Desmoid tumours of the neck: rare but problematic.

Desmoids of the neck are histologically benign but locally aggressive fibrous tumours with a strong propensity to recur. Surgical excision is the treatment of choice, with patients requiring long-term follow-up. We present such a case and review the treatment of such tumours.

Malignant vagal paraganglioma.

Vagal paraganglioma is a rare usually benign tumour of neural crest origin. The malignant form of this tumour is very uncommon and the diagnosis is made on the basis of its clinical behaviour rather than its histological appearance. We report a case of vagal paraganglioma metastatic to adjacent cervical nodes and discuss the diagnosis and management of this tumour.

Carbon dioxide laser cordectomy in the management of bilateral vocal cord paralysis.

Bilateral vocal cord paralysis is a rare but major complication of thyroid surgery. Since 1983, patients with bilateral cord paralysis have been managed in this department using the carbon dioxide laser. Six patients with bilateral cord paralysis secondary to thyroid surgery underwent partial cordectomy and arytenoidectomy. Two patients were operated on with tracheostomy tubes in situ, and both were successfully decannulated. In the remaining four patients, ventilation was maintained during anaesthesia using a Venturi jet ventilation system. None of these patients required a perioperative tracheostomy. Adequate airway improvement and satisfactory voice quality were achieved. Follow-up ranged from 6 to 17 months.

Metastatic carcinoma in the neck: a clinical, radiological, scintigraphic and pathological study.

This study was undertaken to compare clinical evaluation of the neck with 99mTc(v) DMSA planar scintigraphy and computerized tomography (CT) in patients with head and neck carcinoma. Twenty-six patients were studied and in all but one the neck was previously untreated. A total of 31 neck dissections were performed and the specimens examined histopathologically. CT was approximately as accurate (71%) as clinical examination (68%) and more accurate than 99mTc(v) DMSA planar scintigraphy (48%) in predicting which necks contained metastatic carcinoma. Overall, 13% of necks had their staging correctly changed by 99mTc(v) DMSA scintigraphy compared with 10% for CT. Although scintigraphy upstaged 13% of clinically N0 necks compared to 6% for CT, it was less sensitive and specific than either clinical examination or CT. 99mTc(v) DMSA planar scintigraphy has no role to play in the investigation of patients with metastatic carcinoma to include the clinically N0 neck.

Experience in the surgical management of medullary thyroid carcinoma.

The management of 12 patients with medullary thyroid carcinoma is reviewed. All patients underwent total thyroidectomy. Local nodal and extracapsular spread was aggressively resected, followed by radiotherapy. No patient died from uncontrolled local disease. Prolonged survival after radical treatment is demonstrated even in the presence of distant metastases.

Technetium-99m (v) dimercaptosuccinic acid uptake in patients with head and neck squamous carcinoma: experience in imaging.

A recently developed imaging agent, technetium-99m (v) dimercaptosuccinic acid (99mTc (v) DMSA), has been used to assess head and neck squamous carcinoma (SCC). We have prospectively studied 62 patients of whom 53 had a histologically proven head and neck SCC. The remaining nine had benign lesions. The results of planar imaging in patients with primary disease yielded an 85% sensitivity and 78% specificity. Planar imaging in patients with cervical lymphadenopathy revealed a 59% sensitivity. Nineteen patients also had single photon emission computed tomography imaging which improved the image quality, spatial resolution and sensitivity of the investigation. Twenty-seven patients were scanned before and after radiotherapy and, of these, 96% showed positive uptake in the salivary glands with no evidence of tumor recurrence. This study has shown 99mTc (v) DMSA imaging provides a cheap and rapid method of investigating head and neck SCC and further studies are necessary to evaluate its role in the management of patients with this disease.

An evaluation of the uptake of technetium-99m (v) dimercaptosuccinic acid in patients with squamous carcinoma of the head and neck.

A new imaging agent, Technetium-99m (Tc99m) (v) Dimercaptosuccinic acid (DMSA), has recently been developed which has been used to evaluate head and neck tumours. Twenty-four patients were studied of whom 21 had histologically proven SCC of the head and neck. The remaining 3 had benign lesions. Planar imaging of patients with primary disease revealed a sensitivity of 83% and a 75% specificity. The results of planar imaging of patients with cervical metastases yielded a 92% sensitivity and 100% specificity. Seven patients also had single photon emission computerized tomography (SPECT) which improved the image quality, spatial resolution and sensitivity of the investigation. Tc99m (v) DMSA imaging provides a cheap and rapid means of investigating head and neck SCC. This study suggests further work is indicated to assess its role in diagnosis and subsequent management.

Malignant hemangiopericytoma of the parapharyngeal space.

Hemangiopericytoma is a rare vascular neoplasm, occasionally occurring in the head and neck region. Diagnosis is made histologically, but even then, it is difficult to predict the behavior of the tumor in an individual patient. The patient described in this report presented with symptoms of parapharyngeal compression due to such a tumor. It is believed that malignant hemangiopericytoma has not been previously reported in this site.

Interstitial irradiation for squamous carcinoma of the oral cavity.

Interstitial radiation delivered by iridium 192 implants was used to treat 38 patients with squamous carcinoma of the oral cavity. Thirty-six patients had either T1 or T2 tumours and no patient had palpable nodes at the time of implantation. Control of the primary tumour was achieved in all but 2 patients; these 2 were successfully treated by surgery. Fifteen patients (39%) went on to develop metastatic neck nodes. Nine were cured by radical neck dissection but the remaining 6 died of their disease. This gives a 5-year actuarial survival of 81%. Since all deaths occurred after the development of metastatic disease in the neck with control of the primary lesion, the evidence for and against prophylactic treatment of the neck lymphatics in clinically negative necks was reviewed. Prophylactic irradiation of the neck is probably preferable to any form of neck dissection but clear evidence that this improves long-term survival compared with careful follow-up and radical neck dissection for palpable nodes is still lacking.

The management of thyroid swellings.

All cold solid nodules should be pursued relentlessly and all cancers of the thyroid, with the possible exception of anaplastic tumours, should be treated radically. The majority of differentiated cancers of the thyroid may carry a good prognosis but those which recur constitute a group of cases which are very difficult to manage and cure.

Prognostic factors in oral squamous carcinoma and their relation to clinical staging.

One hundred and three patients with an oral squamous carcinoma were studied in an attempt to determine the clinical factors which affect survival. The 5 yr actuarial survival of the whole group of patients was 55%. Although survival depended on clinical staging, in those patients with no palpable nodes on presentation the tumour size did not affect survival. The most significant factor determining survival was the presence of palpable lymph nodes on presentation. Palpable nodes were more likely in patients with large tumours than those with small tumours. On the basis of these findings a modification of the TNM classification is suggested giving more weight to the presence of cervical nodes than in the present staging system.

The management of tumours of the middle ear.

On the basis of a small number of cases, the majority of which were advanced, it would seem that extended surgery has a very definite place in the management of advanced glomus jugulare tumours, but very little place in the management of cancer of the middle ear with obvious signs of spread to adjacent parts.