A simple novel prognostic model for early stage oral tongue cancer.

The prognostication of patient outcome is one of the greatest challenges in the management of early stage oral tongue squamous cell carcinoma (OTSCC). This study introduces a simple histopathological model for the prognostication of survival in patients with early OTSCC. A total of 311 cases (from Finland and Brazil) with clinically evaluated early stage OTSCC (cT1-T2cN0cM0) were included in this multicentre retrospective study. Tumour budding (B) and depth of invasion (D) were scored on haematoxylin-eosin-stained cancer slides. The cut-off point for tumour budding was set at 5 buds (low <5; high ≥5) and for depth of invasion at 4mm (low <4mm; high ≥4mm). The scores of B and D were combined into one model: the BD predictive model. On multivariate analysis, a high risk score (BD score 2) correlated significantly with loco-regional recurrence (P=0.033) and death due to OTSCC (P<0.001) in early stage OTSCC. The new BD model is a promising prognostic tool to identify those patients with aggressive cases of early stage OTSCC who might benefit from multimodality treatment.

How we do it: regular infusion of local anaesthetic in the pedicle of pectoralis major myocutaneous flap to shorten hospitalization of surgically treated head and neck cancer patients.

Keypoints *Regular infusion of the flap with local anaesthetic for 6 days postoperative via an indwelling catheter is easy. *It does not cause any complications. *It shortens hospitalization by 7 days. *The necessary catheter is readily available.

Long-term results and quality of life after endovascular treatment of venous malformations in the face and neck.

PURPOSE: To evaluate the long-term results of endovascular sclerotherapy in treating venous and venocapillary malformations of the face and neck region, and to assess the quality of life after treatment. MATERIAL AND METHODS: Twenty consecutive patients with endovascularly treated venous and capillary-venous malformation of the face and neck were invited to attend for clinical control and magnetic resonance (MR) imaging. To evaluate the quality of life after treatment, patients were asked to fill in a questionnaire which included 20 multiple-choice questions exploring 4 dimensions: psychological, physical, and social functioning, and pain. RESULTS: In 14 patients, symptoms and MR findings improved, while in 6 patients there was no improvement. Results concerning quality of life showed that most patients did well after endovascular treatment. Patients with venous malformations of the tongue had a worse outcome. Patients under the age of 16 at the beginning of the treatment and patients clinically followed by physicians specialized in vascular malformations had a better quality of life. CONCLUSION: Endovascular treatment for venous malformations is effective. Results and quality of life proved to be better when the endovascular treatment was begun before puberty and the patients had regular clinical controls after therapy.

Endovascular treatment of venous malformations in extremities: results of sclerotherapy and the quality of life after treatment.

PURPOSE: To evaluate the long-term results of endovascular sclerotherapy in treating venous extremity malformations and to assess the quality of life after treatment. MATERIAL AND METHODS: Twenty-four patients were included who had completed treatment with ethanol sclerotherapy and a minimum of one year observation period. Nineteen patients attended a clinical control. To evaluate the quality of life after treatment, 23 patients filled in a questionnaire which included 20 multiple-choice questions exploring four dimensions: psychological, physical and social functioning, and pain. RESULTS: At the clinical control seven patients had no clinical symptoms related to the malformation, six had slight, four moderate, and two severe symptoms. In 16 patients the symptoms had diminished after treatment. No deterioration of the initial situation was observed. The results concerning quality of life showed that most patients did well after endovascular treatment. Pain was the most important injurious factor for state of health among the four different dimensions. The poorest outcome was found in malformations that filled the whole muscle or muscle compartment and in larger lesions. The patients whose malformation at the clinical control caused swelling to the extremity affected had poorer quality indices than others. CONCLUSION: Endovascular treatment for venous malformations is an effective treatment.

OK-432 (Picibanil) therapy for lymphangiomas in children.

Lymphangiomas are benign, soft tumors that most often affect the head and neck area, usually causing marked cosmetic and functional problems. Treatment options include surgery and a large number of different sclerotherapy agents. Surgical treatment is challenging because of the need for complete excision. The risk of damage to surrounding structures or poor cosmetic results is high. Various sclerotherapy agents have been shown to have minimal effects on lymphangiomas. Their use has been associated with severe systemic, local and cosmetic side effects. OK-432 (Picibanil) is a new and promising form of sclerotherapy. An intracystic injection of OK-432 produces a local inflammatory reaction, which leads to resolution of the lesion. We have treated 11 pediatric lymphangioma patients with OK-432 with excellent results: complete regression in six, marked regression in four and no response in one case. Local swelling should be anticipated, especially when treating lesions near the upper airway. We found OK-432 injections to be safe and effective as a first line of treatment for lymphangiomas.

Microcatheter embolization of intractable idiopathic epistaxis.

PURPOSE: To assess the efficacy and safety of microcatheter embolization in the treatment of intractable idiopathic epistaxis. METHODS: Thirty-seven patients underwent microcatheter embolization in 1991-1998. We evaluated retrospectively the technical and clinical outcome, the number of complications, the duration of embolization in each case, and the number of blood transfusions needed. All embolizations were done with biplane digital subtraction angiography (DSA) equipment. The procedure was carried out under local anesthesia using transfemoral catheterization, except in one case where the translumbar route was used. Tracker 18 or 10 microcatheters were advanced as far as possible to the distal branches of the sphenopalatine artery. Polyvinyl alcohol (PVA) particles were used for embolization in most cases, while platinum coils or a combination of these two materials were occasionally used. The primary outcome was always assessed immediately by angiography. Follow-up data were obtained from patient records, by interviewing patients on the telephone or by postal questionnaires when necessary. The mean follow-up time was 21 months. RESULTS: The embolization was technically successful in all 37 cases. A curative outcome was achieved in 33 cases (89%). The mean duration of the procedure was 110 min. Four patients (8%) had mild transient complications, but no severe or persistent complications were encountered. Twenty-three patients needed a blood transfusion. Slight rebleeding occurred in three patients during the follow-up; all responded to conservative treatment. One patient suffered two episodes of rebleeding within 2 months after primary embolization. Re-embolizations successfully stopped the bleeding. CONCLUSION: Embolization is the primary invasive modality for treating intractable idiopathic epistaxis. It proved both safe and effective over a relatively long follow-up.

Prognostication of Bell's palsy using transcranial magnetic stimulation.

Transcranial magnetic stimulation (TMS) provides a method to noninvasive excitation of the facial nerve in its intracranial segment close to the internal acoustic meatus. Thus, the site of facial nerve activation with TMS is proximal to or within the site of the lesion in Bell's palsy. To evaluate the prognostic capability of TMS in unilateral Bell's palsy we examined 137 patients with this method, and compared the results with electroneuronography (ENoG). Within 0-4 days from the onset of palsy, the patients with elicitable TMS responses recovered better than those in whom TMS responses were not elicitable. If TMS was performed 5-9 days or 10-28 days after the onset of palsy, it did not provide any prognostic information. Based on amplitude side-to-side differences, ENoG did not contribute prognostic information during the first 9 days from the onset of palsy. Later on, 10-28 days after the onset of palsy, ENoG showed an increased capability to discriminate the patients with poor prognosis. Thus, elicitable facial motor response with TMS predicts good prognosis of Bell's palsy at an early stage whereas poor response with ENoG predicts less favorable prognosis at a later stage.

Immediate histological changes in soft palate after uvulopalatopharyngoplasty with CO2, contact Nd:YAG or combined CO2 and Nd:YAG laser beams.

CO2, contact Nd:YAG and Combolaser (combined, simultaneous and coaxial CO2 + Nd:YAG laser beam) were used for uvulopalatopharyngoplasty (UPPP). It has been proposed that the combined beam geometry diminishes thermal damage to surrounding tissues when compared with single laser radiation. To study the extent of thermal tissue damage produced by the lasers, tissue samples for light (LM) and transmission electron microscopy (TEM) were taken from the surface of the resected area and 2 and 4 mm below the resection plane. The depth of tissue damage and coagulation was measured. The results showed no consistent differences in the inflammatory reactions or the amount and depth of tissue coagulation observed in samples taken immediately after the operation. The CO2 laser typically produced a carbonized and coagulated wound edge. Combolaser and contact Nd:YAG lasers generated slightly less charring but otherwise resembled each other with coagulated and vacuolized resecate margins. These results indicate that the beam geometry in Combolaser does not diminish thermal damage to surrounding tissues.

Wound healing and soft tissue effects of CO2, contact Nd: YAG and combined CO2-Nd: YAG laser beams on rabbit trachea.

Rabbit trachea was used as an experimental model to study tissue effects and healing of full-thickness tracheal lesions produced by CO2, contact Nd: YAG and combined, coaxial CO2-Nd: YAG (Combo) laser beams. Two power settings (10 W and 16 W) were used with CO2 and contact Nd: YAG lasers. Three different CO2/Nd:YAG power ratios (1:1, 1:2 and 1:4) and power settings (12 W 15 W and 16 W) were used with the Combolaser. Histological specimens for light and transmission electron microscopy were prepared immediately and 1, 3, 5, 7, 14 and 21 days postoperatively. The wound with the most precise and fastest healing was produced by contact Nd: YAG laser. CO2 laser produced a moderate amount of charring and the largest amount of coagulated tissue with a slightly prolonged healing period. In the acute phase, tissue defects produced by the Combolaser with power ratios 1:1 and 1:2 resembled the CO2 laser lesions but with slightly less charring. The power ratio 1:4 diminished the cutting properties of the beam considerably. During the healing period the Combolaser produced the most intensive inflammation and granulation tissue formation resulting in delayed regeneration of the lesion. In transmission electron micrographs the most severe damage to chondrocytes was seen after using the Combolaser. These findings indicate that the Combolaser produces deeper tissue damage than CO2 or contact Nd:YAG laser. However, the Combolaser appears to be suitable for tracheobronchial operations, owing to its good simultaneous cutting and haemostatic properties.

Longterm comparison of soft palate scars after UPPP made by CO(2), contact Nd-YAG or combined CO (2) and Nd-YAG laser beams.

C0(2) laser, contact Nd-YAG laser and Combolaser (combined CO(2) and Nd-YAG laser beam) vary distinctively in the way they interact with target tissue. To study the quality of mature scars produced by these lasers, the ultrastructure and amount of collagen in soft palate scars after 60 uvulopalatopharyngoplasty (UPPP) operations were analysed. The CO(2) laser was used in 19, contact Nd-YAG in 21 and Combolaser in 20 operations. At a clinical follow-up examination carried out, on average, 51 (range 34-74) months postoperatively, a specimen was obtained from the soft palate scar for collagen analysis. Postoperative complaints of the patients were acknowledged. No differences between the laser groups were observed concerning the gross appearance of the scars or the amount and ultrastructure of collagen. Neither the frequency nor the quality of post-operative symptoms showed any differences between the lasers. Although the initial tissue effects are different, long-term remodelling produces nearly identical soft palate scars after the use of CO(2), contact Nd-YAG and Combolaser beams.

Histological changes in elastic components of soft palate scars after CO2 and contact Nd:YAG laser incisions in the dog as an experimental model.

Soft palate stiffening operations--often with CO2 or contact Nd:YAG lasers--have been used recently to treat patients with pronounced snoring. Differences in soft palate scars formed after CO2 and contact Nd:YAG laser incisions were studied in an animal model to determine which of these lasers produces a more rigid scar and consequently might be more effective for a soft palate stiffening operation. Six mongrel dogs were placed in each laser group, after which either the CO2 or Nd:YAG laser was used to make a 1.5-cm-long soft palate incision. The scars produced were then excised and studied histologically 4 weeks postoperatively. Special attention was paid to collagen density and elastin fibers in the scar tissue. After contact Nd:YAG laser incisions scar tissue was found to contain densely aligned collagen fibers and practically no elastin fibers. CO2 laser incisions produced significantly different scars: irregularly arranged collagen fibers with some elastin fibers also inside the scar tissue. Differences in the shapes of the scars and wound contractions were also found that were only seen after contact laser incisions. These findings suggest that the contact Nd:YAG laser might be more effective for soft palate stiffening operations.

A comparison of transcranial magnetic stimulation with electroneuronography as a predictive test in patients with Bell's palsy.

The aim of this study was to examine the neuronographic findings of electrical and transcranial magnetic stimulation of the facial nerve and to compare their ability to predict clinical recovery from idiopathic facial nerve palsy (Bell's palsy). Eighty-six patients were examined clinically and neurophysiologically immediately on presentation to Tampere University Hospital. Electroneuronography (ENoG) and transcranial magnetic stimulation (TMS) were performed 1-6 times for each patient. The time interval between each examination varied from 2 to 7 days. Seventy-eight patients were followed for a median period of 13 months after the onset of palsy. Facial nerve function was graded according to the House-Brackmann grading system. Relative amplitude differences of ENoG and TMS during the acute phase were then correlated with clinical outcome. Statistical analysis of the results showed that a TMS response elicitable during the first 5 days of the palsy was correlatable with a good prognosis. ENoG results correlated with clinical outcome at a later time from onset of symptoms. TMS was well tolerated and no adverse effects were seen. These results indicate that TMS is a useful method for the early prediction of outcome in patients with Bell's palsy.

Diagnostic value of plain radiographs in chronic maxillary sinusitis: a comparison between radiological and endoscopic findings in 75 patients.

Preoperative radiologic and intraoperative endoscopic findings of maxillary and ethmoid sinuses were compared in 75 adult patients, in whom 135 chronically inflamed maxillary sinuses were operated using functional endoscopic sinus surgery (FESS). At sinoscopy, secretion was found in 91% (41/45) of the radiologically opacified antra and in 47% (31/65) of the antra with moderate or marked mucosal swelling in plain radiographs. Antral fluid level in radiographs was a relatively rare (23%) finding and showed secretion as reliably as opacification. Radiographic detection of secretion in maxillary sinuses with mucosal thickening is difficult. There was a fair correlation in both antral and ethmoidal mucosal changes with the mucosal findings in antroscopy and endoscopic ethmoid surgery.

Magnetic facial nerve stimulation in Bell's palsy.

The transcranial magnetic stimulation (TMS) technique makes it possible to stimulate the intracranial part of the facial nerve. In a total of 51 patients with acute Bell's palsy, TMS was performed, and the responses were compared with those elicited by conventional extracranial electric stimulation (EES). Clinical recovery was evaluated at 258-539, mean 410, days from the beginning of the palsy. With both techniques the motor evoked potentials (MEPs) could always be elicited on the healthy side, the mean latency being 4.7 ms with TMS and 3.7 ms with EES. In the acute phase, TMS elicited MEPs on the paralyzed side in 47% of the patients, and EES in 98%. The patients with TMS elicitable MEPs during the first 4 days of the palsy had significantly better recovery than those without response (p less than 0.05). The difference in recovery between patients with or without elicitable TMS responses on days 5-8 and 9-14 was not significant. In EES, the amplitude difference between the two sides within the first 4 days was not significantly (p greater than 0.05) different. On days 9-14 the patients with a less than 80% difference between the two sides recovered significantly (p less than 0.05) better than those with a difference of greater than or equal to 80%, So, TMS may be of help in the early prognosis of Bell's palsy.