Is intraoperative margin sampling necessary in inverted papilloma resection?

PURPOSE: To explore the association between intraoperative surgical margin sampling by the frozen sections and recurrence in inverted papilloma surgery. METHODS: A multicenter, retrospective study of patients who underwent attachment-oriented IP resection in four tertiary care medical centers with a minimal follow-up of 36 months. RESULTS: The study included 220 surgeries with a mean follow-up period of 49 months (range 36-204). The endoscopic approach was used in all but 4 cases; 73% of procedures were primary. Overall recurrence was 10.45% (n = 23). Squamous cell carcinoma was found in 5 cases (2.2%). Intraoperative margin sampling was obtained in 145 cases. There was no difference in the recurrence rate between frozen section and no-frozen section groups (p = 0.44). Furthermore, margin sampling in various sites of tumor origin, in cases with concomitant nasal polyps (p = 0.53) and in revision cases (p = 0.08) showed no correlation with recurrence. In 26 cases when the surgery was extended following a positive frozen section, there was a significantly higher recurrence rate (OR = 6.94). CONCLUSIONS: According to our results, intraoperative margin sampling did not affect the recurrence rate of IP, and therefore, its routine use should be questioned.

Prognostic Factors in Differentiated Thyroid Cancer Revisited.

BACKGROUND: More than 90% of all thyroid cancers are differentiated thyroid carcinomas (DTC) with a 10 year survival rate greater than 90%. The commonly used risk stratification systems for DTC include: European Organization for Research and Treatment of Cancer (EORTC), AGES (Age, histologic Grade, Extent of tumor, Size), AMES (Metastasis) and MACIS (Completeness of resection, local Invasion). Other systems are also utilized. Several new factors that may be involved in DTC risk stratification have emerged in recent studies, with other "traditional" factors being challenged. OBJECTIVES: To present recent updates in the literature on new potential prognostic factors for DTC. METHODS: We conducted a literature review and analysis of publications regarding DTC prognostic factors or risk stratification published in the last 10 years. RESULTS: Several new factors with potential prognostic implications for DTC were noted, including family history, lymph node involvement parameters, positive PET-CT findings, multifocal disease, thyroglobulin level and several molecular markers including BRAF. Increasing age is associated with poorer outcome in DTC; however, recent studies suggest that the cutoff point of 45 years may be contested. Furthermore, several studies have shown contradictory results regarding male gender as a negative prognostic factor, thus questioning its prognostic significance. CONCLUSIONS: A number of new factors with potential prognostic implications for DTC have emerged and should be addressed. However, their role and possible inclusion in new staging systems has yet to be determined.

Acute Invasive Fungal Rhinosinusitis in Children With Hematologic Malignancies: Outcome of Surgical Treatment.

The incidence of acute invasive fungal rhinosinusitis (AIFR) is rising due to more aggressive chemotherapy and longer survival of immunosuppressed patients. Early diagnosis and appropriate but nonmutilating surgical treatment are particularly problematic in the pediatric population. This study aimed to evaluate the outcome of surgery for pediatric AIFR. Medical records of children surgically treated for AIFR between 1998 and 2014 were reviewed. Diagnosis was based on both histopathological and microbiological confirmation. Surgery was performed with curative intent and repeated for any resectable extension. The children underwent endoscopy and magnetic resonance imaging every 2 and 6 months, respectively, during the first postoperative year. Thirteen patients (2-18 years old) met the EORTC/MSG criteria for proven invasive fungal sinusitis; fungal invasion was diagnosed by preoperative biopsy and confirmed in the surgical specimen. All patients underwent an average of two endoscopic procedures (range 1-3), and four of them also underwent an open surgery. The local control rate was at least 79%. There was no facial disfiguration during follow-up (average 41 months). Although AIFR is still associated with high mortality, aggressive medical and surgical treatment provides local control in most cases. Fair outcome should encourage a maximal joint effort of pediatric hemato-oncologists and otorhinolaryngologists in the management of AIFR.

Can Computed Tomography Findings Predict the Recurrence of Sinonasal Inverted Papilloma?

OBJECTIVE: To evaluate the correlation between the ability to predict the attachment site of sinonasal inverted papilloma by computed tomography and the long-term surgical outcome. STUDY DESIGN: Retrospective cohort study. SETTING: Five tertiary medical centers. METHODS: Study patients underwent attachment-oriented resection of inverted papilloma. The primary outcome was tumor recurrence. RESULTS: Among 195 patients eligible for the study, focal hyperostosis was recognized on computed tomography in 65% (n = 127), in 71% of primary cases (n = 101), and in 50% of revision procedures (n = 26). There was a trend for a higher incidence of squamous cell carcinoma among the patients without detectable hyperostosis (P = .051). Location of hyperostosis coincided with the actual tumor attachment site in 114 patients (90%). Discordance between these parameters did not differ significantly (P = .463) between 11 primary and 2 revision cases. The overall rate of recurrence was 9.7% (n = 19), with a mean time to recurrence of 20 months (range, 7-96 months). The rate of recurrence did not correlate with any of the following: tumor stage, surgical approach, presence of squamous cell carcinoma, whether the surgery was primary or revision, and the presence or location of focal hyperostosis on computed tomography. Inverted papilloma recurred significantly more often (38.5%) when the intraoperative findings of the tumor attachment site did not match the location of hyperostosis observed on computed tomography (odds ratio, 6.5; 95% CI, 1.78-23.66). CONCLUSION: Detectability of focal hyperostosis on preoperative computed tomography does not affect the long-term outcome of inverted papilloma resection.

Tumor-host histopathologic variables, stromal myofibroblasts and risk score, are significantly associated with recurrent disease in tongue cancer.

Margin status, a major prognostic parameter in oral cancer, was analyzed vis-à-vis the histopathologic parameters of risk scores and stromal myofibroblasts. Specimens of tongue carcinoma (n = 50) were submitted to a risk score assignment consisting of the worst pattern of invasion, lymphocytic infiltration, and perineural invasion. Frequency of stromal myofibroblasts (alpha-smooth muscle actin stain) was assessed. A triple immunostaining assay with E-cadherin, Ki-67 and alpha-smooth muscle actin was used to identify carcinoma cells undergoing epithelial-mesenchymal transition. Margins were considered 'clean' if the tumor was >or=5 mm away from them. Patients

A prospective study of surgical margin status in oral squamous cell carcinoma: a preliminary report.

A protocol was created for prospective margin status evaluation of patients with Oral SCC. Margins are evaluated intra- and post-operatively during three stages. Patients were divided into three groups: group 1 in which one margins were sampled randomly, group 2 with frozen sections taken from the surgical bed and 3 in which they were taken from the tumor specimen itself. Patients in group 3 showed the best correlation with final margin status and survival.

Recurrent pleomorphic adenoma: is treatment considerably delayed thus affecting surgical morbidity?

OBJECTIVE: To examine the incidence of late presentation of patients with recurrent pleomorphic adenoma (RPA) of the parotid gland. METHODS: This is a retrospective analysis of patients treated in our center. We examined patients demographics, disease characteristics, treatment, and outcome and as well as the time period length from the first discovery of a recurrent mass until seeking treatment at our clinic and its effect on morbidity. RESULTS: A total of 30 patients were included. 26% underwent initial enucleation in other institutions. In eight patients (26%), the recurrence of the mass was second or higher. The patients average time period length until seeking treatment was 2.48 years, with 33% of patients showing a time period length of over three years. Multifocal tumor, tumor diameter larger than 2 cm and facial nerve involvement were found in 15 (50%),16 (53.3%) and seven (25%) patients respectively. Patient's delay of presentation by ≥3 years was associated with a tumor size of ≥2 cm (Relative Risk [RR] = 2, p = .02). Patient's delay of presentation by ≥2 years was also associated with a trend towards a higher rate of post-operative facial nerve palsy (RR = 3.37, p = .07, CI = 0.88-12.85). CONCLUSION: Most patients with RPA were presented late, thus affecting disease extent and surgical morbidity.

The clinical behavior of isolated sphenoid sinusitis.

OBJECTIVE: We sought to study the clinical behavior and treatment outcome of isolated sphenoid sinusitis (ISS). STUDY DESIGN AND SETTING: We conducted a retrospective study of patients diagnosed with ISS in a tertiary medical center over 20 years. RESULTS: Of 72 patients with ISS, 79 percent had acute symptoms, 15 percent had chronic symptoms, and 6 percent had incidental radiological findings. Fifteen percent were children. Most patients were diagnosed between January and April (P < 0.01), and increasing incidence was noted over the years (P < 0.001). Headache was the most common presenting symptom (85%). Chronic patients complained also of nasal symptoms (82%). Six patients had a major complication of sinusitis (none of them were children), and two patients died. Immunocompromised patients had more major complications (P

[Recurrent pleomorphic adenomas of the parotid gland--treatment and outcome].

Epithelial tumors of the parotid gland comprise 3% of head and neck tumors, and 70%-80% of those are benign. Pleomorphic adenoma is the most common tumor of the parotid gland. Recurrence rate of pleomorphic adenomas (RPAs) following superficial parotidectomy was reported to be as high as 4%, sometimes associated with inadequate surgical treatment of the primary tumor. These tumors have a very slow growth rate, and a ten-year follow-up period is mandatory. RPAs are usually located in the superficial lobe (75%) and are often multinodular. Treatment of RPAs is challenging due to a high risk of facial nerve paresis (7%-50%) and of re-recurrence. Occasionally, post-operative radiotherapy is indicated, but this treatment must be balanced with potential long term risks of secondary malignancy. Medical records of 16 patients with first recurrence and 4 patients with more than one recurrence who were treated in our institution during the past 5 years were reviewed. Five patients were treated by post-operative radiotherapy. Residual or recurrence rate following a second procedure was 15%. Two patients (10%) had permanent paresis of a single branch of the facial nerve. Seventeen out of 20 patients (85%) treated were disease-free after a follow-up period of 5 years. In conclusion, surgical treatment of RPAs is a complex procedure which should be managed by a trained surgical team and can be performed with success and minimal morbidity.

Limited use of complementary and alternative medicine in Israeli head and neck cancer patients.

HYPOTHESIS/OBJECTIVE: The use of complementary or alternative medicine (CAM) is growing among cancer patients. A Medline search failed to reveal any dedicated report of CAM use specifically in patients with head and neck cancer (HNC). STUDY DESIGN: Use of CAM was evaluated in a cohort of treated HNC patients. METHODS: Patients treated for HNC were asked if they had used CAM since their diagnosis. Demographic data and data pertaining to mode of CAM, duration of treatment and effects were obtained. RESULTS: One hundred forty-three patients (mean age 61 years) were included. Only nine patients (6.3%) reported using disease related CAM. This included acupuncture (4), Reiki (2), naturopathy (2), hypnosis (1), shiatsu (1), chiropractic treatment (1), homeopathy (1), and selenium (1). CONCLUSION: Contrary to the reported use, few of our HNC patients used CAM. Although this could be related to good caregiver-patient relationship, further studies in comparable populations are warranted to evaluate if this is a local or a pervading finding in head and neck cancer patients.

Pulmonary function after pectoralis major myocutaneous flap harvest.

OBJECTIVE: The pectoralis major myocutaneous flap is widely used in the reconstruction of surgical defects in the head and neck region. Pulmonary atelectasis has been reported in patients undergoing these procedures, and many of these patients are heavy smokers and drinkers and have associated cardiopulmonary disorders. Flap harvest and donor site closure may lead to impairment of pulmonary function before and after the use of pectoralis major myocutaneous (PMC) in surgical reconstruction in patients with cancer of the head and neck. METHODS: Patients undergoing extirpation of head and neck tumors with PMC reconstruction were prospectively evaluated. Patient age, smoking history (pack-years), anesthesia duration, percentage predicted pre- and postoperative FEV1, percentage-predicted pre- and postoperative FVC (forced vital capacity), and preoperative SaO2 (oxygen saturation) were evaluated. Preoperative FEV1/FVC ratio was calculated. Chest x-rays were reviewed. RESULTS: Only 11 patients, 5 of whom smoked, could be evaluated postoperatively. Preoperative FEV1/FVC was more than 70 and FEV1 more than 75% predicted in all patients. A decrease in FVC was observed in 7 of the 11 patients, which ranged between 2% and 27% without any clinically obvious respiratory manifestations. A baseline SaO2 of more than 96% was noted in all patients. Four of 9 postoperative chest x-rays demonstrated atelectasis. CONCLUSIONS: PMC harvest and donor site closure may lead to the recorded decrease in FVC measurements. These changes did not manifest clinically. Nevertheless, alternative methods of surgical defect closure should be considered in patients with severe preexisting pulmonary disorders.

Syndrome of inappropriate antidiuretic hormone or arginine vasopressin secretion in patients following neck dissection.

OBJECTIVES/HYPOTHESIS: The syndrome of inappropriate antidiuretic hormone or arginine vasopressin secretion (SIADH) is a disorder in which release of antidiuretic hormone is independent of plasma osmolarity, resulting in fluid retention and development of dilutional hyponatremia. The incidence of SIADH following neck dissection was found to be 18% to 30% in two separate reports. The incidence of SIADH in a cohort of patients who underwent neck dissection was prospectively studied. METHODS: Eighty-six patients were included in the study, along with a control group of 19 patients who underwent other neck procedures. Patient gender, age, physical condition (American Society of Anesthesiologists score), type of neck dissection, prior treatment, and smoking history were noted. Blood and urine osmolarity and sodium levels were sampled before surgery and during the first 24 hours after the surgery. These were recorded daily in cases with SIADH until the syndrome resolved. RESULTS: The incidence of SIADH was only 1.15% in patients before surgery. The syndrome developed in seven patients following neck dissection (8.14%) and in none of the patients in the control group. SIADH resolved within 72 hours at the latest. No association was found with patient gender, age, physical condition, or type or laterality of neck dissection. A statistically significant connection between the syndrome and history of smoking was noted (P <.05), and it was more commonly seen in patients with node-positive necks (P =.1231). CONCLUSIONS: SIADH following neck dissection may be less common than formerly reported. Previous studies have presented contradicting data concerning the influence of tumor recurrence or prior radiation therapy on its incidence. Our results indicate no such association. A statistically significant connection between smoking and the syndrome was found. No clinical symptoms developed in the patients with SIADH, but it seems prudent to suggest limiting fluid intake in the first postoperative 24 hours for patients following neck dissection.

Amputation neuromas after neck dissection.

OBJECTIVE: We sought to define the incidence of neuroma formation after neck dissection in a large series of patients. METHODS: One hundred fifty-three patients who were seen during a 2-year period (followed for 3 months to 10 years; mean, 52 months) were evaluated for neuroma formation after neck dissection (185 procedures). Cut nerve edges were not routinely ligated or cauterized. RESULTS: Operative records indicated that except for 4 cases, the stumps of the great auricular nerve and cervical branches were left intact after resection. No cases of palpable neuromas were found. In one case of a revised neck, a small macroscopically indiscernible nodule was histologically defined as neuroma. CONCLUSION: No neuromas were discovered in our series of neck dissection cases. If found, it is imperative these lesions be differentiated from recurrent cancer. Our results do not support any interference with cut nerve edges.

Coronoidectomy in maxillary swing for reducing the incidence and severity of trismus--a reminder.

PURPOSE: The maxillary swing approach is a proven method for access to the nasopharynx. However, often, trismus is incurred postoperatively, hampering adequate oral care and follow-up and affecting patients' quality of life. CASE REPORTS: Coronoidectomy was performed in four patients undergoing maxillary swing. Minimal trismus was seen in one patient undergoing repeat irradiation and chemotherapy. After a 1-month period no trismus was observed in the other three patients. CONCLUSION: Coronoidectomy, usually performed in maxillectomy for reducing trismus is a useful adjunct in the maxillary swing procedure.

Quality of life of well-differentiated thyroid carcinoma patients.

The thyroid gland is the second most common site for malignancy in the head and neck region. Quality of life (QOL) of thyroid cancer patients has not been studied directly. The QOL of long-term thyroid carcinoma patients was investigated. A standardized set of questions based on the University of Washington QOL questionnaire for head and neck cancer with specific domains associated with thyroid disease was created. This questionnaire was mailed to patients who underwent total thyroidectomy for well-differentiated cancer in the department of Otolaryngology--Head and Neck surgery at the Chaim Sheba Medical Centre in Israel between the years 1994-2000. Seventy-eight patients undergoing total thyroidectomy were identified. Forty-eight patients were excluded and 20 out of the 30 remaining patients responded to the questionnaires. Six were male and 14 female, 12 were under the age of 45 (these 12 patients were staged as stage 1). Eleven patients underwent neck dissection. General health and QOL were significantly better for the younger age group and so was the calcium balance score. General health and QOL were significantly better for patients undergoing neck dissection. The overall QOL score was 3.8 conforming with 'good' in the questionnaire. Surgery and initial radioiodine treatment scored 6.75 and 6.9 respectively in the distressing scale (0-10 range: 10 = most distressing). The highest distress was encountered during withdrawal from thyroid hormone. Women rated the importance of proper replacement therapy significantly higher than men. Global low scores were found for employment and for effective L-thyroxine replacement therapy. Overall, QOL in these patients was good although lower than expected when compared with other forms of cancer. Age and gender-related differences were noted. Better QOL in neck dissection patients is probably associated with age under 45 years. High distress scores for hormone withdrawal during periodical imaging correspond with former reports and supports use of Thyrogen. Better hormone balance is warranted for this group.

Smoking-induced squamous-cell cancer of the nose.

Squamous-cell cancer (SCC) isolated to the anterior nose is uncommon. Numerous industrial and environmental contaminants have been implicated as causative factors in nasal carcinoma. The association between nasal cancer and smoking was recognized in the 1980s, but results have not been consistent and no possible mechanisms have been suggested. The case histories of 11 patients with SCC limited to the anterior nasal cavity were reviewed. The authors found no relationship with exposures to chemicals previously implicated in nasal cancer. Nine patients with SCC were exposed to cigarette smoke (mean = 103 pack-years). Cigarette smoke may induce cancer directly, thus affecting the mucosa, or by inducing genetic alterations. The authors favor the former mechanism.

Delayed Sino-nasal Complications of Radiotherapy for Nasopharyngeal Carcinoma.

OBJECTIVE: There are only sporadic reports of delayed sino-nasal complications associated with nasopharyngeal carcinoma (NPC) treated with radiotherapy. These include choanal stenosis, osteoradionecrosis, chronic sinusitis, and intranasal synechiae. Most likely, these complications are underestimated as in many institutions nasal endoscopies in NPC patients are not performed routinely. The aim of this study was to identify the onset and incidence of delayed sino-nasal complications in NPC patients and their effect on quality of life (QOL). STUDY DESIGN: Case series with chart review. SETTING: Tertiary medical center. SUBJECTS AND METHODS: A retrospective chart review was performed on all patients treated for NPC in our institution between 1988 through 2009. The inclusion criteria required at least a 3-year follow-up without recurrence. Included patients were contacted prospectively and asked to fill a SNOT-16 questionnaire. RESULTS: Sixty-two patients were included in our review. There were 42 males and 20 females. The average age at onset was 42 years. The AJCC staging for T1, T2, T3, and T4 tumors was 22 (35%), 11 (18%), 18 (29%), and 11 (18%), respectively. Eleven patients (18%) suffered from chronic sinusitis. Nine patients (15%) developed choanal stenosis. Five patients (8%) developed osteoradionecrosis. Two patients suffered from nasal synechiae. Forty-eight patients completed the SNOT-16 questionnaire. Patients with choanal stenosis had the lowest QOL scores out of the cohort. CONCLUSION: The incidence of delayed sino-nasal complications after radiation treatment for NPC is not negligible and should be kept in mind when addressing the quality of life of NPC survivors.

Relation between preoperative computed tomographic criteria of injury to the nasofrontal outflow tract and operative findings in fractures of the frontal sinus.

Injury to the nasofrontal outflow tract is important in the treatment of fractures of the frontal sinus. In 2008 preoperative computed tomographic (CT) criteria or signs of such injuries were proposed and stated to be reliable. The aim of this study was to evaluate the validity of these criteria by comparing the radiological evidence with the operative findings. Thirty-nine patients for whom the data from preoperative CT could be compared with operative findings were eligible for the study, all but 4 of whom had at least one indicator of injury to the outflow tract. Patients whose tracts were found to be obstructed at operation had at least 2 preoperative CT signs of obstruction of the tract. If the outflow tract was obstructed all 3 criteria were significantly more likely to be present than if it was intact (p=0.02). Two criteria or fewer did not correlate significantly with obstruction. Fractures were managed by reconstruction (n=18), obliteration (n=11), or cranialisation (n=10). This study is the first to our knowledge to examine the correlation between preoperative CT criteria and operative findings, and there was a significant difference in the number of criteria present depending on whether the outflow tract was intact or injured. Our findings allow for more accurate planning of management of fractures of the frontal sinus.

Secondary tracheoesophageal puncture and myotomy--A novel outpatient technique.

BACKGROUND: The purpose of this study was to show a novel technique for secondary tracheoesophageal puncture (TEP) and myotomy in patients who previously underwent total laryngectomy. METHODS: Fifteen patients underwent secondary TEP and 3 patients underwent myotomy. In 1 patient, both myotomy and TEP were done concurrently. A Foley catheter is nasally inserted into the esophagus with the patient under local anesthesia and the catheter balloon is inflated at the site of the planned procedure. The myotomy is performed over the inflated balloon for esophageal posterior wall protection and a voice prosthesis is inserted in a small incision made by the physician. When only myotomy is performed, the muscles over the mucosa are incised. A voice test is performed immediately. RESULTS: All patients exhibited good voice rehabilitation. One patient who had a myotomy had a penetration of the pharyngeal mucosa with immediate closure and no sequelae. CONCLUSION: Outpatient Foley catheter-guided myotomy and secondary TEP are simple, safe, time saving, and cost-effective procedures.