Endoscopic-assisted craniofacial resection of esthesioneuroblastoma: minimizing facial incisions--technical note and report of 3 cases.

The surgical management of esthesioneuroblastoma with anterior skull base involvement has traditionally been craniofacial resection, which combines a bifrontal craniotomy with a transfacial approach. The latter usually involves a disfiguring facial incision, mid-facial degloving, lateral rhinotomy, and/or extensive facial osteotomies, which may be cosmetically displeasing to the patient. The advent of angled endoscopes has provided excellent magnification and illumination for surgeons to remove tumors using minimally invasive techniques. The authors describe their experience with three cases of esthesioneuroblastoma, which were surgically removed using a transnasal endoscopic approach, avoiding transfacial incisions. Preoperative radiographs were reviewed and tumors were staged according to the Kadish staging system. One patient had a recurrent esthesioneuroblastoma (Kadish stage B), which was removed entirely through a transnasal endoscopic approach. Two patients had intracranial extension (Kadish stage C), which were resected with a combined approach, endoscopically from below and a bifrontal craniotomy from above, to remove intracranial disease. All patients underwent reconstruction of the anterior skull base. Esthesioneuroblastomas confined to the nasal and paranasal cavities (Kadish stage A and B) were readily accessible through the transnasal endoscopic approach. If there was significant intracranial disease (Kadish stage C), adding a bifrontal craniotomy provided excellent exposure for complete resection of involved tumor. All patients underwent complete tumor resection with negative margins. None developed a cerebrospinal fluid (CSF) leak. The endoscopic-assisted craniofacial approach for the surgical management of esthesioneuroblastomas provides excellent exposure, adequate visualization, and the cosmetic benefit of avoiding an external facial incision.

A cadaveric study of the motor nerves to the levator scapulae muscle.

Understanding the surgical anatomic relationships of the motor nerves to the levator scapulae muscle is imperative for reducing postoperative shoulder dysfunction in patients undergoing neck dissection. To elucidate this relevant anatomy, cervical (C3, C4) and brachial (C5 via dorsal scapular nerve) plexi contributions to the levator scapulae were assessed with respect to posterior triangle landmarks in 37 human cadaveric necks. An average of approximately 2 (actual 1.92) nerves from the cervical plexus (range 1 to 4 nerves) emerged from beneath the posterior border of the sternocleidomastoid muscle in a cephalad to caudad progression to enter the posterior triangle of the neck on their way to innervating the levator scapulae. These cervical plexus contributions exhibited a fairly regular relationship to the emergence of cranial nerve XI and the punctum nervosum along the posterior border of the sternocleidomastoid muscle. After emerging from the posterior border of the sternocleidomastoid to enter the posterior triangle of the neck, cervical plexus contributions to the levator scapulae traveled for a variable distance posteriorly and inferiorly, sometimes branching or coming together. Ultimately these nerves crossed the anterior border of the levator scapulae as 1 to 3 nerves (average 1.94) in a regular superior to inferior progression. The dorsal scapular nerve from the brachial plexus exhibited highly variable anatomic relations in the inferior aspect of the posterior triangle, and was found to penetrate or give branches to the levator scapulae in only 11 of 35 neck specimens. We have found that the levator scapulae receives predictable motor supply from the cervical plexus. Our data elucidate surgical anatomy useful to head and neck surgeons.

Poorly differentiated pediatric head and neck neuroblastoma: a diagnostic dilemma.

Primary pediatric head and neck neuroblastoma is rare, with metastatic disease being the more common mode of involvement in this anatomic region. Poorly differentiated neuroblastoma initially presenting in head and neck locations presents a diagnostic dilemma, especially when evidence of primary disease in typical abdominal, retroperitoneal and thoracic sites is lacking. This tumor cannot easily be distinguished from the other common pediatric small round cell malignancies that may originate in or metastasize to the head and neck. Recent years have seen great strides in the immunohistochemical as well as cytogenetic characterization of certain pediatric small round cell lesions. A never before reported solitary, poorly differentiated neuroblastoma of the right parotid gland in a 20-month-old female is presented in order to familiarize the otolaryngologist with the modern diagnostic armamentarium available for the accurate characterization, and thus appropriate workup and treatment of this disease.

Wound repair after fractionated external beam radiation therapy and concomitant hyperthermia in an experimental rat model.

BACKGROUND: Fractionated radiation therapy (RT) with adjuvant hyperthermia (HT) is being used in the treatment of cancer with noted clinical success. However, little information regarding wound repair in tissues receiving this combination therapy is available for comparison of surgical risk. Consequently, this study was undertaken to assess the effects of this combined therapy on wound healing by quantitatively evaluating wound repair using tensile strength measurements. METHODS: Four treatment cohorts were designated: sham control, RT alone (600 cGy/d for 4 days), HT alone (water bath at 41.8 degrees C, subcutaneous temperature of 41.0 +/- 0.5 degrees C for 60 minutes on days 1 and 4), and combined RT and HT. At 1 week after treatment, surgical incisions of the dorsal flank were made. Tensile strength measurements of wounds were obtained at 14 and 21 days after incision. RESULTS: No significant differences were observed in the combined treatment arm (RT and HT) compared with the reduced wound breaking strength of RT alone. Statistically significant differences in tensile strength were seen when the control group or HT alone was compared with RT and HT or RT alone. CONCLUSIONS: Concomitant exposure to fractionated RT and specific HT conditions demonstrated no disproportionate alteration in wound tensile strength compared with radiation exposure alone in this animal model.

Otolaryngologic aspects of Lyme disease.

Lyme disease is a systemic illness caused by the spirochete Borrelia burgdorferi and transmitted by the bite of a tick in the Ixodes ricinus complex. While the illness is often associated with a characteristic rash, erythema migrans, patients may also present with a variety of complaints in the absence of the rash. The otolaryngologist may be called upon to see both groups of patients, with any number of signs and symptoms referable to the head and neck, including headache, neck pain, odynophagia, cranial nerve palsy, head and neck dysesthesia, otalgia, tinnitus, hearing loss, vertigo, temporomandibular pain, lymphadenopathy, and dysgeusia. We review our institutional experience with 266 patients with Lyme disease, 75% of whom experienced head and neck symptoms. We also summarize the diagnostic and treatment modalities for this illness.

Paget disease of the calvaria and facial bones with an osteosarcoma of the maxilla: CT and MR findings.

The CT and magnetic resonance (MR) findings of Paget disease of the calvaria and facial bones are described and compared with one another. The sites of dense, woven bone, myeloid marrow, and background Paget matrix can be clearly identified. A rare case of Paget sarcoma (osteogenic sarcoma) of the facial bones is also presented. The distinction between this sarcoma and the Paget bone was clearer on CT than on MR. This presumably is because the bone is directly seen on CT and only indirectly imaged on MR.