Intraoperative evaluation of cortical bony margins with frozen-section analysis.

OBJECTIVE: To describe and evaluate the efficacy of frozen-section analysis of cortical bone margins in surgery of the craniofacial skeleton. STUDY DESIGN: Retrospective analysis of a consecutive series of patients undergoing oncologic resection of various head and neck neoplasms with osseous involvement by the senior author (Y.D.) from 1998 to 2003. RESULTS: Frozen-section analysis of cortical bone was performed in 38 patients. Adequate specimens for histological analysis were obtained in all patients. Frozen sections were positive in 21 of 22 patients with bone invasion on decalcified specimens. After validating our technique for frozen analysis of cortical bone in 13 patients, the method had a sensitivity of 89% and a specificity of 100% in 25 patients. Malignancies diagnosed on frozen cortical bone specimens included squamous cell carcinoma (15), mucoepidermoid carcinoma (3), and sarcoma (3). Frozen cortical margins altered the extent of bony resection in 8 patients. CONCLUSION: A simple technique for analysis of cortical bone involvement by neoplasm is presented and reviewed. It allows for frozen-section analysis with standard equipment and appears to be a reliable method to evaluate bony margins intra-operatively. EBM RATING: C-4.

Medical and surgical management of subperiosteal orbital abscess secondary to acute sinusitis in children.

OBJECTIVE: To evaluate the presentations and outcomes of pediatric subperiosteal orbital abscesses (SPOA) secondary to acute sinusitis. STUDY DESIGN: Case series SETTING: Tertiary children's hospital. PATIENTS: Forty-three admissions diagnosed with SPOA by clinical presentation and contrast enhanced computed tomography (CECT) were retrospectively reviewed. MAIN OUTCOME MEASURES: Clinical presentations, CECT dimensions, treatment, outcomes, and microbiology. RESULTS: Eighteen/43 (42%) patients resolved their infection with medical management only, including five children older than nine. Twenty-five/43 (58%) children underwent surgical drainage. Purulence was identified in 22 of 25 surgical patients, and the most common organism was Streptococcus milleri (7 patients). Compared to 22 patients with drained purulence, the 18 patients with abscesses managed medically had significant differences for: chemosis in 2/18 (11.1%) versus 14/22 (63.6%, p=0.001), proptosis in 10/18 (55.6%) versus 20/22 (90.9%, p=0.025), elevated intraocular pressure (IOP) in 0/18 (0%) versus 11/22 (50%, p<0.001), severe restriction of extraocular movements in 1/18 (5.6%) versus 12/22 (54.5%, p=0.002), and length of stay (4.3 versus 5.8 days, p=0.038). The dimensions of medial SPOA managed medically were significantly smaller on CECT compared to surgically drained purulent SPOA: width (0.25 versus 1.46cm, p<0.001), height (0.73 versus 1.35cm, p=0.002), and length (1.1 versus 1.86cm, p=0.004). Persistent morbidities occurred in no patients managed medically and in 2/25 (8%) managed surgically. CONCLUSIONS: Children with small medial SPOA without significant ocular signs may be managed medically with favorable outcomes. Proposed criteria for medical management of medial SPOA include: (1) normal vision, pupil, and retina; (2) no ophthalmoplegia; (3) IOP<20mmHg; (4) proptosis of 5mm or less; and (5) abscess width of 4mm or less. In contrast to prior series, older children with SPOA were managed successfully with medical therapy.

Elective transcervical superior mediastinal lymph node dissection for advanced laryngeal and level 4 N3 squamous cell carcinoma.

OBJECTIVES: To review our results with elective superior mediastinal lymph node dissections in patients with advanced laryngeal squamous cell carcinoma (SCCA) and overt level 4 adenopathy. STUDY DESIGN: Retrospective review. METHODS: We searched operative case logs for all patients treated with an elective superior mediastinal dissection by the senior author (Y.D.) during a 7-year period. Charts were reviewed for demographic information, prior treatment with chemotherapy or radiotherapy, and pathologic results. RESULTS: Fifty-six patients who underwent elective superior mediastinal lymph node dissection for advanced laryngeal SCCA and overt level 4 adenopathy were reviewed, and superior mediastinal disease was present in 15 of 56 (26.8%) patients. Superior mediastinal nodes were positive in 11 of 42 (26.2%) patients with advanced laryngeal SCCA and 4 of 14 (28.6%) patients with N3 SCCA involving level 4. Patients with SCCA receiving prior chemotherapy and radiotherapy had a significantly higher rate of positive superior mediastinal nodes (10/21 patients, 47.6%) compared with patients without prior therapy (5/35 patients, 14.3%, P = .01, Fisher's exact test). There were no stomal recurrences in 42 patients treated for advanced laryngeal cancer. CONCLUSIONS: Elective transcervical superior mediastinal dissection was positive in 26.8% of patients with advanced laryngeal cancer or N3 disease in level 4. A transcervical superior mediastinal dissection may be safely performed without a sternotomy.

Complications of acute sinusitis in children.

OBJECTIVE: To review the demographic, microbiologic, and outcome data for children with complications of acute sinusitis. STUDY DESIGN AND SETTING: Retrospective review of children admitted with complications of acute sinusitis from January 1995 to July 2002 to a tertiary care children's hospital. RESULTS: One hundred four patients were reviewed with the following complications: orbital cellulitis (51), orbital abscesses (44), epidural empyemas (7), subdural empyemas (6), intracerebral abscesses (2), meningitis (2), cavernous sinus thrombosis (1), and Pott's puffy tumors (3). Sixty-six percent were males (P < 0.001), and 64.4% presented from November to March (P < 0.001). Patients with isolated orbital complications were younger than patients with intracranial complications (mean, 6.5 versus 12.3 years), had a shorter stay (mean, 4.2 versus 16.6 days), and had shorter duration of symptoms (mean, 5.4 versus 14.3 days; all P < 0.0001). Complete resolution was documented for 54/55 patients with restricted ocular motility, 7/8 with visual loss, 3/3 patients with a nonreactive pupil, 7/7 with neurological deficits, and 2/4 with seizures. The most common organism isolated was Streptococcus milleri (11/36 patients with surgical cultures). No mortalities occurred, and persistent morbidity occurred in 4 patients (3.8%). CONCLUSIONS: Despite significant deficits on presentation, permanent morbidity was low. Streptococcus milleri is a common pathogen with complications of sinusitis in children.

Use of precontoured positioning plates and pericranial flaps in midfacial reconstruction to optimize aesthetic and functional outcomes.

OBJECTIVES: To present our experience with reconstruction of midfacial defects using "precontoured positioning plates" with or without pericranial flaps and to describe our technique in detail. METHODS: Thirty-two consecutive patients with midfacial defects subsequent to oncologic resection that were reconstructed primarily with cranial bone grafts and precontoured positioning plates were reviewed for type of defect, functional outcome, complications, and postoperative appearance. RESULTS: Primary reconstruction of all defects in this series was performed. Defects involved the orbital rim, orbital floor, or both in 28 patients (88%), the body of the zygoma in 24 patients (75%), and extended to the skull base in 16 patients (50%). Pericranial flaps were used to cover the bone grafts in 22 patients (69%). Postoperative radiotherapy was performed in 22 patients (69%), preoperative radiotherapy in 5 (16%), and the other 5 (16%) had no radiotherapy. There were no intraoperative complications, and postoperative complications included plate exposure (n = 2), ectropion (n = 3), and partial bone graft loss or resorption subsequent to completion of radiotherapy (n = 2). Postoperatively, appearance was excellent in 24 patients, fair in 6 patients, and poor in 2 patients. Secondary reconstructive procedures were performed in 4 patients (12%). Follow-up ranged from 12 months to 6 years (median, 4.2 years). CONCLUSIONS: Precontoured positioning plates with or without pericranial flaps enable precise reconstruction of midfacial defects with precise incorporation of cranial bone grafts. In our series we routinely covered the bone grafts with well-vascularized tissues, leading to a low incidence of complications and excellent aesthetic results.

Differential diagnosis and treatment options in paranasal sinus cancers.

Paranasal sinus malignancies are challenging to treat. Most patients present with advanced lesions, often with intracranial or intraorbital extension, and have a poor overall prognosis. Given the low incidence and diverse pathologies of paranasal sinus cancers, it is extremely difficult to perform prospective, randomized clinical trials to compare different treatment approaches. Improving the prognosis of these cancers continues to be a difficult task, even in light of advances in surgical techniques,radiation delivery techniques, and new chemotherapeutic agents. Cranio-facial resection techniques developed in the past few decades have cured many patients with skull base invasion, who would have been considered unresectable in the past. Furthermore, improvements in radiation therapy can allow more accurate administration to the desired region, with decreased damage to surrounding structures such as the orbit and brain. Aggressive and oncologically sound surgical resection combined with radiation therapy remains the treatment of choice for most patients.Finally, advances in the diagnosis and staging by use of molecular or DNA markers of tumor behavior may allow for more directed therapy.

Advanced squamous cell carcinoma of the oropharynx: efficacy of positron emission tomography and computed tomography for determining primary tumor response during induction chemotherapy.

BACKGROUND: To evaluate the efficacy of fluorine-18-fluorodeoxyglucose emission tomography (FDG-PET) and CT versus endoscopy with biopsy under general anesthesia for estimating tumor volume reduction among patients treated with induction chemotherapy for advanced squamous cell carcinoma (SCC) of the oropharynx. METHODS: Twelve patients with oropharyngeal SCC nested in a phase II, induction chemoradiation, organ preservation trial (University of Michigan Cancer Center 9921) underwent tumor volume reduction estimation as assessed by FDG-PET, CT, and endoscopy with biopsy. RESULTS: In 9 of 12 patients, FDG-PET, CT, and endoscopy demonstrated agreement in estimation of tumor reduction. Two patients had discordant results, whereas 1 patient was inadequately evaluated with FDG-PET. The kappa value for PET versus endoscopy was 0.62, which is categorized as substantial agreement. The kappa value for CT versus endoscopy was 0.40, which is categorized as fair agreement. CONCLUSION: FDG-PET may be as efficacious as endoscopy with biopsy under general anesthesia for estimating tumor volume reduction with induction chemotherapy.

Retrograde balloon dilation of complete cervical esophageal and hypopharyngeal strictures.

OBJECTIVES: To evaluate and describe retrograde endoscopic dilation of 100% strictures of the cervical esophagus and hypopharynx. METHODS AND MATERIALS: All patients who presented to the senior author (Y.D.) from September 1997 to September 2003 with strictures of the cervical esophagus and hypopharynx were retrospectively reviewed. RESULTS: Six patients with 100% strictures of the cervical esophagus and hypopharynx were available for review. Eighty-three percent of these patients were successfully treated endoscopically with the outlined technique. All were able to handle their secretions successfully, and four were no longer dependent on a gastrostomy tube. CONCLUSIONS: Retrograde dilation of complete strictures of the hypopharynx and cervical esophagus appears to be safe, reliable, and associated with a high rate of ultimate success. It should be considered a first-line treatment prior to open approaches, which may be reserved for failures.