Elective neck dissection during salvage total laryngectomy--a beneficial prognostic effect in locally advanced recurrent tumours.

OBJECTIVES: Elective neck dissection during salvage laryngectomy is controversial. The goal of our study was to evaluate the effect of elective neck dissection during salvage laryngectomy in patients with locally advanced disease at recurrence. DESIGN: Multicentre, retrospective study. SETTINGS: Two tertiary medical centres. PARTICIPANTS: Eighty-seven patients treated by salvage laryngectomy. MAIN OUTCOME MEASURES: Disease-Free and Overall Survival. RESULTS: Fifty-seven patients underwent salvage total laryngectomy for locally advanced recurrent squamous cell carcinoma of the larynx, and 30 patients underwent salvage laryngectomy for limited recurrent disease. Elective lateral neck dissection was performed in 48 patients. The groups were similar in age, sex, initial TNM stage and pre-operative treatment. Survival analysis showed that both disease-free survival and overall survival were improved in patients with locally advanced disease who underwent elective neck dissection. This beneficial effect was not demonstrated in patients with limited disease at recurrence. Multivariate analysis showed that the extent of the recurrent disease as well as elective neck dissection was associated with improved disease-free survival and overall survival. CONCLUSIONS: Elective neck dissection during salvage total laryngectomy seems to improve survival in patients with advanced local disease at recurrence. The role of neck dissection in the treatment of smaller tumours awaits further studies.

[One stage combined endoscopic and per-oral buccal fat pad approach for large oro-antral-fistula closure with secondary chronic maxillary sinusitis].

There are numerous surgical approaches for oro-antral-fistula (OAF) closure. Secondary sinus disease is still considered by many experts a relative contra indication for primary closure. To describe a single-stage combined endoscopic sinus surgery and per-oral buccal fat pad (BFP) flap approach for large OAF causing chronic maxillary sinusitis. The records of all the patients with OAF and chronic manifestations of secondary rhinosinusitis that were treated between 2010 and 2013 in our tertiary care medical center were reviewed. The exclusion criteria were: OAF 5 mm, resolved sino-nasal disease, OAF secondary to malignancy, recurrent fistula, medical history that included radiotherapy to the maxillary bone and age <18 years. Each procedure was performed by a team consisting of a rhinologist and a maxillofacial surgeon. The surgical approach included an endoscopic middle antrostomy with maxillary sinus drainage, and a per-oral BFP regional flap for OAF closure. Total OAF closure, complications and need for revision surgeries. Forty-five patients that underwent OAF closure together with sinus surgery using a combined endoscopic sinus surgery (ESS) and BFP flap approach met the inclusion criteria. There were 28 males and 17 females with a mean ± SD age of 53.5 ± 14.9 years (range 22-80 years). The presenting signs and symptoms included purulent rhinorrhea (n = 22, 48.9%), foreign body in sinus (n = 10, 22.2%) nasal congestion (n = 7, 15.5%), halitosis (n = 6, 13.3%) and pain (n = 5, 12.2%). Surgical complications included local pain (n = 2, 4.4%), persistent rhinitis (n = 2, 4.4%) and synechia (n = 1, 2.2%). One patient required revision surgery due, to an unresolved OAF. The OAF of all the other 44 patients (97.8%) was closed after the first procedure and the paranasal sinuses on the treated side were completely recovered. The mean follow-up time for the group was 7.6 ± 4.3 months (7-21 months), and no untoward sequelae or recurrence were reported. Combined, one step, endoscopic Maxillary sinus drainage together with per-oral BFP flap approach is an efficacious surgical approach for safe closure of OAFs that are complicated with secondary chronic maxillary sinusitis.

Lymph node density in oral cavity cancer: results of the International Consortium for Outcomes Research.

BACKGROUND: Lymph node density (LND) has previously been reported to reliably predict recurrence risk and survival in oral cavity squamous cell carcinoma (OSCC). This multicenter international study was designed to validate the concept of LND in OSCC. METHODS: The study included 4254 patients diagnosed as having OSCC. The median follow-up was 41 months. Five-year overall survival (OS), disease-specific survival (DSS), disease-free survival (DFS), locoregional control and distant metastasis rates were calculated using the Kaplan-Meier method. Lymph node density (number of positive lymph nodes/total number of excised lymph nodes) was subjected to multivariate analysis. RESULTS: The OS was 49% for patients with LND0.07 compared with 35% for patients with LND>0.07 (P<0.001). Similarly, the DSS was 60% for patients with LND0.07 compared with 41% for those with LND>0.07 (P<0.001). Lymph node density reliably stratified patients according to their risk of failure within the individual N subgroups (P=0.03). A modified TNM staging system based on LND ratio was consistently superior to the traditional system in estimating survival measures. CONCLUSION: This multi-institutional study validates the reliability and applicability of LND as a predictor of outcomes in OSCC. Lymph node density can potentially assist in identifying patients with poor outcomes and therefore for whom more aggressive adjuvant treatment is needed.

Clinical nodal stage is a significant predictor of outcome in patients with oral cavity squamous cell carcinoma and pathologically negative neck metastases: results of the international consortium for outcome research.

BACKGROUND: We aimed to study the importance of clinical N classification (cN) in a subgroup of patients with oral cavity squamous cell carcinoma (OSCC) and pathologically negative neck nodes (pN-). METHODS: A total of 2,258 patients from 11 cancer centers who underwent neck dissection for OSCC (1990-2011) had pN- disease. The median follow-up was 44 months. 5-year overall survival (OS), disease-specific survival (DSS), disease free survival, local control, locoregional control, and distant metastasis rates were calculated by the Kaplan-Meier method. cN classification and tumor, node, metastasis classification system staging variables were subjected to multivariate analysis. RESULTS: A total of 345 patients were preoperatively classified as cN+ and 1,913 were classified as cN-. The 5-year OS and DSS of cN- patients were 73.6 and 82.2 %, respectively. The 5-year OS and DSS of cN+ patients were 64.9 and 76.9 %, respectively (p < 0.0001 each). A cN+ classification was a significant predictor of worse OS (p = 0.03) and DSS (p = 0.016), regardless of treatment, depth of invasion, or extent of neck dissection. cN classification was associated with recurrence-free survival (p = 0.01) and locoregional (neck and primary tumor) control (p = 0.004), but not with local (p = 0.19) and distant (p = 0.06) recurrence rates. CONCLUSIONS: Clinical evidence of neck metastases is an independent predictor of outcome, even in patients with pN- nodes.

Quality of life after mandibulectomy: the impact of the resected subsite.

The purpose of this study was to identify the factors that impact the quality of life (QOL) scores of patients undergoing mandibulectomy. All patients with a diagnosis of an oral cavity neoplasm involving the mandible who underwent a mandibulectomy between January 1, 2000 and December 31, 2015 and completed a University of Washington QOL questionnaire (UW-QOL) were included in the study. Fifty-eight patients fulfilled all inclusion criteria and completed the UW-QOL questionnaire. Forty patients (69%) underwent a segmental mandibulectomy and 18 patients underwent a marginal mandibulectomy. Forty-eight patients (82.7%) had a free flap reconstruction. There was no significant difference in the QOL scores between patients who underwent a marginal or a segmental mandibulectomy. In contrast, patients who underwent symphysial resection reported significantly worse scores in various domains compared to patients with body or ramus segmental mandibulectomy. Patients who underwent a segmental mandibulectomy that included the symphysis had worse outcomes in chewing, recreation, health-related and social QOL domains compared to those whose mandibulectomy did not include the symphysis.

[Fiberoptic endoscopic evaluation of swallowing--the Tel Aviv Voice and Swallowing Disorders Clinic].

Fiberoptic endoscopic evaluation of swallowing (FEES) involves passing a fiberoptic laryngoscope transnasally to visualize the hypopharynx, larynx, and proximal trachea in order to assess swallowing disorders. FEES has been compared with the modified barium swallow (MBS) (the presumed "gold standard"). To date, reports have demonstrated that FEES is as sensitive as, or even more sensitive, for use as a tool in swallowing assessment compared with the MBS. FEES provides the clinician with a safe, portable, effective, and valid means of evaluating individuals with swallowing disturbances. FEES allows the examiner to identify swallowing physiology, determine the safest and least restrictive level of oral intake, implement appropriate compensatory techniques, and identify a dysphagia rehabilitation plan. In this article we present the Tel-Aviv Voice and Swallowing Disorders Center experience. Out of 100 patients that were referred to our center for swallowing evaluation 97 patients underwent 102 FEES examinations. Three patients couldn't tolerate the examination. In 63% of the patients swallowing pathology was found. FEES were performed by teamwork involving a speech-language pathologist and otolaryngologist collaborating together thus optimally managing the individual with dysphagia safely and efficiently.

[The reflux symptom index--a clinical tool for the diagnosis of laryngopharyngeal reflux].

BACKGROUND: Laryngopharyngeal reflux (LPR) refers to the backflow of stomach contents into the throat. Patients with LPR suffer from hoarseness, throat discomfort, dysphonia, chronic cough, chronic throat clearing and dysphagia. In 2001 Koufman et al. published the self-administered nine-item reflux symptom index (RSI) to assist clinicians in detecting and documenting the presence of LPR. This instrument appears to be valid and highly reproducible. OBJECTIVE: To develop the Hebrew version of the Reflux Symptom Index (RSI). METHODS: Validation of the Hebrew questionnaire included translation of the original instrument from English to Hebrew by three independent translators and retranslation back from Hebrew to English by three other translators. In the United States, patients completed the original and back-translated questionnaires. Scores correlation of the two instruments was performed using correlation coefficient analysis. Validation of the questionnaire was performed by measuring the association between the mean RSI score and the reflux findings upon flexible endoscopy. A control group of 9 patients with no clinical signs of reflux was chosen for our outpatient clinic. RESULTS: A total of '14 patients in the United States completed the original and the back-translated questionnaires. The correlation coefficient (r) was 0.92 (p < 0.001). In the second part of the study. 21 consistent Israeli patients that were referred to our voice center because of voice problems were requested to complete the questionnaire. History and endoscopic examinations did not reveal tumors, paralysis, functional voice problems or smoking. The mean age was 53 years (range 37-69 years). There were 14 women in the study group. Twenty patients had RSI higher then 10 (considered positive to the presence of reflux disease). Examination of the larynx demonstrated presence of reflux (e.g. edema of the vocal cords, posterior commissure hypertrophy, arythenoids edema, subglottic edema) in 19 cases (90.5% of patients). All the patients in the control group had a RSI lower then 10. CONCLUSIONS: The Hebrew RSI is an easy self-administered and reliable instrument that can help the clinician detect patients suffering from LPR and monitor their treatment.

Chronic suppurative otitis media without cholesteatoma in children in southern Israel: incidence and risk factors.

The incidence and risk factors for chronic suppurative otitis media without cholesteatoma in children in Southern Israel were determined by comparing 88 children with the disease to 76 controls with similar age distribution who visited 3 clinics serving representative populations of the region. Data were collected during the child's visit to the clinic by means of a structured interview with the parents and by extracting information from medical records. The calculated yearly incidence was 39/100,000 children 0 to 15 years of age. Significantly increased risk for chronic suppurative otitis media was associated with a history of acute and recurrent otitis media, a parental history of chronic otitis media, larger families and more siblings, a higher crowding index and care in large daycare centers. The sex, parental age and education, allergy, sinusitis and recurrent upper respiratory tract infections were not associated with chronic suppurative otitis media.

Outpatient management of chronic suppurative otitis media without cholesteatoma in children.

Prolonged antipseudomonal parenteral antibiotic therapy combined with daily aural toilet has been effective in resolving long standing ear discharge in children with chronic suppurative otitis media. However, such treatment suffered from the disadvantages of prolonged hospitalization. We conducted a prospective study to investigate the feasibility and efficacy of exclusive outpatient treatment of children with chronic suppurative otitis media without cholesteatoma who had failed ototopical/oral antimicrobial therapy. The treatment consisted of daily aural toilet (suction and debridement) and twice daily parenteral ceftazidime (50 mg/kg/dose). Thirty-seven children were included. The duration of discharge from the ear before treatment was 6 to 121 months (median, 30 months). Aerobic cultures yielded Pseudomonas aeruginosa in 97%, often with other organisms. The management and follow-up were performed jointly by otolaryngology and infectious diseases physicians using the hospital ambulatory services. The route of ceftazidime administration (intravenous or intramuscular) was chosen according to the parents' and patients' convenience. Discharge stopped within 3 to 20 days (median, 8 days) in all children but one. Seventy-six percent of the 29 children available for follow-up 12 months after treatment were still free of discharge. Our results demonstrate that a regiment combining daily aural toilet and twice daily parenteral ceftazidime is highly efficacious in resolving ear discharge in children with chronic suppurative otitis media without cholesteatoma and that such a regimen does not require hospitalization.

Early eradication of pathogens from middle ear fluid during antibiotic treatment of acute otitis media is associated with improved clinical outcome.

OBJECTIVE: To determine the relation between early bacteriologic eradication and clinical outcome of acute otitis media (AOM) in infants and young children treated with various antibiotics. STUDY DESIGN: The study group consisted of patients ages 3 to 24 months seen at the Pediatric Emergency Room with: (1) symptoms and physical findings consistent with AOM of < or = 7 days duration; (2) no spontaneous perforation or tympanostomy tubes; (3) positive initial middle ear fluid culture; and (4) a follow-up to at least Day 10+/-2 of the study with a second culture performed 72 to 96 h after initiation of antibiotic treatment. Any patient with a positive middle ear fluid culture 72 to 96 h after initiation of antibiotic treatment was considered to have bacteriologic failure. Otologic evaluation was done by an otolaryngologist unaware of the culture results and of the study drug allocation. A clinical score based on body temperature, report of irritability and ear tugging observed by the parents and the appearance and redness of the ear drum as observed by the otolaryngologist was also used for clinical evaluation. RESULTS: The study group consisted of 123 patients, of whom 57 (46%) had positive middle ear fluid 72 to 96 h after initiation of antibiotic treatment. Clinical failure was observed in 21 of 57 (37%) patients in whom bacteriologic eradication did not occur vs. only 2 of 66 (3%) patients with bacteriologic eradication after 3 to 4 days of treatment (P < 0.001). Clinical score for both moderate and severe disease decreased significantly faster in those with bacteriologic eradication than in those in whom middle ear fluid was still culture-positive 72 to 96 h after initiation of treatment. CONCLUSION: Clinical failures in our population were associated with inability to eradicate the causative organisms of AOM from the middle ear fluid within 3 to 4 days after initiation of antibiotic therapy. Most patients (including those without bacteriologic eradication) improved after 3 to 4 days of treatment, but patients with sterile middle ear fluid felt better after 3 to 4 days of treatment than patients in whom middle ear fluid was still culture-positive.

Dynamics of pneumococcal nasopharyngeal colonization during the first days of antibiotic treatment in pediatric patients.

BACKGROUND: Nasopharyngeal (NP) carriage of antibiotic-resistant Streptococcus pneumoniae was shown to be associated with recent antibiotic treatment. To date no studies have evaluated early dynamics of pneumococcal NP carriage during antibiotic treatment. OBJECTIVES: To observe changes in NP pneumococcal carriage within 3 to 4 days after initiation of antibiotic treatment in acute otitis media (AOM). METHODS: Patients ages 3 to 36 months with AOM treated with various antibiotics were prospectively followed. Nasopharyngeal culture for S. pneumoniae was obtained before (Day 1) and 72 to 96 h after initiation of treatment (Days 4 to 5). Antibiogram and serotyping were performed in all isolates as was also the MIC of penicillin. The disappearance and persistence of the initial isolates as well as the appearance of isolates with new serotype or with new antibiotic susceptibility patterns were investigated. RESULTS: A total of 120 patients were studied: 106 received beta-lactam antibiotics and 14 received azithromycin. Among the initial 76 pneumococcal isolates 63, 37 and 13% were resistant to > or =1, > or =2 and > or =3 antibiotic drugs. After 3 to 4 days of treatment with various beta-lactam drugs, 45, 63 and 100% of isolates with MIC values of <0.1 microg/ml, 0.125 to 0.25 microg/ml and 0.38 to 1.0 microg/ml, respectively, persisted in the NP (P = 0.038). There was a difference between the various beta-lactam drugs in their effect on NP colonization: a drug with lower MIC values (cefuroxime-axetil) had a better eradication rate of penicillin-susceptible organisms than a less active one (cefaclor), but neither significantly reduced carriage of penicillin nonsusceptible isolates. Azithromycin eliminated carriage of macrolide-susceptible organisms but increased the carriage of macrolide-resistant ones. In 19 of 120 (16%) patients a new S. pneumoniae isolate was recovered 3 to 4 days after initiation of treatment. Of those 16 (84%) were resistant to the drug the patient was receiving. CONCLUSION: A rapid selection of nonsusceptible NP pneumococcal isolates during antibiotic treatment for AOM is common. This phenomenon may contribute to the spread of resistant pneumococci.

Impaired bacteriologic response to oral cephalosporins in acute otitis media caused by pneumococci with intermediate resistance to penicillin.

BACKGROUND: Penicillin resistance of Streptococcus pneumoniae, one of the most common causes of acute otitis media, has recently increased and is now highly prevalent in many regions. However, its contribution to clinical failure still must be proved. Because the role of antibiotics in acute otitis media is to eradicate the pathogens present in the middle ear fluid, we conducted a randomized controlled study to determine bacterial eradication of pathogens in acute otitis media by two commonly used oral cephalosporins, cefuroxime axetil (30 mg/kg/day) and cefaclor (40 mg/kg/day). METHODS: Patients 6 to 36 months old with pneumococcal otitis media seen in the Pediatrics Emergency Room were studied. An initial middle ear fluid culture was obtained at enrollment, and a second culture was obtained on Day 4 or 5 during treatment. Follow-up was done also on Days 10, 17 and 42 after initiation of treatment. In cases of clinical relapse a third culture was obtained. RESULTS: In total 78 patients were enrolled, 41 in the cefuroxime axetil group and 37 in the cefaclor group. Of the 78 S. pneumoniae isolates 31 (40%) were intermediately penicillin-resistant (MIC 0.125 to 1.0 microgram/ml). Of the 47 patients with penicillin-susceptible organisms 3 (6%) had bacteriologic failure vs. 4 of 19 (21%) and 7 of 11 (64%) of those with MIC of 0.125 to 0.25 microgram/ml and 0.38 to 1.0 microgram/ml, respectively (P < 0.001). For intermediately resistant pneumococci, in 7 of 12 (58%) of those receiving cefaclor the isolate was not eradicated vs. only 4 of 19 (21%) of those receiving cefuroxime axetil (P = 0.084). MIC to the administered cephalosporin of > 0.5 microgram/ml was associated with bacteriologic failure. Clinical failure was observed in 9 of 14 (64%) patients with bacteriologic failure vs. 10 of 52 (19%) patients with bacteriologic eradication (P = 0.003). CONCLUSION: Intermediately penicillin-resistant S. pneumoniae is associated with an impaired bacteriologic and clinical response of acute otitis media to cefaclor and cefuroxime axetil. This effect was more pronounced with cefaclor than with cefuroxime axetil.

Resistance pattern of middle ear fluid isolates in acute otitis media recently treated with antibiotics.

BACKGROUND: Little information is available about the effect of antibiotic treatment on the prevalence and MIC of the subsequently isolated pathogens in cases of acute otitis media (AOM) failing a course of antibiotic therapy. This information is important, particularly regarding the effectiveness of the oral antibiotics used in children failing initial therapy. PATIENTS AND METHODS: One hundred eighty-one children with culture-positive AOM were prospectively studied between October, 1995, and July, 1996. Sixty-three (35%) patients received various antibiotics for variable periods during the 14 days preceding enrollment. RESULTS: A total of 94 Streptococcus pneumoniae (Pnc) and 113 Haemophilus influenzae (Hi) were isolated. Thirty-eight Pnc and 35 Hi were isolated in the 63 patients with recently treated AOM. Pnc as a single isolate was more prevalent in patients recently treated with antibiotics (27 of 63, 43%) than among those not recently treated (32 of 118, 27%, P = 0.047). The MIC50 values of penicillin, cefaclor and cefuroxime axetil for Pnc were significantly higher in the pneumococci isolated from patients recently treated than among those isolated from patients not recently treated with antibiotics (0.38, 3 and 0.75 microg/ml vs. 0.094, 0.38 and 0.12 microg/ml, respectively). Seventy-nine percent of Pnc isolates in the recently treated group had MIC for penicillin of >0.1 microg/ml vs. only 47% in those not recently treated (P < 0.05). The respective figures for MIC >0.5 microg/ml of cefaclor were 79% vs. 41% for the recently treated and not recently treated groups (P < 0.001); cefuroxime MIC >0.5 microg/ml was found in 61 and 25%, respectively (P = 0.001). CONCLUSIONS: Pneumococcus is more prevalent in AOM after a recent antibiotic treatment, and the MIC of the commonly used beta-lactam drugs for Pnc is considerably higher in this setting. In view of our data, the use of oral cephalosporins like cefaclor or cefuroxime as second line drugs in the treatment of unresponsive AOM, particularly in regions where resistant PNC is prevalent, should be reconsidered.

Bacteriologic efficacy of a three-day intramuscular ceftriaxone regimen in nonresponsive acute otitis media.

OBJECTIVE: To determine the bacteriologic efficacy of ceftriaxone in nonresponsive acute otitis media in children. METHODS: In a prospective study 92 patients ages 3 to 36 months (median, 11 months) with culture-proved nonresponsive acute otitis media were studied from January, 1995, through August, 1997. The patients were treated with intramuscular ceftriaxone (50 mg/kg/l/day) for 3 days. Middle ear fluid was aspirated for culture by tympanocentesis on day of enrollment (Day 1); a second tap was performed on Days 4 to 10. Additional middle ear fluid cultures were obtained if clinical relapse occurred. Bacteriologic failure was defined by positive culture on Days 4 to 10. Patients were followed until Day 17+/-2. Susceptibility was measured by E test. RESULTS: The main drugs administered before enrollment were amoxicillin (38%), amoxicillinclavulanate (25%) and cefaclor (20%). Organisms recovered (n=105) were: Haemophilus influenzae, 54; Streptococcus pneumoniae, 47; Moraxella catarrhalis, 2; and Streptococcus pyogenes, 2. Thirty-four (72%) of the 47 S. pneumoniae isolates were intermediately resistant to penicillin (MIC 0.1 to 1.0 microg/ml), but all were susceptible to ceftriaxone (MIC < 0.5 microg/ml). Bacteriologic eradication was achieved in 100 of 105 (95%) cases: 54 of 54 (10O%) H. influenzae, 43 of 47 (92%) S. pneumoniae, 1 of 2 (50%) M. catarrhalis and 2 of 2 (100%) S. pyogenes. Bacteriologic success (with no relapse) occurred in 13 of 13 (100%) penicillin-susceptible S. pneumoniae vs. 28 of 34 (82%) S. pneumoniae intermediately resistant to penicillin (4 cases of bacteriologic failure and 2 cases of relapse). CONCLUSION: A 3-day intramuscular ceftriaxone regimen is efficacious for the treatment of nonresponsive acute otitis media. The optimal duration of treatment in cases of nonresponsive acute otitis media and whether ceftriaxone is efficacious for the treatment of nonresponsive otitis media caused by S. pneumoniae highly resistant to penicillin is yet to be determined.

Hurthle cell adenoma of the thyroglossal duct.

Neoplasia in thyroglossal duct cysts or ectopic thyroid tissue deposits is rare but well recognized. The first known case of Hurthle cell adenoma in thyroglossal duct anomaly is described. The pathologic course and treatment of Hurthle cell tumors in general is reviewed. Treatment was based on the view that neoplasms in thyroglossal duct remnants represent changes in the ectopic thyroid tissue.

Necrotizing soft-tissue infections in the head and neck: a clinicopathological study.

The clinicopathological aspects of 15 patients with necrotizing soft-tissue infections in the head and neck are reviewed. Our relatively large series suggests that the disease occurs more frequently than described in the literature. Histological studies showed that tissue superficial and deep to the fascia is frequently involved with the infectious inflammatory process, even in early stages of the disease. These pathologic changes were also found in healthy-appearing tissues at the periphery of the lesions. The early recognition of the disease and the prompt and aggressive surgical and medical therapeutic approach have resulted in far lower mortality rates (7%) than those reported in the literature. Frozen-section examination contributed to the maximal eradication of the pathologic process. This successful outcome was achieved in spite of the adverse associated clinical conditions, such as old age, debilitating disease, or complications, observed in half of the patients.

Laryngeal verrucous carcinoma: a clinicopathologic study and detection of human papillomavirus using polymerase chain reaction.

Laryngeal verrucous carcinoma (LVC) is a rare, well-differentiated variant of squamous carcinoma with a low malignant potential. Human papillomavirus (HPV)-16 DNA has been identified in a small number of LVC and an etiologic relationship has been suggested. A correlative clinical and molecular pathological study was performed in order to determine the prevalence and typing of HPV DNA in LVC. Possible associations between patient and tumor subsets, and the presence of HPV DNA were also investigated. Formalin-fixed, paraffin-embedded tissue samples from 29 patients with LVC were examined by polymerase chain reaction (PCR) using DNA primers specific for HPV types 6b/11, 16, and 18. Overall, HPV DNA was detected in 13 (45%) of the cases. Of these, HPV-16 DNA, HPV-18 DNA, and both HPV-16 DNA and HPV-18 DNA were detected in 4 (14% overall; 31% of positive cases), 4, and 5 (17% overall; 38% of positive cases), respectively. HPV-6b/11 DNA was not detected in any LVCs. In 16 cases, no HPV DNA was detected. There was a trend toward HPV DNA detection in higher stage tumors. HPV DNA detection was unrelated to patient age, tumor site, or radiotherapeutic responsiveness. The detection of HPV DNA in 45% of LVCs suggests an association between the presence of HPV-16 DNA and HPV-18 DNA, and some LVCs.

Early outcome and complications of the extended subcranial approach to the anterior skull base.

OBJECTIVES: To present the technique of the extended subcranial approach to the anterior skull base and to review the results in 55 patients who underwent the procedure. STUDY DESIGN: Retrospective review of the records of 55 patients who underwent the extended subcranial approach to the anterior skull base between 1994 and 1998 for the treatment of various neoplasms originating in the nasal cavity, nasopharynx, paranasal sinuses, orbit, or meninges, as well as for the repair of complex craniofacial trauma and/or cerebrospinal fluid (CSF) leak. Preoperative patient evaluation and the surgical technique are also reviewed. METHODS: Patient records were retrospectively reviewed and tabulated for age, sex, and indications for procedure, with special focus on early outcome and complications. RESULTS: Twenty-six patients underwent oncologic resections, 22 patients had reduction of complex fronto-naso-orbital and skull base fractures, and seven patients had repair of CSF leak. Significant complications in the oncologic group consisted of one hematoma requiring needle aspiration and two cases of temporary nontension pneumocephalus. In the fracture group, one patient died because of extensive intracerebral damage and multiorgan failure, and one patient had nontension pneumocephalus coupled with CSF leakage and one patient had temporary nontension pneumocephalus. The most common late complication in all three groups was anosmia. CONCLUSIONS: Based on their review, the authors conclude that the extended subcranial approach to the anterior skull base is a safe, versatile, and effective procedure for the surgical treatment of various pathological conditions involving the anterior skull base.

Free forearm flap in oral reconstruction. Functional outcome.

OBJECTIVE: To examine functional outcome associated with free radical forearm flap reconstruction of oral cavity and oropharyngeal defects. DESIGN AND SETTING: Case series obtained from a head and neck clinic conducted at a regional cancer center. Patients underwent surgery at the associated tertiary care center. PATIENTS: Thirty consecutive patients treated for oral and oropharyngeal malignant neoplasms staged from T1 to T4 were studied. Subjects were assigned to five groups based on the site and extent of their surgical resections, as specified on a resection template. INTERVENTION: All patients had undergone free radial forearm flap reconstruction of their surgical defects. OUTCOME MEASURES: Ten factors reflecting functional properties and processes of the upper aerodigestive tract were evaluated clinically or with videofluoroscopy or both. RESULTS: Near-normal and fair oral and oropharyngeal function wholly characterized the sample. Patients who underwent reconstruction of unilateral tongue, floor of mouth-ventral tongue, and retromolar trigone-buccal defects functioned well on most measures; the function of patients with anterior tongue-jaw and tongue base-tonsil defects varied. CONCLUSIONS: Functional outcome with free radial forearm flap reconstruction was favorable for three of five subgroups of oral and oropharyngeal cancer patients. Qualitatively different functional profiles emerged for subgroups based on resection site. Methodologic issues for research on surgical reconstruction and functional outcome include the need for a meaningful, reliable system of classifying oral and oropharyngeal resections, and the development of standardized procedures for evaluating functional outcome.

Detection and typing of human papillomavirus in verrucous carcinoma of the oral cavity using the polymerase chain reaction.

OBJECTIVE: This study examined the prevalence and types of human papillomavirus (HPV) DNA in oral cavity verrucous carcinoma. DESIGN: This was of a retrospective screening study. Formalin-fixed, paraffin-embedded tissue samples were examined by the polymerase chain reaction using DNA primers specific for HPV types 6b/11, 16, and 18. SETTING: The majority of patients were seen at referral centers in Ontario, Canada. PATIENTS: This study examined 29 oral cavity verrucous carcinomas occurring in a sample of 25 patients from four institutions between 1966 and 1992. All tumors met standardized histologic diagnostic criteria of verrucous carcinoma. MAIN OUTCOME MEASURE: The prevalence of HPV 6b/11, 16, and 18 DNA was determined by the PCR technique. RESULTS: The HPV DNA was detected in 12 (48%) of 25 patients. The HPV 6b/11 DNA, HPV 16 DNA, HPV 18 DNA, and HPV 16 DNA plus HPV 18 DNA, were detected in one (4%), one (4%), nine (36%), and one (4%) cases, respectively. CONCLUSIONS: The detection of HPV 18 DNA in 40% of oral cavity verrucous carcinomas suggests an association between the presence of HPV 18 DNA and some oral cavity verrucous carcinomas. The etiologic and prognostic significance of HPV 18 for oral cavity verrucous carcinoma remains unanswered and will require further study.