Distinguishing tumor recurrence from irradiation sequelae with positron emission tomography in patients treated for larynx cancer.

PURPOSE: Distinguishing persistent or recurrent tumor from postradiation edema, or soft tissue/cartilage necrosis in patients treated for carcinoma of the larynx can be difficult. Because recurrent tumor is often submucosal, multiple deep biopsies may be necessary before a diagnosis can be established. Positron emission tomography with 18F-2fluoro-2deoxyglucose (FDG) was studied for its ability to aid in this problem. METHODS AND MATERIALS: Positron emission tomography (18FDG) scans were performed on 11 patients who were suspected of having persistent or recurrent tumor after radiation treatment for carcinoma of the larynx. Patients underwent thorough history and physical examinations, scans with computerized tomography, and pathologic evaluation when indicated. Standard uptake values were used to quantitate the FDG uptake in the larynx. RESULTS: The time between completion of radiation treatment and positron emission tomography examination ranged from 2 to 26 months with a median of 6 months. Ten patients underwent computed tomography (CT) of the larynx, which revealed edema of the larynx (six patients), glottic mass (four patients), and cervical nodes (one patient). Positron emission tomography scans revealed increased FDG uptake in the larynx in five patients and laryngectomy confirmed the presence of carcinoma in these patients. Five patients had positron emission tomography results consistent with normal tissue changes in the larynx, and one patient had increased FDG uptake in neck nodes. This patient underwent laryngectomy, and no cancer was found in the primary site, but nodes were pathologically positive. One patient had slightly elevated FDG uptake and negative biopsy results. The remaining patients have been followed for 11 to 14 months since their positron emission studies and their examinations have remained stable. In patients without tumor, average standard uptake values of the larynx ranged from 2.4 to 4.7, and in patients with tumor, the range was 4.9 to 10.7. CONCLUSION: Positron emission tomography with labeled FDG appears to be useful in distinguishing benign from malignant changes in the larynx after radiation treatment. This noninvasive technique may be preferable to biopsy, which could traumatize radiation-damaged tissues and precipitate necrosis.

Surgical management and follow-up of a complex tracheobronchial injury.

Tracheobronchial trauma is an uncommon condition with potentially devastating consequences. Appropriate pre-, intra-, and postoperative management is mandatory for a satisfactory functional outcome. We report a case of extensive tracheobronchial injury secondary to blunt trauma, which was managed successfully with emergent surgical repair and careful endoscopic follow-up. We review the important management decisions made in this case.

Postirradiation carcinoma in a thyroglossal duct remnant: follicular variant of papillary thyroid carcinoma.

A case of carcinoma in a thyroglossal duct remnant is presented. The tumor was a rare follicular variant of the papillary type of thyroid carcinoma. The patient had received external beam radiation to the head and neck both as a child and as an adolescent. The recently reported increased incidence of thyroid carcinoma is believed to be related to the former practice of irradiating cervical thymic and lymphoid tissue in children. Since it is normal thyroid tissue that remains in the thyroglossal duct tract, this ectopic tissue presumably has the same malignant potential as that in the thyroid gland. Therefore, more cases of carcinoma in a thyroglossal duct remnant may be seen as those patients who underwent head and neck irradiation in childhood mature.

Endovascular treatment of hemorrhage after tonsillectomy in children.

SUMMARY: Endovascular therapy for hemorrhage after tonsillectomy or adenoidectomy is an important adjunct to the definitive treatment of this life-threatening occurrence. We report two cases of hemorrhage after tonsillectomy and/or adenoidectomy and describe the endovascular management of this complication in children.

The neck mass.

Many head and neck disease processes are manifest as neck masses. These conditions are treated by surgical excision except for some inflammatory masses, and often those too must be excised before a diagnosis can be made. The real question is when to excise the lesion to expedite treatment in the most cost-effective manner. In general, when signs of inflammation are associated with the mass, antibiotic treatment with short-term observation is acceptable. Persistence of the mass or an increase in mass size during observation mandates for their evaluation. Biopsy of a mass is considered for progressive growth, isolated nature or asymmetry of the mass, location (supraclavicular), development of symptoms associated with lymphoma (fever and hypertrophy of the spleen, liver, or Waldeyer's ring), or static size (if > 3 cm). In the adult patient, a complete head and neck physical examination is mandatory before biopsy. Needle biopsy of the neck mass is the current standard of care if no cause of the mass is found on examination. Identified benign cystic lesions or lymphomas indicate a need for excision, either as definitive treatment or for diagnostic reasons. If results of the needle biopsy are positive, equivocal, or even negative in the presence of a high index of suspicion for metastatic squamous cell carcinoma, an endoscopic examination is mandatory before open excision. If no discrete lesion is seen, guided biopsy of the upper aerodigestive tract is performed. Open biopsy of the mass should be accompanied by a frozen-section examination of the mass. A concomitant definitive neck dissection should be performed if the mass proves to be metastatic carcinoma.

Diagnosis and management of masses in the neck, with special emphasis on metastatic malignant disease.

The author presents an algorithmic approach to the diagnosis and treatment of neck masses and reviews individual neck mass entities. He stresses that, until proven otherwise, every adult neck mass should be treated as if it were malignant, and, prior to biopsy, should be worked up appropriately with head and neck exams and endoscopic evaluations in search of the primary tumor. This is important because there can be adverse effects to early, inappropriate biopsy--local wound complications, increased local recurrence, and increased distant metastases. In children, an initial biopsy of the mass after a complete physical examination is acceptable because the incidence of primary mucosal cancers in the pediatric age group is low. The role of panendoscopy for neck masses with a known primary mucosal carcinoma is reviewed in light of the high incidence of two simultaneous head and neck primaries. The technique, role, and timing of needle biopsy of neck masses is also discussed.

Panendoscopy as a screening examination for simultaneous primary tumors in head and neck cancer: a prospective sequential study and review of the literature.

A prospective panendoscopic evaluation comprising direct laryngoscopy, bronchoscopy, and esophagoscopy was conducted in 100 consecutively seen patients with untreated head and neck primary tumors. Of the patients, 16% (18% counting two third primary lesions found in the 16 patients) had synchronous primary malignant tumors of the serodigestive tract. Eleven of the 16 patients had silent lesions found only by endoscopy, and 6 (6% of the total group) had lesions found only because the full panendoscopic protocol was followed. Those 6 tumors would not have been discovered as early by clinical examination or by symptom-only directed studies. The initial treatment plan in 7 patients was changed by the panenodscopic findings. This study verifies the high incidence of synchronous primary tumors in the head and neck areas that have been reported in retrospective studies, and suggests that an intensive, full panendoscopic work-up as a screening test in all patients with primary head and neck tumors can be conducted without increased morbidity and yields enough information to justify its cost.

Head and neck cancer in women--a changing profile.

A progressive trend toward increased occurrence of head and neck cancer in women is reported. Over the most recent 6 year period, 533 newly diagnosed patients were referred for treatment of head and neck cancer; 169 (32%) were women. Review of their cases showed heavy use of tobacco and alcohol by many of these women patients. The acceptance of the use of these mucosal irritants and changing social mores in the tobacco belt society under study predate recent national trends of similar nature. Thus, the increased incidence of head and neck cancer in women reported here probably presages similar increases in that incidence nationwide.

"How I do it"--head and neck. A targeted problem and its solution: securing of intermediate duration feeding tubes.

A method to secure a nasogastric tube for intermediate-duration tube feeding is presented. It is especially appropriate during the postoperative care of a patient with head and neck cancer, when reinsertion of the tube carries the risk of rupture of a suture line. To date, in over 100 patients, we have seen no complications and no premature extubations resulting from the use of this technique.

Management decisions in laryngeal carcinoma in situ.

Twenty-one patients with laryngeal carcinoma in situ (n = 12) or carcinoma in situ with microinvasion (n = 9) were treated with laser mucosal dissection of the vocal cords and/or superficial laser cordectomy. The normal architecture of the vocal cords was preserved because the depth of vaporization was usually superficial in these early cases. Five patients had recurrence, new tumor, or persistence of abnormal tissue that required additional laser surgical treatments. With a follow-up range of 6 months to 4 years, all patients currently are free of laryngeal abnormality, and no patient has needed open laryngeal surgery or radiation therapy. Transoral endoscopic laser resection of laryngeal carcinoma in situ with or without microinvasion should be the treatment of choice for these early lesions.

Cerebrospinal fluid fistula: the identification and management in pediatric temporal bone fractures.

Cerebrospinal fluid (CSF) fistula represents a potentially lethal complication and requires a high index of suspicion to make the diagnosis. A 12-year retrospective study of pediatric basilar skull fractures identified 147 patients with temporal bone fractures, of which 37 patients exhibited evidence of CSF fistula. The diagnosis is made from a combination of clinical, radiographic, and chemical evaluation. The evolution of diagnostic techniques are reviewed, and the more recent and sensitive tests, such as beta-2 transferrin, are emphasized. Treatment of CSF fistula is nonsurgical in most cases. Surgical exploration and mastoid obliteration were required in two patients, and the indications for surgical treatment are explored. The use of antibiotic prophylaxis is controversial and not routinely indicated.

Second laryngeal cancers in previously treated larynges.

OBJECTIVES: To review the management and outcome of patients with new second primary cases of laryngeal cancer occurring more than 3 years after the initial cancer was treated. STUDY DESIGN: Retrospective review of 855 patients with newly diagnosed and treated laryngeal cancers. METHODS: Charts were reviewed and tabulated for occurrence of second primary laryngeal tumors, method of treatment for the index and second primary laryngeal tumors, and effect of smoking status or cessation of smoking. RESULTS: Of the 855 patients, 532 patients retained their larynx; of these 377 lived more than 3 years and thus were at risk for a second new primary cancer. Of these 377 patients at risk, 19 or 5.1% developed second primary tumors. The rate of second primary disease was lower in patients whose index laryngeal cancer was treated by irradiation (4.3%) compared with those treated surgically (9.2%). However, surgical treatment of second primary laryngeal tumors resulted in far higher rates of laryngeal voicing (82%) compared with irradiation (33%). CONCLUSION: When possible, management of the index primary tumor by endoscopic resection has resulted in the highest future retention of laryngeal speech, leaving all treatment options available should a second laryngeal cancer occur. Lifelong follow-up of patients with laryngeal cancer for secondary primary tumors is important. Second primary tumors were equally distributed between patients who continued to smoke and ceased to smoke after their index primary lesion was diagnosed.

Effect of radiation therapy on facial nerve cable autografts.

Facial nerve cable autografts were performed on 20 cats with 10 animals receiving 6,000 Rads of postoperative irradiation over six weeks. Testing by clinical appearance, pontograms, and axon counts showed no statistical difference in the operated only and the operated plus irradiated groups. Pontograms illustrated the clinical observance of spasticity, delay and weakness often seen after grafting. This animal work tends to verify the clinical impression that in patients requiring postoperative irradiation for a malignancy necessitating excision and grafting of the facial nerve, anticipated results should be equivalent to the facial nerve cable autografts without postoperative irradiation.

Surgical approaches to malignant tumors of the nasal septum.

Malignant tumors of the nasal septum are rare, probably not more than 300 having been reported. Most of these tumors are epidermoid carcinomas; the second most common histologic type is melanoma. Unless diagnosed and treated early, these tumors are lethal. We report five cases, four carcinomas and one melanoma. We recommend a combined approach with early, wide surgical excision and postoperative irradiation therapy. Surgical considerations must include functional and cosmetic restoration as well as adequate excision of the tumor. Prosthetic appliances can be quite helpful in patients with large resections.

The otolaryngologist's role in the diagnosis and treatment of amyotrophic lateral sclerosis.

In the early insidious phase of Amyotrophic Lateral Sclerosis (ALS), the patient will often present initially to the otolaryngologist for a presumed speech problem or dysphagia. Adult onset hypernasality, breathiness, articulation defects and voice harshness should all be seen as possible early signs of ALS and may allow the otolaryngologist to be the primary diagnostician for that disease; three such cases are reported here. Once the diagnosis of ALS is made, the otolaryngologist may be involved at different stages in the disease, offering treatment such as Teflon¿ injections, pharyngeal flap, obturator fitting, cricopharyngeal myotomy, tracheostomy, and cervical esophagostomy for speech, swallowing and aspiration problems. Although they do not halt the progression of this fatal disease, these procedures provide an improved quality of life for the patient whose intellectual function is preseved while his motor functions progressively deteriorate. This is more important for the minority of patients having prolonged survival.

Paranasal sinus aspergillosis.

Four cases of aspergillosis of the paranasal sinuses seen recently at the North Carolina Baptist Hospital are reported. Paranasal sinus aspergillosis is prone to develop in patients living in the southeastern states because those states 1. have an agricultural economy and 2. have a hot, humid climate that causes a high incidence of nasal and sinus disorders. The increasing use of immunosuppressive and oncological drugs should further increase the incidence of aspergillosis. Diagnosis of aspergillosis of the paranasal sinuses requires a high index of suspicion which should be present particularly for a patient who has unilateral sinusitis that does not respond to routine therapy, or who has a localized sinus mass or bony erosion. Immunodiffusion tests are specific for aspergillosis. Treatment consists of surgical removal of the diseased mucosa and adequate aeration and drainage of the sinus. Culture of the specimen on Sabouraud's agar will confirm the diagnosis.

Significance of node biopsy before definitive treatment of cervical metastatic carcinoma.

A survey was made of 714 radical neck dissections done alone or in combination with resection of a primary malignancy. Sixty-four (8.9%) of the patients had had a cervical node biopsy before diagnosis and definitive treatment. The complications of wound necrosis, local cervical recurrence, and distant metastasis were significantly higher in those patients than in patients who had had no biopsy or who had biopsy only at the time of definitive treatment. When 40 of the 64 patients were matched on the basis of age, sex, histological diagnosis, site and stage of the lesion and treatment protocol with 40 patients who had had no biopsy, this trend toward a higher complication rate when previous biopsy was done continued and was significantly higher for distant metastasis. The authors believe that these findings quantitatively confirm the accepted belief that, except for instances when no primary lesion can be found and the cervical mass must be biopsied for the purposes of diagnosis, such biopsy increases local complications and, by increasing the incidence of distant metastasis, decreases the chance for survival.

Intracranial complications of acute and chronic infectious ear disease: a problem still with us.

Among 334,884 admissions to the North Carolina Baptist Hospital from 1963 through 1982, 100 patients had central nervous system (CNS) complications of middle ear disease. The complications occurred predominantly in young patients, 85 of the 100 being less than 20 years of age. Meningitis occurred in 76 patients; the acute form was more prevalent (63 cases). The less common nonmeningitic complications included brain abscess (n = 6), effusion (n = 5), lateral sinus thrombosis (n = 5), otitic hydrocephalus (n = 5), and empyema (n = 3). Overall mortality was 10%. One patient with brain abscess died; 9 of the 76 patients with meningitis died (12%), with 4 of those deaths occurring among the 13 patients with chronic meningitis (31%). Because these complications have declined markedly since the advent of antibiotics, many contemporary otolaryngologists have been unexposed to these complications. However, as this series shows, they do still occur, their natural history remains the same, and the resulting mortality is still alarmingly high. A plea is made for otolaryngologists to maintain an awareness of these complications and to work with pediatricians and neurosurgeons for the best team care of patients with CNS complications of middle ear disease.

Normal speech for patients with laryngeal webs: an achievable goal.

Normal speech as well as an improved airway is now an achievable goal in the treatment of laryngeal webs. Seven acquired webs and 3 congenital webs were seen at the North Carolina Baptist Hospital/Bowman Gray School of Medicine. The speech of 6 patients was tested preoperatively and again postoperatively: speech was considered normal postoperatively in 5 patients without the need for speech therapy; normal in the sixth patient after 6 sessions of speech therapy. The authors' preferred method of treatment is development of an endolaryngeal mucosal flap with a variable beam CO2 laser under operating microscopic control.

Tracheobronchial foreign bodies.

A retrospective review of 88 cases of foreign body aspiration was undertaken. The patients ranged in age from 5 months to 73 years; the peak incidences of foreign body aspiration occurred in children less than 3 years of age and in adults older than 50 years. Sixty-one of the 88 patients were male. Physical examination was abnormal in 61% of patients. The most common radiographic abnormality was inspiratory-expiratory abnormality, seen in 27% of patients. Rigid endoscopy under general anesthesia was the preferred method for removal of the aspirated material. Multiple foreign bodies were found in 5% of the patients. Tracheobronchial foreign bodies should, therefore, be strongly suspected in susceptible patient populations who present with a suggestive history, even when no physical or radiographic evidence can be seen. Patients should be carefully examined for multiple foreign bodies at the time of rigid endoscopic removal.