The utility of the pectoralis myocutaneous flap in the management of select cervical esophageal anastomotic complications.

OBJECTIVE: The majority of cervical esophageal anastomotic complications can be successfully managed nonoperatively. A small group of patients may have anastomotic strictures or leakage and fistula formation that are chronic and resistant to nonoperative therapy. The purpose of this study was to review our experience with the use of the pectoralis myocutaneous flap to treat these patients. METHODS: Since April 1992, four patients have undergone pectoralis myocutaneous flap repair of cervical esophageal anastomotic complications at our institution. Two patients had chronic strictures, one patient underwent prophylactic repair with a pectoralis myocutaneous flap to prevent stricture formation, and one patient had a chronic anastomotic fistula. The pectoralis myocutaneous flap was harvested in the standard fashion. The technique of anastomotic repair is described. The medical records were retrospectively reviewed to determine patient characteristics and our results. RESULTS: Two suture line leaks developed: one small, contained leak required no intervention, and the other resolved with cervical drainage. Pneumonia, seroma at the site of the pectoralis myocutaneous flap donor, transient hoarseness, and partial skin graft loss occurred in one case each. There were no deaths. Hospital stay ranged from 12 to 22 days. A good functional result was obtained in three patients. CONCLUSION: Our results show that pectoralis myocutaneous flap repair of select cervical anastomotic complications is safe and well tolerated even in patients with complicated problems.

Occult tonsillar carcinoma in the unknown primary.

OBJECTIVES: Evaluate effectiveness of routine tonsillectomy in the assessment of patients with squamous cell carcinoma of the neck of unknown primary, and evaluate outcomes of this group compared with patients without a primary identified initially. STUDY DESIGN: A retrospective review of the medical records of 37 patients presenting with an unknown primary tumor over a 10-year period. METHODS: Charts were reviewed for age and sex of patients, methods of evaluation and diagnosis, sites of tissues obtained on biopsy, N stage of disease, and presence of extracapsular spread. Recurrence and survival data were collected over a mean follow-up period of 34 months. RESULTS: All primary lesions discovered through pathologic evaluation arose from the tonsil (9/9), and all were detected in patients undergoing tonsillectomy in conjunction with direct laryngoscopy. None of the patients (0/9) with occult tonsillar carcinoma have had recurrence, in contrast to 60% (15/25) of remaining patients. Patients with tonsillar primary lesions demonstrated less extracapsular spread of disease (25%) than patients without tonsillar primaries (67%), despite similar N staging within the two groups. CONCLUSIONS: Occult tonsillar carcinoma accounts for the unknown primary more frequently than was previously recognized. Bilateral tonsillectomy is recommended to increase the detection yield and to capture the rare case of bilateral disease. A lower incidence of extracapsular spread and reduced recurrence rates in patients with unknown primary tumors presenting as occult tonsillar carcinoma may contribute to the improved prognosis observed in this group.

Acute viral and bacterial infections of the salivary glands.

Acute infection can involve any salivary gland, but it predominately affects the major salivary glands, especially the parotid gland. The anatomic and physiologic factors accounting for the parotid gland's predilection for infection are reviewed. Numerous conditions that are predisposed to acute bacterial sialadenitis and differ from risk factors associated with viral infection are also reviewed. The pathogenesis, diagnostic evaluation, treatment, complications, and prognosis of bacterial infections are discussed and contrasted with those of viral infections.

Nasal mucosal headache presenting as orofacial pain: a review of the literature and a case report.

Headaches are a significant component of many facial pain syndromes. These facial pain/headache syndromes often have various etiologies, including neurologic, vascular, musculoskeletal, or combinations of vascular/musculoskeletal origins. Referred rhinologic headache, however, can be overlooked as a cause of facial pain in the dental literature. We report a case of nasal mucosal headache that presented as facial pain and include a review of the literature.

Clinical and molecular aspects of squamous cell carcinoma of the head and neck in the nonsmoker and nondrinker.

Most molecular analyses of head and neck squamous cell carcinoma involve patients who have used tobacco and alcohol. The pathways involved in tumorigenesis in patients lacking these lifestyle risks may be quite different. Research involving rigorous epidemiologic and molecular methods is needed to identify the unique spectra of genetic alterations in subsets of the population. This review considers recent information on the accumulation of genetic changes in the typical head and neck squamous cell carcinoma population and several studies that attempt to analyze subsets of patients categorized by age, gender, and carcinogen exposure. Efforts to identify risk factors in nonsmoking and nondrinking head and neck squamous cell carcinoma patients are evaluated, including studies of family history, human papillomavirus, chromosome fragmentability, microsatellite instability, and carcinogen-metabolizing enzyme genotype.

Intraoperative fine needle aspiration of pancreatic and extrahepatic biliary masses.

Intraoperative fine needle aspiration (IFNA) of masses of the pancreas and extrahepatic biliary system provides a method of rapid tissue diagnosis with a much lower complication rate than either wedge or large bore needle biopsies. Few series include IFNA of extrahepatic biliary system masses in their analyses. We retrospectively evaluated all IFNA of pancreatic, extrahepatic biliary and ampullary masses at the University of Virginia from March 1981 to December 1991 to assess the diagnostic accuracy of this procedure. Ninety-nine IFNA were performed--75 of the pancreas, 17 of the extrahepatic biliary system and seven of the ampulla. All aspirations were performed with direct visualization or palpation of the tumor, or both, using several passes with a 22 gauge needle. A diagnostic "positive" or "negative" reading was rendered in 90 of 99 IFNA. Carcinoma was confirmed by positive tissue diagnosis or clinical course consistent with cancer. Benign disease was confirmed by negative pathologic factors from a resected specimen or confirmatory clinical course of at least 18 months. Diagnosis was confirmed by these criteria in 82 patients. Thirty-four of 43 patients with confirmed carcinoma of the pancreas had positive cytologic factors by IFNA. Three pancreas IFNA were deemed as "suspicious" and six as "unsatisfactory." Two patients with "suspicious" findings had pathologically confirmed well-differentiated carcinoma. Carcinoma of the ampulla and extrahepatic biliary tract was detected by IFNA in 17 of 18 confirmed patients. The overall sensitivity of positive or negative IFNA in this series in 90 percent, with 100 percent specificity and 92 percent accuracy. IFNA has a positive predictive value of 100 percent and negative predictive value of 74 percent. We conclude that IFNA is a highly accurate diagnostic procedure and represents the preferred technique of obtaining an intraoperative tissue diagnosis in masses of the pancreas, extrahepatic biliary tract and ampulla. Positive IFNA may definitively guide surgical decision-making; however, we caution that negative IFNA cannot be relied on definitively to exclude the diagnosis of carcinoma.