Differentiation of recurrent nasopharyngeal carcinoma and skull base osteoradionecrosis by Epstein-Barr virus-derived latent membrane protein-1 gene.

OBJECTIVES: In patients with nasopharyngeal carcinoma (NPC), the differentiation between recurrent primary cancer and osteoradionecrosis (ORN) is clinically difficult. Epstein-Barr virus (EBV)-derived latent membrane protein-1 (LMP-1) has been demonstrated to be highly associated with NPC. The objective of this study is to define the role of the LMP-1 gene in the differential diagnosis of recurrent NPC and ORN. STUDY DESIGN: Prospective. METHODS: From July 1998 to June 2000, 15 postirradiated patients with NPC who were initially diagnosed to have skull base ORN underwent endoscopic sequestrectomy. The sequestra were examined for the presence of the LMP-1 gene and cancer. RESULTS: Two of 15 patients had recurrent cancer and only these two patients demonstrated a positive LMP-1 gene in their surgically removed sequestra. The presence of the LMP-1 gene in the sequestrum coincided with biopsy-proven local recurrence. CONCLUSIONS: The LMP-1 gene is a potential marker to differentiate between recurrent NPC and ORN. The presence of the LMP-1 gene in patients with ORN may indicate local recurrence.

Endoscopic management of skull base osteoradionecrosis.

OBJECTIVE: Osteoradionecrosis is one of the most serious complications in radiotherapy of nasopharyngeal carcinoma. We describe a new endoscopic approach to resolve resultant skull base osteoradionecrosis. The objective of this study is to evaluate the efficacy of endoscopic management of skull base osteoradionecrosis. STUDY DESIGN: A prospective study of the outcome of endoscopic management for patients with skull base osteoradionecrosis. METHODS: Between 1994 and 1998 six patients who had irradiation previously for nasopharyngeal carcinoma had skull base osteoradionecrosis. A sinoscopic approach was applied for diagnosis and sequestrectomy. This diagnosis was based on the criterion of exposed necrotic bone after removing all crust in the nasopharynx and further confirmed on pathological examination after sequestrectomy. Effective cure was defined as intact mucosal coverage without any ulcer or exposed necrotic bone observed in the nasopharynx and the absence of antecedent accompanying symptoms after management. RESULTS: Six patients (10%) were symptom free. Five (83.3%) patients had effective cure. There was no surgical morbidity or mortality. CONCLUSION: Endoscopic sequestrectomy is a justified approach to skull base osteoradionecrosis.

Systematic management of osteoradionecrosis in the head and neck.

OBJECTIVES: Osteoradionecrosis is one of the most serious and devastating complications of radiotherapy. The proper management of osteoradionecrosis is currently undetermined. The objective of this study is to evaluate the treatment results of a systematic approach to osteoradionecrosis. STUDY DESIGN: A prospective study of a systematic approach to osteoradionecrosis in the head and neck area was undertaken. METHODS: From July 1993 to June 1998, 33 cases of osteoradionecrosis in the head and neck area were treated using a systematic approach that combined sequestrectomy and hyperbaric oxygen therapy. RESULTS: Seven (21%) had recurrent cancer. The control rate of the other 26 osteoradionecrosis cases was 77% (20/26). CONCLUSIONS: Persistent osteoradionecrosis, despite diligent radical treatment, raises the suspicion of recurrent cancer. Extensive osteoradionecrosis with a multiple discharging fistula, a large area of exposed necrotic bone, or a coexistent fracture should be treated primarily with radical sequestrectomy and microvascular free flap reconstruction. Surgery still plays a major role in controlling osteoradionecrosis, and hyperbaric oxygen therapy is adjuvant.

T3 glottic carcinoma revisited. Transglottic vs pure glottic carcinoma.

OBJECTIVE: To compare results of treatment of patients who have T3 transglottic carcinoma with patients who have T3 pure glottic carcinoma. DESIGN: A retrospective cohort study from January 1976 to December 1990 with a minimum 2-year follow-up. SETTING: Eye and Ear Hospital, University of Pittsburgh Medical Center. PATIENTS: The medical records of 161 patients with T3 glottic carcinoma were reviewed. We excluded 17 patients who were unavailable for follow-up or who had died of other causes but were free of glottic carcinoma. Therefore, 144 patients were entered into this study--79 patients with transglottic carcinoma and 65 with pure glottic carcinoma. INTERVENTION: Three treatment groups consisted of the following: 30 patients in whom a full course of radiation therapy failed and who subsequently underwent salvage surgery; 92 patients who underwent surgery only; and 22 patients who underwent surgery and had postoperative radiation therapy. Seventy-five patients had total laryngectomy, and 69 had total laryngectomy with neck dissection. MAIN OUTCOME MEASURES: Cervical metastasis, extracapsular spread, local failure, stomal recurrence, distant metastasis, and 2 years with no evidence of disease. RESULTS: Patients with T3 transglottic carcinoma had a higher incidence of occult cervical metastasis (12% vs 9%), overall cervical metastasis (27% vs 17%), and extracapsular spread (43% vs 27%) than did patients with T3 pure glottic carcinoma. Two years of no disease was similar in these two groups (80% vs 79%). Extracapsular spread had a notable effect on distant metastasis and on 2 years of no disease. CONCLUSION: Patients with T3 transglottic carcinoma had a higher incidence of cervical metastasis and extracapsular spread than patients with T3 pure glottic carcinoma. Every patient with T3 transglottic carcinoma should be treated with total laryngectomy with neck dissection.

Reconstruction of oral defects with the pedicled buccal fat pad flap.

Pedicled buccal fat pad flaps were used to reconstruct defects produced by resection of tumors of the oral cavity in 21 patients. The indications included defects of the oral mucosa and defects after excision of a benign or malignant tumor, preferably smaller than 5 cm in diameter. The results were excellent, and there was no added morbidity. Only 1 delay failure and 1 complication were observed. The anatomy and surgical technique are described. The results suggest that these flaps are a direct, convenient, and reliable option for the reconstruction of small defects of the oral mucosa.

Facial translocation approach to the skull base: the viability of translocated facial bone graft.

OBJECTIVES: A retrospective review of 56 patients who were operated through a facial translocation approach was carried out to assess the viability of the translocated facial bone segment. METHODS: Eleven patients had preoperative radiotherapy, and 26 had postoperative radiotherapy. In 14 patients the translocated bone segment was kept attached to the anterior cheek, and in 42 patients the bone segment was detached and then implanted. A vascularized flap was used to obliterate the defect in the paranasal sinuses in 15 patients. RESULTS: Twelve (21.4%) patients had devitalized bone segment and required sequestrectomy. The incidence of devitalized bone segment was higher in the patients who received postoperative radiotherapy (P = 0.04) and lower in the patients in whom the defect in the paranasal sinuses was reconstructed with a vascularized flap (P = 0.006). CONCLUSIONS: The translocated facial bone segment should be kept attached to the cheek soft tissue when possible, or the defect in the paranasal sinuses should be reconstructed with a vascularized flap.

Magnetic resonance imaging versus clinical palpation in evaluating cervical metastasis from head and neck cancer.

We prospectively compared the value of MRI and clinical palpation for detecting cervical metastases in patients with primary cancer of the head and neck. Sixty patients with squamous cell carcinoma of the upper aerodigestive tract were evaluated with MRI and clinical palpation before undergoing a total of 81 neck dissections. The results of preoperative clinical palpation and MRI were compared with the histopathologic outcome. The sensitivity and specificity were 75.6% and 97.5%, respectively, for clinical palpation and 73.2% and 95%, respectively, for MRI. The rate of occult cervical metastasis was 24% with clinical palpation and 26.8% with MRI. The use of MRI did not improve the rate of early detection of occult metastasis, nor did it improve the detection of extracapsular spread. Our findings show that we could not depend on palpation or MRI alone to determine the need for elective neck dissection. However, MRI can be used to improve the preoperative grading of cervical lymph nodes. In selected cases, this may direct surgeons to convert the treatment plan to choose a more conservative neck dissection or, after sentinel node sampling and frozen-section control, to convert the treatment to a more radical dissection.

Objective comparison of shoulder dysfunction after three neck dissection techniques.

A prospective study with subjective evaluation of shoulder pain and objective evaluation of shoulder muscle strength by isokinetic testing and electromyographic and electroneurographic studies of spinal accessory nerve function was performed on patients who had undergone neck dissection procedures. Twenty-one patients with head and neck cancer were enrolled in this study. Three types of neck dissection were performed: 7 selective neck dissections, 9 modified radical neck dissections, and 5 radical neck dissections. All patients who underwent radical neck dissection had shoulder pain, and 80% of them had shoulder droop after the operation. In the patients who underwent selective neck dissection, the electromyographic findings of the spinal accessory nerve were relatively normal. Their shoulder strength was sometimes decreased at I month after operation, but it had returned to preoperative strength by the 6-month follow-up visit. These findings suggested that patients who underwent selective neck dissection had the least damage to spinal accessory nerve function and the least shoulder disability after neck dissection.

Outcome of open surgical therapy for glottic carcinoma.

A retrospective review was undertaken of the medical records of 270 patients with carcinoma of the glottic larynx. Patients were staged pathologically, and clinical pathologic correlates were made with outcome. In 92 patients with early glottic cancer, the 2-year rate of no evidence of disease for T1 was 98%, and for T2, 84%. Vertical partial laryngectomy resulted in voice preservation in 89%. Patients treated for advanced (T3 or T4) glottic carcinoma underwent total laryngectomy with or without neck dissection. Cervical nodes were involved in 22% of T3 and 41% of T4 patients at the time of treatment. Survival with no evidence of disease was chiefly determined by the development of regional recurrence, distant metastasis, and new primary cancer. Distant metastasis was associated with extracapsular spread (p = .003). Patients treated for T4 glottic carcinoma with neck dissection had improved survival compared with patients treated with laryngectomy alone (p = .006). Improved survival must be aimed at regional control, prevention, and management of distant metastasis and new primary carcinoma.

Ganglion cyst and synovial cyst of the temporomandibular joint. Two case reports.

Ganglion cysts and synovial cysts are lesions rarely associated with the temporomandibular joint. Ganglion cysts arise from myxoid degeneration of the connective tissue of the joint capsule, are filled with viscoid fluid or gelatinous material, and have a fibrous lining. Synovial cysts also contain gelatinous fluid and are lined with cuboidal to somewhat flattened cells consistent with a synovial origin. One case of a ganglion cyst and one case of a synovial cyst of the temporomandibular joint are presented, and their differential diagnosis and management are discussed.

Mucocele of the sphenoid sinus with acute bilateral blindness: report of a case.

Paranasal sinus mucocele is not uncommon in Taiwan, but is relatively rare in the sphenoid sinus. The symptomatology of mucocele in the sphenoid sinus is quite vague, but it could be well explained by compressive neuropathy. Computed tomographic scanning is the diagnostic imaging study of choice if paranasal mucocele is suspected. This is a report of an unusual case of sphenoid sinus mucocele, presenting with sudden bilateral blindness. The bilaterla optic nerve neuropathy focused attention on the sphenoid sinus, and the patient's previous history of intranasal surgery further suggested the possibility of a mucocele. Computed tomography confirmed the suspicion. The patient recovered her visual function after sphenoidotomy.

Craniofacial resection for tumors of the nasal cavity and paranasal sinuses.

BACKGROUND AND PURPOSE: Craniofacial resection provides multidirectional approaches to remove nasal and paranasal tumors that involve the skull base. The purpose of this study was to determine the survival and local control rate in patients undergoing craniofacial resection for tumors of the nasal cavity, paranasal sinuses, and adjacent areas. METHODS: The medical records of 30 consecutive patients who had undergone craniofacial resection for tumors of the nasal cavity, paranasal sinuses, and adjacent areas were reviewed. The extent of disease, treatment results, complications, and prognoses were analyzed. RESULTS: Lesions were malignant in 28 patients and benign in two. Sixteen of the patients had dural or intradural involvement. There was no surgical mortality, and the rate of surgical morbidity was 7%. The 2-year survival of the 28 patients with malignancies was 46% and the mean follow-up time was 35 months. Local control was achieved in 53% of patients. Nine of 16 patients with dural or intradural invasion had a mean survival time of 17 months. There was no significant difference in the frequency of local control between previously treated and untreated patients. Patients who had a clear margin showed significantly better local control than those with an involved or questionable margin. CONCLUSIONS: Tumors of the nasal cavity and paranasal sinus that involve the skull base can be effectively treated using craniofacial resection, with a reasonable survival and low complication rate.

Six primary squamous cell carcinomas of the head and neck.

The chronic irritation to mucosa of the head and neck area by carcinogen, commonly stemming from heavy usage of betel nuts, tobacco and alcohol, leads to dysplastic mucosal changes and eventually, multiple primary squamous cell carcinomas. With improvements in locoregional control, the problem of multiple primary malignancies of the head and neck is becoming apparent. We reported a unique case of six primary squamous cell carcinomas in the head and neck area. We attribute the success of controlling cancer in this patient to our alert attitude and prompt management. Surgery remains one of the best options in treating multiple head and neck malignancies, as surgery offers an effective, quick and low morbidity approach, and does not take the chance of inducing another cancer.

A combined approach to benign but advanced mandibular tumor.

Mandibular tumors such as ameloblastoma or fibrous dysplasia frequently follow a relentless course despite the fact that they are pathologically benign. Patients suffered from multiple recurrences and repeated surgery, and might still lose their masticatory function. To solve the above problems, a new combined approach--segmental mandibulectomy, free fibular flap reconstruction and primary osseointegration--was applied to three cases of aggressive mandibular tumors. The pathology spectrum included an enormous ameloblastoma, a fibrous dysplasia and a multiple recurrent ameloblastoma. Fixed partial prosthesis were loaded 6 months after the procedure. There were no detectable recurrence after 30 months' follow-up. The patients regained their facial contour, dental occlusion and masticatory function in a relatively short period of time. Segmental mandibulectomy lessens the likelihood of recurrence, free fibular flap transfer restores the dental articulation function and facial contour, and immediate osseointegration has further enhanced the masticatory function. This combined approach thus improves the patients' satisfaction and ensure their social interactions. It is justified for some selected aggressive mandibular tumors.