Predictors of long-term smoking cessation in head and neck cancer patients.

Cigarette smoking is a major risk factor for head and neck cancer, and individuals who continue to smoke past diagnosis and treatment are at elevated risk for further disease. In a randomized controlled trial, a state of the art provider-delivered smoking cessation intervention was compared to a usual care advice control condition. The intervention consisted of surgeon- or dentist-delivered advice to stop smoking, a contracted quit date, tailored written materials, and booster advice sessions. Subjects were 186 patients with newly diagnosed first primary squamous cell carcinomas of the upper aerodigestive tract who had smoked cigarettes within the past year. At randomization, 88.2% of subjects were current smokers. At 12-month follow-up, 70.2% of subjects completing the trial (n = 114) were continuous abstainers; among baseline smokers alone the continuous abstinence (CA) rate was 64.6%. The cotinine validation rate at 12 months was 89.6%. Modeling techniques were utilized in order to derive expected CA rates, which included noncompleter subjects (n = 72). The CA rate expected at 1 year for the entire patient population was 64.2%, and for smokers alone the expected CA rate was 59.4%. Logistic regression analysis carried out on baseline smokers identified predictors of 12-month CA status. These included medical treatment, stage of change, age, nicotine dependence, and race. The intervention effect was not significant, although the sign of the effect was positive. Based on these findings, we recommend systematic brief advice to stop smoking for head and neck cancer patients, with a stepped care approach for patients less able to quit.

Trichoepithelioma: report of an unusual case and review of the literature.

Trichoepitheliomas are benign and uncommon skin tumors presenting in the head and neck region. Although they can be solitary, they occur more frequently as multiple lesions with an autosomal dominant inheritance. To the surgeon, they often present the problem of clinical differentiation from basal-cell carcinoma. An unusual case is described, and experience in the treatment of 19 patients is reviewed.

Frontal bone defect with frontal sinus mucopyocele.

For this patient's treatment, all three consultants advise against the Lynch-type frontoethmoidectomy procedure, with or without mucoperiosteal flap reconstruction of the nasofrontal duct. Treatment plan: Culture and sensitivity of pus; 2-3 weeks of intravenous antibiotics followed by osteoplastic flap fat obliteration of frontal sinus; delayed defect repair with methyl methacrylate (Montgomery). Trephination followed by treatment with local and systemic antibiotics (Donald); removal of infected bone and soft tissue (sinus collapse) and delayed defect repair in 6-12 months (Donald, Calcaterra) with metylmethacrylate (Donald) or in situ cured silicone elastomer (Calcaterra).

Partial laryngectomy for glottic cancer after high-dose radiotherapy.

A vertical partial laryngectomy (VPL) for salvage was performed on 25 patients with locally persistent or recurrent squamous cell carcinoma of the vocal cord(s) after high-dose radiotherapy at the UCLA Medical Center between 1969 and 1988. Patients were followed for a minimum of 2 years and a median of 4.4 years after VPL. Ninety-six percent of patients remained free of disease. Tumor was controlled in patients with impaired vocal cord mobility and involvement of the contralateral cord or false cord. The actuarial survival rate was 80% at 5 years. There were no serious wound healing problems. A permanent tracheostomy was required in one patient due to recurrent aspiration pneumonia. Swallowing and voice function were satisfactory in all other patients. These results indicate that the selection criteria for initial VPL can be applied to the salvage situation with similar success.

Tongue flap repair of postlaryngectomy hypopharyngeal stenosis.

Hypopharyngeal stenosis after total laryngectomy has been reported as high as 40%. The most consistent and important causal factor is the extent of the pharyngeal resection since cancers of the pyriform sinus and postcricoid region have the highest incidence of stenosis. Dilation is frequently unsuccessful in the management of postlaryngectomy hypopharyngeal stenosis probably because of its excessive length. The laterally-based tongue flap is effective for repair of these stenoses because of its proximity, epithelial compatibility, and ample length. The technique, details, and successful use in three patients are presented.

Esthesioneuroblastoma: the UCLA experience 1970-1990.

A retrospective review was conducted of all esthesioneuroblastoma cases treated at UCLA Medical Center from 1970 through 1990. Patients were staged according to the staging systems of Kadish, et al., Biller, et al., and a new staging system proposed by the authors. Of 26 patients treated, 74% were alive at 5 years and 60% were alive at 10 years. Combined treatment with surgery and radiation is advocated since a recurrence-free status was achieved in 92% of the patients, compared with 14% for surgery alone and 40% for radiation alone. A craniofacial resection was performed in 7 patients, all of whom have remained disease free. Negative prognostic factors included: age over 50 years at presentation, female sex, tumor recurrence, and metastasis. The proposed new staging system predicted disease-free status better than the other staging systems.

Epiglottic reconstruction after supraglottic laryngectomy.

It has been well established that supraglottic laryngectomy is an effective treatment of laryngeal cancer arising above the vocal cords with cure rates equaling total laryngectomy. Although there is preservation of a near normal voice after supraglottic laryngectomy, chronic aspiration occurs in some patients particularly after extended supraglottic laryngectomy or when there is associated compromised pulmonary function. During normal deglutition, the epiglottis serves to divert food to the pyriform fossae and partially covers the inlet to the airway. These important functions can be accomplished after supraglottic laryngectomy by reconstructing a neoepiglottis from an epiglottic remnant whenever one third or more of the epiglottis can be preserved which is microscopically free of tumor. Our results in 14 patients have shown no clinically significant aspiration after epiglottic reconstruction.

Sternohyoid myofascial flap reconstruction of the larynx for vertical partial laryngectomy.

Reconstruction of the larynx for vertical partial laryngectomy is of paramount importance in eventual voice and deglutition rehabilitation. Many different methods of laryngeal reconstruction have been tried attesting to the challenge of minimizing hoarseness and aspiration after this type of surgery. During the past decade the scope of partial laryngeal surgery has broadened, mandating more extensive reconstructive procedures in order to acceptably rehabilitate upper aerodigestive function. During the past 6 years the author has employed a superiorly-based sternohyoid myofascial flap to reconstruct the larynx after vertical partial laryngectomy in 31 patients. Swallowing was resumed in all patients without significant aspiration. Although decannulation was delayed in 8 patients, all patients were eventually extubated. Voice quality was considered far superior to other reconstructive methods formerly used by the author.

Bilateral omohyoid muscle flap reconstruction for anterior commissure cancer.

Partial laryngectomy for anterior commissure cancer often results in a shortened glottis which produces a high pitched strained voice and an inadequate airway lumen which requires permanent tracheostomy. Vocal fold vibration is impaired both by the shortened length and anterior scarring which profoundly affects the myoelastic properties of the larynx. Many different methods of reconstructing the anterior commissure have been attempted with limited success and many require multiple procedures. A method of anterior commissure reconstruction employing bilateral omohyoid muscle flaps has been performed successfully in four patients. The omohyoid muscles and investing fascia are readily available during partial laryngectomy and can be tailored to reconstitute the anterior commissure. The myofascial flaps epithelialize rapidly and there is little tendency for anterior glottic stenosis. The sphincteric function of the larynx remains intact and the vocal quality surpasses other methods of reconstruction employed by the author.

Antral-ethmoidal decompression of the orbit in Graves' disease: ten-year experience.

The orbital manifestations of Graves' disease usually comprise the most distressing component of this inadequately understood disease entity. Patients with optic neuropathy, exposure keratopathy, or disfiguring proptosis can be helped considerably by decompression of the swollen orbital tissues into the maxillary and sinus cavities. Experience with 104 patients personally operated by the senior author and analyzed by chart review and patient questionnaire indicates that antral-ethmoidal decompression is a successful form of therapy, generally free of serious complications. It is now employed earlier in the course of Graves' ophtholmopathy than in the past.

Parotid hypertrophy with bulimia: a report of surgical management.

Benign hypertrophy of the salivary glands can occur in patients with anorexia nervosa. This enlargement has been related to nutritional deficiencies and bulimia, which is a form of episodic binge eating followed by vomiting. The surgical management of a patient with bulimia and benign bilateral parotid enlargement secondary to bulimia will be discussed. Superficial parotidectomy may be a useful adjunct in managing the cosmetic and psychological aspects of patients with anorexia nervosa and bulimia complicated by massive parotid hypertrophy intractable to medical management.

Supraglottic laryngectomy: series report and analysis of results.

Forty-one consecutive patients who underwent supraglottic laryngectomy at UCLA were reviewed. All of the operations were performed by or under the direct supervision of the same surgeon (T.C.). The majority (68%) had advanced squamous cell carcinoma (Stage III-IV). Approximately one half received radiation therapy as part of planned combined therapy. The overall tumor-free survival, with a two-year minimum follow-up period, was 90%. The most common site of tumor recurrence was neck metastasis. There were four laryngeal recurrences, three of which were salvaged with completion laryngectomy. There was only one completion laryngectomy for severe aspiration. The favorable results in this series are attributed to frozen section control of surgical margins, surgical or radiation therapy treatment of cervical lymph nodes at risk for metastatic disease, and the employment of surgical techniques designed to minimize aspiration.

The coexistence of parathyroid adenoma and thyroid carcinoma.

Not well-known and inadequately understood is the high incidence of conexistent parathyroid adenoma and nonmedullary thyroid carcinoma. In a series of 144 patients with parathyroid adenoma, 11 (8%) were found to have concurrent thyroid carcinoma. Although similar to other multiple endocrine tumor syndromes, these two tumors have no common embryologic cell origin. The most likely explanation for this apparent relationship is the specific oncogenic effect of hypercalcemia on the thyroid gland.

Aerodigestive dysfunction secondary to thyroid tumors.

Although most thyroid tumors first manifest clinically by a neck mass, several patients with thyroid tumor have been treated whose initial complaint was a disturbance of the respiratory and digestive tracts. Because this association is not well recognized, the diagnosis of a thyroid tumor can be delayed, or even missed until the tumor grows much larger causing other symptoms. A series of 269 patients with thyroid tumors seen at UCLA from 1979-1980 was reviewed. Approximately 16% of these patients sought treatment because of aerodigestive dysfunction such as dyspnea, dysphagia, hoarseness, throat discomfort and hemoptysis. Such symptoms often indicate malignancy of substernal extension of tumor. The management of these tumors is discussed.

Prosthetic rehabilitation of large midfacial defects.

Advanced tumors of the midfacial region often require removal of the nose, upper lip, portions of the maxilla, and other adjacent structures. When the resultant defects do not lend themselves to surgical reconstruction, prosthetic appliances may be used successfully to restore the functions of speech and swallowing to near-normal levels. The degree of success depends upon the nature of the previous treatment, the existing surgical defect, and the adaptability of the patient. The most important anatomical consideration is the form and amount of the remaining maxilla. Recent advances in the development of the polyurethanes have resulted in lighter, more flexible, and, therefore, better tolerated prostheses. Close cooperation between the surgeon and the prosthodontist is necessary if successful rehabilitation of these patients is to be achieved.

Current adjuncts for surgery of the sphenoid sinus and pituitary gland.

Surgical intervention in the region of the sphenoid sinus pituitary gland requires extreme precision because of enveloping vital structures. The rhinologic approach to the pituitary gland, once abandoned due to limited visibility and the risk of meningitis, has experienced a renaissance as a result of recent medical and technical advances. Antibiotics have almost eliminated the risk of meningitis, and the operating microscope and televised radiofluoroscope now provide sufficient illumination, magnification, and orientation that injury to nearby structures can be avoided. A mid-line rhinologic approach provides ample exposure and further minimizes operative hazards.

Pseudomonas meningitis complicating head and neck surgery.

Three patients, each of whom had Pseudomonas meningitis as a sequela of an extensive head and neck operation, have been treated successfully. All three patients had cerebrospinal fluid leaks, and operative management of this complication is discussed. Antibiotic management included the parenteral administration of the recently developed drugs gentamicin, carbenicillin, and intrathecal gentamicin. Since extensive head and neck operations are being performed, with increasing frequency and since infectious complications are inevitable, it is mandatory that the otolaryngologist be familiar with current methods of managing these potentially lethal conditions.

Transpharyngeal approach to base of tongue tumors: a comparative study.

Tumors of the tongue base have been traditionally removed by resecting the mandible or using a translabial transmandibular approach. These procedures involve significant morbidity including lip and chin scars, malocclusion, compromised deglutition, chronic aspiration, and altered speech articulation. Therefore alternative techniques have been described to minimize the morbidity associated with transmandibular tongue resection. A retrospective analysis of patients with base of tongue tumors treated at the University of California, Los Angeles, Medical Center between 1981 and 1994 was undertaken. Thirteen patients were treated using a transpharyngeal approach compared with 18 patients who underwent a transmandibular resection. There was no difference in terms of survival or tumor-free margins. However, there was a significant difference in function (P < .05). Patients who underwent transpharyngeal resection had significantly better speech and swallowing and less aspiration compared with those who underwent transmandibular resection of tumors.

Unintentional parathyroidectomy during thyroidectomy.

OBJECTIVES: In the United States thyroidectomy is a frequently performed surgery by both general and head and neck surgeons. Even the most experienced thyroid surgeon, however, has probably received a pathology report stating that an incidental parathyroid gland or parathyroid tissue was found in the submitted thyroidectomy specimen. The aim of this report is to explore some of the pathologic and clinical characteristics of unintentional parathyroidectomy during thyroidectomy. STUDY DESIGN: A retrospective review was performed of thyroidectomies performed at the University of California, Los Angeles, Center for the Health Sciences between 1989 and June 1998 which had pathology reports showing parathyroid tissue contained within the thyroidectomy specimen. This excluded any tissue submitted separately to be evaluated for parathyroid tissue and parathyroid tissue removed unintentionally during a thyroidectomy for a different procedure such as a laryngectomy or surgery for parathyroid disease. METHODS: The pathology slides were reviewed to determine the incidence of unintentional parathyroid tissue removal, the size of the parathyroid tissue found within the thyroid specimen, the location of the parathyroid tissue (extracapsular, intracapsular, intrathyroidal), and whether this unintentional parathyroidectomy during thyroidectomy caused clinical consequences. RESULTS: Four hundred fourteen applicable thyroidectomies were performed during this time with 45 (11%) discovered cases of unintentional parathyroidectomy during thyroidectomy. Twenty-five (56%) cases were discovered during thyroidectomy for benign disease, and 20 (44%) during thyroidectomy for malignant thyroid disease. All the parathyroid tissue was normal and was found in extracapsular (58%), intracapsular (20%), or intrathyroidal (22%) locations. Of these 45 cases, recurrent laryngeal nerve paralysis was found only in two patients who had the nerve resected intentionally during the thyroidectomy, and none of the patients developed permanent hypocalcemia. CONCLUSIONS: Incidental parathyroid gland tissue was reported in 11% of the thyroidectomies performed in our series, without the clinical consequence of hypocalcemia. The majority (78%) of this parathyroid tissue was found in the extracapsular and intracapsular locations; therefore it is possible that these parathyroid glands may be identified and preserved with more meticulous inspection of the thyroid capsule during and after thyroidectomy to decrease the incidence of unintentional parathyroidectomy during thyroidectomy in the future.

Inverting papillomas of the nose and paranasal sinuses.

Inverting papilloma of the nose and paranasal sinuses can sometimes be very difficult to distinguish from other nasal tumors, and the confusion ranges from allergic nasal polyposis to carcinoma. They are also certainly characterized by multiple recurrence, particularly after limited operations. The experience with 34 cases seen at UCLA over the past two decades is analyzed and a philosophy of treatment is outlined. We favor wide local excision which generally necessitates a lateral rhinotomy and medial maxillectomy. The operative approach will be described in detail.