Spontaneous Giant Pseudomeningocele in the Middle Cranial Fossa as a Cause of Pulsatile Proptosis.

The authors report a case of a 70-year-old man who presented with a long history of left pulsatile proptosis, irritation, and a pressure sensation behind the eye. Initial computed tomography brain demonstrated the presence of a suspected ethmoid sinus mucocele. Endoscopic sinus surgery was performed to drain the mucocele. On cautious opening of the nasal mucosa, cerebrospinal fluid was encountered requiring subsequent repair with local mucosal flap and fat graft. On further magnetic resonance imaging, the lesion was confirmed to be giant pseudomeningocele arising from the sphenoid sinus, with extensive invasion and erosion of the middle cranial fossa including the left lateral orbital wall. Here, the authors report, to the best of their knowledge, the first case of spontaneous giant pseudomeningocele in the middle cranial fossa causing pulsatile proptosis. In examining this case, the authors will also discuss the pathogenesis, diagnosis, and management of giant pseudomeningoceles, especially in the situation of a misdiagnosis.

Survival Outcomes of Mucosal Melanoma in the Head and Neck: Case Series and Review of Current Treatment Guidelines.

PURPOSE: Malignant mucosal melanoma of the head and neck (MMHN) is an aggressive and rare neoplasm with poor long-term outcomes. The aim of this study is to evaluate the outcomes of patients treated by a single-institution head and neck multidisciplinary team. MATERIALS AND METHODS: In this retrospective case series, all MMHN cases treated at the Royal Melbourne Hospital from 1990-2015 were retrospectively reviewed. Patient demographic characteristics (eg, age), treatment offered, pathology, and outcomes were collected, tabulated, and correlated with outcomes. Survival outcomes were calculated by the Kaplan-Meier method. Comparison was made between oral and sinonasal melanomas. RESULTS: A total of 16 cases were identified. Two were excluded because of inaccessible data. Of the 14 remaining cases, 8 were sinonasal melanomas and 6 were oral cavity melanomas. Sinonasal tumor patients presented with epistaxis or visual impairment. Oral melanoma patients presented with pigmented lesions or ulceration. Follow-up ranged from 4 months to 11 years. In 2 patients, locoregional recurrences developed that were successfully re-excised. Six patients died of distant metastases despite clear surgical margins. Two patients with sinonasal melanomas died of extensive local disease with intracranial invasion. One patient died 4 years after diagnosis without disease. There were no failures in the neck. The 2- and 5-year overall survival rates were 63.3% and 31.7%, respectively, by the Kaplan-Meier method. The difference in survival between oral and sinonasal melanomas was not statistically significant. CONCLUSIONS: Despite clear surgical margins, MMHN has a poor prognosis and most deaths are due to distant metastases. Systemic therapies such as those used in cutaneous melanoma treatment might be used in the future for MMHN.

Saliva management options for difficult-to-wean people with tracheostomy following severe acquired brain injury (ABI): A review of the literature.

PRIMARY OBJECTIVE: To evaluate the evidence on saliva management options in those people who have a tracheostomy in situ following an acquired brain injury and to ascertain whether any of these treatments may facilitate tracheostomy decannulation. METHODS: The search was conducted on Medline, Embase, Cinahl and Central databases since 1990 and the evidence has been critiqued and summarized. Saliva management options were identified and analysed to see whether they had evidence or clinical support for the population. MAIN OUTCOMES AND RESULTS: There is a paucity of evidence in this area and clinical decision-making requires evidence from other populations. Saliva management issues in this population are most likely to be related to dysphagia. Treatment options include behavioural/compensatory therapies which should be tried in all cases, with adjunct pharmaceutical therapies or surgical options to reduce saliva volume as clinically appropriate. CONCLUSION AND FUTURE DIRECTIONS: This group of people is complex and requires a multi-disciplinary team to guide decision-making. High quality control studies looking at the effectiveness of dysphagia therapy and guidelines regarding botulinum toxin injections are recommended.

Optimising Patient Outcomes in Tongue Cancer: A Multidisciplinary Approach.

A multidisciplinary approach to the management of tongue cancer is vital for achieving optimal patient outcomes. Nursing and allied health professionals play essential roles within the team. We developed symposia comprising a series of online lectures offering a detailed perspective on the role each discipline and consumer perspective has in the management of patients with tongue cancer. The topics, including epidemiology and prevention, diagnosis, treatment planning, surgery, adjuvant care, and the management of recurrent or metastatic disease, were thoroughly examined. The symposia highlighted the significance of fostering collaboration and continuous learning through a multidisciplinary approach. This initiative should be relevant to healthcare professionals, researchers, and policymakers striving to enhance patient outcomes in tongue cancer care through innovative collaboration.

Anatomic comparison of nasal versus lateral surgical access to the petrous apex.

To compare anatomic access to the petrous apex via the nasal and lateral approaches. Hundred consecutive fine-cut CT temporal bones at the Royal Melbourne Hospital from July 27, 2007 to October 30, 2010 were reviewed. Easy lateral access allowed use of a 4 mm burr past vital structures. Easy nasal access was defined as sphenoid pneumatization to/beyond the posterior sella and laterally beyond the maxillary/vidian nerves. Three patients with petrous apex pathology were also reviewed. Easy lateral and nasal access occurred in 74 (37%) and 79 (39.5%) sides, respectively. Easy nasal and lateral access were not strongly correlated (r = 0.10, P = 0.15). A well-pneumatized mastoid (62.5%) was strongly correlated with a large sphenoid (63%, P < 0.001). Pneumatization of the mastoid corresponds to sphenoid sinus size. However, surgical access to the petrous apex is more determined by proximity of vital structures. Easy surgical access via the nasal or lateral approaches was not strongly correlated. Petrous apex lesions requiring surgery should be considered for both approaches.

Head and neck mucoepidermoid carcinoma: does AFIP histological grading correlate with rate of nodal metastases?

OBJECTIVE: The aim of this study is to retrospectively evaluate the presentation of head and neck mucoepidermoid carcinoma at the Royal Melbourne Hospital and identify the significance of AFIP histological grading on the risk of neck metastasis and cancer free survival. MATERIALS AND METHODS: This study is a retrospective cohort analysis of patients treated for head and neck mucoepidermoid carcinoma at the RMH between 2005 and 2022. Patient demographics, treatment, pathology, in particular the AFIP histological grading of the primary tumour, and outcomes were collected and tabulated. Time to recurrence was recorded, and survival outcomes were calculated with Kaplan-Meier method. Comparisons were made on different histological grading and regional metastases. RESULTS: Thirty-three patients were identified and thirty met the inclusion criteria. There was an age range of 18-77 years (median 54 years) with no significant sex difference. Our patients had a 94% 5-year survival and an 86% 10-year survival. Thirteen patients had elective neck dissection and 2 out of 13 (15%) of the patients had positive neck disease. Of the two patients with regional metastasis, the primary tumour was graded as intermediate and low grade. No high-grade MEC patients had regional metastasis. CONCLUSION: Mucoepidermoid carcinoma of the head and neck is associated with a good disease-specific and overall survival despite the presence of regional metastasis. The AFIP histological grading system did not have a statistically significant correlation to the incidence of nodal metastasis.

Outcomes of patients with maxillofacial osteosarcoma: a review of 15 cases.

PURPOSE: To assess clinical behavior, response to treatment, and factors affecting survival in maxillofacial osteosarcoma treated at a tertiary referral center. PATIENTS AND METHODS: Ethics-approved retrospective review of clinical and pathological records was undertaken for 15 patients managed by the Royal Melbourne Hospital Head and Neck Oncology Tumor Stream. RESULTS: Treatment was a combination of surgery and chemotherapy. Chemotherapy was given as adjuvant, neoadjuvant, or in combination. The overall 2-, 5-, and 15-year disease-free survival rates in this study were 92%, 74%, and 74%, respectively. Using Kaplan-Meier analysis with log rank tests, increasing T stage (P = .01) and positive margins (P = .003) were found to affect survival significantly. Neoadjuvant chemotherapy was not significantly associated with tumor necrosis or improved survival. CONCLUSIONS: Tumor size and adequacy of local control were found to be the most important predictors of outcome.

Genomic Signature of Oral Squamous Cell Carcinomas from Non-Smoking Non-Drinking Patients.

Molecular alterations in 176 patients with oral squamous cell carcinomas (OSCC) were evaluated to delineate differences in non-smoking non-drinking (NSND) patients. Somatic mutations and DNA copy number variations (CNVs) in a 68-gene panel and human papilloma virus (HPV) status were interrogated using targeted next-generation sequencing. In the entire cohort, TP53 (60%) and CDKN2A (24%) were most frequently mutated, and the most common CNVs were EGFR amplifications (9%) and deletions of BRCA2 (5%) and CDKN2A (4%). Significant associations were found for TP53 mutation and nodal disease, lymphovascular invasion and extracapsular spread, CDKN2A mutation or deletion with advanced tumour stage, and EGFR amplification with perineural invasion and extracapsular spread. PIK3CA mutation, CDKN2A deletion, and EGFR amplification were associated with worse survival in univariate analyses (p < 0.05 for all comparisons). There were 59 NSND patients who tended to be female and older than patients who smoke and/or drink, and showed enrichment of CDKN2A mutations, EGFR amplifications, and BRCA2 deletions (p < 0.05 for all comparisons), with a younger subset showing higher mutation burden. HPV was detected in three OSCC patients and not associated with smoking and drinking habits. NSND OSCC exhibits distinct genomic profiles and further exploration to elucidate the molecular aetiology in these patients is warranted.

Contralateral neck failure in oral tongue cancer: Outcomes from two centers using predefined treatment criteria.

BACKGROUND: The objective was to determine the incidence of, and factors associated with contralateral neck failure (CNF) in oral tongue squamous cell carcinoma (OTSCC). METHODS: Consecutive patients with OTSCC between 2007 and 2016 were included. The predefined policy of the contralateral neck included neck dissection (ND) where the primary tumor extended/crossed midline or the contralateral neck was involved; and elective nodal irradiation (ENI) where the primary tumor was ≤1 cm from midline/2 cm from tip. RESULTS: This study included 258 patients. ND was ipsilateral 169 (66%) and bilateral 33 (13%). Fifty-five patients (21%) received ENI to the undissected contralateral neck. CNF occurred in 19 patients (7%) and was similar by treatment received. Utilizing this approach, we observed higher rates of CNF with increasing N classification, perineural invasion, extracapsular extension, and depth of invasion ≥6 mm. CONCLUSIONS: Using our institutional policy of treatment to the contralateral neck, a low rate of CNF (≤10%) was observed.

Relationship between age, comorbidities and complications in head and neck cancer patients undergoing curative surgery.

BACKGROUND: Both age and comorbidity are accepted as significant prognostic factors for adverse perioperative outcomes in major surgery. Elderly patients may be overlooked for radical treatment for fear of poor perioperative outcome. We aim to assess the relationship between age, comorbidities and post-operative outcomes in a tertiary head and neck unit. METHODS: A retrospective analysis was undertaken on 651 patients who underwent surgery for head and neck cancer at a tertiary hospital between 2007 and 2014. RESULTS: A total of 253 (38.9%) patients were aged ≥70 years and 398 (61.1%) patients were ≤69 years. Age alone did not predict prolonged post-operative stay, perioperative complications nor perioperative mortality. Congestive cardiac failure and/or complicated diabetes were significantly associated with poor outcomes, as was male sex. CONCLUSION: Patients of any age with cardiac failure or complicated diabetes have a higher rate of post-operative complications in head and neck surgery.

Impact of histological Oral Tongue Cancer margins on locoregional recurrence: A multi-centre retrospective analysis.

OBJECTIVES: To assess the effect of the histological margins (HM) upon locoregional failure (LRF) and overall survival (OS) for oral tongue squamous cell carcinoma (OTSCC). MATERIALS AND METHODS: We undertook a retrospective review of 258 patients, across two institutions, treated for OTSCC between 2007 and 2016. A Cox-proportional hazards model was used to compare the relative hazard ratio of HM to the accepted standard of 5 mm margins for LRF and OS. RESULTS: The median follow up period was 4.8 years. The 5 year OS and freedom from LRF were 69% and 75% respectively. The Cox-proportional hazards model adjusted for age, DOI and LVI showed increasing risk of mortality and LRF with decreasing HM widths of <5 mm. CONCLUSION: HM >5 mm were associated with a risk reduction of both LRF and mortality in OTSCC. This study supports >5 mm HM being the oncologic goal of surgery.

Functional outcomes after transoral robotic surgery for head and neck cancer.

OBJECTIVE: To evaluate functional outcomes following transoral robotic surgery for head and neck cancer. STUDY DESIGN: Case series with planned data collection. SETTING: Academic hospital. SUBJECTS AND METHODS: Between March 2007 and December 2008, 54 of 62 candidate patients underwent transoral robotic tumor resection. Outcomes include airway management, swallowing (MD Anderson Dysphagia Inventory), and enterogastric feeding. RESULTS: Tumors were most commonly oropharynx (61%) or larynx (22%) and T1 (35%) or T2 (44%). Many received radiotherapy (22% preoperatively, 41% postoperatively) and chemotherapy (31%). Endotracheal intubation was retained (22%) for up to 48 hours, tracheostomy less frequently (9%), and all were decannulated by 14 days. Most commenced oral intake prior to discharge (69%) or within two weeks (83%). A worse postoperative Dysphagia Inventory score was associated with retained feeding tube (P=0.020), age>60 (P=0.017), higher T stage (P=0.009), laryngeal site (P=0.017), and complications (P=0.035). At a mean 12 months' follow-up, 17 percent retained a feeding tube (9.5% among primary cases). Retained feeding tube was associated with preoperative tube requirement (P=0.017), higher T stage (P=0.043), oropharyngeal/laryngeal site (P=0.034), and recurrent/second primary tumor (P=0.008). Complications including airway edema (9%), aspiration (6%), bleeding (6%), and salivary fistula (2%) were managed without major sequelae. CONCLUSION: Transoral robotic surgery provides an emerging alternative for selected primary and salvage head and neck tumors with low morbidity and acceptable functional outcomes. Patients with advanced T stage, laryngeal or oropharyngeal site, and preoperative enterogastric feeding may be at increased risk of enterogastric feeding and poor swallowing outcomes.

Endoscopic approach for pituitary surgery improves rhinologic outcomes.

OBJECTIVES: We hypothesized that the endoscopic approach to pituitary surgery improves rhinology-specific quality of life and has satisfactory tumor outcomes compared with the open approach. METHODS: Cases of pituitary surgery from the Department of Neurosurgery database included an inception cohort of all patients who had endoscopic procedures and consecutive patients who had open procedures between January 1998 and February 2008. The Sino-Nasal Outcome Test-22 was mailed. RESULTS: Since January 1998, 71 endoscopic and 122 open pituitary surgeries had been performed. The mean followup was longer for open procedures (49.3 months) than for endoscopic procedures (18.8 months). Recurrence was more common after open surgery (28.4%) than after endoscopic surgery (18.2%; p = 0.219). The most common diagnosis was macroadenoma (77.1% of endoscopic procedures and 93.4% of open procedures). The mean hospital stay was shorter for endoscopic procedures (4.1 days) than for open procedures (6.0 days; p <0.001). Of patients who presented with visual deterioration, 53.8% with endoscopic surgery and 46.7% with open surgery had improvement. Among patients with normal preoperative hormonal function, 27.5% of patients in the endoscopy group and 29.4% of patients in the open group required medication for more than 2 months after surgery. Complications occurred in 33.3% of endoscopic procedures and 43.4% of open procedures. Cerebrospinal fluid leaks were more common in the endoscopy group (p = 0.035), and diabetes insipidus lasting more than 30 days was more common in the open group (p = 0.017). The mean Sino-Nasal Outcome Test-22 score was lower for patients in the endoscopy group (20.4) than for those in the open group (23.2; p = 0.41). Patients in the endoscopy group had a significantly lower rhinology-specific mean score (6.5) than did patients in the open group (9.2; p = 0.03). CONCLUSIONS: The endoscopic approach to pituitary surgery offers tumor outcomes comparable to those of open surgery, with no greater incidence of complications and an improved rhinology-specific quality of life.

Non-smoking, non-drinking elderly females, a 5 year follow-up of a clinically distinct cohort of oral squamous cell carcinoma patients.

To examine differences in survival and clinical outcomes of elderly patients without traditional risk factors presenting with oral squamous cell carcinoma. Retrospective review of 287 consecutive patients divided into 2 treatment period cohorts treated for oral SCC between the 1st Jan 2007 and 31st Dec 2012. Patients were classified as either smoker-drinkers (SD) or non-smoking, non-drinking (NSND). Only patients with oral sub-site primaries according to ICD-10 were included. Carcinomas of the lip, tonsil, base of tongue and oro-pharyngeal subsites were excluded. Of the study population (N = 287), 24.4% were NSND and 9.75% were NSND elderly (older than 70 years) females. >50% of tumours arose from the oral tongue in NSND patients (p = 0.022) and there was a higher rate of recurrent and persistent disease (42.9% vs 27.6%, p = 0.005). Disease specific survival at 5 years was significantly reduced when NSND elderly females were compared to all other patients (p < 0.001) as well as age matched controls (p = 0.006). This effect was verified independently in each cohort.The results of this study suggest that NSND elderly females are a distinct patient population with poorer disease specific survival outcomes.

Functional outcomes following total laryngopharyngectomy.

BACKGROUND: Despite increasing use of laryngeal preserving protocols, laryngopharyngectomy remains the gold standard treatment for locally advanced hypopharyngeal and upper oesophageal tumours and for salvage following failed chemoradiotherapy. Nevertheless, improved perioperative medical care and experience in reconstruction have reduced mortality and improved functional outcomes. METHODS: All patients undergoing total laryngopharyngectomy between July 2001 and July 2006 were prospectively recorded in a head and neck database. Demographics and functional outcomes were recorded. RESULTS: Eighteen patients underwent laryngopharyngectomies with 5 having failed chemoradiotherapy and 13 presented with locally advanced tumours. Patients were reconstructed using free jejunal interposition if the lower anastomosis was in the neck (50%). They developed early fistulas (33%), late strictures (33%) and 44% spoke with a tracheo-oesophageal puncture, the rest with an electrolarynx. If the lower anastomosis was below the manubrium, patients required a gastric pull-up (38.9%). Gastric pull-up patients had fewer fistulas but more number of chest complications. More gastric pull-up patients tolerated solid diet and 43% managed oesophageal speech, the remainder using an electrolarynx. Overall, 88.9% of jejunums and 100% of gastric pull-ups tolerated oral alimentation and 100% used verbal communication. During a mean follow up of 34 months, 7 patients (38.9%) died; four patients died of local recurrence, two of distant metastases and one of unrelated causes. CONCLUSION: Surgical treatment of neoplasms of the hypopharynx and cervical oesophagus is technically demanding and involves careful postoperative care to manage complications. Despite having a poor tumour-related prognosis, laryngopharyngectomy may be carried out in selected patients with low mortality and acceptable functional and survival results.

Imaging characteristics of nodal metastases in paraganglioma, ameloblastoma and olfactory neuroblastoma: case reports and literature review.

Paraganglioma, ameloblastoma and olfactory neuroblastoma are uncommon primary head and neck tumours. When nodal metastases from these tumours occur, they may present later than and with different imaging characteristics compared with squamous cell carcinoma (SCC), demonstrating appearances similar to the primary tumour type rather than features typical of metastatic nodal SCC. We present three cases in which imaging characteristics of nodal metastases in paraganglioma, ameloblastoma and olfactory neuroblastoma mimicked the primary tumour and discuss their implications for clinicoradiological follow-up.

Concha bullosa: reducing middle meatal adhesions by preserving the lateral mucosa as a posterior pedicle flap.

BACKGROUND: Concha bullosa, an extensively pneumatized middle turbinate, may obstruct the paranasal sinuses. Messerklinger's partial lateral turbinectomy is commonly used to debulk the concha bullosa, leaving a raw surface with the potential for adhesions. MATERIALS AND METHODS: A modified technique of partial lateral turbinectomy is described. A posterior pedicled mucosal flap covers the inferior raw surface of the medial lamella of the middle turbinate. Three-month follow up of a consecutive series is compared with concurrent controls. RESULTS: Two (7 per cent) of 28 posterior pedicled flap and four (21 per cent) of 19 traditional partial lateral turbinectomies developed mild middle meatal adhesions (p = 0.011). Posterior pedicled flap reduced the need for post-operative cleaning of the middle meatus. CONCLUSION: The posterior pedicled mucosal flap is a simple modification to partial lateral turbinectomy that covers the raw surface facing the lateral nasal wall, significantly reducing adhesions and speeding recovery.