CT and MR appearance of recurrent malignant head and neck neoplasms after resection and flap reconstruction.

PURPOSE: To describe the appearance of recurrent malignant neoplasms in patients who have undergone resection of primary head and neck tumors with flap reconstruction. METHODS: Thirty-two examinations, 26 CT and 6 MR scans, were retrospectively reviewed in 25 patients with documented recurrent malignant neoplasms. Confirmation of disease was by biopsy or disease progression. The flaps included 15 myocutaneous, 6 free composite, 2 jejunal free grafts, and 2 combined jejunal and myocutaneous flaps. RESULTS: The most common location of recurrence was in the primary tumor bed involving the undersurface or suture line of the reconstruction flaps, 14 of 32 scans; both nodal and flap recurrence was seen in 12 of 32 scans. CONCLUSIONS: When examining patients who may have recurrent disease after flap reconstruction, the radiologist should be aware of the type of flap used and the expected appearance. Tumor recurrence in this patient population is manifest either as a focal recurrent mass at or near the suture line of the reconstruction flap, or nodal disease, usually in the contralateral neck.

CT of muscle necrosis following radiation therapy in a patient with head and neck malignancy.

Radiation-induced changes within skeletal muscle may be seen on follow-up CT or MR scans in patients who have undergone postoperative radiation therapy for head and neck tumors. Because they may mimic recurrent disease, these changes should be borne in mind.

Endoscopic paranasal sinus surgery: radiographic evaluation of severe complications.

PURPOSE: To report our experience with the radiographic evaluation of severe complications resulting from the functional endoscopic sinus surgery (FESS) procedure. PATIENTS: Ten major complications were reviewed retrospectively. FINDINGS: Ten major complications occurred. Eight of 10 had injury to the floor of the anterior cranial fossa, fovea ethmoidalis (roof of the ethmoid sinus), or roof of the sphenoid sinus. Six patients presented with meningitis or rhinorrhea, two presented with headache and massive pneumocephalus; one patient who presented with meningitis had a large nasal frontal encephalocele. Noncontrast brain CT that included the paranasal sinuses adequately evaluated the source of pneumocephalus. Thin-section coronal CT accurately predicted the site of leak in five patients. Both coronal sinus CT and MR imaging were useful to confirm the nasal encephalocele. Two of 10 had vascular injury secondary to FESS. One patient presented with subarachnoid hemorrhage seen on noncontrast CT and cerebral angiography demonstrated an aneurysm of the anterior cerebral artery. The second patient suffered severe intraoperative hemorrhage. Emergency angiography revealed a pseudoaneurysm of the cavernous carotid artery, and balloon occlusion of the artery was performed. No deaths occurred in this series. CONCLUSION: Radiologists should be familiar with the rare, but potential complications of this commonly performed procedure in order to help direct the work-up in an efficacious manner.

Metastatic follicular thyroid carcinoma masquerading as a chordoma.

A 61-year-old Caucasian man presented with otalgia, dysarthria, and weight loss. Neurological examination revealed palatal hypomotility, and weakness of the facial and tongue muscles. Magnetic resonance imaging of the head demonstrated the presence of a soft tissue mass in the clivus. Histologic examination of resected tumor disclosed well-differentiated thyroid follicles that invaded the local osseous tissues. Physical examination and radioiodine images of the thyroid gland were normal. The serum thyroglobulin concentration was markedly elevated (1011 ng/mL). A 0.9-cm well-differentiated benign-appearing left thyroid lobe follicular neoplasm with a thick fibrous capsule was found following diagnostic thyroidectomy. This report illustrates that clinically significant distant metastases can arise from occult follicular thyroid neoplasms that, according to standard histologic criteria, are benign. The presence of a thick fibrous capsule, even in the absence of vascular or capsular invasion, may identify follicular neoplasms that have metastatic potential.

Major ambulatory surgery of the otolaryngologic patient.

Many otolaryngologic procedures can be performed safely on an ambulatory basis. Complications can be minimized by careful patient and procedure selection. This article describes common procedures adaptable to outpatient surgery and addresses the surgeon's added responsibility in this setting.

Oncofetal antigen expression in head and neck carcinoma.

Oncofetal antigens (OFA) are proteins expressed during periods of embryonal/fetal development and on malignant cells. Previous investigations detected the presence of phase-specific 44- and 200-kd OFA, using a monoclonal antibody (MoAb 115). This study will determine if primary head and neck squamous cell carcinomas express the 44-kd OFA, and will assess the possible role of OFA in oncogenesis. Fifteen primary human head and neck squamous cell carcinomas (HNSCC) and six HNSCC cell lines were tested for OFA expression. Thirteen primary cancers and three cell lines demonstrated various degrees of OFA positivity. Oncofetal antigens are proposed to represent a proto-oncogene active during fetal development and malignant growth in head and neck squamous cell carcinomas.

Imaging modalities in recurrent head and neck tumors.

Patients with recurrent neoplasms of the head and neck present perplexing management problems, and accurate preoperative assessment of their disease is crucial. Thirty-eight patients with suspected recurrent neoplasms comprise this study: 30 had computed tomography scans, 4 had magnetic resonance images, and 4 patients underwent both computed tomography and magnetic resonance imaging to assess the anatomical extent of pathology in 34 malignant and 4 benign tumors. Contrast enhancement was essential for detecting disease on computed tomography scan. Differentiation of recurrent tumor was more difficult when the patient had undergone radiation. Magnetic resonance imaging demonstrated superior visibility in recurrent parotid and paranasal sinus neoplasm, but was less helpful in laryngeal and pharyngeal recurrences. Computed tomography demonstration of a mass with infiltration of normal fat or tissue planes or lymphadenopathy correlated highly with recurrent disease. Imaging techniques and fine points for determining recurrent neoplasms are presented.

Prognostic factors in craniofacial surgery.

From 1979 to 1989, 21 patients underwent craniofacial resection for malignancies involving the anterior skull base. Histologic types included 8 squamous cell carcinomas, 3 chondrosarcomas, 2 melanomas, 2 basal cell carcinomas, 2 adenocarcinomas, 2 poorly differentiated carcinomas, 1 malignant schwannoma, and 1 malignant hemangiopericytoma. Survival was 57%, with follow-up of 41 months. A 50% complication rate included osteomyelitis, cerebrospinal fluid rhinorrhea, meningitis, brain abscess, epidural abscess, and syndrome of inappropriate antidiuretic hormone. Recurrent disease occurred in 9 patients (41%), the most reliable predictor being dural invasion indicated preoperatively by CT scan or at operation. Patients demonstrating dural involvement (N = 9) had a 22% survival rate, while patients without (N = 12) had a survival rate of 83%. The impact of dural invasion on long-term survival is emphasized. Though complications were frequent, long-term results were favorable.

Pediatric penetrating head and neck trauma.

Penetrating head and neck trauma in children causes uncommon and potentially life-threatening injuries. We reviewed the charts of 21 patients who sustained penetrating injuries to the face or upper neck. Seventeen males and 4 females, aged 32 weeks' gestation to 19 years (mean = 10.2 years) comprised the study population. There were 15 gun-shot wounds, 1 shotgun injury, and 5 stab wounds. Significant problems included 7 vascular injuries, 6 central nervous system injuries, 5 ocular injuries, 3 airway compromises, 2 facial nerve injuries, 1 cervical esophageal penetration, and 2 cases of pneumothorax. Three deaths occurred, but the majority of the patients survived and sustained minimal permanent disability. Included in this review is a unique case of an intrauterine gunshot wound to the face at approximately 32 weeks' gestation. The treatment protocol, differences from adult patients, and management highlights are reviewed.

Laryngotracheal trauma: a protocol approach to a rare injury.

Laryngotracheal trauma is rare and complications are frequent. Twelve major series totalling 392 cases have been published over the past decade, with complication rates as high as 40%. We have treated over 30,000 trauma victims at our Level I Trauma Center over the past 5 years, of which 109 had neck injuries, but only 12 suffered cervical laryngotracheal trauma. The mechanism of injury was penetrating in eight and blunt trauma in four. The time to tracheostomy decannulation varied from 7 to 60 days. Airway patency was assured without stenosis or significant granulation tissue in 10 of the 12 patients. Three patients suffered permanent voice changes. Based on review of the 392 previously reported cases and a critical analysis of our 12 cases, a detailed management algorithm is proposed.

Biology of tumors and head and neck cancer chemotherapy.

The management of advanced squamous cell carcinomas of the head and neck has shown disappointing results with surgery and radiation alone. Chemotherapy offers a third method of managing these patients. A background of basic tumor biology and cell cycle kinetics is essential in designing an effective head and neck chemotherapeutic protocol. The principles of the cell cycle, stem cell regulation, and doubling times are discussed. The kinetic classification of chemotherapeutic agents and experimental hypotheses of clinical relevance are reviewed.

Management of nasopharyngeal and oropharyngeal stenosis in children.

Nasopharyngeal stenosis and oropharyngeal stenosis are rare and challenging problems in the pediatric population. The most common etiology is currently the surgical trauma associated with adenotonsillectomy. Stenosis can vary from a thin band to a complete obstructing cicatrix. Presenting symptoms range from mild hyponasal speech to severe airway obstruction. We present a series of eight children with varying degrees of stenosis and associated symptoms. Choice of treatment varied with the severity of disease. In our series, successful interventions included triamcinolone acetonide injection, lysis of adhesions, rotational and advancement mucosal flaps, and jejunal free flap. Preoperative evaluation and individualized surgical repair are essential for successful treatment.

Pediatric maxillofacial trauma: unique features in diagnosis and treatment.

The purpose of this study was to review mechanisms, etiologies, associated injuries, and treatment of maxillofacial trauma in children and to compare them to similar adult injuries. Thirty blunt injuries (1984-1986) comprised the children's group, and 176 injuries, the adult group. Multiple associated injuries were more common in children, the most frequent being CNS and orthopedic injuries. Detailed anatomy of mandibular fractures required pleuridirectional tomography in 63% of the pediatric cases compared to 12% in adults. In the children's group, the mandibular fractures were favorable in 56% of cases compared to 15% in adults. Children required shorter periods of intermaxillary fixation with no child requiring reapplication of fixation. Based on these comparisons, a protocol for the management of pediatric maxillofacial injuries has been developed.

Three-dimensional magnetic resonance imaging evaluation of pediatric tracheobronchial tree.

Magnetic resonance imaging (MRI) of the airway has recently emerged as a diagnostic tool for evaluating tracheobronchial obstruction in pediatric patients. Computer-assisted reconstructions of transaxial images have enabled three-dimensional reconstructions of the airway to be manipulated in any plane and visualized in relation to adjacent anatomical structures. Eight patients in whom magnetic resonance imaging was used to diagnose a variety of airway obstructive lesions are presented. A protocol for the evaluation of pediatric tracheobronchial obstruction is presented, with the role of three dimensionally reconstructed MR imaging emphasized.

Neonatal laryngoceles. A cause for airway obstruction.

The neonatal laryngocele is a congenital pathologic entity originating in the saccule of the laryngeal ventricle. This entity may present as an uncommon cause of neonatal airway obstruction. We present two cases of this condition and the management undertaken. Both patients demonstrated significant airway distress. Evaluation of each patient included either plain x-ray films of the neck, ultrasound, or computed tomography of the neck. A cystic mass, containing air and fluid, was identified causing external compression of the airway in each case. Surgical intervention required airway endoscopy and an external approach to excise the mass. Tracheotomy was avoided in both cases; however, one infant required further surgery for laryngomalacia. Both children have done well in follow-up.

44-kd oncofetal transplantation antigen in rodent and human fetal cells. Implications of recrudescence in human and rodent cancers.

OBJECTIVE: This article summarizes the phase-specific nature of a cell surface, 44-kd tumor-associated transplantation antigen glycoprotein expressed during early and middle gestation in a portion of rodent and human fetal cells during normal fetal tissue development and illustrates how this glycoprotein is consistently recrudesced in primary and established human squamous cell carcinomas and other human and rodent tumors. The oncofetal antigen was not detectable in any human or rodent term fetal tissue or normal adult tissues tested. The tumor-associated transplantation antigen was tumor specific, yet not germ-line specific (expressed in lymphomas, sarcomas, and carcinomas) in human or rodent cancers. Rodent model tumor studies have shown 44-kd oncofetal antigen can act as a tumor-associated autoantigen of potential use in cancer detection and therapy. DESIGN: The oncofetal antigen was detected by immunogenicity, flow cytometry, and Western blotting in syngeneic rodent tumor recipients and by the last two methods in humans with progressive cancer. Syngeneically derived mouse monoclonal antibody (MoAb 115) was used to identify 44-kd oncofetal antigen. Early to middle gestation, oncofetal antigen-positive, mouse embryo/fetal cells used to stimulate the hybridoma were tested for immunogenicity as a tumor-associated transplantation antigen in syngeneic hosts. SETTING AND PATIENTS: Patients presenting with head and neck squamous cell carcinoma (N = 25) and other carcinomas at the University of South Alabama Medical Center, Mobile, underwent a biopsy, and the tumors were mechanically dispersed and were then tested for oncofetal antigen expression directly in flow cytometry. The tumors were also cultured and tested as squamous carcinoma cell lines. Growing squamous carcinoma cells and uncultured tumor cells were stained with MoAb 115 or control MoAb. Extracts of the cells were banded by electrophoresis in gels, Western blotted, and reacted with MoAbs and enzyme-linked immunosorbent assay second antibody. Time-mated mouse fetus and human fetal cells were also stained with MoAb 115 or control antibody and analyzed in the flow cytometer. RESULTS: Eight- to 13-day mouse fetal cells conferred protection against syngeneic tumor challenge. Term 18- to 21-day fetal or neonate or adult mouse cells were nonprotective. All head and neck squamous cell carcinomas tested expressed 44-kd oncofetal antigen by flow cytometric analysis and in Western blots as did ATCC cell lines of these tumors, whereas normal control tissues were negative. Second trimester human fetal cells were 44-kd oncofetal antigen positive. A large spectrum of rodent sarcomas and lymphomas express the OFA. CONCLUSIONS: Shared 44-kd oncofetal antigen OFA offers promise as a tumor detection marker in human squamous cell carcinoma and other human carcinoma development, and syngeneic mouse tumors are good model systems to explore oncofetal antigen antigenicity.

The role of radiation therapy in the management of catecholamine-secreting glomus tumors.

The major source of controversy that surrounds the use of radiation for glomus tumors is the finding of persistent chief cells years after completion of the treatment. Questions have been raised as to the viability of the irradiated chief cell and its capacity to proliferate. The radiotherapists consider a stable glomus tumor a radiation "cure," whereas skull base surgeons are fearful that these lesions will continue to slowly grow and cause problems 20 to 30 years later. We have recently managed a patient who was not a candidate for surgery, with a catecholamine-secreting glomus jugulare tumor. After 4750 rad of radiation therapy, no changes in tumor size or in catecholamine secretion have been observed (at 20 months of followup). The implications of the case are discussed.

Intravenous anesthesia and jet ventilation for laser microlaryngeal surgery.

Competition between otolaryngologists and anesthesiologists for the limited space of the airway results in compromised control for both concerns. The surgeon desires an unobstructed view, whereas the anesthesiologist must ensure adequate ventilation. The drawbacks of standard methods include inadequate airways, inadequate visualization, and operating room contamination from inspired gases. Since 1984, we have developed a technique utilizing jet ventilation delivered through a metal delivery system providing a relatively safe, ignition-free environment. A total intravenous anesthetic technique is used to avoid any environmental contamination. The newer short acting, high potency narcotic, sufentanil citrate, combined with a short acting muscle relaxant, atracurium besylate or vecuronium bromide, have made this technique an ideal one for our needs. The pulse oximeter provides an invaluable margin of safety. This technique has been employed in 36 microlaryngeal procedures performed on 21 patients with a uniformly smooth perioperative course and only one complication. The technique, possible pitfalls, and applications are discussed.

Craniofacial approach for the neonatal management of frontonasal encephalocoeles.

Three nasofrontal encephalocoeles managed at the University of South Alabama Medical Center are presented. Each consisted of abnormal brain originating from one frontal lobe, although the amount of cerebral tissue and the accompanying skin and meningeal layers varied. The encephalocoeles protruded through a defect in the anterior skull base near the cribiform plate. Repair in the neonatal period was required in two of the infants because of the size of the lesion and obstruction of the nasal airway. The operative approach utilized a bifrontal craniotomy with resection of the encephalocoele intradurally, repair of the anterior cranial fossa dura and osteoplastic repair of the foramen cecum defect. The closure of the facial defect depended upon the nature of the skin covering the herniation; either absence or excess of skin occurred. The preoperative evaluation disclosed associated congenital deformities in 2 of 3 patients in this series. Computerized tomographic scanning was of importance in preoperative planning. The operative technique can be modified to allow for each child's unique anatomy. Repair of nasofrontal encephalocoeles in the neonatal period may simplify the required operative procedures.

Invasive basal cell carcinoma of the temporal bone.

Basal cell carcinomas involving the ear represent a spectrum of diseases, from a small superficial auricular lesion to an advanced destructive malignancy invading the temporal bone. The biologic activity of the morphea-form basal cell carcinoma variant of tumor and a postauricular location predispose to an aggressive biologic pattern. Management requires a thorough evaluation with determination of the degree of cranial and possible intracranial invasion. These lesions usually can be managed with partial temporal bone resections, although prognosis for patients with advanced lesions may be poor.