Correlation between clinical and MRI assessment of depth of invasion in oral tongue squamous cell carcinoma.

BACKGROUND: Neck metastasis is the most important prognostic factor in oral cavity squamous cell carcinomas (SCC). Apart from the T- stage, depth of invasion has been used as a highly predictable factor for microscopic neck metastasis, despite the controversy on the exact depth cut off point. Depth of invasion can be determined clinically and radio logically. However, there is no standard tool to determine depth of invasion preoperatively. Although MRI is used widely to stage the head and neck disease, its utility in depth evaluation has not formally been assessed. OBJECTIVE: To compare preoperative clinical and radiological depth evaluation in oral tongue SCC using the standard pathological depth. To compare clinical and radiological accuracy between superficial (<5 mm) vs. deep invaded tumor (≥5 mm) METHODS: This prospective study used consecutive biopsy-proven oral tongue invasive SCC that presented to the University health network (UHN), Toronto. Clinical examination, radiological scan and appropriate staging were determined preoperatively. Standard pathology reports postoperatively were reviewed to determine the depth of invasion from the tumor specimen. RESULTS: 72 tumour samples were available for analysis and 53 patients were included. For all tumors, both clinical depth (r = 0.779; p < 0.001) and radiographic depth (r =0.907; p <0.001) correlated well with pathological depth, with radiographic depth correlating slightly better. Clinical depth also correlated well with radiographic depth (r = 0.731; p < 0.001). By contrast, for superficial tumors (less than 5 mm on pathological measurement) neither clinical (r = 0.333, p = 0.34) nor radiographic examination (r = - 0.211; p = 0.56) correlated with pathological depth of invasion. CONCLUSION: This is the first study evaluating the clinical assessment of tumor thickness in comparison to radiographic interpretation in oral cavity cancer. There are strong correlations between pathological, radiological, and clinical measurements in deep tumors (≥5 mm). In superficial tumors (<5 mm), clinical and radiological examination had low correlation with pathological thickness.

International guidelines for the diagnosis and management of hereditary haemorrhagic telangiectasia.

BACKGROUND: HHT is an autosomal dominant disease with an estimated prevalence of at least 1/5000 which can frequently be complicated by the presence of clinically significant arteriovenous malformations in the brain, lung, gastrointestinal tract and liver. HHT is under-diagnosed and families may be unaware of the available screening and treatment, leading to unnecessary stroke and life-threatening hemorrhage in children and adults. OBJECTIVE: The goal of this international HHT guidelines process was to develop evidence-informed consensus guidelines regarding the diagnosis of HHT and the prevention of HHT-related complications and treatment of symptomatic disease. METHODS: The overall guidelines process was developed using the AGREE framework, using a systematic search strategy and literature retrieval with incorporation of expert evidence in a structured consensus process where published literature was lacking. The Guidelines Working Group included experts (clinical and genetic) from eleven countries, in all aspects of HHT, guidelines methodologists, health care workers, health care administrators, HHT clinic staff, medical trainees, patient advocacy representatives and patients with HHT. The Working Group determined clinically relevant questions during the pre-conference process. The literature search was conducted using the OVID MEDLINE database, from 1966 to October 2006. The Working Group subsequently convened at the Guidelines Conference to partake in a structured consensus process using the evidence tables generated from the systematic searches. RESULTS: The outcome of the conference was the generation of 33 recommendations for the diagnosis and management of HHT, with at least 80% agreement amongst the expert panel for 30 of the 33 recommendations.

Prognostic indicators in carcinoma of the nasal vestibule.

OBJECTIVES: Squamous cell carcinoma of the nasal vestibule is rare variant of skin cancer. The TNM classification for skin cancer has been used, whereas, Wang has devised an independent staging system, which he stated was more accurate. The purpose of this study was to analyse the prognostic indicators for survival in a patients with nasal vestibule cancer from the Princess Margaret Hospital, Toronto. DESIGN: A retrospective review of case notes from the Princess Margaret Hospital archives was performed. SETTING: The Princess Margaret Hospital/Ontario Cancer Institute is the tertiary regional Head and Neck Oncology Centre for ON, Canada. PARTICIPANTS: All patients with nasal vestibule cancer (ICD10 C300) were included. MAIN OUTCOME MEASURES: Univariate and multivariate analyses were performed and Kaplan-Meier survival curves constructed. RESULTS: Eighty-four patients were identified. The mean age was 67, there was a male preponderance of 2 : 1. Primary radical radiation was used in 77% of patients. Age (P = 0.02), N stage (P = 0.0001) and Wang classification (P = 0.0001) were associated with prediction of overall survival using multivariate analysis. Grade, depth of invasion and N stage were associated with disease-free survival outcome. A 5-year overall survival rate of 58% and disease-free survival of 52% was seen. CONCLUSION: Nasal vestibule cancer behaves in a more aggressive manner than any other skin cancers affecting the head and neck. The Wangs' classification appears to be a better prognostic indicator for overall survival then the TNM classification for skin cancer.

Reconstructive options in the treatment of osteoradionecrosis of the craniomaxillofacial skeleton.

Osteoradionecrosis (ORN) of the craniomaxillofacial skeleton is a serious and debilitating complication that can occur following radiation therapy in the head and neck. Patients require effective treatment, which eradicates diseased tissue and restores function with minimal additional morbidity in a single stage, a requirement fulfilled in many cases by free tissue transfer. In a 6-year period from 1994 to 1999, 21 patients with ORN were treated by wide resection and free-flap reconstruction. The median interval between radiation therapy and ORN was 4 years (range: 1-33 years). The median radiation dose was 6000cGy. The affected areas were the mandible (15 patients), the temporal bone (three patients), the maxilla (one patient), the cervical vertebrae (one patient) and the frontal bone (one patient). Clinical symptoms included pain, ulceration, a persistent draining fistula, exposure of bone or hardware, and pathological fracture or non-union of bone. Six patients had had previous unsuccessful attempts at conservative surgical resection. Ten patients had preoperative hyperbaric oxygen (HBO) therapy. A number of different flaps were used for reconstruction in these patients. These included free fibula flaps (13 patients), iliac crest flaps (two patients), scapula flaps (three patients) and rectus abdominis flaps (three patients). All patients achieved relief from their presenting symptoms and primary bone or wound healing. One flap (4.8%) was lost. This was successfully reconstructed in a subsequent procedure. There were three flap re-explorations, two for arterial thrombosis and one for venous thrombosis. Conservative measures, such as limited debridement and HBO therapy, may be effective in preventing the progression of ORN. However, they fail to eradicate established ORN, which requires radical surgical resection followed by functional reconstruction with well-vascularised tissue.

A patient- and observer-rated analysis of the impact of lateral rhinotomy on facial aesthetics.

OBJECTIVE: To determine, using patient- and observer-rated facial disfigurement measures, whether a lateral rhinotomy imparts significant aesthetic morbidity. DESIGN: Retrospective and subject-controlled study in a large, tertiary-referral, academic otolaryngology department. Twenty-one consecutive patients who had undergone lateral rhinotomy for the treatment of inverted papilloma were studied in the long-term. MAIN OUTCOME MEASURES: Scores on the following: (1) the novel Patient-Rated Facial Disfigurement Analogue Scale questionnaire and (2) the reliable and validated Observer-Rated Facial Disfigurement 9-Point Likert Scale. RESULTS: Patients rated their facial appearance as minimally altered and significantly less apparent to others. The observers in this study, a surgeon (J.C.I.) and a psychiatrist (M.R.K.), rated the patients' facial disfigurement as minimally visible. Patients seem to rate how apparent their appearance is to others in a similar fashion to observers. The observer-rated facial disfigurement scale used is valid and reliable. CONCLUSION: Patient- and observer-rated facial disfigurement measures suggest that a lateral rhinotomy does not impart significant aesthetic morbidity.

Hyperbaric oxygen therapy and mandibular osteoradionecrosis: a retrospective study and analysis of treatment outcomes.

BACKGROUND: Hyperbaric oxygen (HBO) therapy is recognized as an adjunctive treatment for osteoradionecrosis (ORN). It may also be used prophylactically in patients who require dental extractions and are at high risk for developing ORN. This article reviews the treatment outcomes of patients treated with HBO therapy at the Toronto General Hospital from 1985 to 1997. MATERIALS AND METHODS: A total of 297 charts of patients treated with HBO were reviewed. Criteria assessed included age of patient, gender, original diagnosis, radiation dose, time between radiation treatment and onset of ORN, presence or absence of fracture, orocutaneous fistula, pain, history of a precipitating event triggering ORN, medical status, HBO therapy (total oxygen time, number of dives), method of treatment of ORN and follow-up period. Minimum patient follow-up time for inclusion in the study was 6 months. RESULTS: Adequate information to meet the inclusion criteria was obtained for 75 patients. Group A (51 patients) had been treated for overt ORN with HBO alone, HBO with sequestrectomy, or HBO with sequestrectomy and reconstruction. Group B (24 patients at risk for developing ORN) had been treated with HBO prophylactically for dental extractions. In group A, only 3 patients (5.9%) failed to show improvement. In group B, only one patient (4.2%) had complications during healing. CONCLUSIONS: Encouraging results were achieved when HBO was used in the 2 groups described above. This paper supports existing literature on the potential benefit of HBO as a prophylactic agent and adjunctive treatment of ORN.

The versatile contact Nd:YAG laser in head and neck surgery: an in vivo and clinical analysis.

OBJECTIVE: Lasers have been used in otolaryngology as a surgical instrument for more than 25 years, and the CO2 laser has emerged as the most widely employed surgical laser in use today. However, recent technological advances have made the Nd:YAG laser a challenger as an effective photothermal surgical tool. STUDY DESIGN AND METHODS: This is a two-part study. Tissue injury and healing profiles after application of both the CO2 and Nd:YAG lasers are compared using an in vivo rat tongue model. A prospective clinical review based on the experience of 327 operative cases spanning a 7-year interval using the Nd:YAG laser, highlighting its various applications and associated complications, is detailed. RESULTS: Comparable tissue and healing effects were noted with both lasers in the in vivo rat tongue model with no statistical differences. The clinical application of the laser showed wide versatility in the head and neck with a complication rate of 3%. CONCLUSION: The Nd:YAG laser has proved equivalent in tissue damage and healing to the CO2 laser. The Nd:YAG laser has proved itself to be an excellent and perhaps superior laser for use in head and neck surgery.

Interferons and bladder cancer.

With the introduction of BCG, intravesical instillation of immunotherapeutic agents has become a mainstay of therapy in the treatment of superficial bladder cancer. Interferon is capable of inducing a non-specific cellular and humoral immune response towards tumor cells. It has shown promise in reducing the recurrence and progression rates of superficial bladder cancer. In contrast to BCG, intravesical interferon is associated with minimal side effects and a very low dropout rate. Current research has focused on the use of interferon in combination with immunotherapeutic and cytotoxic drugs.

MR appearances of the locked knee.

This review illustrates the MR appearances of commonly encountered problems that can present as a "locked knee", as well as several unusual causes. Internal derangement of menisci, particularly bucket handle tears, predominate. Loose bodies as a result of trauma/degeneration and lesions such as cysts of the cruciate ligaments and focal pigmented villonodular synovitis are also illustrated. While meniscal tears are the major cause of "locked knee" in clinical practice, interference with normal knee kinematics is non-specific with regard to the diagnosis. Emphasis is therefore given to less frequently seen abnormalities that lead to a mechanical block of knee extension.

Comparison of computer-assisted instruction and seminar instruction to acquire psychomotor and cognitive knowledge of epistaxis management.

Epistaxis is a common problem faced by primary care physicians. Typically, first-hand experience with this problem is not obtained in medical school. A computer learning module was developed to address practical management of epistaxis. It was evaluated by use of third-year clerks and compared with an interactive seminar based on the same material. Fifty-eight students doing their required otolaryngology rotations were randomly separated into 3 groups: (1) doing a preinstruction test, (2) using the computer module, and (3) participating in a small-group seminar. All participants were tested with a short written test and a practical test that involved performing anterior nasal pack placement in a model patient. Percentage scores for the 2 groups were compared by use of t tests, and there was no significant difference between the written, practical, or combined scores at a level where P = 0.05. This study shows that basic patient management and a simple procedure can be taught as effectively with a computer module as with a small-group interactive seminar.

The free iliac crest and fibula flaps in vascularized oromandibular reconstruction: comparison and long-term evaluation.

BACKGROUND: A variety of free flaps have been successfully used for mandible reconstruction. This study compared the short- and long-term results of using the free iliac crest and fibula flaps. METHODS: We conducted a retrospective analysis of 117 patients who underwent mandibular reconstruction, 59 patients with iliac crest and 58 with free fibula. Accurate long-term functional assessment was possible in 31 cases in the iliac crest group and in 48 patients with fibular reconstruction. Anterior or combined anterolateral defects formed 72% and 64% in the iliac crest and fibula groups, respectively. The remainder were pure lateral defects. In both series, a skin paddle was included to provide either lining, skin cover, or both in 77% of the cases, whereas in 23% bone only was used. RESULTS: Complications included two perioperative deaths and three flap losses in the iliac crest group and five flap losses in the fibula group. Long-term functional and cosmetic assessment showed no statistically significant differences in oral continence (p > 0.9), speech (p = 0.57), and contour results (p = 0.80) between the two groups. However, oral deglutition was statistically significantly better in the fibula free flap group (p = 0.009). CONCLUSION: Although the fibula free flap is the flap of choice, the iliac crest is an excellent and reliable complementary flap for mandibular reconstruction.

Needs assessment for an undergraduate otolaryngology curriculum.

A needs assessment was conducted to determine what family doctors need to know about otolaryngology. A survey was mailed to a group of community otolaryngologists and family doctors. They were asked to rate the importance of 46 otolaryngologic topics. A true needs assessment was carried out with a small group of family practice residents to examine which needs were perceived to be significantly different in importance between these 2 survey groups. A list of important topics was generated from the survey. There were many statistically significant differences between the survey groups, but only 2, vertigo and epistaxis, appeared to be potentially important. The family practice residents (n = 8) were asked to complete a short-answer test about epistaxis management and then to demonstrate placement of an anterior nasal pack. Despite having already faced this problem in 50% of cases, the residents had average scores of less than 30%, indicating a lack of knowledge in this area.

A retrospective comparison of the morbidity and cost of different reconstructive strategies in oral and oropharyngeal carcinoma.

PURPOSE: Evaluate and compare the morbidity and costs of different reconstructive strategies in oral and oropharyngeal carcinoma. STUDY DESIGN: Retrospective cross-sectional. PATIENTS AND METHODS: One hundred twenty-seven consecutive patients treated surgically for oral and oropharyngeal carcinoma between 1990 and 1996 were evaluated. Sixty-three patients had segmental mandibulectomies with 30 plate-soft tissue reconstructions and 33 bone-soft tissue flaps. Sixty-four patients had soft-tissue-only reconstructions. The following outcome parameters were analyzed: operative time, intraoperative blood loss, postoperative admission length, ICU and coronary care unit admission length, surgical interventions for complications, re-admissions, and prolonged (>6 mo) gastrostomy tube feeding, and all costs within the disease-free interval. Means and standard deviations were calculated for continuous parameters. Differences among the three groups were analyzed using one-way analysis of variance. For discontinuous parameters, the chi-square test was applied. RESULTS: Longer operative time (1.8 h) and more blood loss (150 mL) for bone-soft tissue flaps were the only statistically significant findings (P<.05) between the three groups. CONCLUSION: There is no rationale for allowing presumed factors of morbidity or cost select for type of reconstruction in patients with oral and oropharyngeal carcinoma.

Supraomohyoid neck dissection. Is it diagnostic or therapeutic?

BACKGROUND: The supraomohyoid neck dissection (SOHND) is often performed in patients with cancer of the oral cavity, where there is no clinical or radiologic evidence of regional metastases. When on pathologic examination positive neck nodes are found, however, some consider it a curative operation, whereas others regard it as a staging procedure only. METHODS: We retrospectively reviewed 43 patients with cancer of the oral cavity who had a SOHND during the period from 1991 to 1994. All patients were staged as having N0 disease and had a total of 48 SOHNDs (38 unilateral, 5 bilateral). The follow-up period was at least 2 years. RESULTS: Seven of 48 N0-staged necks showed occult metastasis (15%). Two of these patients received postoperative radiotherapy. One of 7 (14%) patients with pathologic node-positive disease on the SOHND side developed recurrent ipsilateral neck disease during the follow-up period, whereas 4 (10%) recurrences developed in 41 necks that were pathologically staged as N0. Survival was 88% for patients with pathologically N0 necks versus 86% for patients with pathologically N+; disease. CONCLUSION: Supraomohyoid neck dissection is an effective staging procedure; however, in this group of patients, neck recurrence and patient survival after SOHND appear not to be related to pathology N stage. Also, SOHND with or without adjuvant radiotherapy appears to control the neck in the majority of patients, attesting to therapeutic efficacy. A prospective study is needed, however, to see if a "wait and see" policy does not achieve similar long-term outcome.

An objective analysis of the impact of lateral rhinotomy and medial maxillectomy on nasal airway function.

OBJECTIVE: The lateral rhinotomy and medial maxillectomy procedure, while known to interrupt nasal valve supports, has not previously been reported to adversely affect nasal airway function. The purpose of this study was to utilize state-of-the-art techniques to objectively analyze the impact of this procedure on nasal airway function. DESIGN: The study design was retrospective and subject controlled. METHODS: The study population was derived from an academic, tertiary-referral, otolaryngology-head and neck surgery department with an estimated catchment population of 4 million people. Subjects included 21 consecutive, long-term postoperative patients who had undergone lateral rhinotomy and medial maxillectomy for inverted papilloma. Objective measures included vestibular cephalometric measurements, airflow rhinomanometry, and acoustic rhinometry. RESULTS: Statistically significant results reveal that although lateral rhinotomy and medial maxillectomy are associated with alar collapse, both overall nasal airflow and valve areas are increased. CONCLUSION: Lateral rhinotomy and medial maxillectomy does not adversely affect nasal airway function. This appears to be the result of concomitant resection of the functionally dominant inferior turbinate. This suggests that lateral rhinotomy performed in conjunction with operations not requiring inferior turbinectomy, such as anterior craniofacial resection, may adversely affect nasal airway function.

The value of a routine bone scan in a metastatic survey.

OBJECTIVE: Currently, there is no uniformly accepted metastatic work-up of the patient with head and neck cancer. Various protocols range from selected laboratory investigations and a chest x-ray to more extensive radiologic screening surveys. Although it is desirable to have as much information available as possible prior to making a decision of operability, one is confined by the cost of extensive investigations. This study was conducted to evaluate the benefit of routine bone scanning preoperatively in these patients. METHOD: A retrospective study looked at a consecutive 172 patients undergoing a bone scan with respect to indication, diagnosis, scan result, and tumour stage. RESULTS: Only three patients had a change in their management based on the bone scan results. CONCLUSIONS: The incidence of bone metastases in the majority of patients with squamous cell carcinoma of the head and neck do not warrant routine bone scans for investigation of metastases.

Pharyngocutaneous fistulae in laryngectomy patients: the Toronto Hospital experience.

OBJECTIVE: The purpose of this study was to determine the rate of post-laryngectomy pharyngocutaneous fistulae and its association with age, gender, preoperative radiation, TNM staging, patients comorbidity factors, choice of ablation, choice of reconstruction, modality of postoperative feeding, and whether or not a primary tracheoesophageal puncture was performed. DESIGN: Retrospective clinical study. SETTING: The Toronto Hospital/Princess Margaret Hospital, University of Toronto, Toronto, Ontario. METHOD: One hundred and twenty-five consecutive laryngectomy procedures performed between July 1, 1992, and October 1, 1996, were reviewed. RESULTS: There was an overall fistula rate of 22%. No association found was between fistula rates and age, gender, patient comorbidity factors, TNM stage, choice of ablation, choice of reconstruction, modality of postoperative feeding, or whether a primary tracheoesophageal puncture was performed or not. CONCLUSIONS: At this tertiary care head and neck oncology centre, pharyngocutaneous fistulae remain an unpredictable and serious complication with an estimated economic cost of Cdn $400,000 per year.

Internal jugular vein thrombosis following modified neck dissection: implications for head and neck flap reconstruction.

BACKGROUND: The incidence of internal jugular vein thrombosis (IJVT) following a modified neck dissection remains uncertain. The effect of, or consequences following, IJVT upon pedicled and free flap head and neck reconstructions remains unexplored. METHODS: Twenty-nine preserved internal jugular veins in 24 patients undergoing modified neck dissection were available for prospective study. All patients required a pedicled or free flap reconstruction and received a modified, unilateral or bilateral cervical lymphadenectomy. The patency of all jugular veins was determined preoperatively and postoperatively using a combination of computed tomography (CT) scanning, high-resolution ultrasound, and color-flow Doppler (CFD). RESULTS: The IJVT rate was 14%. The presence of a pedicled myocutaneous flap and left-sided jugular dissections may represent risks to the postoperative patency of the internal jugular vein. Preoperative radiotherapy did not appear to impact negatively upon the thrombosis rate. CONCLUSIONS: Thrombosis of the internal jugular vein may result in significant morbidity for the postoperative oncologic patient. An internal jugular-dependent-free-tissue transfer may risk venous compromise of the flap, whereas the use of a pedicled flap may place the jugular at increased risk for thrombosis. Strategies for deep venous system microvascular recipient recruitment in the head and neck are discussed. Wherever possible, we employ two deep venous systems, the internal jugular, and subclavian (via the external jugular) for flap drainage.