Temporal and Physiologic Measurements of Deglutition in the Upright and Supine Position with Videofluoroscopy (VFS) in Healthy Subjects.

Cross-sectional imaging has long been employed to examine swallowing in both the sagittal and axial planes. However, data regarding temporal swallow measures in the upright and supine positions are sparse, and none have employed the MBS impairment profile (MBSImP). We report temporal swallow measures, physiologic variables, and swallow safety of upright and supine swallowing in healthy subjects using videofluoroscopy (VFS). Twenty healthy subjects ages 21-40 underwent VFS study upright and supine. Subjects were viewed in the sagittal plane and swallowed 5 mL liquid and pudding barium. Oral transit time, pharyngeal delay time, pharyngeal response time, pharyngeal transit time, and total swallow duration were measured. Penetration/aspiration scores and 14 MBSImP variables were analyzed in both positions. All subjects completed swallows supine, although one aspirated on one liquid bolus. Temporal measures of swallowing were similar for pudding upright and supine. Pharyngeal phase swallow measures were longer for liquids in supine. MBSImP physiologic measures revealed a pharyngeal delay in both positions. Although Pen/Asp range was higher supine, more subjects penetrated upright. Temporal measures were increased for liquids in supine. Although Pen/Asp range was higher in supine, more subjects penetrated upright. These results provide support for cross-sectional supine imaging of swallowing for pudding, but perhaps not thin liquids for dysphagic patients. Slightly thicker liquids might prove reliable in supine without compromising swallow safety. Future research should examine swallow physiology in both positions in dysphagic and older healthy subjects.

Development of a new lingual range-of-motion assessment scale: normative data in surgically treated oral cancer patients.

Surgical resection in oral cancer patients can result in altered speech, swallowing, and patient perception of quality of life (QOL). Oral surgery can result in reduced lingual range of motion (ROM). However, few studies have quantified the degree of lingual restriction after surgery. This pilot study describes a new measurement system to define tongue ROM in surgically treated tongue cancer patients. This measurement system was validated by comparing results in these treated surgical patients versus healthy individuals. This scale was further validated by correlating ROM with performance status, oral outcomes, and patient-rated QOL. Thirty-six patients who underwent oral tongue surgery and 31 healthy individuals were included. Tongue ROM was assessed using a novel ROM assessment system. This novel system was examined in these patients versus healthy subjects. This measurement tool was further validated by correlating tongue ROM in treated patients with performance status, oral outcomes, and patient-rated QOL. Tongue ROM was found to be significantly lower in the surgically treated patients than in the healthy individuals (p = 0.0001). Tongue ROM correlated with performance status, oral outcomes, and all QOL measures. This new tongue ROM measurement system defined tongue deficits in surgically treated oral cancer patients. This tool was validated by comparing results to those in healthy individuals, as well as by correlating tongue ROM to performance status, oral outcomes, and QOL. This measurement tool can be used to define baseline and postsurgery tongue ROM in oral cancer patients, as well as track change over time with recovery and therapy. Future studies should examine use of this measurement tool with other populations demonstrating tongue deficits.

Functional outcomes and quality of life after chemoradiotherapy: baseline and 3 and 6 months post-treatment.

Concomitant chemoradiotherapy provides organ preservation for those patients with head and neck cancer. We report the results of a prospective study that examined functional outcomes and quality of life (QOL) after chemoradiotherapy over the first 6 months post-treatment (tx). Twenty-nine patients with head and neck cancer were treated with chemoradiotherapy. All were seen baseline and 3 and 6 months post-tx. Assessments included the performance status scale (PSS), Karnofsky performance status scale, tongue strength, jaw opening, and saliva weight. QOL was patient-rated using the eating assessment tool (EAT-10), MD Anderson dysphagia inventory, speech handicap index (SHI), and the EORTC H&N35 scale. Repeated-measures ANOVAs were used, with significance at p < 0.05. PSS scores were significantly different across time points. Tongue strength, jaw range of motion (ROM), and saliva weight were significantly lower at 3 and 6 months than at baseline. QOL was significantly worse after tx, although it improved by 6 months as rated with the EAT-10 and the SHI scores were significantly worse at 3 and 6 months. EORTC domains of swallowing, senses, speech, dry mouth, and sticky saliva were significantly worse at 3 and 6 months. Concomitant chemoradiotherapy for treatment of head and neck tumors can result in impaired performance outcomes and QOL over the first 6 months post-tx. However, performance status, tongue strength, jaw ROM, and eating QOL were only mildly impaired by 6 months post-tx. Saliva production and speech QOL remained significantly impaired at 6 months post-treatment. Current studies are examining outcomes at 12 and 24 months post-treatment to better predict outcomes over time in this population.

Anatomic relationship between the spinal accessory nerve and the jugular vein: a cadaveric study.

BACKGROUND/PURPOSE: Previous studies of the course of the Spinal Accessory Nerve (SAN) and its relationship to the Internal Jugular Vein (IJV) have yielded conflicting results because of the small number of anatomic specimens and anatomic variability. Classic teaching in Head and Neck Surgery is that the SAN almost always crosses the IJV anteriorly in the upper neck. However, because of the morbidity associated with the injury to the IJV during nerve dissection, it is imperative that the surgeon is wary of the posteriorly crossing nerve. In order to further elucidate the anatomy of the SAN in relation to its surrounding structures, we have studied its anatomy at various points. Specifically, we have aimed to: (1) characterize the anatomic relationship of the SAN to the IJV at three major points: (a) within jugular foramen (JF), (b) at base of skull (BoS), and (c) at the posterior belly of the digastric muscle, (2) record the distance travelled by the SAN from the BoS to its medial to lateral crossing of the IJV, and (3) characterize the anatomy of the JF by with respect to greatest length, width, and partitioning. METHODS: Sixty-one cadavers, 27 male, and 34 female (84 necks) were dissected and the course of the SAN was followed from the BoS to the crossing the IJV. Data recorded included the relationship of the SAN to the IJV (a) within the JF from an intracranial view, (b) exiting the JF at BoS, and (c) in the neck at the level of the posterior belly of the digastric muscle where anterior versus posterior positioning of the crossing nerve with respect to the IJV was noted. The distance travelled by the SAN from BoS until crossing the IJV, the length and width of the JF within the cranial fossa, and JF partitioning were also recorded. RESULTS: Within the JF, the SAN travelled anteromedial to the IJV in 73/84 (87%) necks. While exiting the JF, the SAN was found lateral to the IJV in 56/84 (67%) of necks. In the anterior triangle of the neck the SAN crossed the IJV anteriorly in 67/84 (80%) necks, posteriorly in 16/84 (19%) and in the one case of IJV bifurcation, the nerve pierced the vein. The average distance travelled by SAN from BoS to crossing the IJV was 2.38 cm. The average length and width of the JF were, respectively, 1.42 and 0.78 cm, and the IJV was partitioned in 36/84 necks, with 3 of the partitions being bony and the remainder fibrinous. No relationship was found between JF dimensions/partitioning and the anatomic relationship of the structures exiting it. DISCUSSION/CONCLUSION: In this study, the dimensions and relationship of the IJV and SAN are described in detail. This relationship is specifically noted at three major points, namely within the cranium, at the BoS, and in the anterior neck triangle. In its medial to lateral path in the anterior neck triangle, the SAN crossed the IJV anteriorly in a majority of the cases. However, a posteriorly crossing nerve was not uncommon. These findings support results in previous literature in that the SAN is located anterior to the IJV in the majority of the cases, however, it is imperative for the surgeon to be mindful to the anatomic variability and possible posterior crossing of the IJV by the SAN in the neck to avoid injury to the IJV during the dissection of the nerve. The distance travelled by the nerve prior to crossing the IJV was measured and can be used as a helpful tool for the surgeon in finding the nerve during dissections. We were not able to demonstrate a correlation between the relationship of the SAN and IJV at other recorded points and their crossing relationship. Similarly, no correlation was found between the anatomy of JF and the relationship of the SAN and IJV at any point.

Postoperative Imaging Appearance of Iliac Crest Free Flaps Used for Palatomaxillary Reconstructions.

The osteomyocutaneous iliac crest free flap is a reconstructive option for segmental mandibular or complex palatomaxillary defects. Familiarity with the radiographic appearance of free flaps such as the iliac crest is necessary for the postoperative evaluation of patients after mandibular, maxillary, or palatal reconstructions because it allows radiologists to properly monitor and interpret the appearance of the flap over time. This study presents a retrospective review of 5 patients who underwent palatomaxillary reconstruction with an iliac crest free flap at our institution. The imaging appearances of the 5 patients were analyzed to determine the key radiographic characteristics of a healthy and successful iliac crest free flap. Radiographic fluency with the imaging appearance of the iliac crest free flap, as well as the new anatomy of the region in the postoperative period, will allow for better interpretation of the flap appearance on imaging and will prevent false identification of tumor recurrence.

Osteoradionecrosis of the subaxial cervical spine following treatment for head and neck carcinomas.

OBJECTIVE: To study MRI and positron emission tomography (PET)/CT imaging of osteoradionecrosis (ORN) of the subaxial cervical spine, a serious long-term complication of radiation therapy (RT) for head and neck cancers that can lead to pain, vertebral instability, myelopathy and cord compression. METHODS: This is a single-institution retrospective review of patients diagnosed and treated for ORN of the subaxial cervical spine following surgery and radiation for head and neck cancer. RESULTS: We report PET/CT imaging and MRI for four patients, each with extensive treatment for recurrent head and neck cancer. Osteomyelitis (OM) and discitis are the end-stage manifestations of ORN of the subaxial spine. CONCLUSION: ORN of the subaxial spine has variable imaging appearance and needs to be differentiated from recurrent or metastatic disease. Surgical violation of the posterior pharyngeal wall on top of the compromised vasculature in patients treated heavily with RT may pre-dispose the subaxial cervical vertebrae to ORN, with possible resultant OM and discitis. MRI and PET/CT imaging are complimentary in this setting. PET/CT images may be misinterpreted in view of the history of head and neck cancer. MRI should be utilized for definitive diagnosis of OM and discitis in view of its imaging specificity. ADVANCES IN KNOWLEDGE: We identify the end-stage manifestation of ORN in the sub-axial spine on PET/CT and MRI to facilitate its correct diagnosis.

Mucoepidermoid carcinoma: a clinicopathologic study of 80 patients with special reference to histological grading.

We sought to review our experience with salivary mucoepidermoid carcinoma (MEC) over two decades to confirm the validity and reproducibility of histologic grading and to investigate MIB-1 index as a prognosticator. Diagnosis was confirmed on 80 cases, and chart review or patient contact was achieved for 48 patients, with follow-up from 5 to 240 months (median 36 months). Immunohistochemistry with citrate antigen retrieval for MIB-1 was performed on a subset of cases. Kaplan-Meier survival curves were generated for each stage, site, and grade according to our proposed grading system. To address the issue of grading reproducibility, 20 slides were circulated among five observers, without prior discussion; slides were categorized as low-, intermediate-, or high-grade according to one's "own" criteria, and then according to the AFIP criteria proposed by Goode et al.10 Weighted kappa (kappa) estimates were obtained to describe the extent of agreement between pairs of rating. The Wilcoxon signed rank test or the Friedman test as appropriate tested variation across ratings. There was no gender predominance and a wide age range (15-86 years, median 49 years). The two most common sites were parotid and palate. All grade 1 MECs presented as Stage I tumors, and no failures were seen for this category. The local disease failure rates at 75 months for grades 2 and 3 MEC were 30% and 70%, respectively. Tumor grade, stage, and negative margin status all correlated with disease-free survival (DFS) (p = 0.0091, 0.0002, and 0.048, respectively). The MIB index was not found to be predictive of grade. Regarding the reproducibility of grading, the interobserver variation for pathologists using their "own" grading, as expressed by the kappa value, ranged from good agreement (kappa = 0.79) to poor (kappa = 0.27) (average kappa = 0.49). A somewhat better interobserver reproducibility was achieved when the pathologists utilized the standardized AFIP criteria (average kappa = 0.61, range 0.38-0.77). This greater agreement was also reflected in the Friedman test (statistical testing of intraobserver equality), which indicated significant differences in using one's own grading systems (p = 0.0001) but not in applying the AFIP "standardized" grading (p = 0.33). When one's own grading was compared with the AFIP grading, there were 100 pairs of grading "events," with 46 disagreements/100 pairs. For 98% of disagreements, the AFIP grading "downgraded" tumors. This led us to reanalyze a subset of 31 patients for DFS versus grade, for our grading schema compared with the AFIP grading. Although statistical significance was not achieved for this subset, the log rank value revealed a trend for our grading (p = 0.0993) compared with the Goode schema (p = 0.2493). This clinicopathologic analysis confirms the predictive value of tumor staging and three-tiered histologic grading. Our grading exercise confirms that there is significant grading disparity for MEC, even among experienced ENT/oral pathologists. The improved reproducibility obtained when the weighted AFIP criteria were used speaks to the need for an accepted and easily reproducible system. However, these proposed criteria have a tendency to downgrade MEC. Therefore, the addition of other criteria (such as vascular invasion, pattern of tumor infiltration [i.e., small islands and individual cells vs cohesive islands]) is necessary. We propose a modified grading schema, which enhances predictability and provides much needed reproducibility.

Salvage surgery for recurrent neck carcinoma after multimodality therapy.

Recurrent carcinoma of the neck after treatment by radical neck dissection and radiotherapy leads to a progressive downhill course if no further therapy is instituted. Nine such patients having fixed, recurrent neck tumors with carotid artery involvement underwent 10 salvage procedures with carotid artery resection and replacement. One patient developed a transient hemiparesis that resolved in 3 days, and in another, a permanent hemiparesis occurred. Three patients have survived longer than 12 months. One patient is free of disease at 42 months following two salvage operations. We attribute the low operative morbidity to the frequent use of the subclavian artery for proximal anastomosis and myocutaneous flaps to resurface cutaneous and mucosal defects. We conclude that salvage surgery with carotid artery replacement can be performed on selected patients who have failed combined therapy as a palliative and possibly curative measure.

Management of early vocal cord carcinoma.

Endoscopic stripping or laser therapy are the primary modalities for patients with premalignant vocal cord lesions and patients with T1 carcinomas of the mid-portion of the vocal cord. Partial laryngectomy is advocated for patients whose resection margins are positive following laser cordectomy, or where tumor extends to the arytenoid, anterior commissure, opposite vocal cord or subglottis. Radiotherapy is reserved for patients with tumors involving the interarytenoid region, professional voice patients, or patients unfit for general anesthesia.

Intratemporal carotid artery bypass in resection of a base of skull tumor.

Tumors of the skull base with carotid artery involvement have heretofore required carotid ligation or been deemed inoperable. Two case reports are presented in which en bloc resection of malignant base of skull tumors included removal of a portion of the internal carotid artery. In the first case, the tumor was primarily in the parapharyngeal space and extended to the base of skull. Partial temporal bone resection was carried out to obtain exposure for carotid reconstruction. The second case involved an en bloc temporal bone resection for a recurrent, malignant, mixed tumor that had invaded the carotid canal. Revascularization was achieved in both cases by an autogenous, saphenous vein graft. The patients suffered no postoperative ischemic neurologic sequelae. These are the first known cases of a carotid bypass with distal anastomosis to the intratemporal portion of the internal carotid artery for a malignant base of skull neoplasm. The authors propose this procedure as an alternative to carotid ligation during surgery of tumors of the skull base requiring carotid resection.

Carotid artery resection and bypass for neck carcinoma.

Twenty-six patients were treated by carotid artery resection and vascular replacement for recurrent cancer of the neck. The incidence of postoperative neurologic sequelae was 7%. The absolute 12-month disease-free survival for metastatic squamous cell carcinoma was 25%. It is concluded that in selected patients, this aggressive surgical therapy is indicated.

Anatomy and vascular perfusion territories of the superior thyroid artery in Macaca mulatta.

OBJECTIVE: Currently, methods used to repair long segment tracheal stenosis are unreliable. Here, a new nonhuman primate model of tracheal transplantation is used based on its evolutionary proximity to humans. STUDY DESIGN: Prospective dye perfusion study in Macaca mulatta. METHODS: After anatomical characterization, Evan's blue solution was injected into the right superior thyroid artery unilaterally (n = 5). Staining of the tracheal vasculature was then examined. RESULTS: In M mulatta, the superior thyroid artery branched from the lingual-facial trunk and was 0.64 +/- 0.18 mm in diameter. Dye staining was bilateral, with the ipsilateral side extending to 2.98 +/- 0.58 cm and the contralateral to 2.88 +/- 0.88 cm, 12.9 +/- 3.45 rings (47% of trachea). CONCLUSIONS: The tracheal vasculature has extensive bilateral collateral vascular channels that may provide a graft survival advantage. Macaques may serve as a good model of tracheal transplantation because of the collateral vascularization of the trachea and the extensive tracheal segment supplied by the superior thyroid artery, and because the superior thyroid artery and vein are anastomosable.

The neurofasciocutaneous radial forearm flap in head and neck reconstruction: a preliminary report.

The radial forearm free flap has achieved considerable popularity as a reconstructive technique due to its thin, pliable tissue and long vascular pedicle. The successful use of this flap as a carrier of a vascularized nerve to bridge motor nerve gaps and as a sensate flap has not been previously reported in head and neck reconstruction. The superficial branch of the radial nerve was used as a vascularized nerve graft to bridge a facial nerve defect following radical parotidectomy. The medial and lateral antebrachial cutaneous nerves were used to re-establish sensation in a reconstructed pharyngeal mucosal defect. The published clinical and experimental studies on vascularized nerves and sensate flaps are reviewed in detail.

Abnormally large frontal sinus. II. Nomenclature, pathology, and symptoms.

Based on a review of the literature and analysis of six new cases, three categories of enlarged, aerated sinuses are defined, namely: hypersinus, pneumosinus dilatans, and pneumocele. The information gained by our study of the area variation of the frontal sinuses in a normal population (part I of this paper) was utilized to define the term hypersinus. In this condition there is generalized enlargement of the sinus beyond the upper limit of normal in an asymptomatic patient. The principal difference between pneumosinus dilatans and a pneumocele is the presence of bony thinning or erosion in the latter entity. The clinical findings and the possible etiologies of these conditions are discussed.

The abnormally large frontal sinus. I. A practical method for its determination based upon an analysis of 100 normal patients.

One hundred normal Caldwell view radiographs were examined on patients who had no signs or symptoms referable to the frontal sinuses. Magnification factors were determined for Caldwell views obtained on a dedicated head unit and as part of a skull series. The areas of the frontal sinuses were actually measured with a Zeiss Videoplan 2 computer and corrected for magnification. The area variation in this normal population was determined. Four linear measurements were individually correlated with these areas. Two of these lines had excellent correlation with the sinus area and if either of these lines exceeds a calculated value, the sinus area exceeds the 99th percentile of the normal population and can be considered abnormally enlarged. This technique provides a rapid, easy, and reliable method for assessing abnormally enlarged frontal sinus areas.

Tracheal transplantation: superior and inferior thyroid artery perfusion territory.

OBJECTIVE: To determine the perfusion territories of the superior and inferior thyroid arteries in humans. Tracheal transplantation is a potential option for management of long-segment tracheal stenosis. However, the maximum length of vascularized trachea that can be reliably transplanted has not been established. STUDY DESIGN: The tracheal vascular territory of individual superior and inferior thyroid arteries was determined separately in 10 humans postmortem. METHODS: India ink was infused unilaterally under controlled pressure into the superior (n = 5) and inferior (n = 5) thyroid arteries of cadaveric tracheas. Tracheas were sectioned longitudinally and the caudalmost extent of mucosal dye staining was determined via microscopic assessment. RESULTS: The tracheal perfusion territory of the superior thyroid artery was two to five rings (1.7 +/- 0.5 cm) and the inferior thyroid artery, nine to 13 rings (6.5 +/- 1.1 cm). In both cases, the tracheal mucosa on the contralateral side was stained to the same caudal level. CONCLUSIONS: The inferior thyroid artery was shown to perfuse the trachea maximally to the 13th ring (8.1 cm). As such, the unilateral inferior thyroid artery would serve as a suitable vascular component for long-segment tracheal transplantation in humans.

The internal oblique-iliac crest free flap in composite defects of the oral cavity involving bone, skin, and mucosa.

The reconstruction of oromandibular defects following ablative surgery is a challenging undertaking. When the defect involves skin as well as mucosa, the challenge becomes even greater. The internal oblique iliac crest osteomyocutaneous free flap is particularly useful for reconstruction of through-and-through composite defects due to the inclusion of two separate soft-tissue flaps on the same vascular pedicle. We report our experience with this flap in the reconstruction of 10 patients with such defects. The utility, and the limitations of this form of reconstruction are discussed in detail.

The use of acellular dermis in the prevention of Frey's syndrome.

EDUCATIONAL OBJECTIVE: At the conclusion of this presentation, the participant should be able to discuss the indications and advantages of using acellular dermis in the prevention of post-parotidectomy gustatory sweating (Frey's Syndrome). INTRODUCTION: Gustatory sweating is a common postoperative problem and a challenge to treat. The purpose of this study was to evaluate the role of acellular dermis in preventing post-parotidectomy gustatory sweating. METHODS: Sixty-four patients were randomly assigned to two groups. Group I consisted of 32 patients who underwent a superficial lobe parotidectomy. Group II consisted of 32 patients who underwent a superficial lobe parotidectomy and underwent intraoperative placement of acellular dermis within the parotid bed, between the skin flap and the remaining parotid tissue. The implanted volume of acellular dermis was determined by the amount required to aesthetically restore lateral facial contour. All 64 patients were evaluated for gustatory sweating by identical phone and mail questionnaires. Thirty randomly chosen patients (group I = 15, group II = 15) were evaluated using a modified Minor's Starch-Iodine Test (MSIT). In all 30 patients, the MSIT was administered to both sides of the face. RESULTS: The responses to questionnaires (N = 64) demonstrated the subjective presence of gustatory sweating in 3 of 32 patients (9.3%) in group I, whereas group II demonstrated a subjective incidence in 1 of 32 patients (3.1%). The objective incidence determined by those who underwent the MSIT (n = 30) revealed a 40% (6) and 0% incidence of Frey's Syndrome in groups I and II, respectively. The complication rate in group I was 9% (3 seromas) and in group II it was 25% (7 seromas and 1 wound infection). CONCLUSIONS: Acellular dermis appears to be an effective method for preventing post-parotidectomy gustatory sweating, despite its higher complication rate.

Laryngeal paraganglioma: update on diagnosis and treatment.

Sixty-one cases of laryngeal paraganglioma have been reported in the world literature. Histologic and clinical similarities between this neuroendocrine neoplasm and other organoid laryngeal tumors have led to uncertainty regarding the malignant potential and prognosis of this entity. Immunohistochemical assays have identified biogenic amines and hormonal peptides in these tumors which may prove useful as diagnostic markers. Computer tomography (CT) scanning demonstrates an enhancing lesion and can determine the location and extent of the tumor. The generally small size and constant blood supply of the laryngeal paraganglioma make preoperative angiography unnecessary. Accordingly, intraoperative ligation of the arterial blood supply negates the need for embolization. Partial laryngectomy remains the mainstay of treatment. A case is reported of a patient with a paraganglioma of the larynx who was unsuccessfully treated by laser excision and required surgical resection.

The combined sensate radical forearm and iliac crest free flaps for reconstruction of significant glossectomy-mandibulectomy defects.

The loss of motor and sensory function of the tongue following ablative surgery has a devastating effect on oral function. At the present time, there is no way to restore lost tongue musculature following partial glossectomy. The use of sensate cutaneous flaps has been shown to restore sensory feedback to reconstructed areas of the oral cavity. No single composite flap supplies a sensate soft-tissue component together with an osseous component of sufficient bone stock for functional mastication. In this article, the combination of the radial forearm free flap with the iliac crest osteocutaneous or osteomyocutaneous free flap is reported. The radial forearm free flap was used to resurface the resected portion of the tongue to provide maximum mobility and sensation. The lingual nerve was the recipient nerve for anastomosis to the antebrachial cutaneous nerves in all but one case. The iliac bone was used to reconstruct the mandible, with the iliac skin paddle or the internal oblique muscle used to reconstruct the neoridge. This combination of flaps was used in 10 patients. There was one flap failure due to vascular kinking from "piggybacking" the iliac crest to the distal end of the radial forearm flap. As a result, the use of two separate sets of recipient vessels is now advocated. Although a single composite free flap offers an excellent form of oromandibular reconstruction in most cases, it has been shown that oral function deteriorates when large areas of anesthesia are present in the oral cavity. We believe that this combination of two free flaps offers an opportunity for superior function in select patients with significant glossectomy and/or large mucosal defects.