The response rate of PET-CT in the follow-up of head and neck squamous cell carcinoma patients.

BACKGROUND: The aim of this study was to evaluate the clinical value and the role of 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) during the follow-up of Head and Neck Squamous Cell Carcinoma (HNSCC) patients. 18F-FDG PET/CT scanner combines functional and anatomical information in a synergistic manner to improve diagnostic interpretation. METHODS: Sixty-five patients (53 males, 12 females; mean age: 63.94 years, range: 31-87 years) with a diagnosis of cancer of the head and neck region were observed and treated by the interdisciplinary group for the treatment of head and neck cancer of the University ENT Department in Chieti, Italy. They were scanned by 18F-FDG PET/CT during follow-up. RESULTS: We evaluated the responses of PET/CT and checked their reliability; we also decided to re-evaluate the patients (with a clinical revaluation and/or with radiological tests and/or with a histological examination). We found a concordance of results in 52 of 65 patients. CONCLUSIONS: PET/CT is useful in the follow-up of HNSCC patients and its results have been considered at the light of the high risk for local residual disease, recurrence, distant metastases, second primary tumors. Its employ can change in the future the pattern of the follow-up of these patients.

Multimodal Evaluation of Voice Outcome in Early Glottic Cancers Treated With Definitive Radiotherapy.

Background/Aim: We employed a multimodal evaluation of voice outcome (MEVO) model to assess long-term voice outcome in early glottic cancer (EGC) patients treated with primary radiotherapy (RT). The model consisted of objective and subjective vocal evaluation during follow-up, by a dedicated Speech Pathologist and Speech Therapist. Patients and Methods: MEVO methodology includes Self-perception Voice Handicap Index (VHI-30), evaluation of parameters Grade (G), Roughness (R), Breathiness (B), Asthenia (A) and Strain (S) according to GRBAS scale, objective analysis and aerodynamics using the PRAAT software and laryngeal evaluation with videostroboscope (VS). Results: The MEVO methodology was described and tested on a sample of 10 EGCs submitted to definitive RT (total dose 66-70 Gy). Mean follow-up was 48.9 months (range=9-115). VHI was mild-moderate in 90% of patients; overall voice function (GRBAS) was normal-mildly impaired in 70% of patients; VS evaluation showed normal vocal cord motion in 90% of patients, but complete glottic closure in 60%. PRAAT scores confirmed these findings. Conclusion: A multidimensional voice evaluation is time consuming, but useful to objectify vocal impact of radiotherapy. The MEVO model allowed to quantify vocal dysfunction, showing a good objective vocal outcome.

Evidence and Considerations on Treatment of Small Size Merkel Cell Head and Neck Carcinoma

Abstract Introduction Merkel cell carcinoma (MCC) is a rare and aggressive neuroendocrine malignant cancer. It is an epidermal cancer common in the head and neck. Objectives Though there is limited number of cases described in the literature for the treatment difficult to obtain. Our purpose was to present the clinical course and treatment of four patients with MCC. Methods We conducted a retrospective analysis and obtained detailed clinical information for all 4 patients treated for MCC at the ENT Department of the SS Annunziata Hospital in Chieti, Italy, from 2013 through 2015. Results In our study, two patients presented with the tumor in a rare site (lower eyelid). All of the patients underwent surgical treatment: three patients had free excision margins and negative sentinel lymph nodes (SLNs) while 1 patient had free excision margins and positive SLNs. The latter patient underwent ipsilateral neck dissection. In another patient, the fluorodeoxyglucose positron emission topography (FDG PET)/computed tomography (CT) performed 6 months after the surgery has shown high metabolic activity in the left parotid gland, and the patient underwent total parotidectomy and a neck dissection. Conclusion Sentinel lymph node biopsy is a useful technique in small size MCCs of the head and neck. However, the parotid gland should be strictly controlled in patients with lower eyelid tumors.

Neck subcutaneous nodule as first metastasis from broad ligament leiomyosarcoma: a case report and review of literature.

BACKGROUND: Leiomyosarcoma usually develops in the myometrium and is characterized by a high recurrence rate, frequent hematogenous dissemination, and poor prognosis. Metastasis is usually to lungs, liver, and bone, and occasionally to the brain, but seldom to the head and neck region. Primary leiomyosarcoma very rarely arises in the broad ligament. CASE PRESENTATION: A 54-year old woman presented to the otolaryngology department with a mass in the right posterior region of the neck 4 years after surgery for a primary leiomyosarcoma of the right broad ligament. The neck mass was removed and found to be a metastatic leiomyosarcoma. Leiomyosarcoma localizations in lungs and liver were absent. Morphological examination showed both the primary and the secondary leiomyosarcomas to have features of low-grade tumors. One year after excision of the neck mass, the patient presented with tachycardia. Echocardiography detected two intracardiac nodules suggestive of metastatic tumors. Chemotherapy was administered; the disease has been stable since then. CONCLUSIONS: We report the first case of broad ligament leiomyosarcoma with the neck subcutaneous region being the first site of secondary involvement. We speculate that the Batson venous plexus might have been the pathway of dissemination.

Evidence and Considerations on Treatment of Small Size Merkel Cell Head and Neck Carcinoma.

Introduction Merkel cell carcinoma (MCC) is a rare and aggressive neuroendocrine malignant cancer. It is an epidermal cancer common in the head and neck. Objectives Though there is limited number of cases described in the literature for the treatment difficult to obtain. Our purpose was to present the clinical course and treatment of four patients with MCC. Methods We conducted a retrospective analysis and obtained detailed clinical information for all 4 patients treated for MCC at the ENT Department of the SS Annunziata Hospital in Chieti, Italy, from 2013 through 2015. Results In our study, two patients presented with the tumor in a rare site (lower eyelid). All of the patients underwent surgical treatment: three patients had free excision margins and negative sentinel lymph nodes (SLNs) while 1 patient had free excision margins and positive SLNs. The latter patient underwent ipsilateral neck dissection. In another patient, the fluorodeoxyglucose positron emission topography (FDG PET)/computed tomography (CT) performed 6 months after the surgery has shown high metabolic activity in the left parotid gland, and the patient underwent total parotidectomy and a neck dissection. Conclusion Sentinel lymph node biopsy is a useful technique in small size MCCs of the head and neck. However, the parotid gland should be strictly controlled in patients with lower eyelid tumors.

Prevention of withdrawal symptoms in alcoholic patients with head and neck cancer.

BACKGROUND: The role of alcohol abuse is common in the onset of cancer of the upper aerodigestive tract, especially that affecting the tongue, floor of the mouth, palatine tonsil and piriform sinus. The consequences of the abuse of alcohol immediately after surgery in these patients are less known. But they are very important to achieve good final results. METHODS: To try to understand the best treatment for withdrawal symptoms in a group of Italian patient with head and neck cancers, we administered a 10-item questionnaire. Subsequently, we decided to send the questionnaire to the main Italian centers of head and neck oncology using the platform of online surveys SurveyMonkey. RESULTS: The results show clearly that it is not easy, within the Italian "latin" culture and lifestyle to correctly identify the alcoholic patient (patients in the last stage of the of the disease with a "behavioral dependency") and that the centers which address these problems mostly use a drug treatment, employing in particular two classes of drugs, associated or not with thiamine, with a varying quantity of other vitamins. CONCLUSIONS: It is important to know the early withdrawal syndrome to assess the ideal treatment. We propose a personal protocol to present this complication.

Audiovestibular Symptoms in Systemic Autoimmune Diseases.

Immune-mediated inner ear disease can be primary, when the autoimmune response is against the inner ear, or secondary. The latter is characterized by the involvement of the ear in the presence of systemic autoimmune conditions. Sensorineural hearing loss is the most common audiovestibular symptom associated with systemic autoimmune diseases, although conductive hearing impairment may also be present. Hearing loss may present in a sudden, slowly, rapidly progressive or fluctuating form, and is mostly bilateral and asymmetric. Hearing loss shows a good response to corticosteroid therapy that may lead to near-complete hearing restoration. Vestibular symptoms, tinnitus, and aural fullness can be found in patients with systemic autoimmune diseases; they often mimic primary inner ear disorders such as Menière's disease and mainly affect both ears simultaneously. Awareness of inner ear involvement in systemic autoimmune diseases is essential for the good response shown to appropriate treatment. However, it is often misdiagnosed due to variable clinical presentation, limited knowledge, sparse evidence, and lack of specific diagnostic tests. The aim of this review is to analyse available evidence, often only reported in the form of case reports due to the rarity of some of these conditions, of the different clinical presentations of audiological and vestibular symptoms in systemic autoimmune diseases.

TNM classification of the oral cavity carcinomas: some suggested modifications.

TNM system is a universally recognized cancer classification. It's based on the assessment of anatomical extent of tumor (T), nodal (N) and distant metastases (M). The first edition of TNM was published in 1968 and has since been updated several times. Relevant characteristics that affect prognosis prognosis, such as depth of invasion, tumor volume, surgical margin infiltration, and the number of involved nodes as well as the presence of extracapsular spread (such data should be determined by the pathologist and included in pTNM staging ­ ed. note) are not included in the TNM classification. Following a discussion on most recent classification updates we will discuss the factors, which in our opinion and in concordance with the most recent literature, deserve special consideration and influence management of oral carcinomas.

Early percutaneous endoscopic gastrostomy and nutritional supplementation for patients with head and neck cancer: an Italian survey of head and neck radiation oncologists.

PURPOSE: The aim of this paper is to survey among Italian radiation oncologists about the role of nutritional supplementation and an early placement of endoscopic percutaneous gastrostomy in head and neck cancer patients treated with radiotherapy or chemo-radiotherapy. METHODS: The survey was carried out in 106 Italian centers of radiation oncology through a SurveyMonkey online interface questionnaire. RESULTS: The response rate to the survey was of 63%, with 67 analyzable questionnaires. The majority of the respondents do not use preventive nutritional supplement. In 73.1% of the cases, percutaneous endoscopic gastrostomy (PEG) is positioned only in case of necessity. The 82.1% of the interviewed physicians, indeed, argued that the preventive placement of the endoscopic percutaneous gastrostomy should not be a standard procedure. Nutritional counseling before starting a treatment is not a routine, but 88.1% of the respondents stated that this should represent a standard procedure. CONCLUSIONS: Although some studies agree that a reactive approach should be preferred to an early endoscopic percutaneous gastrostomy placement, firm evidences and a clear consensus are still lacking. This survey shows a wide agreement about both timing and criteria for endoscopic percutaneous gastrostomy placement; however, the management of nutritional supplementation in head and neck cancer patients appears to be still widely variable and to deserve more focused studies.

A multicenter observational study on the role of comorbidities in the recurrent episodes of benign paroxysmal positional vertigo.

OBJECTIVE: Primary objective of this study was to find a statistical link between the most worldwide comorbidities affecting the elderly population (hypertension, diabetes, osteoarthrosis, osteoporosis and depression) and recurrent episodes of BPPV. Secondary objective was defining possible "groups of risk" for people suffering recurrent positional vertigo related to the presence of a well documented comorbidity. METHODS: This was an observational, cross-sectional, multicenter, spontaneous, non-pharmacological study. The data of 1092 patients suffering BPPV evaluated in 11 different Departments of Otolaryngology, Otoneurology and Neurology, referring Centers for positional vertigo evaluation, were retrospectively collected. RESULTS: Regarding evaluated comorbidities (hypertension, diabetes, osteoarthrosis, osteoporosis and depression), data analysis showed the presence of at least one comorbid disorder in 216 subjects (19.8%) and 2 or more in 408 subjects (37.4%). Moreover there was a statistical significant difference between the number of comorbidities and the number of recurrences, otherwise said as comorbidity disorders increased the number of relapses increased too. CONCLUSION: The presence of a systemic disease may worsen the status of the posterior labyrinth causing a more frequent otolith detachment. This condition increases the risk for patients suffering BPPV to have recurrent episodes, even if correctly managed by repositioning maneuvers. The combination of two or more of aforementioned comorbidities further increases the risk of relapsing BPPV, worsened by the presence of osteoporosis. On the basis of this results it was possible to define "groups of risk" useful for predicting BPPV recurrence in patients with one or more comorbidity.

Features of biopsy in diagnosis of metatypical basal cell carcinoma (Basosquamous Carcinoma) of head and neck.

Metatypical Basal Cell Carcinoma, also known as Basosquamous Carcinoma is a subtype of Basal Cell Carcinoma. It is similar to Basal Cell Carcinoma for the gross aspect and regional recurrences, but it has the capacity to spread and develop metastasis. This terrible characteristic endangers the life of the patient if it is not readily recognized by the physicians. Herein we present a report of two patients affected by BSC originating in the nasal region and external ear that after a series of devastating local recurrences metastasized to the lung and bones in one case. The true incidence of Basoquamous Carcinoma may be higher, with underreporting arising because of rarity of diagnosis and lack of awareness on the part of clinicians. Our experience suggests that a deep biopsy is often necessary to discover a BSC that appears as BCC but with local aggressive features.

Leiomyosarcoma of the base of the tongue and free edge of the epiglottis: a case report.

INTRODUCTION: We present the case of a man with a leiomyosarcoma of the base of the tongue. We feel this case is important as this kind of pathology, though rare, can occur at a site where carcinomas are more frequent. CASE PRESENTATION: A 77-year-old Caucasian man had been reporting difficulty in swallowing and hoarseness for a month before admission to our department. After several preliminary tests, including a biopsy which was positive for a malignant epithelial neoplasm which required further immunohistochemical study, we decided to operate, removing the base of our patient's tongue and performing a total laryngectomy. Histological examination of the specimen revealed a high-grade leiomyosarcoma of the base of the tongue and of the free edge of the epiglottis. CONCLUSIONS: We wish to stress the rarity of this clinical case, related to the site of implantation of the tumor, as confirmed by the difficulties in finding reference to this topic in the international literature. In fact, several cases of leiomyosarcoma have been described, but in different locations from that seen in our patient's case.

Peri-orbital foreign body: a case report.

INTRODUCTION: Foreign bodies inside the orbital cavity are rare. They can cause more or less serious complications, depending on their nature and size. CASE PRESENTATION: We report a case of a work-related accident involving a peri-orbital foreign body. The patient was a 50-year-old Caucasian man whose face was injured on the right side while he was working with an agricultural machine. On admission, he was fully conscious and did not have any neurological deficits. He had no loss of vision or ocular motility, but had a laceration of the lateral side of his right upper eyelid. A computed tomographic scan revealed a 6-cm-long bended metal object lodged in the lateral bulbar space of the right orbit. The patient recovered well after surgery and a course of antibiotic therapy. CONCLUSION: The original aspects of this case are the singularity of the foreign body and its relative harmlessness in spite of its large size.

Are postural restrictions necessary for management of posterior canal benign paroxysmal positional vertigo?

OBJECTIVES: An important component of management of benign paroxysmal positional vertigo (BPPV) has been the application of postural restrictions after use of a canalith repositioning maneuver (CRM) to prevent the return of otolithic debris into the posterior semicircular canal (PSC). This study was designed to explore the effectiveness of postural restrictions in patients with BPPV caused by otolithic debris in the PSC. METHODS: Seventy-four adult patients with unilateral PSC BPPV were enrolled into this study. All patients were managed with a CRM--either the modified Epley maneuver or the Semont maneuver. The patients were divided randomly into 2 groups: group A, with postural restrictions, and group B, without postural restrictions. The statistical analysis was performed with X2 tests and t-tests. RESULTS: No patients in either group showed positional nystagmus in the posttreatment evaluation under infrared videonystagmoscopy. No patients had symptoms of vertigo after the therapy. The results of follow-up vestibular tests were normal in both groups. CONCLUSIONS: In our experience, postural restrictions do not enhance the beneficial effect of the CRMs. They do not seem to have any protective role and therefore should not be recommended as an adjunct to the treatment of PSC BPPV.

Spontaneous nystagmus in benign paroxysmal positional vertigo.

OBJECTIVE: The purpose of this study was to evaluate the presence and eventually to study the features of spontaneous nystagmus (Ny) in our patients with diagnosis of benign paroxysmal positional vertigo (BPPV). PATIENTS AND METHODS: We retrospectively reviewed the clinical records of patients who presented with vertigo spells and were managed at our tertiary care referral center. Patients with only idiopathic BPPV presenting with typical vertigo spells and positioning Ny characteristic of the disease were included in this study. To investigate the positioning Ny, we studied the patients in the sitting position, during the head shaking test, and during the Dix-Hallpike test and the McClure-Pagnini test (Ny provoked by rotation of the head in a supine patient). Ny responses in all patients were observed using infrared videoscopy. RESULTS: We managed 412 patients affected by BPPV. Of the 412 patients, 292 (70.87%) were diagnosed to be having posterior canal-BPPV and 110 (26.99%) patients had horizontal canal-BPPV (HC-BPPV). The remaining 10 patients (2.44%) were identified to have anterior canal-BPPV. Spontaneous Ny in sitting position was observed, by infrared videoscopy, only in the patients affected by HC-BPPV. CONCLUSION: Spontaneous Ny in BPPV can be observed with infrared videoscopy in patients affected by HC-BPPV. The origin of this Ny is most likely due to a natural inclination of horizontal semicircular canal with respect to the horizontal plane. This Ny stops after flexion of the head in neutral position, and for this reason, it should be considered as a seemingly spontaneous Ny. This Ny, in our experience, is observed in most HC-BPPV patients but does not indicate the need for a different management protocol or any different prognostic value of HC-BPPV.

Benign paroxysmal positional vertigo following whiplash injury: a myth or a reality?

OBJECTIVE: The aim of the study was to evaluate the true incidence, diagnosis, and treatment of benign paroxysmal positional vertigo (BPPV) arising after whiplash injury and to distinguish this type of posttraumatic vertigo from other types of dizziness complained after trauma. METHODS: This was a retrospective study comprising patients referred to our center after whiplash injury. The patients were evaluated with neurotologic examination including bedside and instrumental tests. A Dizziness Handicap Inventory evaluating the symptoms of patients was submitted before and after treatment and was evaluated. The BPPV patients were separately evaluated from those with cervicogenic vertigo, and a comparison between our data about idiopathic BPPV was done. RESULTS: Eighteen patients of whiplash who had BPPV were evaluated. The mean age was 38.2 years. BPPV was the cause of vertigo in 33.9% of total whiplash patients. In 16 cases, the posterior semicircular canal was involved; the lateral semicircular canal was involved in 2 cases. The instrumental neurotologic assessment did not show any alteration of either vestibulospinal reflexes or dynamic ocular movements. Duration of symptoms before treatment ranged from 3 to 26 days. A total of 55.5% of patients had relief from their symptoms after first repositioning maneuver. The Dizziness Handicap Inventory score improved in all patients treated with repositioning maneuvers, but no difference emerged with idiopathic BPPV data. CONCLUSION: BPPV after whiplash injury could be unveiled with a simple bedside examination of peripheral vestibular system, and a treatment could be done in the same session. The diagnosis of posttraumatic BPPV is not different from the idiopathic form, but the treatment may require more maneuvers to achieve satisfactory results.

Transcription and translation of the chemokines RANTES and MCP-1 in nasal polyps and mucosa in allergic and non-allergic rhinopathies.

The pathogenetic findings of rhinopathies show an increase in infiltrating cells including eosinophils. RANTES is a beta chemokine in which the cysteines are adjacent (C-C), and it attracts and activates eosinophil. We hypothesize that RANTES is locally produced within the nasal polyp microenvironment and is responsible for the inflammatory cell recruitment present in nasal polyposis. To test this hypothesis, we evaluated nasal polyps and mucosa from allergic and control, non-allergic patients for RANTES content. The relative levels of RANTES and MCP-1 protein in tissue homogenates were quantified using enzyme-linked immunosorbent assay technology, and quantitative reverse transcriptase-polymerase chain reaction (RT-PCR) tests for RANTES and MCP-1 mRNA expression were performed. The results indicate that RANTES expression and production increase in nasal mucosa (septal and turbinate portions) of allergic patients compared to the same mucosa in non-allergic patients. In allergic patients, RANTES levels of nasal polyp homogenates were nearly 12-fold higher than the RANTES levels in mucosa homogenate. In this study, we hypothesize that the particular anatomic structure and physiologic function of the turbinates are more involved in the pathogenesis of rhinitis and may undergo polypoid degeneration in allergic rhinitis than any other anatomical structure of the nose. Our data suggest that RANTES is more involved than MCP-1 in recruiting inflammatory cells in rhinological disease and may reflect the degree of local inflammation as consequence of the specific chemoattractant properties of RANTES. The level of RANTES in nasal polyps could be important in the development of the pathological state.