during the first wave of COVID-19 at an academic, tertiary care hospital in eastern Canada. Participants underwent semi-structured interviews and completed two questionnaires: Hospital Anxiety and Depression Scale (HADS) and Perceived Stress Scale (PSS). Qualitative analysis was completed through a thematic analysis approach, with integration achieved through triangulation. Fourteen participants were recruited, with cancer sites including thyroid, kidney, breast, prostate, and a gynecological disorder. Increased anxiety symptoms were found in 36% of patients and depressive symptoms in 14%. Similarly, 64% of patients experienced moderate or high stress. Six key themes were identified, including uncertainty, life changes, coping strategies, communication, experience, and health services. Participants discussed substantial distress associated with lifestyle changes and uncertain treatment timelines. Participants identified quality communication with their healthcare team and individualized coping strategies as being partially protective against such symptoms. Delays in surgery for patients with cancer during the COVID-19 pandemic resulted in extensive psychosocial distress. Patients may be able to mitigate these symptoms partially through various coping mechanisms and improved communication with their healthcare teams.

Background: Healthcare systems generate substantial carbon footprints that may be targeted to decrease greenhouse gas emissions. Outreach clinics may represent tools to assist in this reduction by optimizing patient related travel. Therefore, we sought to estimate the carbon footprint savings associated with a head and neck surgery outreach clinic., Methods: This study was a cross-sectional survey of patient travel patterns to a surgical outreach clinic compared to a regional cancer treatment centre from December 2019 to February 2020. Participants completed a self-administered survey of 12 items eliciting travel distance, vehicle details, and ability to combine medical appointments. Canadian datasets of manufacturer provided vehicular efficiency were used to estimate carbon emissions for each participant. Geographic information systems were used for analyses., Results: One hundred thirteen patients were included for analysis. The majority of patients (85.8%) used their own personal vehicle to travel to the outreach clinic. The median distance to the clinic and regional centre were 29.0 km (IQR 6.0-51.9) and 327.0 km (IQR 309.0-337.0) respectively. The mean carbon emission reduction per person was therefore 117,495.4 g (SD: 29,040.0) to 143,570.9 g (SD: 40,236.0). This represents up to 2.5% of an average individual's yearly carbon footprint. Fewer than 10% of patients indicated they were able to carpool or group their appointments., Conclusion: Surgical outreach clinics decrease carbon footprints associated with patient travel compared to continued care at a regional centre. Further research is needed to determine possible interventions to further reduce carbon emissions associated with the surgical care of patients.

Introduction: The abscopal effect is a rarely observed outcome of radiotherapy wherein there is a reduction in metastatic disease burden outside of the targeted treatment area. Likely due to an in situ vaccine effect of radiotherapy, the abscopal effect may be augmented by immunotherapy. This report is the first case of the abscopal effect observed in metastatic head-and-neck squamous cell carcinoma (hnscc) treated with concurrent radiotherapy and single-agent nivolumab., Case Description: An otherwise healthy 57-year-old man underwent craniofacial resection and adjuvant chemoradiotherapy for advanced sinonasal squamous cell carcinoma. Distant metastatic disease developed shortly after primary treatment, and immunotherapy in the form of nivolumab was initiated. Subsequent oligometastatic progression despite immunotherapy prompted palliative radiotherapy to a single metastasis due to pending symptomatology. Post-radiotherapy, the abscopal effect was observed with all distant sites of metastatic disease shrinking. Five months following treatment, a sustained reduction in disease burden has been demonstrated., Summary: We present the first case of the abscopal effect in a patient with metastatic hnscc treated with palliative radiotherapy concurrent with single-agent nivolumab immunotherapy, and only the third case of the abscopal effect in metastatic head-and-neck cancer. Dual treatment with immunotherapy and radiotherapy may be an important treatment option in the future, mediated through the abscopal effect., Competing Interests: CONFLICT OF INTEREST DISCLOSURES We have read and understood Current Oncology’s policy on disclosing conflicts of interest, and we declare that we have none., (2020 Multimed Inc.)

Introduction: Advanced oral cancer and its ensuing treatment engenders significant morbidity and mortality. Patients are often elderly with significant comorbidities. Toxicities associated with surgical resection can be devastating and they are often highlighted by patients as impactful. Given the potential for suboptimal oncological and functional outcomes in this vulnerable patient population, promotion and performance of shared decision making (SDM) is crucial.Decision aids (DAs) are useful instruments for facilitating the SDM process by presenting patients with up-to-date evidence regarding risks, benefits and the possible postoperative course. Importantly, DAs also help elicit and clarify patient values and preferences. The use of DAs in cancer treatment has been shown to reduce decisional conflict and increase SDM. No DAs for oral cavity cancer have yet been developed.This study endeavours to answer the question: Is there a patient or surgeon driven need for development and implementation of a DA for adult patients considering major surgery for oral cancer?, Methods and Analysis: This study is the first step in a multiphase investigation of SDM during major head and neck surgery. It is a multi-institutional convergent parallel mixed-methods needs assessment study. Patients and surgeon dyads will be recruited to complete questionnaires related to their perception of the SDM process (nine-item Shared Decision-Making Questionnaire, SDM-Q-9 and SDM-Q-Doc) and to take part in semistructured interviews. Patients will also complete questionnaires examining decisional self-efficacy (Ottawa Decision Self-Efficacy Scale) and decisional conflict (Decisional Conflict Scale). Questionnaires will be completed at time of recruitment and will be used to assess the current level of SDM, self-efficacy and conflict in this setting. Thematic analysis will be used to analyse transcripts of interviews. Quantitative and qualitative components of the study will be integrated through triangulation, with matrix developed to promote visualisation of the data., Ethics and Dissemination: This study has been approved by the research ethics boards of the Nova Scotia Health Authority (Halifax, Nova Scotia) and the University Health Network (Toronto, Ontario). Dissemination to clinicians will be through traditional approaches and creation of a head and neck cancer SDM website. Dissemination to patients will include a section within the website, patient advocacy groups and postings within clinical environments., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: Peritonsillar abscesses (PTAs) are common emergency consultations for otolaryngologists. Medical management alone may offer satisfactory treatment without the risk associated with surgical drainage. Therefore, we performed a systematic review of medical treatment alone compared to surgical drainage for the treatment of PTA., Data Sources: MEDLINE, EMBASE, Cochrane CENTRAL, and ClinicalTrials.gov., Review Methods: Studies comparing the outcomes of medically treated to surgically treated patients were included. Risk of bias was assessed using the Newcastle-Ottawa Scale. All screening and data extraction were completed by 2 independent reviewers. Meta-analysis was performed using a random-effects model. Subgroup and sensitivity analyses were performed., Results: Ten cohort studies and 2 randomized studies were included (n total = 33,468). Study quality was low, with only 1 study providing multivariable analysis. The combined rate of treatment failure in patients initially treated with medical management alone was 5.7% compared to 5.5% in the surgical group. There was no statistically significant difference in the odds of treatment failure between interventions through random-effects meta-analysis (odds ratio [OR], 1.10; 95% CI, 0.53-2.26; I 2 = 41%; P = .13). Subgroup analysis excluding pediatric-specific studies revealed similar odds of treatment failure when initially managed with medical intervention (OR, 0.92; 95% CI, 0.56-1.50; P = .39; I 2 = 0%)., Conclusion: Meta-analysis of available studies demonstrated no difference in odds of treatment failure for patients with PTA managed through medical intervention alone compared to surgical intervention. These findings should be interpreted with caution due to high probability of bias and overall low quality of studies.

Background: Primary chondrosarcomas of the nasal septum are rare, with a variety of clinical features that evade detection and treatment. While endoscopic surgery has become increasingly accessible, open approaches may be needed to provide adequate visualization for tumour ablation and reconstruction. We report the resection and reconstructive considerations of a septal chondrosarcoma., Case Presentation: A 75-year-old woman presented with a 3-year history of a slow growing, firm mass in the nasal tip causing protrusion and septal fullness. Computed Tomography scan of the paranasal sinuses revealed a well-circumscribed, 2.2 cm mass at the anterior nasal septum extending into the right vestibule. Biopsy of the cartilaginous lesion confirmed the diagnosis of a low-grade chondrosarcoma by histopathology. The tumour was removed using a transcolumellar open rhinoplasty approach with a large septal resection. Primary reconstruction of the surgical defect was performed using an L-shaped strut from the nasal keystone area to the columella. Follow-up examinations demonstrated no evidence of recurrent disease with satisfactory functional and cosmetic outcomes at 1-year., Conclusion: This report describes a case of nasal septal chondrosarcoma successfully treated with surgical excision using an open rhinoplasty approach. Only 5-10% of chondrosarcomas are located in the head and neck region and arise rarely in the nasal septum in approximately 2-4%. With this mass, an open rhinoplasty approach was required to allow optimal exposure of the margins and to facilitate reconstruction without disruption of normal sinonasal anatomy and function. Although rare, chondrosarcoma of the nasal septum should be considered in the differential diagnosis of nasal masses.

Background: Transoral laser microsurgery for glottic squamous cell carcinoma is the standard of care at many institutions. Repeat transoral laser microsurgery for recurrence may avoid the need for radiotherapy and total laryngectomy. This study aimed to identify oncological and functional outcomes in a cohort of patients who had undergone repeat transoral laser microsurgery procedures., Method: A retrospective review of prospectively collected data of patients treated with transoral laser microsurgery for carcinoma in situ or tumour stages T1 or T2 glottic cancer, from 2003 to 2018., Results: Twenty patients were identified. Additional treatment was not needed in 45 per cent of patients. The five-year overall survival rate was 90 per cent. The disease-specific survival rate was 100 per cent. The laryngeal preservation rate was 85 per cent. There was improvement in mean Voice Handicap Index-10 scores following repeat transoral laser microsurgery treatment, when comparing the pre- and post-operative periods (mean scores = 15.5 vs 11.5, p = 0.373)., Conclusion: Repeat transoral laser microsurgery can be an oncologically safe alternative to other salvage therapies for glottic squamous cell carcinoma recurrence, without sacrificing functional outcomes.

Background: There is a paucity of evidence comparing oncological and voice outcomes between T2a and T2b glottic squamous cell carcinoma (SCC) patients treated with transoral laser microsurgery (TLM). This study identified functional and oncological outcomes in this cohort., Methods: Retrospective review of prospectively collected data of patients treated with TLM for T2 glottic SCC from 2003 to 2017., Results: In total, 75 patients were included. Five-year local control rates were significantly different between T2a and T2b patients (75.2% vs 57.0%, p = 0.022). There was no difference in five-year survival between patients with T2a disease and T2b disease (69.5% vs 73.4%, p = 0.627). There was no significant difference in mean VHI-10 scores in the pre-operative period (18.3 vs 21.4, p = 0.409). However, patients with T2b disease had significantly worse perceived voice outcomes post-operatively (6.6 vs 21.3 p = 0.001). Patients with T2a disease saw significant improvements in mean VHI-10 scores following surgery (18.3 vs 6.6, p = 0.000), while T2b patients did not (21.4 vs 21.3, p = 0.979). The overall laryngeal preservation rate was 94.7%, with 11.5% of T2b patients requiring salvage organ sacrifice., Conclusions: This study highlights positive functional outcomes for T2a glottic SCC. Patients with T2b disease appear to have significantly worse oncological and functional outcomes, including worse voice quality following surgery and higher rates of salvage laryngectomy.

Background: Secretory Carcinoma (SC) is a recently described malignancy affecting salivary glands of the head and neck, with a paucity of evidence regarding the natural history, morbidity, and mortality. This study aimed to investigate the current treatment options utilized for SC, as well as its presentation and outcomes., Methods: This study is a retrospective case series and includes patients diagnosed with SC at four Maritime Canadian institutions. Literature review of patient outcomes following treatment of SC is also included., Results: Thirteen patients were identified. Parotid was the most common subsite (69%), followed by minor salivary gland (23%) and submandibular gland (8%). All patients were S100 positive and had at least one additional positive confirmatory stain, including mammaglobin, CK7, or vimentin. Two patients had N2b disease. All patients were treated with primary surgery, and four were offered adjuvant radiotherapy. There was one instance of locoregional recurrence, and one of metastasis. Three patients displayed perineural invasion on pathology, and one patient displayed lymphovascular invasion., Conclusion: Secretory Carcinoma remains understudied regarding its natural history, presentation, and treatment options. This study is the largest single case series in Canada, and highlights the young age and possible aggressiveness of SC. As well, we provide the most comprehensive literature review to date, with a focus on treatment and outcomes for this disease entity.

Our objectives were to review all reported cases of late flap failure in head and neck surgery and describe any relevant patterns. We conducted a systematic review of all published cases of free flap failure after postoperative day 7 in head and neck surgery from January 1990 to January 2018. Data were collected with respect to flap type, site of reconstruction, reason for failure, and time to failure. A total of 45 cases of late free flap failure in the head and neck were identified. Among the 34 cases in which the necessary data were available for analysis, 50% of late failures occurred between postoperative day 7 and 14. Common reasons for failure were abscess and vascular compromise. We conclude that most late flap failures occur in the second postoperative week. In patients with risk factors for flap failure, close monitoring for up to 14 days after surgery could detect flap compromise before the flap is lost.

Surgery is the mainstay of treatment for low-stage (stage I/II, ie, T1N0/T2N0) squamous cell carcinoma of oral cavity. However, a significant percentage of low-stage squamous cell carcinoma of oral cavity will develop local recurrence and disease-related mortality. In this study, we stratified 64 patients with low-stage of oral tongue and floor of mouth patients into high-, intermediate- and low-risk categories based on existing histologic risk model. The classification of these risk categories was based on presence or absence of perineural invasion and evaluation of tumor-host junction for worst pattern of invasion and lymphocytic host response. We correlated risk category and other variables with recurrence and death. In a univariate model, high-risk category tumors had a significantly higher rate of recurrence and death due to recurrence compared with low/intermediate-risk categories (P=0.000 and P=0.047, respectively). Controlling for margin status and T-stage, high-risk category had a 12.4 odds ratio of later recurrence when compared with low/intermediate-risk categories, with a P-value of 0.001. In conclusion, we found low-stage oral cavity squamous cell carcinoma patients with high-risk category have a significantly higher risk for recurrence when compared with patients in the low- or intermediate-risk category, even when controlling for margin status and T-stage. These patients may be suitable candidates for adjuvant treatment to decrease morbidity and mortality associated with a recurrence. Our results indicate that the histologic risk model is a useful and simple tool to assess risk of recurrence in stage I or II squamous cell carcinoma of oral cavity.

Background: Neuroendocrine tumors (NETs) of small intestinal origin are generally slow-growing tumors with a relatively high propensity for metastases to surrounding organs and lymphatic tissue. We present the first case of an ileal NET metastasizing to the submandibular gland in a woman with metastatic carcinoid syndrome., Case Presentation: A 55-year-old female presented with a four-month history of a palpable, left-sided neck mass. The patient had a history of metastatic neuroendocrine tumor of ileal origin, initially treated with primary resection 4.5 years previously, with known subdiaphragmatic metastases to the liver, mesenteric nodes, and peritoneum. Four years following primary resection she developed carcinoid syndrome leading to therapy with radiolabelled metaiodobenzylguanidine (MIBG), as well as telotristat etiprate in the context of a clinical trial due to progressive symptoms. A fine needle aspiration biopsy of the neck mass revealed an immunohistochemical staining pattern consistent with ileal NET. The patient underwent a left level 1b neck dissection and submandibular gland excision. Pathology was consistent with metastastic ileal NET., Conclusion: We report the first case of ileal NET metastasis to the submandibular gland. Familiarity with the carcinoid syndrome and associated physiology should be maintained as it can affect the head and neck on rare occasions. Maintaining a broad differential is key in diagnosis of undifferentiated neck masses., (Copyright © 2018 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: HPV infection causes cervical cancer, mediated in part by the degradation of Scribble via the HPV E6 oncoprotein. Recently, Scribble has been shown to be an important regulator of the Hippo signaling cascade. Deregulation of the Hippo pathway induces an abnormal cellular transformation, epithelial to mesenchymal transition, which promotes oncogenic progression. Given the recent rise in oropharyngeal HPV squamous cell carcinoma we sought to determine if Hippo signaling components are implicated in oropharyngeal squamous cell carcinoma., Methods: Molecular and cellular techniques including immunoprecipiations, Western blotting and immunocytochemistry were used to identify the key Hippo pathway effector Yes-Associated Protein (YAP)1. Oropharyngeal tissue was collected from CO 2 laser resections, and probed with YAP1 antibody in tumor and pre-malignant regions of HPV positive OPSCC tissue., Results: This study reveals that the Scribble binding protein Nitric Oxide Synthase 1 Adaptor Protein (NOS1AP) forms a complex with YAP. Further, the NOS1APa and NOS1APc isoforms show differential association with activated and non-activated YAP, and impact cellular proliferation. Consistent with deregulated Hippo signaling in OPSCC HPV tumors, we see a delocalization of Scribble and increased nuclear accumulation of YAP1 in an HPV-positive OPSCC., Conclusion: Our preliminary data indicates that NOS1AP isoforms differentially associate with YAP1, which, together with our previous findings, predicts that loss of YAP1 enhances cellular transformation. Moreover, YAP1 is highly accumulated in the nucleus of HPV-positive OPSCC, implying that Hippo signaling and possibly NOS1AP expression are de-regulated in OPSCC. Further studies will help determine if NOS1AP isoforms, Scribble and Hippo components will be useful biomarkers in OPSCC tumor biology.

Primary chronic osteomyelitis of the mandible is a rare condition that presents with a long-standing chronic facial swelling over the mandible, pain with mastication, and trismus. With no clinically appreciated acute phase, the aetiology often remains unknown. Many patients achieve adequate symptom control with broad-spectrum antibiotics, hyperbaric oxygen therapy and surgical debridement, or decortication of bone sequestration. However, because of the rarity of primary chronic osteomyelitis and the extensive involvement of the mandible that can result, we present a case of a 32-year-old woman with chronic disease of the left mandible requiring a left hemimandibulectomy and fibular free flap reconstruction. Few such cases have been reported in the literature, which require such extensive resection and reconstruction to control long-standing symptoms.

Objective: The optimal treatment strategy for oropharyngeal squamous cell carcinoma is highly debated. However, growing evidence supports the use of minimally invasive techniques, such as transoral laser microsurgery (TLM), as a first-line treatment modality for these carcinomas. The purpose of our study was to assess the efficacy and safety of TLM for the treatment of primary and recurrent oropharyngeal carcinomas., Methods: All patients with oropharyngeal carcinoma undergoing TLM at the QEII Health Sciences Centre in Halifax, Nova Scotia were identified within a prospective database monitoring TLM outcomes. Kaplan-Meier survival analysis was used to evaluate the following end points at 36 months: local control (LC), disease-specific survival (DSS), and disease-free survival (DFS). Safety endpoints included complications following surgery and long term morbidity related to TLM., Results: Between 2003 and 2014, 39 patients with oropharyngeal carcinoma underwent TLM resection. Twenty-eight (72%) patients had primary carcinoma, nine (23%) were radiation/chemoradiation (RT/CRT) failures, and two (5%) had second primaries following previous RT/CRT. Three patients had stage I disease, 8 stage II, 5 stage III, and 23 stage IV disease. HPV status was available for 26 patients, of which 23 (88%) had HPV positive disease. Kaplan-Meier estimates of 36-month LC, DSS, and DFS for primary oropharyngeal carcinomas were 85.5% (SE 10.6%), 85.7% (SE 13.2%) and 77.7% (SE 12.5%) respectively. Thirty-six-month outcomes for RT/CRT failures were 66.76% (SE 15.7%) for LC and 55.6% (SE 16.6%) for DSS and DFS. Three patients developed complications following surgery., Conclusions: Observed 36-month efficacy and safety outcomes support the use of TLM for the treatment of primary and recurrent oropharyngeal carcinoma.

Objectives: Papillary thyroid cancer (PTC) is increasing in incidence. Fine needle aspiration is the gold standard for diagnosis, but results can be indeterminate. Identifying tissue and serum biomarkers, like microRNA, is therefore desirable. We sought to identify miRNA that is differentially expressed in the serum of patients with PTC., Methods: Serum miRNA was quantified in 31 female thyroidectomy patients: 13 with benign disease and 18 with PTC. qPCR results were compared for significant fold-changes in 175 miRNAs, against a pooled control., Results: 128 miRNA qualified for analysis. There were identifiable fold-changes in miRNA levels between benign and control, and between PTC and control. There were statistically significant fold changes in the level of four miRNAs between benign and PTC: hsa-miR-146a-5p and hsa-miR-199b-3p were down-regulated, while hsa-let7b-5p and hsa-miR-10a-5p were up-regulated., Conclusions: MicroRNA is differentially expressed in the serum of patients with PTC. Serum miRNA has the potential to aid in thyroid cancer diagnosis.

Objective: Patients who have undergone treatment for head and neck cancer are at risk for neck lymphedema, which can severely affect quality of life. Liposuction has been used successfully for cancer patients who suffer from posttreatment limb lymphedema. The purpose of our study was to review the outcomes of head and neck cancer patients at our center who have undergone submental liposuction for posttreatment lymphedema., Study Design: Prospective cohort study., Setting: Oncology center in tertiary hospital setting., Subjects and Methods: Head and neck cancer patients who underwent submental liposuction for posttreatment lymphedema were included. Nine patients met the study criteria. Patients completed 2 surveys (Modified Blepharoplasty Outcome Evaluation and the validated Derriford Appearance Scale) pre- and postoperatively to assess satisfaction. Patients' pre- and postoperative photos were graded by independent observers to assess outcomes objectively., Results: Our study demonstrated a statistically significant improvement in patients' self-perception of appearance and statistically significant objective scoring of appearance following submental liposuction., Conclusion: Submental liposuction improves the appearance and quality of life for head and neck cancer patients suffering from posttreatment lymphedema by way of improving their self-perception and self-confidence., (© American Academy of Otolaryngology—Head and Neck Surgery Foundation 2014.)

Background: Fine needle aspiration (FNA) of thyroid nodules is a cornerstone of surgical decision making in thyroid cancer. The most widely utilized system for reporting thyroid FNA results is the Bethesda System, which includes predicted malignancy rates for each FNA category. To date there have been few studies to determine whether these predictions are widely applicable., Methods: All thyroid FNA results at the Queen Elizabeth II Health Science Centre from 2006-2010 were included in this study. The results were tabulated by FNA category and the health records were reviewed to determine whether the patient went on to have surgery and the result of surgical histopathology. Rates of malignancy were calculated and compared to published values., Results: A total of 1491 thyroid FNAs were included in the study, representing 1117 individual patients with available health records. The majority of these FNAs were Benign, but the proportion of Unsatisfactory FNAs was higher than predicted while Malignant and Suspicious for Malignancy were lower than predicted. Surgery was performed on 388 patients and 110 were positive for malignancy (28%). The malignancy rate for each FNA category was higher than predicted based on literature values., Conclusions: The proportions of FNA diagnoses and the rates of malignancy for each FNA category at our institution were not consistent with predicted values. It is important for clinicians to base their surgical recommendations on institution specific malignancy rates, not solely on literature values.

Objective: To assess the oncological and functional outcomes of T1b squamous cell carcinoma (SCC) of the glottic larynx treated with laser in comparison with radiation., Design: A Canadian multicenter cohort study., Setting: Three tertiary referral centers for head and neck cancer- Dalhousie University in Halifax, Nova Scotia, Western University in London, Ontario and the University of Manitoba, Winnipeg., Methods: Patients with T1b glottic SCC who underwent transoral laser resection or radiation as the primary modality of treatment., Outcome Measures: Oncological outcomes were evaluated using local control, laryngeal preservation, disease free survival and disease specific survival. Voice outcomes were assessed using the Voice Handicap Index-10 (VHI-10)., Results: 63 patients met study criteria. 21 were treated with laser and 42 with radiation. Oncologic outcomes at 2 years for laser and radiation demonstrated local control of 95% and 85.9%; laryngeal preservation of 100% and 85.9%; disease free survival of 88.7% and 85.9% and overall survival of 94.1% and 94.8% respectively. VHI-10 data was available for 23/63 patients. During the last follow up visit VHI-10 ranged from 0 to 11 (median 6) in the laser group and 0 to 34 (median 7) in the radiation group., Conclusion: T1b SCC of the glottis can be effectively treated with transoral laser microsurgery with oncological outcomes that are at least equivalent to radiation. For patients with VHI scores, voice quality was similar between the two groups. To our knowledge this is the first study directly comparing the oncologic and voice outcomes with laser and radiation for the treatment of glottic cancer involving the anterior commissure.

Objective: To describe current management practices among Canadian otolaryngologists for small thyroid nodule disease and nodules in the context of goitre., Methods: An online survey was e-mailed to all active members of the Canadian Society of Otolaryngology-Head and Neck Surgery (CSOHNS). The responses were anonymous. Information was gathered on practice demographics and individual practices pertaining to diagnostic workup, surgical management, and follow-up of patients with goitre and small nodule disease., Results: A total of 113 surveys were returned from 431 active CSOHNS members (26% response). The majority of respondents were less than 40 years (54%), resided in Ontario or Quebec (63%), and described their practice as academic (65%). Management of a small thyroid nodule following fine-needle aspiration cytology results reported as benign, nondiagnostic, abnormal, or papillary thyroid cancer was inconsistent. Papillary thyroid cancer was managed by total thyroidectomy (59%), total thyroidectomy plus level VI neck dissection (38%), hemithyroidectomy plus level VI neck dissection (2%), and hemithyroidectomy (1%). Management of goitre was not uniform. Symptomatic goitre management included discharge from practice (6%), follow-up with serial ultrasonography (12%), hemithyroidectomy (15%), and total thyroidectomy (66%). Practice demographics had a significant effect on intraoperative techniques, such as the use of an electromyographic nerve monitor., Conclusion: There was a lack of consensus among Canadian otolaryngologists regarding treatment of small thyroid nodules and nodules in the context of goitre. Canadian guidelines for management of small nodule disease may standardize care.

Objective: Between 2002 and 2008, over 100 patients with glottic carcinoma have undergone transoral laser microsurgical (TLM) resection at the QEII Health Sciences Centre in Halifax, Nova Scotia. The objective of this study was to assess the oncologic outcomes for all cases staged as T2 in this cohort., Methods: A prospective database was developed to monitor outcomes. All 36 cases of primary T2 glottic carcinoma were selected from the database for analysis. Kaplan-Meier survival analyses evaluated the following end points at 36 months: overall survival, disease-specific survival, and local control and disease-free survival with one procedure., Results: The Kaplan-Meier estimates of 36-month outcomes were 89% (SE 6.0%) overall survival and disease-specific survival, 81% (SE 7.1%) local control with one procedure, and 70% (SE 8.0%) disease-free survival with one procedure., Conclusions: The observed 36-month outcomes support the use of TLM as the primary treatment modality for T2 glottic cancers.

Fine-needle aspiration (FNA) biopsy of the parapharyngeal space (PPS) is a diagnostic challenge and sampling is often done without image guidance, often trans-orally. Primary PPS tumors are rare, and there is a broad differential diagnosis. The accuracy of PPS FNA, in particular without CT-guidance and using liquid-based cytology (LBC), has not been well studied. Pathology records from our institution (a 1,100 bed Canadian academic tertiary care centre) were searched to identify all patients who underwent PPS FNA from September 1991 to August 2009. The FNA diagnosis was compared to the gold standard of subsequent histopathology or long-term clinical follow-up. Of 36 FNAs, 3 employed image guidance. Eleven (31%) FNAs were nondiagnostic. In the 25 diagnostic FNAs, there was sensitivity 89%, specificity 94%, PPV 89%, NPV 94%, and accuracy 92% for the diagnosis of positive or negative for malignancy. A correct specific diagnosis was made in 9/25 (36%) cases. The nondiagnostic rate was significantly higher (P < 0.025) in FNAs prepared as conventional smears (9/17 = 53%) versus LBC (2/19 = 11%). A specific diagnosis was made significantly more often (P < 0.05) with LBC (8/19 = 43%) versus conventional smear (1/17 = 5.9%). One minor complication from FNA occurred. In conclusion, PPS FNA is safe and accurate for the diagnosis of malignancy. The rate of reporting a specific diagnosis is low. Nondiagnostic FNAs are common. There are more specific diagnoses and fewer nondiagnostic tests with LBC than with conventional smears. Improved specimen quality with LBC is likely a factor., (Copyright © 2010 Wiley Periodicals, Inc.)

Objective: To review the current literature on hyalinizing trabecular tumor (HTT) and the relationship to other, more sinister neoplasms of the thyroid including papillary thyroid carcinoma (PTC). To apply this information to clinical practice and thus elucidate the best approach regarding the management of patients with thyroid tumours., Methods: A thorough literature search was performed on articles published on HTT thus far. Articles were then reviewed for epidemiology, discussion of categorization, and possible areas of differentiation from other thyroid tumor types. Our own hospital records were all reviewed for any possible cases of HTT., Results: There have been many attempts made to find objective ways of categorizing HTT from other thyroid tumors. The articles found highlighted the difficulties in understanding the classification, molecular genetics, and pathology of HTT, especially with regard to the differentiation from PTC. In our own institution, we found only one such case of confirmed HTT., Conclusions: The ability to differentiate between HTT and PTC remains imperfect. Currently, permanent histologic sections are the best means for obtaining a diagnosis. Once this relationship is elucidated further, the treatment approach can be tailored, and patients will possibly avoid a total thyroidectomy and radioactive iodine ablation, as currently indicated for PTC.

Objective: To investigate the prevalence of complementary and alternative medicine (CAM) use among patients being investigated for thyroid nodules in a head and neck oncology practice. Subsequently, to determine whether the common therapies used were likely to interfere with the planned patient's care and whether the predominance was significant to warrant inclusion in routine history assessments., Study Design: Cross-sectional survey., Setting: Dalhousie University, Halifax, Nova Scotia, Canada., Subjects and Methods: A survey regarding CAM use was completed by 100 patients being investigated for thyroid nodules upon their initial presentation to a head and neck oncology practice., Results: Preliminary results showed that 79% of participants have a history of CAM use and 51% of participants were actively using oral supplements. Thirty-one percent of participants reported using supplements known to have hemostasis-affecting properties., Conclusion: Medical professionals should incorporate CAM questioning in any thyroid patient assessment to reduce patient risk and optimize medical and surgical outcomes.

Background: Level VI central neck dissections are commonly completed with thyroidectomy. This procedure involves risk of damage to, or incidental excision of, one or more of the parathyroid glands., Methods: This study examined the pathology reports of patients undergoing thyroid surgery to determine the incidence of parathyroid tissue associated with level VI neck dissections and the risk factors associated with incidental parathyroidectomy., Results: Ninety pathology specimens were analyzed. The incidence of parathyroid tissue associated with level VI neck dissections was 41.4%. We discovered that a higher frequency of incidental parathyroid tissue was located in level VI neck dissections among patients discovered to have malignant thyroid disease. There was no significant association between incidental parathyroidectomy and the sex of the patient, the age of the patient, the type of thyroid surgery, or transient or permanent hypoparathyroidism., Conclusion: A large percentage of level VI neck dissections in thyroid surgery were associated with incidental parathyroid tissue. A more detailed examination of surgical specimens may decrease this possibly preventable surgical complication.

Objective: To determine the impact of fibula free flaps (FFFs) on gait., Design: Prospective trial., Setting: FFF patients who gave consent were enrolled., Methods: At preoperative and 3-month postoperative visits, patients walked 30 m with the Walkabout Portable Gait Monitor (WPGM), a portable device developed at Dalhousie University that records acceleration of the centre of mass. Gaitview software provided several outputs for analysis: vertical (VA) and forward (FA) asymmetry, horizontal to vertical power ratio (HVP), vertical to forward power ratio (VFP), velocity, and step length. Patients were compared pre- and postoperatively and to age-matched control data with a Student paired t-test. Patients completed a self-comorbidity questionnaire and a point evaluation system (PES) with subjective questions on gait. PES data were compared to a Mann-Whitney U test using SPSS, version 15.0.1., Main Outcome Measures: Gaitview output and PES questionnaire., Results: From September 2008 to January 2010, 12 patients enrolled in the study. Eight provided 3-month postoperative data. The Gaitview analysis showed that none of the six parameters changed postoperatively. The VA and FA preoperatively and at 3 months postoperatively were 21.3 versus 24.2, p > .50, and 65.4 versus 74.9, p > .50, respectively. The HVP and VFP preoperatively and postoperatively were 133.4 versus 138.9, p > .50, and 129.6 versus 122.8, p > .50, respectively. The velocity and step length preoperatively and postoperatively were 125.9 versus 119.5 cm/s, p > .50, and 76.0 versus 74.9 cm, p > .50, respectively. The subjective PES questionnaire did not change significantly (p  =  .26)., Conclusion: Preliminary findings confirm that the FFF is associated with little subjective or objective gait impairment.

Background: reconstruction of a total nasal defect presents a significant challenge to the reconstructive surgeon. The form, function, and aesthetic appeal of all the nasal subunits must be addressed. Classic teaching emphasizes the importance of restoring the internal lining of the nose, the rigid scaffolding, and the outer skin and soft tissue layer., Methods: a restrospective review was undertaken in eight patients who had undergone total nasal reconstruction in two Canadian tertiary care centres. All eight patients had their nasal defect reconstructed with a radial forearm free flap for internal lining, titanium mesh for structural support, and a paramedian forehead flap for skin and soft tissue cover. Nasal function, graft survival, patient satisfaction, and complications were recorded., Results: seven of eight patients were satisfied with the cosmetic outcome of their nasal reconstruction. Two patients reported poor nasal breathing owing to nasal stenosis. Two cases of minor titanium extrusion required operative intervention for repair. There were no cases of loss of the radial forearm free flap or paramedian forehead flap in this series., Conclusions: reconstruction with a radial forearm free flap, titanium mesh, and a paramedian forehead flap is a reliable, cosmetically appealing, and functional method for total nasal reconstruction. Minor surgical revisions should be anticipated to achieve the best cosmetic outcome. This is the first reported series using these three entities together to reconstruct total and subtotal rhinectomy defects.

Merkel cell carcinoma (MCC) is a rare aggressive primary cutaneous neuroendocrine neoplasm with a high rate of recurrence and metastasis. We report a case of a 94-year-old woman who experienced complete spontaneous regression of metastatic MCC. Nine months after complete excision of the primary MCC on her left eyebrow, metastatic MCC was confirmed with a fine-needle aspiration of a 4-cm mass on the left side of her neck. Three months later the mass had reduced in size to 2 cm and a neck dissection was performed. Her submandibular gland, thoracic duct and 25 lymph nodes were negative for MCC. Two of the lymph nodes, the larger measuring 1.3 cm, contained extensive amounts of fibrosis, with accumulation of macrophages and other chronic inflammatory cells. The literature documents 6 similar cases of complete spontaneous regression of metastatic MCC. The mechanism for regression is not well understood and is thought to involve T-cell-mediated immune response and apoptosis.

Background: The aim of this study was to determine the prevalence of complementary and alternative medicine (CAM) use among patients presenting to a head and neck oncology clinic prior to a diagnosis., Methods: The study was conducted by administering questionnaires to 102 patients after being seen in the Head and Neck Oncology clinic for their initial consultation. The questionnaire assessed the extent of CAM use, types of CAMs used, and their reasons for use., Results: A total of 132 CAMs were currently being used among 56 patients. The most common CAMs in use were multivitamins (26/132) and vitamin D (21/132). Meditation and yoga were associated with the greatest perceived benefit. The majority of patients obtained their information from family and friends. Most patients were using CAMs for physical health and well-being., Conclusion: As CAM use among the population is widespread, it is important for clinicians to specifically address their use on initial presentation., ((c) 2009 Wiley Periodicals, Inc. Head Neck, 2010.)

Objective: The radial forearm free flap (RFFF) is a workhorse in reconstruction of head and neck defects. The superficial cephalic vein is used most commonly for microvascular anastomosis; however, this vein has a variable course in the subcutaneous tissues. We have routinely isolated the cephalic vein within a reliable double fat plane, which has not been previously described. This study demonstrates the consistency of the cephalic vein within this double fat plane using a cadaveric model and our prospective operative experience raising the RFFF., Method: Four lightly preserved cadavers and one fresh cadaver were dissected by elevating a RFFF, identifying the double fat plane, and isolating the cephalic vein within this plane. Between August 2006 and April 2008, we prospectively recorded the anatomic location of the cephalic vein in 35 patients who had RFFF surgery., Results: The double fat plane and cephalic vein were identified in all cadaveric dissections. The double fat plane was identified and led to injury-free dissection of the cephalic vein in all 35 patients., Discussion: To our knowledge, this is the first report of the presence of the double fat plane within the subcutaneous tissue of the radial forearm and its use as a consistent landmark in finding the cephalic vein. Our cadaveric studies and operative observations have demonstrated that the double fat plane is a reliable, consistent, and helpful guide for the isolation of the cephalic vein in RFFF surgery.

Objective: To determine the incidence of metastatic lymph nodes < 1 cm in routine level VI neck dissections in papillary thyroid cancer (PTC)., Design: Retrospective chart review., Setting: Tertiary referral hospital., Methods: A retrospective review was conducted of all patients who had thyroid surgery and routine level VI neck dissection for PTC from June 2005 to February 2009. The number of lymph nodes present, node size, and malignancy status were recorded. Patients with level VI micrometastases (positive nodes < 1 cm) were compared with those with no positive nodes., Results: Forty-six patients had level VI neck dissection for PTC, with a total of 379 lymph nodes. No patient had permanent hypocalcemia or recurrent laryngeal nerve injury. Nodes > or = 1 cm had a 77% likelihood of being positive (95% confidence interval [CI] 0.58-1.00), whereas nodes < 1 cm had a 24% (95% CI 0.20-1.00) likelihood of being positive. Seventeen (37%) patients had micrometastases only. Older age, male sex, and primary tumour > 5 cm were not predictive of an increased risk of micrometastases. Patients with extrathyroidal extension were significantly more likely to have micrometastases (p < .05)., Conclusions: With a significant percentage of metastatic level VI neck nodes < 1 cm in PTC, the decision to perform a level VI neck dissection cannot be based on preoperative ultrasound size criteria alone. Routine level VI neck dissection is a safe addition to thyroid surgery for PTC. We could identify no preoperative risk factors to predict the likelihood of micrometastases.

Objective: To compare endoscopic stapling versus external transcervical approaches in the treatment of Zenker diverticulum., Design: A 10-year retrospective institutional review was performed to identify all patients treated for Zenker diverticulum., Setting: Academic tertiary care centre., Methods: Patients treated surgically for Zenker diverticulum were identified through an electronic records search. Patient charts were reviewed, and patients were interviewed at follow-up., Main Outcome Measures: Patient age, sex, duration of symptoms, procedural time, time to oral liquids, length of posttreatment hospital stay, and post procedure patient satisfaction were recorded and compared., Results: Ten patients treated endoscopically were compared with eight patients treated via an external approach. There were no significant differences in patient age, sex, and duration of symptoms. The external technique took significantly longer (110.88 +/- 59.61 minutes) than the staple technique (19.50 +/- 6.47 minutes) (p < .0001). There was no significant difference in time to full oral liquids (p = .11). The postsurgical hospital stay (4.71 +/- 1.98 days) was significantly longer for the external technique compared with the staple technique (2.30 +/- 2.83) (p = .03). Patient symptom relief was reported as completely resolved or improved in all cases, regardless of treatment type., Conclusions: Endoscopic stapling of Zenker diverticulum achieves operative success and patient satisfaction comparable to those of traditional external transcervical techniques, with significantly decreased operative times and hospital stays, allowing for more efficient use of resources.

Objective: There is debate over whether radiation therapy or transoral laser microsurgery (TLM) is the superior treatment for early glottic cancer. Both offer similar cure rates and posttherapy quality of life. One factor that could decide the optimum therapy is cost. Several studies in Europe and the United States show that TLM is the most cost-effective treatment. The goal of this study was to conduct the first cost analysis in Canada on the treatment of early glottic cancer comparing radiation therapy and TLM., Design and Methods: The study was conducted retrospectively. TLM and radiation therapy were broken down into individual components, and then the price for each component was summed., Setting: The study was conducted at the Queen Elizabeth II Health Science Centre in Halifax, Nova Scotia., Main Outcome Measures: The main outcome measure was total cost., Results: It was found that radiation therapy was approximately four times more expensive than TLM., Conclusions: This study suggests that TLM should be the preferred treatment option for treating early glottic cancer in Canada as it is the most economical and has been shown in previous studies to be as effective as radiation therapy in both cure rates and quality of life.

Background: Arteriovenous malformation of the scalp resulting from blunt trauma to the head is an unusual occurrence and is rarely associated with neurological sequelae. This case details an arteriovenous malformation with a cerebral steal phenomenon., Methods: A 21-year-old man presented with an enlarging, pulsatile mass in the right facial/temporal area without known cause. CT and angiography were consistent with a large arteriovenous malformation involving the external carotid system, causing a secondary cerebral steal that resulted in neurological symptoms including seizure. Surgical resection of the mass was undertaken., Results: The patient had an uncomplicated preoperative course with complete resolution of all neurologic symptoms., Conclusion: Cerebral steal is an uncommon consequence of traumatic extracranial arteriovenous malformation. The current literature is reviewed, and the diagnostic approach as well as therapeutic options are discussed., ((c) 2009 Wiley Periodicals, Inc. Head Neck, 2009.)

CO(2) laser has become a common surgical technique in the management of glottic cancer. The patients treated with this modality may benefit from additional phonosurgical techniques used to improve postoperative vocal outcome.The aim of this article was to review those phonosurgical techniques described for glottic reconstruction after CO(2) laser excision of glottic cancer. The indications for using each technique are discussed, with particular attention paid to functional outcomes following these reconstructive efforts., ((c) 2009 Wiley Periodicals, Inc.)

Objective: Chondrosarcoma is a malignant tumour of mesenchymal origin. Chondrosarcomas most commonly occur on axial structures and are rarely found in the head and neck. A review of these tumours was carried out, focusing on management and outcomes., Methods: Eleven chondrosarcoma cases of the head and neck were retrospectively identified at a tertiary care teaching centre., Results: There were seven males and four females; ages ranged from 18 to 77 years. Specific sites included the larynx (3), trachea (1), petrous apex (2), skull base (2), cervical spine (1), clivus (1), and cavernous sinus region (1). Eight of the 11 patients had grade I disease (73%), whereas the remaining 3 (27%) had grade II tumours. None had metastatic disease at presentation. Surgical resection with postoperative radiation was the most widely employed primary treatment (55%); the remaining patients (45%) had surgical resection only. There were two recurrences. Salvage surgeries were performed in both. Disease-specific survival was 73% at 5 years., Conclusion: Chondrosarcomas are rare tumours of the head and neck. Treatment should be aimed at complete surgical resection with the option of postoperative radiotherapy. They usually portend a favourable long-term prognosis.

Objectives: To describe the use of the fibular free flap in the achondroplastic patient and to report the potential pitfalls of free flap surgery on this group of patients., Design: Retrospective chart analysis., Methods: We reviewed our experience with two fibular free flaps in this rare situation., Results: This is the largest series of fibular free flaps reported on the achondroplastic patient. An acute adrenal event resulted in hypothermia and hypotension and ultimately led to the failure of our first reconstructive attempt. Corrective measures were taken during the secondary reconstruction to prevent these systemic issues from coming into play, which ultimately led to a successful free fibular transfer., Conclusion: Free fibular transfer is possible for facial reconstruction in the achondroplastic patient, and success can be improved if measures are taken to prevent systemic complications of hypothermia and hypotension in the case of an acute adrenal event.

Nodular fasciitis (NF), a benign proliferation of fibroblasts, commonly presents as a solitary, well-circumscribed, rapidly growing soft tissue mass. It is most commonly located in the upper extremities, particularly on the volar aspect of the elbow, and on the chest and trunk. In adults, NF is rarely found in the head and neck region. Although benign, it can often be confused with a more malignant process and therefore must be properly diagnosed histologically. The cause of NF is unknown but an association with trauma may be present. Treatment is most commonly by local surgical excision, and recurrence is rare. A case of NF over the zygoma in a 60-year-old man not associated with trauma is presented.

Objective: To determine the incidence of lymph node metastases in the submuscular recess (level 2B) in selective neck dissections. The goal was to evaluate the oncologic need for dissection in this area owing to the increased morbidity from devascularization of the spinal accessory nerve., Methods: A prospective analysis of 74 patients who underwent 80 neck dissections from July 2002 to March 6, 2004, was undertaken. Seventy-six of the 80 neck dissections were performed in patients with squamous cell carcinoma, whereas the remainder were done for papillary carcinoma of the thyroid. All submuscular recess specimens were sent separately from the remainder of the neck dissection. The location of the primary tumour, staging, presurgical radiation status, and the number of nodes in both specimens were recorded., Results: Forty-six percent (37 of 80) of the neck dissections were positive for malignancy. Of the 80 neck dissections, 8.75% (7) had positive nodes in the submuscular recess. All patients with disease in the submuscular recess were preoperatively staged as N2B or greater., Conclusion: Our data suggest that dissection of the submuscular recess in patients with squamous cell carcinoma of the head and neck may be warranted only in patients with N2B disease or greater.