Relationship of the recurrent laryngeal nerve to the superior parathyroid gland during thyroidectomy.

Design: The relationship of the recurrent laryngeal nerve to the superior parathyroid gland during consecutive thyroidectomies was prospectively evaluated. When one structure was noted, careful dissection was performed to locate the other structure, to preserve their natural anatomical relationship. Patients: In total, 103 consecutive thyroid lobectomies were performed on 73 patients. The distance from the superior parathyroid gland to the recurrent laryngeal nerve was recorded. Results: In 88 cases (88.9 per cent), the superior parathyroid gland was identified within 5 mm of the recurrent laryngeal nerve. In 62 cases (62.6 per cent), the gland was within 1 mm of the recurrent laryngeal nerve. The height of the thyroid lobe was positively associated with the distance between the two structures (p = 0.001), as was the incidence of cancer (p = 0.033). The incidence of recurrent laryngeal nerve paresis was less than 4 per cent. Conclusion: In most cases, the recurrent laryngeal nerve was found in close proximity to the superior parathyroid gland. In a thyroid gland with a large height, or in a cancerous lobe, this relationship is less reliable.

Sebaceoma of the auricle.

OBJECTIVE: To report a case of sebaceoma of the auricle, and to discuss the differential diagnosis, histopathological features, surgical management and genetic associations of this entity. METHODS: Case report and review of the medical literature. RESULTS: A 79-year-old man presented with a slowly growing lesion of his auricle. Excision of the mass and histopathological review revealed a benign, basaloid, adnexal neoplasm consistent with sebaceoma. Due to its association with Muir-Torre syndrome and increased risk of visceral malignancy, the patient was followed closely for signs of malignancy. At 36 months post-excision, there were no signs of recurrence; thereafter, the patient continued to receive routine cancer surveillance follow up. CONCLUSION: Sebaceoma is a rarely encountered, benign, adnexal neoplasm which can occur in the head and neck. The treatment is surgical excision, and recurrence is rare. Sebaceoma can occur as part of Muir-Torre syndrome, and in these patients there is an increased risk of other sebaceous lesions and visceral malignancy; thus, genetic testing and surveillance should be strongly considered.

Lymph node central necrosis on computed tomography as predictor of extracapsular spread in metastatic head and neck squamous cell carcinoma: pilot study.

OBJECTIVE: This study aimed (1) to investigate the relationship between the presence of lymph node central necrosis, viewed on pre-operative computed tomography imaging, and the occurrence of histopathologically determined metastatic lymph node extracapsular spread and (2) to determine whether a larger scale study would be valuable. MATERIALS AND METHODS: Pre-operative computed tomography scans, surgical records and post-operative histopathological analysis results were reviewed for 19 consecutive neck dissections performed in 17 patients with head and neck squamous cell carcinoma. RESULTS: A total of 20/26 (77 per cent) lymph nodes with central necrosis had extracapsular spread on histopathological analysis. Twenty of 21 (95 per cent) lymph nodes with extracapsular spread had central necrosis on pre-operative computed tomography. Thirty-four of 40 (85 per cent) lymph nodes without extracapsular spread had no evidence of central necrosis on computed tomography. Only three of 12 (25 per cent) patients with lymph node central necrosis identified on pre-operative computed tomography were found to have actual necrosis on final histopathological analysis. CONCLUSIONS: Lymph node central necrosis viewed on pre-operative computed tomography scans is a useful indicator of metastatic lymph node extracapsular spread, with a sensitivity of 95 per cent, a specificity of 85 per cent, a positive predictive value of 69 per cent and a negative predictive value of 98 per cent. Lymph node diameter is not a sensitive indicator of extracapsular spread.

Re-irradiation of metastatic disease in the neck from xeroderma pigmentosum.

BACKGROUND: Xeroderma pigmentosum, an autosomal recessive disease that occurs with a frequency of 1:250,000, is caused by a genetic defect in nucleotide excision repair enzymes. Mutation of these enzymes leads to the development of multiple basal cell and squamous cell carcinomas. OBJECTIVES: We present a case of xeroderma pigmentosum in a patient with cervical and intraparotid metastatic disease from recurrent cutaneous squamous cell carcinomas of the face and scalp, treated with neck dissection and re-irradiation. With the illustrative case report, we include a literature review of diagnosis, prognostic factors, and treatment, with emphasis on surgical and radiation treatment of cervical metastatic disease from recurrent skin carcinomas. CASE PRESENTATION: A xeroderma pigmentosum patient presented to our clinic with a 2-cm right submental and 1-cm right infra-auricular mass after resection of multiple squamous cell carcinomas of the scalp and face, and external-beam radiation therapy to the right face and neck. Fine-needle aspiration biopsy of the submental mass revealed poorly differentiated squamous cell carcinoma. The patient was brought to the operating room for a right modified radical neck dissection and excision of the right submental and intraparotid mass. Surgical pathology revealed 3 level ia and supraclavicular lymph nodes that were positive for metastatic squamous cell carcinoma. Re-irradiation to the entire right hemi-neck and left submandibular nodal region was performed using opposed oblique portals for the upper neck and a low anterior en face hemi-neck portal. The left parotid region was also included in the re-irradiation volume. Treatment was completed without delayed complications or recurrences to date. CONCLUSIONS: To our knowledge, this is the first case report in the literature of a patient with xeroderma pigmentosum who subsequently developed metastatic disease from recurrent cutaneous squamous cell carcinoma. Because of the rarity of xeroderma pigmentosum, this case report is also the first to describe re-irradiation to treat cervical and intraparotid metastatic disease in a xeroderma pigmentosum patient.

The external approach for submucosal lesions of the larynx.

OBJECTIVE: The surgical excision of benign submucosal lesions of the larynx can be performed using a variety of techniques including direct laryngoscopy and external approaches. We propose that small submucosal lesions of the larynx can be removed via the external approach without a tracheotomy. STUDY DESIGN: Retrospective chart review. SETTING: Six patients at The Long Island Jewish Medical Center and at the New York University School of Medicine underwent an external approach for the removal of benign submucosal laryngeal lesions without tracheotomies. Lesions included a mixed laryngopyocele, an internal laryngopyocele, a mixed laryngocele, a paraganglioma, a neurilemmoma and a lymphoma. Follow-up ranged from 1 to 9 years. RESULTS: All patients were female with an average age of 72. No patient required a tracheotomy. One patient remained intubated for 24 hours postoperatively to ensure an adequate airway. Mild dysphagia was noted in all patients, but it was short-lived and did not require alternate methods of alimentation. There have been no recurrences of disease. CONCLUSION: The external approach without tracheotomy allows for good exposure with minimal functional disability for the removal of benign submucosal lesions of the larynx.

Laryngeal pyogenic granulomas do not express oestrogen or progesterone receptors.

The objective of this study was to determine the presence of oestrogen and/or progesterone receptors in laryngeal pyogenic granulomas and the impact of these receptors on recurrence of pyogenic granulomas. Twenty-two consecutive patients who underwent microlaryngoscopy and removal of pyogenic granulomas were studied retrospectively. The indications for surgery were airway compromise, failure of medical therapy and suspicion of malignancy. Twelve of these patients' granulomas were analysed for oestrogen and progesterone receptors. Charts were analysed for age, sex, location of the lesion, history of trauma, intubation or gastroesophageal reflux disease (GORD), airway symptoms and recurrence. Oestrogen/progesterone receptors were analysed following deparaffinization of specimens and immunostaining with prediluted anti-oestrogen receptor monoclonal antibody and anti-progesterone receptor monoclonal antibody. No sample expressed oestrogen or progesterone receptors. There were too few recurrences to detect if lack of these receptors played any role in determining outcome in this group. Most of the patients had a history of GORD, intubation or laryngeal surgery. There were 12 recurrences in four patients. All of the recurrences improved on prolonged courses of omeprazole. Pyogenic granulomas do not possess oestrogen or progesterone receptors and are unlikely to respond to hormonal therapy. Patients who have, or are being operated on for, laryngeal pyogenic granulomas should be placed on proton pump inhibitors to decrease the likelihood of recurrence.

A comparison of radiation-induced and presbylaryngeal dysphonia.

OBJECTIVE: The goal of this study was to assess voice after radiotherapy compared with patients with presbylaryngeal dysphonia. STUDY DESIGN AND SETTING: Prospective assessment of 20 patients aged 60+ years who remained free of disease longer than 1 year after radiotherapy for T1 squamous cell carcinoma and retrospective review of 46 patients aged 60+ with presbylaryngeal dysphonia, conducted at a tertiary care, academic hospital. Assessment data included videostroboscopy, spectrography, voice range profile, and Voice Handicap Index. RESULTS: Eighty percent of the radiotherapy patients reported a voice disorder. Acoustic data and functional measures reflected similar limitations and abnormalities for both groups. A high incidence of glottal gap in all patients may have been associated with increased mucosal stiffness in the radiotherapy group and vocal fold atrophy in the presbylaryngeal group. CONCLUSION: Patient perception and functional outcome of voice were similar for both groups, despite differences in etiology of abnormal vocal fold vibratory behavior. SIGNIFICANCE: Radiotherapy in older individuals may yield dysphonia that is no greater than that caused by normal aging.

Head and neck paragangliomas: an overview.

Paragangliomas of the head and neck are unique tumors. Their pathology, tissue of origin, location, genetics, potential for bio-chemical activity, multicentricity, and growth pattern are unusual compared with more common head and neck tumors. Because these tumors are widespread and can appear in the ear, neck, larynx, nose, orbit, and chest, they cross subspecialties of otolaryngology.

Head and neck paragangliomas: physiology and biochemistry.

Paragangliomas of the head and neck are derivatives of neural crest cells, comprising part of the diffuse neuroendocrine system. Indeed, paragangliomas encompass a unique subset of tumors of the head and neck. Their biochemistry and physiology are similar to other neuroendocrine tumors unlike tumors based on location. This article discusses their distinct biologic attributes.

Laryngeal and sinonasal paragangliomas.

Laryngeal paragangliomas are classified as supraglottic and infraglottic. This article defines each type of paraganglioma, discusses the clinical features and diagnoses, and covers the surgical management. This article also addresses sinonasal paragangliomas, including their clinical features, diagnosis, and treatment.

Immobile vocal fold secondary to thyroid abscess: a case report.

Vocal fold paralysis as a result of a thyroid abscess is extremely rare. In this article, we report only the second documented case of such a finding. The paralysis was discovered after our patient, a 40-year-old woman, had come to the office with a complaint of discomfort in the right lower neck. Computed tomography confirmed the presence of an abscess in the posterior thyroid gland. Fine-needle aspiration did not identify any inflammatory or suspicious cells. The abscess was treated with hemithyroidectomy, and the paralysis resolved 3 weeks later. There has been no recurrence after 4 years.

Intralingual dermoid cysts: a report of two new cases.

Dermoid cysts of the oral cavity are rare. When they do occur, the most common site is the floor of the mouth. Intralingual dermoid cysts are even more rare, and until now, there were only 15 such reports in the English-language literature. In this article, we describe two additional cases. Magnetic resonance imaging is extremely helpful in establishing a differential diagnosis. Surgical excision is recommended to correct deglutition and speech problems. Its rarity notwithstanding, dermoid cyst should be considered in the differential diagnosis of tongue masses in the younger population.

Mutations in SDHD, a mitochondrial complex II gene, in hereditary paraganglioma.

Hereditary paraganglioma (PGL) is characterized by the development of benign, vascularized tumors in the head and neck. The most common tumor site is the carotid body (CB), a chemoreceptive organ that senses oxygen levels in the blood. Analysis of families carrying the PGL1 gene, described here, revealed germ line mutations in the SDHD gene on chromosome 11q23. SDHD encodes a mitochondrial respiratory chain protein-the small subunit of cytochrome b in succinate-ubiquinone oxidoreductase (cybS). In contrast to expectations based on the inheritance pattern of PGL, the SDHD gene showed no evidence of imprinting. These findings indicate that mitochondria play an important role in the pathogenesis of certain tumors and that cybS plays a role in normal CB physiology.

Repositioning the hereditary paraganglioma critical region on chromosome band 11q23.

Hereditary paragangliomas (PGL, glomus tumors, MIM no.168000) are mostly benign, slow-growing tumors of the head and neck region. The gene (or genes) affecting risk to PGL are subject to genomic imprinting: children of affected fathers exhibit an autosomal dominant pattern of disease inheritance, whereas children of affected mothers rarely if ever develop the disease through maternal transmission. We previously confined the disease gene to an approximately 6 Mb critical region on chromosome band 11q23 (PGL1). Based on haplotype analysis of an extended Dutch pedigree, a 2 Mb sub-region between D11S938 and D11S1885 was proposed as the PGL1 critical interval. In this study, we excluded this interval by analysis of two new single tandem repeat polymorphisms (STRP) contained therein. Instead, we predicted a non-overlapping, more proximal 2 Mb critical interval between D11S1647 and D11S897, and evaluated this new region using nine STRP (D11S1986, five new, closely-linked STRP, D11S1347, D11S3178, and D11S1987). Consistent with our prediction, we observed substantial haplotype-sharing within the Dutch pedigree. We also analyzed four new American PGL families. A recombination event detected in one family further defined D11S1347 as the new telomeric border. We observed significant haplotype-sharing within this new interval among three unrelated American PGL families, strongly suggesting that they originated from a common ancestor. Thus, we confined PGL1 to an approximately 1.5 Mb region between D11S1986 and D11S1347, and showed identity-by-descent sharing for a group of American PGL families.

Fluoroscopically placed percutaneous gastrostomies in the head and neck patient.

OBJECTIVE: At our institution, percutaneous gastrostomy tubes have been inserted under fluoroscopic guidance (fluoroscopic cutaneous gastrostomy [FPG]), thereby avoiding the need to traverse the pharynx and esophagus with a large-bore esophagoscope. For this reason, placement in the postoperative patient does not jeopardize the surgical reconstruction. METHODS: Thirty-five patients underwent percutaneous gastrostomy placement under fluoroscopic guidance. These included 12 patients whose cervical esophagus could not be entered safely because of a lesion in the head neck, 11 patients who had recently undergone resection of a head and neck cancer with pharyngeal reconstruction where traditional percutaneous enteral gastrostomy (PEG) placement was contraindicated, and two patients with postoperative fistulae. RESULTS: Thirty-four of 35 patients underwent successful gastrostomy or gastrojejunostomy placement. One patient had an intrathoracic position of the stomach, and one patient required repeat placement because the tube dislodged 5 days after insertion. No tube occluded. CONCLUSIONS: Percutaneous gastrostomy under fluoroscopic guidance (FPG) is an effective, safe method for access for prolonged enteral feeding of the patient whose cervical esophagus cannot be accessed for a variety of reasons. It also allows the safe placement of a gastrostomy catheter when the patient's postoperative course becomes complicated and prolonged enteral nutrition is required.

111Indium pentetreotide scan detection of familial paragangliomas.

Approximately 10% of head and neck paragangliomas are familial. Magnetic resonance imaging (MRI) is reported to be the best method for screening these families. 111Indium pentetreotide (Octreoscan) scintigraphy has been shown to be a sensitive indicator of neural crest tumors such as paragangliomas. Early diagnosis and treatment of familial paragangliomas (FP) would decrease the morbidity of tumor excision. Patients from two kindred with FP were scanned 24 hours after intravenous injection with approximately 6 millicuries of 111Indium pentetreotide. The entire body was imaged. Areas of increased uptake were further imaged with MRI. Altogether, five patients had positive 111Indium pentetreotide scans. Two unsuspected glomus tympanicums and bilateral carotid body tumors were identified. Three people tested had no abnormal uptake. There were no untoward reactions to the nuclide. 111Indium pentetreotide scanning is a safe, noninvasive method for early diagnosis of FP and is useful in detecting multicentric lesions. Patients suspect for FP are undergoing 111Indium pentetreotide imaging and followed up with MRI of the involved site if positive.

Osteosarcoma of the larynx.

About 11,600 cases of laryngeal cancer were reported in the United States in 1995, accounting for 1% of all reported cancers. Fewer than 1% of laryngeal cancers are sarcomas, osteosarcoma being the rarest type. Twelve cases of laryngeal osteosarcoma have been cited in the literature. A 47-year-old man presented with hoarseness following a benign vocal polypectomy. The entire larynx appeared swollen, although both vocal folds moved well. Biopsies did not reveal pathologic tissue. Computed tomographic imaging revealed a destructive, expansile lesion of the thyroid cartilage. A computed tomography-guided biopsy of this cartilage revealed a high-grade sarcoma. Laryngeal osteosarcoma was diagnosed following total laryngectomy. Laryngeal osteosarcoma is a highly malignant neoplasm with early hematogenous spread. Survival statistics for peripheral osteosarcoma are poor. Limited experience reveals that a combination of surgery and radiotherapy with adjuvant chemotherapy can offer some palliation. The literature and published cases of laryngeal osteosarcoma are reviewed.