Submandibular gland carcinoma; an audit of local control and survival following adjuvant radiotherapy.

Carcinoma of the submandibular gland is a rare diagnosis, accounting for less than 2% of cases of salivary gland tumours. We have examined the treatment and outcome of a total of 30 patients treated with radiotherapy at the Christie Hospital, Manchester between 1980 and 1993. In most cases this followed radical surgery, though 12 patients were referred following either incomplete excision or biopsy only. Adenoid-cystic histology accounted for 19 cases (63%). Standard radiotherapy was delivered using a beam directed technique to treat the whole submandibular compartment. Doses prescribed were most commonly from 50 to 55 Gy in 16 fractions over three weeks. Cancer specific survival was 79% and 57% at 5 and 10 yr respectively, the continued fall at 10 yr reflected late recurrence seen in patients with adenoid-cystic histology. Local control was 85% and 73%, respectively. Nine of twelve patients with incomplete excision or biopsy only had local control with radiotherapy. Six patients developed lung metastases, all of whom had adenoid-cystic histology. Radiotherapy was well-tolerated acutely, and only one patient experienced osteoradionecrosis requiring surgical intervention. The incidence of adenoid-cystic carcinoma is higher in the submandibular than the parotid gland. This typically results in late recurrence, and a high incidence of lung metastases and this was confirmed in our study. However, overall survival was very similar to that of parotid carcinoma.

External ear canal cholesteatoma. Case report.

External ear canal cholesteatoma is a rare condition in otologic practice. A case in a 43-year-old woman is presented in which despite the extensive nature of the lesion, minimal symptoms and absence of signs delayed diagnosis. The cause of the lesion and its treatment are discussed.

Pneumoparotitis, subcutaneous emphysema and pleomorphic adenoma.

Self-induced pneumoparotitis is a distinct clinical entity which should be considered in any inflammatory swelling of the parotid gland. When complicated by subcutaneous emphysema, other more important causes should be excluded. An unusual case is presented, which was further complicated by the presence of a pleomorphic adenoma.

Localized tracheopathia osteoplastica of the subglottis.

Tracheopathia osteoplastica is a benign dysplasia of the tracheobronchial tree which rarely presents clinical problems especially when localized. We present a case which caused an unexpected difficulty in intubation and was subsequently removed endoscopically using the CO2 laser.

Vomiting in pregnancy resulting in oesophageal perforation in a 15-year-old.

Spontaneous perforation of the oesophagus is extremely rare in children, as is perforation due to vomiting in pregnancy. We report the case of a 15-year-old in whom vomiting in early pregnancy resulted in oesophageal perforation with subcutaneous emphysema causing marked facial swelling in the absence of other signs. The more common clinical presentation of spontaneous oesophageal rupture (Boerhaave's syndrome) is discussed.

Primary synovial sarcoma of the middle ear.

Synovial sarcoma is a soft tissue malignancy which most commonly affects the lower limbs of young adults and rarely occurs in the head and neck region. The term synovial sarcoma may be a misnomer as most of these tumours occur in tissues not known to contain synovial tissue. There has only been one previously reported case affecting the middle ear, which was metastatic, and we report the first case of primary synovial sarcoma of the middle ear.

Cerebellopontine angle lipoma.

A case of a cerebellopontine angle lipoma is presented with a typical clinical, audiometric and radiological features of an acoustic neuroma. The correct pre-operative diagnosis was elusive even with the aid of magnetic resonance imaging.

Intralabyrinthine schwannoma.

Intralabyrinthine schwannomas are rare tumours which present with symptoms similar to Menière's disease. Preoperative diagnosis is rarely possible and most are found incidentally during labyrinthectomy for persistent vertigo. A further case of this tumour is reported together with a review of the literature.

An extensive vestibular schwannoma with both intracranial spread and lateral extension to the external auditory canal.

An extensive schwannoma in a 54-year-old woman is described. There was extension intracranially to involve the brain stem, laterally to fill the middle ear and external meatus, and inferiorly into the infratemporal fossa. Initially the intracranial portion of the tumour was excised. Later a second operation was undertaken to remove the residual tumour from the temporal bone and infratemporal fossa.

Recurrent respiratory papillomatosis--the Manchester experience, 1974-1992.

A series of 59 patients of all ages with recurrent respiratory papillomatosis (RRP) treated over an 18-year period is presented. A number of these patients were initially diagnosed in childhood but required treatment throughout adult life. The frequency of laser treatment was not related to either disease duration or age at onset. In 28 patients, the HPV type was identified, showing that HPV type 11 was more common in children and ran a more protracted clinical course. The requirement for tracheostomy in this series was small, whereas the incidence of malignant change in adult patients was significant.

Severe radionecrosis of the temporal bone.

Severe radionecrosis of the temporal bone is a potentially lethal condition which still occurs despite improvements in radiotherapy. A series of seven such cases is presented to outline the varied clinical features and management of this disease.

Haemangiopericytoma of the temporal bone.

Haemangiopericytoma is an uncommon vascular tumour with a widespread distribution. Although meningeal involvement is well recognized, only a few sporadic cases of temporal bone lesions have been documented, all with doubtful sites of origin. Late presentation together with the restrictive anatomy of this region often precludes its effective removal and even minimal residual disease may progress rapidly. A series of three such patients are presented in order to discuss the natural history, histological features and treatment of this disease.

The diagnostic value of positron emission tomography (PET) with radiolabelled fluorodeoxyglucose (18F-FDG) in head and neck cancer.

Positron emission tomography (PET) scanning has recently been introduced into clinical practice but its usefulness in the management of head and neck cancer is not well defined. The aim of this prospective preliminary study was to examine the clinical value of fluorodeoxyglucose (FDG)--PET in patients with head and neck cancer treated by radiotherapy with surgery in reserve by (i) relating quantitative uptake of isotope to tumour type and histological grade and (ii) comparing the imaging findings of PET and magnetic resonance imaging (MRI) in post-radiotherapy assessment of tumour response. Twenty-one patients had pre-treatment PET and MRI scans and these were repeated four and eight months after treatment if there was no clinical relapse. Pre-treatment uptake of FDG using tumour to cerebellar ratio parameters was significantly related to the histological grade of squamous cancer (p = 0.04) but not to tumour type. Discordance of post-treatment PET/MRI findings in one case indicates a possible role for PET in the early detection of tumour recurrence. Other potential uses of PET scanning in the management of head and neck cancer are discussed.

Endovascular management of the carotid blowout syndrome.

Bleeding from the carotid artery or its branches ('carotid blowout') is a well recognized complication following treatment or recurrence of head and neck cancer. The traditional surgical treatment for carotid blowout is often technically difficult and is associated with an unacceptably high morbidity and mortality. The majority of such patients are currently treated conservatively with end of life supportive measures. We report the case of a young patient with recurrent supraglottic carcinoma complicated by carotid blowout on two separate occasions over a five month period, which was successfully treated endovascularly under local anaesthetic, without neurological sequelae. With the continuing development of interventional radiology, endovascular techniques are now emerging as a viable, low morbidity treatment option in selected patients.

The effect of early blood transfusion on severe epistaxis.

This retrospective study assesses the effect of early blood transfusion on the subsequent progress of patients admitted with severe epistaxis. Both further bleeding and surgical procedures were more frequent in those receiving blood within the initial 24 h. It was concluded that the need for early blood transfusion should be assessed with care.

Ménière's disease.

Even more than a century after the first description of Ménière's disease, Portmann (1927) said: 'Ménière's is one of the least understood disorders both by doctors in general and specialists. It is variable in clinical presentation, imprecise in diagnosis, and because the effectiveness of treatment is doubtful, leaves the clinician disillusioned, depriving the patient of the potential cure that has become the rule.'

Radiotherapy in the treatment of middle ear and mastoid carcinoma.

The treatment of temporal bone carcinoma is a widely discussed topic with marked variation in published results. Most conclude that a combination of radical surgery and radiotherapy is the optimum treatment. The present study reviews the results of radiotherapy used as the main primary treatment for this condition. Five-year survival in 56 patients was 32% for radical and palliative therapy, with an excellent response in 'early' cases. It is concluded that improvement in survival could be attained by defining those groups which would benefit from a combination of treatment methods.

Intralabyrinthine schwannoma shown by magnetic resonance imaging.

Intralabyrinthine schwannomas are rare benign tumours which present with progressive or fluctuant audiovestibular symptoms and may mimic Meniéres disease. The size and position of these lesions make preoperative diagnosis unusual and most are discovered incidentally at labyrinthectomy. A case is reported which was diagnosed on magnetic resonance imaging and confirmed at surgery.

Reconstruction of discharging mastoid cavities using the temporalis myofascial flap.

Muscle obliteration of the troublesome mastoid cavity is one method of achieving a permanently dry ear, although long-term results are often disappointing. An operation is described, which is a modification of existing techniques and utilizes a temporalis myofascial flap. This procedure has been used on 46 discharging mastoid cavities and produced encouraging results. It provides a simple, safe and reliable solution to the problem.

Accuracy of hospital activity analysis operation codes.

The accuracy of operation codes on hospital activity analysis printouts has been compared with unit and patient records. Inaccurate information is being provided by the hospital activity analysis in a significant number of cases. The same mistake is often repeatedly made, suggesting deficient monitoring procedures. These lapses occurred despite a unit policy of medical staff entering the operation and diagnostic details on the HMRI(IP) sheet and the checking of all entries by a consultant.