Proposal for standardized ultrasound analysis of the salivary glands: Part 1 submandibular gland.

Objectives: The Salivary Gland Committee of the American Academy of Otolaryngology-Head and Neck Surgery seeks to standardize terminology and technique for ultrasonograpy used in the evaluation and treatment of salivary gland disorders. Methods: Development of expert opinion obtained through interaction with international practitioners representing multiple specialties. This committee work includes a comprehensive literature review with presentation of case examples to propose a standardized protocol for the language used in ultrasound salivary gland assessment. Results: A multiple segment proposal is initiated with this focus on the submandibular gland. We provide a concise rationale for recommended descriptive language highlighted by a more extensive supplement that includes an extensive literature review with additional case examples. Conclusion: Recommendations are provided to improve consistency both in performing and reporting submandibular gland ultrasound.

Spinal accessory nerve monitoring in selective and modified neck dissection.

OBJECTIVES: To determine whether a threshold increase in current is required to stimulate the spinal accessory nerve (SAN), comparing current on initial identification of the SAN and after completion of the dissection and before closure for selective neck dissection (SND), zones 1, 2, and 3, and modified radical neck dissection (MRND), zones 1, 2, 3, 4, and 5, and compare clinical outcome measures for "shoulder syndrome" for SND and MRND. STUDY DESIGN: Prospective study of 22 consecutive patients receiving SND or MRND by one surgeon at one institution. METHODS: Electrophysiologic recording of current on initial identification of the SAN was compared with the current recorded at the completion of the procedure and before closure for SND and MRND. Clinical correlation measured and compared parameters of "shoulder syndrome" (shrug, flexion, abduction, winging, and pain) for SND and MRND at 2 months. RESULTS: Zero of 11 (0%) patients with SND and 3 of 11 (27%) patients with MRND had significant threshold increases (>0.4 mAmp) on completion of the dissection. One of 11 (9%) patients with SND and 3 of 11 (27%) with MRND had less than 90 degrees of shoulder abduction, scapular winging, or significant pain. CONCLUSIONS: Electrophysiologic integrity of the SAN does not completely correlate with clinical outcome measures for "shoulder syndrome." It is significant that 17 of 19 (89%) patients without an electrophysiologic threshold increase did not develop "shoulder syndrome." This study demonstrated less electrophysiologic threshold shift and "shoulder syndrome" with SND compared with MRND.

Comparing the long-term outcome of immediate postoperative facial nerve dysfunction and vocal fold immobility after parotid and thyroid surgery.

HYPOTHESIS: The long-term recovery rate of immediate postoperative facial nerve dysfunction with an electrophysiologically and anatomically intact facial nerve is higher than the long-term recovery rate of immediate postoperative vocal fold immobility with an electrophysiologically and anatomically intact recurrent laryngeal nerve. METHODS: A retrospective review of parotid and thyroid surgery with electrophysiologic monitoring of the facial and recurrent laryngeal nerves, respectively. RESULTS: Forty-five consecutive patients had electrophysiologic and anatomic integrity of the facial nerve at the conclusion of the parotidectomy. Eight of 45 (18%) patients developed a postoperative facial nerve dysfunction. All eight patients with facial nerve dysfunction had complete return of facial nerve function within 3 months. A total of 102 consecutive patients underwent dissection of the recurrent laryngeal nerve during thyroid surgery. Seven of 102 (7%) had immediate unilateral vocal fold dysfunction. All 102 had electrophysiologic and anatomic integrity of the recurrent laryngeal nerve at the conclusion of the procedure. Two of 102 (2%) have clinically complete permanent vocal fold dysfunction. Five of seven (71%) with immediate complete vocal fold immobility had complete return of mobility. CONCLUSIONS: A higher immediate postoperative rate of transient facial nerve dysfunction is reported compared with vocal fold immobility in parotid and thyroid surgery, respectively (P < 0.05). Immediate postoperative facial nerve dysfunction with an electrophysiologically response at 1 mA and an anatomically intact facial nerve during parotid surgery resulted in a complete return of function in all cases in this series. Immediate postoperative vocal fold immobility with an electrophysiological response at 1 mA and an anatomically intact recurrent laryngeal nerve had a 30% rate of being permanent in this series.

Recurrent Benign Salivary Gland Neoplasms.

The most important causes of recurrence of benign pleomorphic adenoma are enucleation with intraoperative spillage and incomplete tumor excision in association with characteristic histologic findings for the lesion (incomplete pseudocapsule and the presence of pseudopodia). Most recurrent pleomorphic adenomas (RPAs) are multinodular. MRI is the imaging method of choice for their assessment. Nerve integrity monitoring may reduce morbidity of RPA surgery. Although treatment of RPA must be individualized, total parotidectomy is generally recommended given the multicentricity of the lesions. However, surgery alone may be inadequate for controlling RPA over the long term. There is growing evidence from retrospective series that postoperative radiotherapy results in significantly better local control. A high percentage of RPAs are incurable. All patients should therefore be informed about the possibility of needing multiple treatment procedures, with possible impairment of facial nerve function, and radiation therapy for RPA. Reappearance of Warthin tumor is a metachronous occurrence of a new focus or residual incomplete excision of all primary multicentric foci of Warthin tumor. Selected cases can be observed. Conservative surgical management can include partial superficial parotidectomy or extracapsular dissection. Not uncommonly, other major and minor salivary gland neoplasms, including myoepithelioma, basal cell adenoma, oncocytoma, canalicular adenoma, cystadenoma, and ductal papilloma, follow an indolent course after surgical resection, with rare cases of recurrence.

Missed opportunity for larynx preservation? Failure to distinguish verrucous and squamous cell carcinoma on microlaryngoscopy and biopsy.

The current standard for stage III and selected stage IV squamous cell carcinoma of the larynx includes organ sparing concurrent chemoradiation therapy. Verrucous carcinoma is predominantly treated with surgery, including laryngectomy in selected cases. Expert and appropriate pathologic interpretation of verrucous carcinoma with an ample biopsy specimen of the larynx using microlaryngoscopy can differ from the final pathology (squamous cell carcinoma) in a laryngectomy specimen. This can potentially lead to a failed opportunity for larynx preservation. A 68-year-old African-American male presented with a chief complaint of airway obstruction from a massive obstructing laryngeal tumor. This patient was initially treated with operative microlaryngoscopy and debulking of the laryngeal neoplasm. Computed tomography scan was not interpreted for cartilaginous invasion. Final pathological interpretation of this microlaryngoscopy and biopsy specimen included an "outside the institution" expert second opinion and that interpretation was consistent with verrucous carcinoma. Multidisciplinary head and neck oncology team recommendation was total laryngectomy. Final pathology report of the laryngectomy specimen revealed squamous cell carcinoma with extension through cartilage and anterior soft tissue extension. Expert and appropriate interpretation of an ample biopsy specimen by microlaryngoscopy can result in failure to distinguish verrucous from squamous cell carcinoma, potentially leading to missed opportunities for larynx preservation. In this case, cartilage invasion of a massive larynx squamous cell carcinoma made laryngectomy a reasonable therapeutic option.