Asymptomatic oropharyngeal lipoma complicating intubation.

Oropharyngeal lipomas are rare tumours. We present the case of a young man with an asymptomatic lipoma almost completely occluding his supraglottic airway, found on magnetic resonance imaging (MRI) for a separate oral cavity lesion. Pre-operative anaesthetic assessment was undertaken because of the risk of airway obstruction at induction of general anaesthesia. We discuss the awake fibre-optic technique used for induction, as well as the treatment and follow-up of these tumours. This case highlights the need for formal anaesthetic assessment, in such cases, to avoid total airway obstruction at induction of general anaesthesia. It also emphasizes the extent of supraglottic obstruction that can be present without giving rise to any symptoms.

Raynaud's phenomenon after radical radiotherapy for tumours of the head and neck.

Endothelial cell injury is implicated in the development of radiation induced tissue damage and may also be involved in the pathophysiology of secondary Raynaud's phenomenon. Two patients are presented in whom the typical symptoms and signs of Raynaud's phenomenon developed as a late complication of radical radiotherapy. One had Raynaud's of the tongue and one of the lip. Both patients had a prior history of primary Raynaud's phenomenon and in each case the symptoms were repeatedly precipitated by sudden cold exposure. The possible pathogenesis of radiation induced Raynaud's phenomenon in the head and neck region is discussed.

C-erbB receptors in squamous cell carcinomas of the head and neck: clinical significance and correlation with matrix metalloproteinases and vascular endothelial growth factors.

We studied the profile of four c-erbB receptors in head and neck squamous cell carcinomas (HNSCC) and to determine whether their expression was associated with clinicopathological features and key molecules involved in angiogenesis and metastasis. We also assessed the impact of expression on survival. This study included 54 cases of primary HNSCC, of which 27 cases showed lymph node metastasis. The expression of c-erbB receptors, matrix metalloproteinases (MMPs) and vascular endothelial growth factor (VEGF) family members was analysed in the same tissue homogenates by semi-quantitative RT-PCR. HNSCC frequently co-expressed multiple c-erbB receptors and showed significant correlations amongst their levels. High expression of epidermal growth factor receptor (EGFR), c-erbB-2 or c-erbB-3 was associated with an infiltrating mode of invasion, nodal metastases and advanced pathological stages. EGFR and c-erbB-2 levels were strongly correlated (P=0.0004-0.029) with the expression of MMP-2, MMP-7, MMP-9, MMP-10, MMP-11, MMP-13, VEGF-A and VEGF-C whereas the levels of c-erbB-3 and B-4 showed a weaker correlation (P=0.049-0.01) with some MMPs and VEGF-C. Only nodal metastasis and EGFR levels were significantly associated with poor outcome in uni- and multi-variate analysis. We conclude that co-operative signalling of all four c-erbB receptors may play a significant role in the pathogenesis of HNSCC. Amongst these, EGFR appears to be the dominant component controlling the invasive and angio-/lymphangiogenic phenotype in HNSCC via upregulation of multiple MMPs and VEGFs.

Radiation induced sarcoma of the head and neck.

BACKGROUND: Radiation-induced sarcoma of the head and neck (RISHN) is a long-term complication of treatment. The rarity of this tumour is reflected in the very few series reported in the English language medical literature. The incidence of RISHN is, however, likely to increase due to progressive aging of the population combined with improved survival in head and neck cancer patients resulting from better treatment regimes. Diagnosis and management of this problem can be extremely challenging and the overall outlook has been reported to be very bleak. As survival data from isolated case reports cannot be expected to provide reliable information on outcome, we have reviewed 69 cases reported in the English medical literature since 1966 and pooled this information with our experience in treatment of RISHN. PATIENTS AND METHODS: Ten patients with features of a RISHN were treated at the Royal Marsden Hospital between 1944 and 1997. The features of RISHN, treatment, and outcome were analysed in these patients. Additionally, 61 eligible patients with RISHN reported in the literature between 1966 and 1997 were pooled with nine of our patients to form the RISHN group (n = 70). This group was then compared for survival with 124 patients with a diagnosis of head and neck sarcoma registered on the Head and Neck Sarcoma database at the Royal Marsden Hospital (SHN group). Lifetables were constructed using the Kaplan-Meier method and compared using the log-rank test. RESULTS: There was no site of predilection for RISHN, but malignant fibrous histiocytoma (MFH) was the commonest pathological diagnosis. The period of latency between initial radiation therapy and diagnosis of RISHN ranged from 9 to 45 years with a median of 17 years. Surgery was the mainstay of treatment and follow-up ranged from 6 months to 15 years with a median of 48 months. The actuarial five-year disease free survival in these patients was 60%. CONCLUSION: There is at present little or no prospect for effective prevention of RISHN and therefore, a high index of suspicion based on the patient's symptoms assumes great importance in the outcome of these patients. Although surgical management of RISHN is challenging because of the close proximity of the tumour to important regional structures and the technical difficulties of operating in an irradiated area, complete surgical excision appears to offer the best means for palliation and the only realistic chance for long-term survival.

Meningiomas in the region of the cavernous sinus: a review of 21 patients.

This is a review of 21 patients with meningiomas involving the region of the cavernous sinus. All underwent surgery, and the fronto-zygomatic (F-Z) approach, first described by Fujitsu and Kubawara, was employed in every case. The mean age at presentation was 47 years; seven patients were male and 14 female. The mean duration of symptoms before surgery was 4 years. In 10 patients, resection was considered to be complete. Peri-operatively there were two deaths, but the majority of deficits in the survivors were temporary and quickly resolved. The mean follow-up period was 48 months. In that time, five patients experienced recurrence or progression of tumour, of whom three required repeat operation (followed by radiotherapy); and two patients were referred for radiotherapy alone. These five patients appear to be disease-free 2-5 years after their additional treatment. Of the 19 patients who left hospital, 17 were able to live independent lives. It would appear from this review that: (1) F-Z craniotomy usually gives excellent exposure to the region of the cavernous sinus; (2) selected patients should undergo angiography with balloon occlusion to evaluate the collateral vascular supply; (3) regular review should include annual MRI. Evaluation over a much longer time of both surgery and radiotherapy, individually and in combination, is needed before it will be possible to furnish a treatment protocol for individual cases at initial presentation or recurrence.

Adenoid cystic carcinoma of the maxilla--the value of histopathology in diagnosing a second primary.

Adenoid cystic carcinoma is the commonest tumour of minor salivary glands. In the case described here a pulmonary mass was found. This was likely to be a distant metastasis, particularly as the primary tumour was of cribriform subtype with perineural invasion and resection was microscopically incomplete. However, surgical excision of the pulmonary mass enabled histopathological studies to be carried out which found it to be an unrelated bronchioloalveolar carcinoma.

Imaging after titanium cranioplasty.

Titanium cranioplasty has been used in our unit for reconstruction of cranial defects following trauma, tumour resection and bone loss due to postcraniotomy infection. It has previously been assumed that imaging to assess recurrence of disease progression after cranioplasty would be severely compromised in the presence of metallic material. Titanium is a non-ferrous metal of low atomic number, which is relatively radiolucent and allows exceptionally clear images to be obtained without significant degradation of image quality, on CT and magnetic resonance (MR) imaging. Cases are presented that demonstrate the use of CT contrast cisternography and MR imaging after titanium cranioplasty. On the basis of its strength, biocompatibility and excellent handling characteristics, allied to its suitability for all post-operative imaging techniques, we conclude that titanium plate is the material of choice for cranioplasty.

Prolactinomas in men masquerading as invasive skull base tumours.

Four giant prolactin-secreting tumours invading the skull base are described. All of them occurred in men. The presenting features were sufficiently diverse to be clinically misleading. We advocate the estimation of prolactin levels before embarking on complicated skull base surgery in men where doubt remains regarding the diagnosis after clinical and radiological study.

Chondrosarcoma of the skull base: a series of eight cases.

Chondrosarcomas of the skull base are indolent, locally invasive tumors with a marked tendency to recur. Surgery is the mainstay of treatment because these tumors are generally resistant to other forms of treatment. A surgical approach with wide access to the skull base and one that is easily repeatable is required, because recurrence is common. We have used the LeFort I maxillotomy or mobilization of the zygoma at the time of craniotomy to obtain wide access to the skull base in eight cases of chondrosarcoma. Three patients have undergone subsequent procedures by us for recurrent disease. One patient died 30 days after the operation, and one has required an open repair of a cerebrospinal fluid leak. Good palliation of symptoms has been achieved in all survivors. These approaches fulfill the criteria for the surgical management of these difficult tumors by allowing excellent exposure, safe repetition if required, satisfactory palliation, and acceptable morbidity.

Midline aneurysms of the vertebrobasilar junction: an effective anterior approach.

There are acknowledged difficulties associated with operations on midline aneurysms at the vertebrobasilar junction. This report describes a series of such aneurysms treated by an anterior approach using a Le Fort maxillotomy to gain access via the clivus to the aneurysm. In each case the aneurysm was dealt with satisfactorily with no long-term morbidity or mortality. Attention is directed to the necessity for a water-tight dural seal postoperatively. We advocate wider use of this technique in appropriate circumstances.

Giant cell tumors of the sphenoid bone.

Giant cell tumors of the sphenoid are rare; there are 36 previously reported cases. We report two cases of these tumors in women in their thirties, both associated with pregnancy. In the first patient, the tumor was removed via a transnasal transsphenoidal approach. In the second patient, a Le Fort maxillotomy was required. In these cases, an interoperative diagnosis was made, and in both, this diagnosis directed surgical tactics towards a more radical excision. Reported experience with the outcome of giant cell tumors in other sites suggest that total removal by curettage is the ideal treatment; the main principle is to prevent local recurrence because the metastatic potential of this tumor is low. A combination of surgery and radiotherapy is essential for giant cell tumors occurring in sites where access is difficult, such as the sphenoid bone. Previous objections to radiotherapy have included poor response rate and malignant change. Recent studies suggest that neither of these problems is significant when modern therapeutic techniques are employed.

Giant cell tumour of the sphenoid sinus: an unusual skull base tumour.

An unusual skull base tumour is presented. Intraoperative smears made the diagnosis and dictated a change in surgical strategy. Giant-cell tumours of the sphenoid bone are discussed, together with current management.

Multiple recurrent giant cell lesions associated with high circulating levels of parathyroid hormone-related peptide in a young adult.

Parathyroid hormone-related peptide (PTHrP, PLP) has previously been identified and assays are now available which can be used in clinical situations. A case is reported of a normocalcaemic young adult female in whom multifocal recurrent giant cell osteolytic lesions in the maxilla and elsewhere were associated with a raised plasma level of parathyroid hormone-related peptide. The lesions were histologically identical to reparative giant cell granuloma of the jaws and to osteitis fibrosa cystica associated with hyperparathyroidism.

Improved access to lesions of the central skull base by mobilization of the zygoma: experience with 54 cases.

Improved access to lesions at the medial end of the sphenoid wing or in the interpeduncular cistern after mobilization of the zygoma has been a subject of growing interest in recent years. This study describes the operative technique we have adopted and records our experience with 55 operations in 54 patients who underwent the procedure in the past 3 years. Seven patients had vascular lesions, 44 had tumors, and 3 had miscellaneous lesions. The majority of the tumors were medial meningiomas, and particular note is made of those arising from the cavernous sinus with respect to their resectability. Sixteen of these tumors were encountered, and total excision was possible in 11 cases. Access to the infratemporal fossa is facilitated, and in 2 cases we were able to excise completely trigeminal neuromas that had extended there. The extra maneuver adds little to the overall operating time, and complications relating to it are uncommon, mild in degree, and usually self-limiting. We conclude that the operation is extremely valuable in appropriate circumstances.

Surgical management of midline skull-base tumors: a new approach.

Many surgical approaches to the clivus and upper cervical spine have been used in the treatment of skull-base tumors over the past 50 years. However, the outcome of surgery has been complicated by difficulties of access to the whole clivus, together with pharyngeal wound breakdown with subsequent development of cerebrospinal fluid (CSF) fistula and meningitis. A technique described recently utilized Le Fort I osteotomy to improve exposure of the clivus in the approach to vertebrobasilar aneurysms, facilitating control of the aneurysm and reducing the risk of posttraumatic CSF fistula. The same approach, via maxillotomy, has permitted partial or total tumor resection in 13 consecutive procedures carried out at Atkinson Morley's Hospital on 10 patients presenting with tumors of the skull base. Neurological status was either improved or unchanged in all patients postoperatively, and pain relief was obtained in five of eight cases in which this was a presenting symptom. No patient developed a CSF fistula following surgery. Cosmetic results were good, and no problems related to malocclusion were reported. This approach may be used to advantage in the surgical treatment of skull-base tumors, at initial presentation, and can be repeated without undue difficulty should there be tumor recurrence.

Basilar aneurysms: a new transclival approach via maxillotomy.

A transoral transclival approach to vertebrobasilar aneurysms, using a Le Fort I maxillary osteotomy rather than splitting the soft and hard palates, was employed successfully in three patients. This technique gave much improved access to the clivus, and eased exposure of the aneurysms without the need for traction on the brain stem or cranial nerves. There were no postoperative cerebrospinal fluid fistulae and no neurological complications. In one patient, a human-derived fibrin adhesive was used for dural repair. The postoperative cosmetic results were excellent and no problems relating to malocclusion were reported. This approach may have advantages when dealing with other diseases in or around the clivus.

Reconstruction of the mandible with autogenous bone following treatment for squamous carcinoma.

In a series of 24 patients treated for squamous carcinoma of the oral cavity and oropharynx, 26 mandibular reconstructions using 27 grafts or flaps were performed. Reconstruction was immediate in 23 cases and delayed in three. There were five 'simple' bone grafts, 10 pedicled compound myocutaneous flaps, and 12 vascularized free compound flaps. Operative mortality was 12% and complication rate 65%, but 70% of the grafts survived till death or follow-up of the patients. Three 'simple' bone grafts failed and were removed. Three of five compound pectoralis major flaps failed along with one of five pedicled compound latissimus dorsi flaps. Only one vascularized free compound flap was lost. The major cause of graft failure was intra-oral suture line dehiscence exposing the bone to saliva. Under these circumstances, bone graft necrosis occurred when blood supply to the bone was poor--viz. 'simple' grafts and compound pectoralis major flaps. The vascularized free compound flaps were most reliable but the need for jaw preservation where possible and better patient selection are recognized.

The use of free tissue transfer in reconstruction following head and neck tumour resection.

Experience in the use of free vascularised tissue flaps in reconstruction following major head and neck resections for malignant disease has been described. The benefits of the use of free flaps are improved function and cosmesis with more rapid rehabilitation and reduced in-patient stay in a group of patients, many of whom had a limited life expectancy. The disadvantages of this technique are the need for special equipment and for medical and nursing staff trained and experienced in this type of work.

Traumatic haemobilia: value of ultrasonography.

A case of post-traumatic haemobilia treated by right hepatic artery ligation is described. The role of 'B'-mode grey-scale ultrasonography in the investigation of hepatic trauma is discussed.