Human papillomavirus-associated oropharyngeal cancer: review of current evidence and management.

Oropharyngeal cancer (opc) has become the leading site for human papillomavirus (hpv)-associated cancers in humans. It is an epidemic that remains relatively unfamiliar to most physicians, potentially delaying diagnosis and treatment. Traditionally, cancers involving the head and neck have occurred in smokers and in those with a significant alcohol history. Typically, hpv-positive opc presents in a younger, healthier population with a different set of risk factors and good prognosis for survival. However, many head-and-neck cancer patients, including those with hpv-positive disease, develop lifelong disabilities because of the morbid nature of their treatments, and those patients have the highest level of unmet needs in studies spanning cancer sites. Knowledge of this epidemic, a high index of suspicion, and an understanding of how the tumours present in clinical practice can help physicians to make an early diagnosis, thus sparing the patient significant morbidity from treatments associated with more advanced disease stages. Furthermore, recognizing that these patients have distinct psychosocial needs and implementing a collaborative team approach is critical to providing optimal care and improving quality of life in the survivorship period.

Multimedia information intervention and its benefits in partners of the head and neck cancer patients.

We aimed to investigate the levels of anxiety, depression, satisfaction with information provision and cancer-related knowledge in partners of head and neck cancer (HNC) patients receiving a Multimode Comprehensive Tailored Information Package (MCTIP). A non-randomised, controlled trial was conducted with partners of HNC patients recruited at two academic hospitals in Montreal. The Test participants received the MCTIP, while the Control participants received information in an ad hoc manner. All participants were evaluated using the Hospital Anxiety and Depression Scale (HADS), Satisfaction with Cancer Information Profile and a cancer knowledge questionnaire at baseline, and 3 and 6 months later. Data were analysed using descriptive statistics, t-test and chi-square test, and mixed model analysis to test the impact of the intervention. A total of 31 partners of HNC patients participated in this study and completed all the evaluations. The partners in the Test group experienced significantly lower levels of anxiety (P = 0.001) and depression (P = 0.003) symptoms and were more satisfied (P = 0.002) with cancer information provided than partners in the Control group. Providing tailored information seems to have positive outcomes regarding anxiety, depression, and satisfaction in partners of HNC patients. Larger randomised studies are warranted to validate these effects.

Three-dimensional organotypic culture of human salivary glands: the slice culture model.

OBJECTIVE: A challenge in studying human salivary glands is to maintain the cells ex vivo in their three-dimensional (3D) morphology with an intact native extracellular matrix (ECM) environment. This paper established a human salivary 3D organotypic slice culture model that could maintain its physiological functions as well as allowing a direct visualization of the cells. METHODS: Human salivary biopsies from six patients were embedded in agarose and submerged in cold buffer for thin (50 µm) sectioning using a vibratome. 'Salivary slices' were mechanically supported by a porous membrane insert that allowed an air-liquid interface and cultured in serum-free culture media. Cell viability, proliferation, apoptosis, physiological functions, and gene expression were assessed during 14 days of culture. RESULTS: Human salivary slices maintained cell survival (70-40%) and proliferation (6-17%) for 14 days ex vivo. The protein secretory (amylase) function decreased, but fluid (intracellular calcium mobilization) function was maintained. Acinar, ductal, and myoepithelial cell populations survived and maintained their 3D organization within the slice culture model. CONCLUSION: The human salivary slice culture model kept cells alive ex vivo for 14 days as well as maintaining their 3D morphology and physiological functions.

Natural extracellular matrix scaffolds recycled from human salivary digests: a morphometric study.

OBJECTIVE: A challenge in engineering tissues is to supply parenchymal cells with suitable scaffolds which ideally reproduce the extracellular matrix (ECM). This study tested the hypothesis of preserving the 'residual connective tissue' remaining after mechanical and enzymatic release of cells from human submandibular gland biopsies (that we named 'natural ExtraCellular Matrix scaffolds', nECMsc) to be used as recycled natural scaffolds. The objective was to test whether nECMsc and native salivary tissue were comparable morphologically, in ECM proteins composition, and in cell seeding efficiency. METHODS: Following cell isolation procedures, nECMsc were kept, either fresh or frozen (sectioned into 12-µm-thick slices), and examined with high-resolution electron microscopy (HRSEM) for its three-dimensional structure, and with picrosirius red staining and immunogold staining for ECM protein composition and distribution, respectively. nECMsc were seeded with human epithelial cells and fibroblasts to assess cell attachment and proliferation in short-term experiments. RESULTS: Under HRSEM, nECMsc had comparable fiber arrangement to original glands. Histochemical and immunogold-labeling examinations revealed the presence of collagen types I, III, and IV. Seeded epithelial cells and fibroblasts attached, proliferated (14-55%), and were alive (86-99%) after 4-8 days of culture. CONCLUSIONS: nECMsc retained native ECM proteins and maintained their distribution. Seeded cells remained viable on nECMsc.

Do multimedia based information services increase knowledge and satisfaction in head and neck cancer patients?

OBJECTIVES: To investigate the impact of a Multimode Comprehensive Tailored Information Package (MCTIP) on Head and Neck (H&N) cancer patients' knowledge and satisfaction. METHODS: A non-randomized controlled trial was conducted at two participating hospitals. One hospital delivered the MCTIP and the second hospital provided normal care. The study was approved by local ethical committees. Patients with Stage III and IV cancer in the H&N region were recruited between their diagnosis and treatment. All participants were evaluated at baseline, 3 and 6months later using the Satisfaction with Cancer Information Profile (SCIP) and a Cancer Knowledge questionnaire. Data were analyzed using descriptive statistics, T tests, chi square tests and finally linear mixed model analyses to test the potential impact of the intervention. RESULTS: A total of 103 participants participated in this study and complete data at all time points were collected for 96. The Test group reported higher levels of Cancer Knowledge and Satisfaction at all time points (p<0.001 with all comparisons) compared to the Control group. CONCLUSION: Our study demonstrated an association between receiving the multimedia based tailored information and higher levels of satisfaction and cancer knowledge compared to those who receive information in ad hoc manner. IMPLICATIONS: Exploring patients' informational needs is necessary before planning information services to them.

An investigation of the effect of tailored information on symptoms of anxiety and depression in Head and Neck cancer patients.

OBJECTIVE: To investigate if tailored information provision decreases symptoms of anxiety and depression in late stage Head and Neck (H&N) cancer patients. METHODS: This non-randomized, controlled trial was conducted with stage III or IV H&N cancer patients. Subjects were recruited at two academic health centers in Montreal. At the test center, subjects received the Multimode Comprehensive Tailored Information Package (MCTIP), while at the control center, they received normal information provision. Participants were evaluated using the Hospital Anxiety and Depression Scale (HADS) at baseline and 3 and 6 month later. Data were analyzed using descriptive statistics then T tests and chi square tests to compare group differences and finally mixed model analysis to test differences in outcome variables. RESULTS: A total of 103 subjects were recruited and of them 96 (47 tests and 49 controls) participants completed baseline, 3 and 6 month evaluations. The test group experienced lower levels of anxiety (p = 0.001) and depression (p = 0.089) than the control group. CONCLUSION: The subjects receiving tailored information had lower levels of anxiety than their counterparts. In addition, depression showed a reduction in the expected direction in the test group. PRACTICE IMPLICATIONS: Our results need to be further confirmed using a randomized approach in different samples but they suggest benefits for stage III and IV H&N cancer patients receiving tailored, multi-modal information concerning their cancer.

Acoustic neuroma: outcome study.

Three therapeutic modalities have been advocated in the management of acoustic neuromas: observation, surgery, and radiosurgery. Although surgery is still considered conventional treatment, at times the management can be controversial. The objectives of this article are to assess the results of each of these treatment modalities in a tertiary care acoustic neuroma referral setting. The methodology chosen was to group the patients along the initial intent to treat and then to see the results obtained. A total of 51 patients followed in the Skull Base Clinic of the McGill University Health Centre were included. The intent to treat was as follows: observation, 22 patients; surgery, 26 patients; and radiosurgery, 3 patients. The results showed that 50% of those followed by observation demonstrated growth and required surgery or radiotherapy. Surgical results, in terms of facial nerve outcome, varied with tumour size but also improved dramatically with the introduction of facial nerve monitoring and a multidisciplinary approach. In small and medium-size tumours (< 30 mm), intent to treat by observation or by surgery (with intraoperative monitoring) yielded similar results. The limitations of this study are discussed. In the future, a prospective multicentric study may help better in assessing the value of the various management options.

Clinical applications of a finite-element model of the human middle ear.

Computer-generated models are increasingly being used in otolaryngology for teaching purposes, preoperative planning, and clinical simulations, especially when dealing with small, complex areas such as the middle ear. One technique used to analyze the mechanics of complex models is the finite-element method, whereby the system of interest is divided into a large number of small, simple elements. The mechanical properties and applied forces are represented by functions defined over each element, and the mechanical response of the whole system can then be computed. We present a unique three-dimensional finite-element model of the human eardrum and middle ear. Our model takes advantage of phase-shift moiré shape measurements to precisely define the shape of the eardrum. The middle ear geometry is derived from histologic serial sections and from high-resolution magnetic resonance microscopy of the human ear. We discuss the importance of this model in terms of understanding and teaching the mechanics of the human middle ear, simulating various pathologic conditions, and designing ossicular prostheses.

Hearing preservation in acoustic neuroma surgery.

This article reviews the Montreal experience of hearing preservation in acoustic neuroma surgery. The medical records since 1995 of 36 patients who underwent acoustic neuroma extirpation with the intent to preserve hearing were examined. Intraoperative monitoring was conducted using auditory brainstem response measurement with electrocochleography via a transtympanic electrode. The role of intraoperative monitoring in guiding surgical technique and its correlation with postoperative hearing outcome are discussed. A review of the literature regarding hearing preservation in acoustic neuroma surgery is included.

Skull base meningioma: delayed extracranial presentation.

Meningiomas are common intracranial tumors that rarely extend to extracranial sites. When they occur extracranially near the skull base, their diagnosis and management represent tremendous challenges. Although the extracranial component tends to manifest at the same time as the intracranial component, this is not always the case. In the patient reported in this article, 13 years separated the diagnosis of the intracranial tumor from the appearance of an extracranial component. The clinical presentation, radiologic findings, and management of this large skull base meningioma are discussed with reference to the literature. A high index of suspicion and clinical acumen are needed to ensure that the extracranial component of these frequent tumors is discovered, especially when it presents later than the intracranial component.

Assessment of the caloric-induced tilt in the perceived visual vertical: preliminary report.

OBJECTIVE: The perceived visual vertical (PVV) has been shown to be abnormal in patients with acute vestibular lesions but reverts to normal in compensated patients. The objectives of this study are to ascertain whether the PVV can be modulated by caloric stimulation and whether this modulation diminishes in compensated patients with unilateral vestibular lesions. DESIGN: Prospective. SETTING: Tertiary care facility. METHOD: Sixty-eight patients referred for vestibular testing had an electronystagmography and a PVV. MAIN OUTCOME MEASURES: Tilt in PVV, in degrees after caloric stimulation. RESULTS: Cold caloric stimulation resulted in a mean tilt in the PVV toward the irrigated ear and warm irrigation had the reverse effect. The mean modulation (amplitude of the angular distance in degrees between cold and warm tilts) was 4.3 degrees. In a subgroup of patients with severe unilateral vestibular dysfunction, this modulation of the PVV with caloric stimulation was diminished on the side of the lesion (p = .0001). CONCLUSION: Further study is required to assess the potential of the caloric PVV as a test of otolith function.

Meningioma of the internal auditory canal.

Meningiomas are the second most common tumor to involve the cerebellopontine angle (CPA), but controversy exists as to whether they can arise within the internal auditory canal (IAC) or whether involvement of the IAC occurs secondarily by extension from the CPA. This paper reports on a patient with an enhancing IAC meningioma that then grew and on subsequent scans was found to involve the CPA. This case demonstrates that these tumors can arise within the IAC and can grow out to involve the CPA. These findings are discussed within the context of meningioma tumor genetics and the histologic evidence for precursor cells in the IAC. The radiologic findings useful in distinguishing an acoustic neuroma from a meningioma are reviewed in the light of this case. While an enhancing mass projecting into the IAC is most often an acoustic neuroma, this radiologic findings is not pathognomonic.

Prognostic significance of intraoperative facial nerve stimulus thresholds.

OBJECTIVE: Intraoperative facial nerve monitoring has reduced the incidence of facial nerve paralysis associated with acoustic neuroma surgery, but poor facial nerve outcomes continue to occur. Intraoperative prediction of facial nerve outcome would be advantageous in patient management and counseling. This study seeks to evaluate intraoperative facial nerve stimulus thresholds as a tool for predicting postoperative facial nerve outcome. STUDY DESIGN: This study is a prospective clinical study of the prognostic value of intraoperative stimulus thresholds. SETTING: The study was performed at a tertiary referral center. PATIENTS: There were 109 patients undergoing excision of acoustic neuromas included in this study. INTERVENTIONS: The minimum current required to stimulate the facial nerve at the brain stem was prospectively recorded after excision of the acoustic neuroma. MAIN OUTCOME MEASURES: Facial nerve outcome was evaluated by the House-Brackmann grade. RESULTS: A statistically significant relationship was found between poor initial facial nerve outcome and higher stimulus thresholds. Long-term impaired facial function was also more common in the higher stimulus group compared to that of the lower stimulus groups. CONCLUSIONS: Although these findings suggest that intraoperative stimulus thresholds have prognostic potential, other prognostic factors should also be considered and additional research is needed.

Severe complications of the anterior cricoid split operation and single-stage laryngotracheoplasty.

The management of congenital and acquired subglottic stenosis has been considerably facilitated with the introduction of the anterior cricoid split operation and, more recently, the single-stage laryngotracheoplasty. These procedures are followed by a 1- to 2-week period of sedation, during which the patient is paralyzed and completely dependent on mechanical ventilation. Although these procedures have proven very successful at achieving decannulation, the postoperative period can be the source of significant complications. This is illustrated with 4 cases of severe postoperative complications. The possible pathophysiologic causes are discussed, and the literature concerning the postoperative complications of these procedures is reviewed. The avoidance of neuromuscular blockade must be weighed against the possible increased need for narcotics and increased risk of self-extubation. An intensive care unit setting proficient in the care of these patients is necessary for a successful outcome.

Endoscopic repair of anterior skull base cerebrospinal fluid fistulas: an emphasis on postoperative nasal function maximization.

Endoscopic repair of cerebrospinal fluid (CSF) fistulas has been proposed as an alternative to the traditional intracranial and extracranial approaches. This study reports on four consecutive adult cases of anterior skull base CSF fistulas. The technique used for endoscopic repair, which was designed to maximize postoperative nasal function, is described in detail. The results and complications recorded, using this technique, are reported. Endoscopic repair appears to be a safe and successful approach in the surgical treatment of CSF fistulas while preserving nasal function.

Functional imaging of head and neck tumors using positron emission tomography.

Positron emission tomography (PET) is an imaging modality that generates in vivo maps of tissue radioactivity originating from a labelled substrate of glucose metabolism: 18-fluorine labelled deoxy-glucose (FDG). This study was undertaken to evaluate PET in the detection of head and neck malignancies, and to determine its effectiveness in diagnosing recurrent cancer in operated or irradiated fields. PET revealed that each biopsy-proven tumour is an area of increased radioactivity. Tumour radioactivity ranged from 130% to 300% above that of the cerebellum, and up to 650% above the contralateral, normal side. By basing the maps on tissue metabolic function, PET proved capable of distinguishing tumour (increased radioactivity) from scar tissue (reduced radioactivity). Its application may facilitate the diagnosis of recurrent tumours amid the fibrosis and distortion of normal architecture in operated, irradiated fields.

Tracheostomy: a retrospective review of 281 cases.

Although tracheostomy is an ancient technique, disagreement continues concerning the complication rate associated with the procedure. A retrospective review of 281 consecutive tracheostomies was undertaken to evaluate the current risks of tracheostomy in tertiary care teaching hospitals. In addition, we sought to identify factors associated with increased morbidity. The intraoperative and postoperative complications were analyzed regarding indication and comorbidity factors. The majority of cases (56%) were performed on ICU patients. The total complication rate was 24%. A statistically significant increased risk of complications was found both in emergency situations and in ICU patients. Delaying tracheostomy was associated with prolongation of ICU stay. Despite the relatively large number of patients studied, there were no deaths.

Tracheotomy in the first year of life.

Tracheotomy in infants is considered to be associated with a high complication rate. This study was conducted to establish the indications and complications associated with tracheotomy in patients less than one year old. The charts of 44 consecutive infants operated on between 1982 and 1991 at the Montreal Children's Hospital were reviewed. The intra-operative complication rate was 9%; the postoperative was 18%. Home care was associated with a very low morbidity. The mortality attributable to tracheotomy was 5%. Significant complications were associated with the lack of availability of the correct size tracheotomy cannula. This study finds a significant rate of complications in the infant age group, but differs from other studies in finding that very premature neonates do not experience a higher rate of complications.

Cogan's syndrome: a review of otologic management and 10-year follow-up of a pediatric case.

Although first characterized over 45 years ago Cogan's syndrome still remains a rare disease, with a high incidence of poor outcome. Experience with a case of Cogan's syndrome over a 10-year period is presented. The fluctuating clinical evolution and laboratory findings over this period are depicted, starting from presentation at age 10. The response to treatment, as revealed by audiograms, is traced. The literature is reviewed with regard to treatments that have been proposed. In those cases where a sustained follow-up is available, the success of the therapy on the vestibuloauditory system is evaluated. Although some patients have a positive response to steroids, the prognosis for hearing remains poor. The ability of steroids to change the prognosis for hearing loss is not yet established, but warrants further clinical trial.