The value of postoperative anticoagulants to improve flap survival in the free radial forearm flap: a systematic review and retrospective multicentre analysis.

BACKGROUND: Free radial forearm flap (FRFF) reconstruction is a valuable technique in head and neck surgery, which allows closure of large defects while striving to maintain functionality. Anticoagulative drugs are often administered to improve flap survival, although evidence regarding effectiveness is lacking. OBJECTIVE OF REVIEW: To investigate the effectiveness of postoperative anticoagulants to improve survival of the FRFF in head and neck reconstruction. TYPE OF REVIEW: Systematic review and multicentre, individual patient data meta-analysis. SEARCH STRATEGY: MEDLINE, EMBASE, Web of Science and CINAHL were searched for synonyms of 'anticoagulants' and 'free flap reconstruction'. EVALUATION METHOD: Studies were critically appraised for directness of evidence and risk of bias. Authors of the highest quality publications were invited to submit their original data for meta-analysis. RESULTS: Five studies were of adequate quality, and data from four studies (80%) were available for meta-analysis, describing 759 FRFF procedures. Anticoagulants used were as follows: aspirin (12%), low molecular weight dextran (18.3%), unfractioned heparin (28.1%), low molecular weight heparin (49%) and prostaglandin-E1 (2.1%). Thirty-one per cent did not receive anticoagulants. Flap failure occurred in 40 of 759 patients (5.3%) On univariate analysis, use of unfractioned heparin was associated with a higher rate of flap failure. However, these regimens were often administered to patients who had revision surgery of the anastomosis. In multivariate logistic regression analysis, anticoagulant use was not associated with improved flap survival or flap-related complications. CONCLUSIONS: The studied anticoagulative drugs did not improve FRFF survival or lower the rate of flap-related complications. In addition, some anticoagulants may cause systemic complications.

Radial forearm osteocutaneous free flap in maxillofacial and oromandibular reconstructions.

OBJECTIVES/HYPOTHESIS: The radial forearm osteocutaneous free flap is an excellent reconstructive modality for oromandibular and maxillofacial reconstruction in certain well-defined circumstances. The initial concern over donor site morbidity and the ability of the bone to reconstruct mandibular defects have led to only a few published series. STUDY DESIGN: Retrospective study of the experience of two tertiary medical centers with radial forearm osteocutaneous free flap. METHODS: Retrospectively, 52 patients were studied who underwent radial forearm osteocutaneous free flap reconstruction for cancer (49 cases) and trauma (3 cases). Bone length and skin paddle harvested, general morbidity (hematoma, wound infection, and dehiscence), recipient site morbidity (nonunion of neomandible, flap failure, and bone or plate exposure), and donor site morbidity (radius bone fracture, plate exposure, and skin graft failure) were reviewed. RESULTS: The average skin paddle size was 55.1 cm (range, 15-112 cm). The average radius bone harvest length was 6.3 cm (range, 2.5-11 cm). Donor site complications included tendon exposure (3 cases), radius bone fracture (1 case), and exposure of the plate (0). Recipient site complications included nonunion of the mandible (4), exposed mandible (1), exposed mandibular plates (2), exposed maxillary plates or bone (0), venous compromise (1), and flap failure (1). Two patients had perioperative deaths. CONCLUSION: Radial forearm osteocutaneous free flap is a valuable and viable option for oromandibular and maxillofacial reconstruction.

Use of the radial forearm free tissue flap to treat persistent stricture after esophagogastrectomy.

BACKGROUND: Persistent stricturing or anastomotic leakage at the cervical esophagogastric anastomosis can be a troublesome complication of gastric pull-up procedures. When the stricture is the result of ischemia of the stomach, the strictures are long and often not responsive to dilatation and require large operations such as jejunal interposition or replacement with colonic pull-up. In this report we describe the use of a radial forearm flap to patch strictures. METHODS: The radial forearm flap is a fascia cutaneous flap taken from the forearm and based on the radial artery and its venae comitantes. The advantages of this flap are that it is thin and pliable, conforms easily, has excellent reliability due to the size of the feeding vessels, and has a relatively long pedicle. The vascular anastomosis can be made to several arteries and veins within the neck. The epithelial component can be made in sizes up to 10 by 20 cm. RESULTS: We have used the radial forearm flap to patch strictures in 6 patients with persistent complex strictures in the cervical region after esophagectomy. Results were excellent in 4 patients (able to eat liquids and solids without problems) and good in 1 patient (liquids okay, some problem with solids), and 1 patient died postoperatively. Follow-up is 4 months to 7 years. CONCLUSIONS: The radial forearm flap is an excellent option for handling persistent stricture after esophagogastrectomy. In many instances, this flap can be used in lieu of a jejunal interposition flap and obviates a laparotomy to harvest jejunum. The flap fits easily into the neck and conforms to the space.

Pulmonary atelectasis after reconstruction with a latissimus dorsi myocutaneous flap.

Atelectasis is the most common postoperative complication encountered in head and neck surgery. Risk factors include preexisting pulmonary disease, type of surgery performed, and the length of anesthetic. It is controversial whether reconstruction of defects with regional myogenous flaps predisposes to atelectasis. The latissimus dorsi myocutaneous flap requires the patient to be placed on his side for a period of time. Whether it is the position or the surgery that contributes to the development of atelectasis has not been examined. Eighteen patients underwent latissimus dorsi myocutaneous flap reconstruction following major ablative procedures for head and neck cancer. The cutaneous area transferred ranged from 70 to 225 cm2 (mean, 128 cm2). The flap size ranged from 7 x 10 to 15 x 15 cm. The majority of flaps were 10 x 15 cm or greater. These patients were compared to 18 patients who did not undergo pedicled myocutaneous chest flap reconstruction. Patients were matched for age, sex, length of operation, site of primary, and stage of disease. Postoperative atelectasis was radiographically detected in 89% of flap patients vs. 79% of controls. Major atelectasis was encountered in 16% of patients undergoing flap surgery vs. 11% of patients in the control group. Patients with large cutaneous paddles on the flaps (> 120 cm2) had significantly more atelectasis than patients with smaller cutaneous paddles (P<.05, chi-squared). The incidence of radiographic postoperative atelectasis in patients having a latissimus dorsi myocutaneous flap is high. The size of the skin paddle harvested as well as the position change may contribute to this.

Effects of acute thyroxin depletion on hearing in humans.

OBJECTIVE: To study the physiologic effect of acute thyroid hormone depletion on hearing and the function of outer hair cells. DESIGN: Audiologic and otoacoustic emission testing of subjects undergoing total thyroidectomy before surgery and up to 6 weeks after surgery. Magnitude of thyroxin depletion monitored by serum thyroid-stimulating hormone levels. SETTING: Hearing research laboratory at a state university. SUBJECTS: Ten patients undergoing total thyroidectomy. MAIN OUTCOME MEASURES: Detection of hearing loss on audiogram and decrease or disappearance of otoacoustic emissions as a result of acute thyroxin depletion. RESULTS: No significant changes in the audiogram and otoacoustic emission configurations were detected, although thyroid-stimulating hormone levels became elevated after total thyroidectomy. CONCLUSION: Although thyroid hormone is thought to play a role in the physiology of hearing in humans, no deleterious effects on hearing can be identified up to 6 weeks after thyroxin depletion.

Management of the N0 neck during salvage laryngectomy.

BACKGROUND: Radiotherapy is effective treatment for laryngeal carcinoma. Early-stage laryngeal carcinoma has a low incidence of cervical metastasis. Patients initially clinically N0 usually remain N0 when they fail at the primary site. The incidence of subclinical metastasis in these patients is not well described. Watchful waiting or elective neck dissections are advocated. OBJECTIVE: Examine the incidence of subclinical metastatic disease in patients undergoing elective neck dissections with salvage laryngectomy. STUDY DESIGN: Prospective study (1991-1996) of patients who failed radiotherapy and underwent salvage laryngectomy with elective neck dissection. METHODS: Thirty-four patients underwent salvage laryngectomy with neck dissection (30 bilateral, 4 unilateral). All were clinically N0 at initial presentation and remained N0 at recurrence. Pathologic study of the neck dissection specimens was undertaken. Patients were followed for a minimum of 2 years (mean, 4 y). RESULTS: The male-to-female ratio was 4.5:1, with a mean age of 62 years (range, 38 to 75 y). Metastatic disease was present in 6 patients (17%); 4 of 14 (28%) supraglottic, and 2 of 20 (10%) glottic. Presence of disease in the neck according to stage at recurrence was as follows: T2, 2 of 12; T3, 3 of 14; and T4, 2 of 8. Neck disease was ipsilateral in 4 and contralateral in 2 patients (both supraglottic primaries). CONCLUSIONS: Subclinical cervical metastasis may be present in N0 laryngeal carcinoma patients who have recurrence following radiotherapy. Morbidity of a lateral neck dissection is minimal, with excellent control of the neck being possible. Supraglottic and advanced glottic (T3-T4) patients may benefit the most.

Significance of unilateral submandibular gland excision on salivary flow in noncancer patients.

OBJECTIVES/HYPOTHESIS: Normal salivary flow is important for maintaining good oral hygiene. Lack of normal flow predisposes to an increased incidence of dental caries and symptomatic xerostomia. The submandibular glands are responsible for 70% of resting salivary flow. Removal of the submandibular gland is most commonly performed for sialolithiasis, chronic sialoadenitis, or as part of a neck dissection. The effect of unilateral gland resection for benign disease on resting salivary flow has not been well examined in the literature. STUDY DESIGN: Case controlled study involving patients who had undergone a unilateral submandibular gland resection matched with normal control subjects. METHOD: Stimulated and unstimulated salivary flow rates in surgical and control subjects were measured in a controlled setting. RESULTS: Unstimulated salivary flow rates were 0.805 mL/min in the control group and 0.405 mL/min in the surgical group (P = .01). Stimulated salivary flow rates were not significantly different between the two groups (P > .05). Fifty-seven percent of patients in the surgical group and 14% in the control group had xerostomia (P < .05). CONCLUSION: Unilateral submandibular gland excision results in a decreased rate of resting salivary flow and an increase in subjective xerostomia.

Effect of anemia on the fasciocutaneous flap survival in a rat model.

OBJECTIVE/HYPOTHESIS: Ablative surgery for head and neck cancer that creates large composite defects often results in a significant decrease in the hematocrit level. These defects are best reconstructed with a microvascular free tissue transfer. Effect of the decreased hematocrit on microvascular flap survival is controversial. The purpose of this study was to assess the effect of isovolemic anemia on flap survival in a rat model. STUDY DESIGN: Prospective analysis. METHODS: Ninety rats were used (30 control and 60 experimental animals). Experimental animals were rendered anemic by blood draw and volume resuscitated with either a colloid (30 animals) or crystalloid (30 animals) solution. In all animals a ventral fasciocutaneous flap was raised. A vascular clamp was applied to the arteriovenous pedicle, and different ischemic times were allowed to elapse before clamp removal. Flap survival was assessed at 5 days. Probit analysis was performed for the three animal groups. RESULTS: A significantly increased probability of the flap survival was found in the anemic animals compared with the control group (P < or = .05). No difference was found between the colloid and crystalloid resuscitation groups. CONCLUSIONS: A decreased hematocrit level increases fasciocutaneous flap tolerance to ischemia and significantly increases the primary ischemic time in the ventral flap clamp model in rats. Fluid replacement with either crystalloid or colloid produces identical results.

Internal jugular vein patency in patients undergoing microvascular reconstruction.

The objective of this study was to determine the incidence of internal jugular vein thrombosis in patients undergoing free flap reconstruction and simultaneous neck dissection. Patients underwent Doppler ultrasound examination of their internal jugular veins on postoperative days 1 and 7 after functional neck dissection and free flap transfer. Long-term follow up was obtained at a minimum of 3 months. The incidence of internal jugular vein thrombosis in patients undergoing free flap reconstruction with simultaneous neck dissection is similar to that of patients undergoing just neck dissection. A significant number of these veins recanalize and have excellent long term patency. There does not seem to be a correlation between venous thrombosis and free flap survival.

Endoscopically monitored percutaneous dilational tracheotomy in a residency program.

OBJECTIVES/HYPOTHESIS: Endoscopically guided percutaneous dilational tracheotomy (PDT) has become a well-established alternative to the more traditional open tracheotomy, yet its use by otolaryngologists is limited. As airway management specialists, otolaryngologists should be familiar with a wide range of definitive procedures, including PDT. Few otolaryngology programs teach the technique. The objective of the present study was to determine the complication rate and outcome of PDT after its introduction in a residency teaching program. We also wished to evaluate whether the time savings reported by experienced surgeons could be repeated in our setting. SETTING: Tertiary referral teaching hospital. METHODS: We prospectively reviewed our first 54 consecutive PDTs and compared them to 29 consecutive standard open tracheotomies, which were reviewed retrospectively. RESULTS: Complications (13% vs. 33%, P = .030), operative time (12 vs. 24 min, P < .0001) and total procedure time (37 vs. 80 min, P < .001) were significantly reduced in the PDT group as compared with standard tracheotomy. Initial outcome data were equal in both groups. CONCLUSIONS: We found that PDT can be safely and effectively taught as part of an otolaryngology residency training program.

Tracheostomal stenosis revision with simultaneous tracheoesophageal puncture.

OBJECTIVES/HYPOTHESIS: Vocal rehabilitation of patients who have undergone laryngectomy is best accomplished by a tracheoesophageal puncture. Optimal function of the prosthesis requires an adequate stoma. Patients with tracheostomal stenosis require revision of the stoma if vocal rehabilitation is to take place. Revision and tracheoesophageal placement are usually done as two separate procedures. Creating a tracheoesophageal fistula at the time of stomal revision has not been addressed in the literature. STUDY DESIGN: Prospective analysis and follow-up of 10 patients undergoing simultaneous tracheoesophageal puncture and stomal revision for tracheostomal stenosis between 1991 and 1996. METHODS: Ten patients were reviewed. An inferiorly based V-Y advancement flap was used so as not to interfere with the tracheoesophageal puncture. All patients had received radiation prior to revision and tracheoesophageal puncture. Patients were followed for a minimum of 2 years (range, 2-6 y; median, 3 y). RESULTS: All patients maintained an adequate stoma without stenting. Eight of ten patients (80%) developed and maintained good tracheoesophageal speech. Two patients had their speech fistulas removed. There were no intraoperative or postoperative complications. CONCLUSIONS: Creation of a tracheoesophageal fistula at the time of stomal revision allows for vocal rehabilitation with a single visit to the operating room.

Management of tracheostomal stenosis.

BACKGROUND: Tracheostomal stenosis following laryngectomy is a distressing complication with major effects on patient rehabilitation. Management ranges from stenting with a prosthetic device to surgical revision. The goal is a widely patent stoma that is amenable to tracheoesophageal puncture. OBJECTIVE: Review the long-term results of different methods of tracheostomal revision. METHODS: Review of 43 patients with symptomatic tracheostomal stenosis. End point was ability to function with no artificial stenting of their stoma. RESULTS: Forty-three patients underwent 55 revisions. The male-to-female ratio was 1.3:1.0. The age range was from 38 to 81 years (mean age, 59.5 y). Median time to revision was 11 months following the initial surgical procedure (range, 1-150 mo). Thirty-three patients underwent one revision; eight patients, two revisions; and two patients, three revisions. In 40 of 43 patients (93%) revision was successful. Of the last 21 patients who underwent revision, 18 had tracheoesophageal punctures placed. Fifteen developed excellent tracheoesophageal speech. The initial rates of success for these procedures were as follows: advancement flaps, 8 of 9; Z-plasty, 13 of 15; V-Y inset, 8 of 8; other procedures, 2 of 4; and dilation, 2 of 7 (P < .05 for dilation vs. all others). The ultimate success rates for these procedures were as follows: advancement flaps, 8 of 11; Z-plasty, 15 of 18; V-Y inset, 12 of 13; other procedures, 3 of 6; and dilation, 2 of 7. Other procedures and dilation were inferior (P < .05) compared with advancement flap, Z-plasty, and V-Y insets. CONCLUSION: Tracheostomal stenosis can be successfully managed in a multitude of ways.

Neck dissection with simultaneous carotid endarterectomy.

BACKGROUND: Patients with metastatic neck disease from upper aerodigestive tract carcinomas have an extensive history of tobacco and alcohol abuse. These patients are predisposed to develop atherosclerotic vascular disease. OBJECTIVE: An increased incidence and severity of carotid stenosis in patients receiving radiotherapy for head and neck cancers is known. Management of patients with severe carotid stenosis who require surgical treatment of their neck disease has not been described. The authors describe our experience with simultaneous carotid endarterectomy and neck dissection. STUDY DESIGN: Prospective data collection. METHODS: From 1991 to 1997 at West Virginia University Hospitals, Morgantown, West Virginia, and State University of New York (SUNY) at Buffalo, three patients with severe carotid stenosis required surgery for metastatic neck disease. Preoperative evaluation revealed a bilateral carotid stenosis greater than 90% in all patients. All patients underwent modified radical neck dissections and simultaneous carotid endarterectomies with saphenous vein grafting. Two patients, one undergoing partial pharyngectomy and laryngectomy and the other a laryngectomy and neck dissection, had coverage of the carotid artery with the myogenous component of a pectoral major graft. One patient had only a neck dissection. RESULTS: Two patients healed with no local morbidity, no neck recurrence, and a patent carotid artery by Doppler. No strokes were encountered. One patient died of a myocardial infarction. CONCLUSION: Severe carotid stenosis that requires revascularization may have endarterectomy performed simultaneously with treatment of head and neck primary with no increase in morbidity.

Effect of photodynamic therapy on the critical primary ischemic time of fasciocutaneous flaps.

BACKGROUND: Photodynamic therapy (PDT) may be used as an adjuvant intraoperative therapy to improve locoregional control. PDT has been shown to delay wound healing. This raises concern about PDTs effect on survival of fasciocutaneous flaps. OBJECTIVE: Evaluate the effect of 1) PDT on the critical ischemic time in a rat fasciocutaneous flap model and 2) photosensitizer activation by the surgical light source. DESIGN: A fasciocutaneous flap, based on the left inferior epigastric vessels, was used. Ischemic times of 2, 4, 6, 8, 10, and 12 hours were induced by clamping the vascular pedicle. Animals were randomly divided into five groups: ischemia only, group I; light treatment to wound bed, group II; Photofrin before surgery with the flap elevated without a fiber optic head light, group III, or with a headlight, group IV; Photofrin prior to surgery with light treatment to the wound bed, group V. Flap survival was assessed on postoperative day 7. RESULTS: The critical primary ischemic time of group V (PDT) was significantly less (P < .05) than groups I, II, III, and IV. There was no statistical difference in the critical primary ischemic time when a fiber optic headlight was used (group III vs. group IV). CONCLUSION: Intraoperative PDT significantly reduces the critical primary ischemic time of the rat fasciocutaneous flap. White light illumination of the operative field does not result in photosensitizer activation and has no effect on the critical primary ischemic time.

Pursestring closure of radial forearm fasciocutaneous donor sites.

BACKGROUND: The radial forearm fasciocutaneous free flap has become one of the most common methods of reconstructing defects after head and neck ablative surgery. The fasciocutaneous flap is an excellent replacement for the tissue that has been removed. Unfortunately, donor site morbidity remains a problem. Donor site morbidity is primarily related to poor skin graft take, cosmesis, and neural dysfunction. Decreasing the size of the donor site defect may allow for improved cosmesis with decreased morbidity. MATERIAL AND METHODS: Prospective evaluation of a pursestring closure of radial forearm fasciocutaneous donor sites over a 16-month period. RESULTS: Seventy-one radial forearm free flaps were used. Sixty-seven had a pursestring closure of the donor site. After flap elevation the mean size of the defect was 61 cm2 (range, 28-140 cm2). Pursestring closure decreased the mean of the defect to 34 cm2 (range, 10-104 cm2) (P <.0001). Defect size was decreased by a mean of 44.5% (range, 24.5%-66.7%) (P <.0001). COMPLICATIONS: The rate of skin graft loss (>25%) (9% of patients) was less than that reported in the literature. No patient required a second surgical procedure. Neural morbidity was equal in both groups. Cosmesis was much improved. CONCLUSIONS: Pursestring closure allowed for a significantly decreased donor defect, associated with better cosmesis and less skin graft loss.

A prospective comparison of scalpel versus bipolar scissors in the elevation of radial forearm fasciocutaneous free flaps.

OBJECTIVES/HYPOTHESIS: The radial forearm fasciocutaneous free flap has become the workhorse for reconstruction of head and neck ablative defects. A location distal to the head and neck allows this flap to be elevated concurrent with the ablation. Most commonly, the flap is elevated under tourniquet control. This involves a primary ischemic insult with a certain amount of hemorrhage after the tourniquet is released. Bipolar scissors are a new method of dissection. They may allow for a speedier dissection with a concomitant decrease in ischemic time. Their hemostatic properties may control hemorrhage after use of the tourniquet. STUDY DESIGN: A prospective study of patients undergoing radial forearm free flaps over a 12-month period at a tertiary care referral center was undertaken. RESULTS: Forty patients were entered into the study, flaps were elevated with scalpel (20) and with bipolar scissors (20). Mean time under tourniquet was 39 minutes (range, 30-56 min) with scalpel compared with 27 minutes (range, 21-31 min) with bipolar scissors (P <.001). Total mean time of elevation (including control of hemostasis and pedicle dissection) for scalpel elevation was 50 minutes (range, 35-61 min) compared with 32 minutes (range, 20-41 min) for bipolar scissors elevation (P <.001). Mean blood loss was 46 mL (range, 15-110 mL) in the scalpel elevation group compared with 14 mL (range, 0-50 mL) in the bipolar scissors elevation group (P <.001). Complications at the donor site were equal between groups. CONCLUSIONS: Bipolar scissors are a safe, efficient method for elevating radial forearm free flaps.

Effect of photodynamic therapy on revascularization of fasciocutaneous flaps.

OBJECTIVE: Photodynamic therapy (PDT) may be used as an adjuvant intraoperative treatment to improve locoregional control. PDT has been shown both to delay wound healing and to have a deleterious effect on flap survival after a primary ischemic insult. This delay in wound healing may make the flap dependent on its pedicled blood supply for a prolonged period. Long-term flap loss may be experienced. The effect of PDT on flap revascularization, with subsequent dependence on its vascular pedicle, is evaluated. STUDY DESIGN: Randomized controlled trial using a rodent model. METHODS: A rat fasciocutaneous flap was used. Study groups were as follows: group I received no treatment; group II received treatment with 630-nm light; groups IH and IV were given Photofrin (in group III, loupes without a fiberoptic light source were used for flap elevation, and in group IV, light source was employed); and group V was given Photofrin and 630-nm light. Primary ischemic times of 2 or 4 hours were used. Vascular pedicles were ligated on postoperative day (POD) 5, 6, or 7, and percentage of flap survival was evaluated 7 days later. RESULTS: With 2 hours of ischemia, revascularization was decreased in the PDT group on POD 6 (P < .05) and on day 7 (P < .005) when compared with the other groups. With 4 hours of ischemia, revascularization was decreased in the PDT group on PODs 5 (P < .001), 6 (P < .01), and 7 (P < .005). CONCLUSION: Intraoperative PDT decreases revascularization of a rat fasciocutaneous flap.

A retrospective analysis of temporomandibular joint reconstruction with free fibula microvascular flap.

OBJECTIVES: The temporomandibular joint is occasionally encountered in extirpative surgery of the head and neck. It presents a difficult management issue. Little has been reported on functional outcomes after resection and reconstruction of the temporomandibular joint. DESIGN: A retrospective analysis consisting of chart reviews and phone interviews was performed on 17 patients who underwent fibular free flap reconstruction of the temporomandibular joint from 1993 to 1998. RESULTS: Mean follow-up in surviving patients (10) was 41.3 months. Mean age of the group was 62; male-to-female ratio was 11:6. Average hospital stay was 11.6 days. Four patients had no radiation therapy, 2 had preoperative and 11 had postoperative treatment. Five patients had one osteotomy, seven had two, one had three, and one had four. Ten patients could chew, one could not, and none were recorded for the remaining. Diet consisted of regular food for two patients, soft food for seven, full liquids for four, and tube feeds for four. Cosmesis was judged as excellent by eight patients, acceptable by two, and unacceptable by two. Five patients did not describe cosmesis. Most patients stated that bony contour was excellent, but that the soft tissue defect was noticeable. Speech was judged as intelligible by seven and moderately understandable by one. Nine patients did not describe speech. Two patients had postoperative displacement of the fibular head out of the fossa. CONCLUSION: Primary reconstruction of the temporomandibular joint with microvascular fibular flaps is a viable and effective means of restoring function. The majority of patients are able to resume oral feeds, obtain excellent or pleasing cosmetic results, and maintain intelligible speech.

Positron emission tomography in the evaluation of the N0 neck.

The presence of cervical lymph node metastasis in patients with head and neck cancer is associated with an unfavorable prognosis. Reports vary as to whether various conventional radiographic studies, such as computed tomography (CT) and magnetic resonance imaging, confer an advantage over physical examination in the patient without clinical findings of cervical metastasis (N0). Positron emission tomography (PET) is a functional imaging modality that has recently been used for head and neck neoplasms. The use of PET in the evaluation of the N0-staged neck in 14 consecutive patients with squamous cell carcinoma (SCC) of the upper aerodigestive tract is reported. Seven patients (50%) undergoing 13 neck dissections had pathologic evidence of disease. PET scans were positive in five patients with pathologically confirmed cervical metastasis. PET scans were negative in seven patients (11 neck dissections) with no pathologic evidence of disease. PET scans were positive for unilateral cervical metastasis in two of three patients with involvement of a single lymph node. PET scans were positive in two of three patients with more than two lymph nodes involved. PET had an accuracy of 100% in the eight patients with SCC of the oral cavity. In patients with oropharyngeal or hypopharyngeal carcinoma PET localized cervical metastasis in two of four patients with neck metastasis. In the patient with an N0-staged neck on clinical examination, PET was found to have an overall sensitivity of 78%, specificity of 100%, positive predictive value of 100%, negative predictive value of 88%, and accuracy of 92%. CT demonstrated sensitivity of 57%, specificity of 90%, positive predictive value of 80%, negative predictive value of 75%, and accuracy of 76%. PET showed a trend in increased accuracy (P = 0.11) over CT. PET appears to be a promising diagnostic aid that may be applied when evaluating the N0-staged neck, especially for SCC of the oral cavity.

MRI detection of cervical metastasis from differentiated thyroid carcinoma.

BACKGROUND: With the advent of the use of serum thyroglobulin as a marker for the recurrence of well-differentiated thyroid cancer (WDTC) after total thyroidectomy, clinicians are increasingly faced with the diagnostic dilemma of detecting the site of recurrence in thyroglobulin-positive patients with normal clinical examinations. The high protein content of this thyroglobulin may make it specifically detectable by magnetic resonance (MR) imaging. OBJECTIVE: To determine the ability of MR imaging to detect the presence of metastatic WDTC in cervical lymph nodes. STUDY DESIGN: Retrospective cohort. METHODS: Blinded review by two independent head and neck radiologists of 34 head and neck MR scans obtained from 26 patients with thyroid cancer (12 with primary disease and 14 with recurrent disease) all of whom subsequently underwent surgical removal of the lymph nodes considered at risk by imaging. RESULTS: The average overall percent sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of MR imaging were 95%, 51%, 84%, 78%, and 83%, respectively. The concordance between the two radiologists was 69%. There was no overall difference in the ability of the MR scan to detect the presence of disease in the upper jugular, lower jugular, or paratracheal nodal stations. However, it was more useful for papillary carcinoma (PPV 86%, accuracy 85%) than for follicular carcinoma or the follicular variant of papillary carcinoma (PPV 63%, accuracy 67%). CONCLUSION: MR imaging is a sensitive and accurate technique for the detection of WDTC, particularly papillary carcinoma, metastatic to cervical lymph nodes. However, the lower specificity of this modality precludes its use as a screening tool.