Infections of the head and neck

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1. Infections of the head and neck were secondary to infections of the skin, 42.5 per cent, and the mouth, 37 per cent. Upper respiratory tract infections and suppurative parotitis accounted for the remainder of antecedent conditions.     

Liposuction of the head and neck

It has been 4 years since liposuction was introduced as a surgical technique to sculpture and remove the subcutaneous layer of fat in the head and neck. Otolaryngologists and facial plastic surgeons have been reluctant to incorporate this procedure into their surgical armamentarium, fearing that liposuction would be a passing fad and not live up to original expectations. Basic animal research and clinical studies now show that liposuction is a safe, fast, and effective means of removing subcutaneous fat.     

Angiosarcoma of the head and neck

Angiosarcomas are uncommon tumors of the skin and soft tissues, but occur in endothelial cells of almost any internal organ. When they occur in the skin, the head and neck are the most common sites of origin. Nothing is pathognomonic about their clinical presentation, and the pathologic diagnosis can only be established by biopsy. The frequent multicentric nature of the tumor and propensity for extensive subcutaneous spread require wide treatment fields, whatever the modality of therapy, and account for the low survival reported. Four cases and their outcome are reported, with only one patient achieving an apparent cure following irradiation therapy. Based on experience and extensive review of the literature, a best therapeutic approach cannot be recommended. Since the outlook for cure is so unfavorable, there appears to be a need for cooperative studies using surgery, irradiation, and perhaps, chemotherapy.     

Hibernomas of the head and neck

Hibernomas are rare tumors derived from brown adipose tissue, a specialized form of fat tissue found in hibernating and nonhibernating animals. Only a minority of reported hibernomas have occurred in the head and neck region. This report describes two cases of cervical hibernomas, one of which was preoperatively diagnosed by the use of fine-needle aspiration biopsy. The clinical and pathologic characteristics of this neoplasm are reviewed. In general, hibernomas are slow-growing tumors with inconclusive evidence for the existence of a malignant variant. A review of the literature supports the conclusion that excision, sparing vital structures, appears to be curative.     

Enterocystoma of the head and neck

Enterocystomas of the head and neck are exceedingly rare lesions; only 21 cases have been reported previously. We describe a case of a newborn infant with an enterocystoma of the anterior tongue. All of the previously reported cases and the three theories of embryogenesis are reviewed. Diagnostic evaluation includes computerized axial tomography and radioiodine thyroid scan, particularly if the tongue is involved. Complete surgical excision is the only appropriate therapy and is curative.     

Neurofibromatosis of the head and neck

Neurofibromatosis (von Recklinghausen's disease) is an autosomal dominant disease that affects one in 2,500-3,000 births. Because the head and neck is unique in its anatomical compartmentalization of the central and peripheral nervous systems, the potential for involvement of these areas with neurofibromas is substantial and accounts for a myriad of clinicopathologic presentations. In the present study, the incidence of involvement in the head and neck is 37%. We found 81% of the patients had café au lait spots, 63% had positive family histories, and 66% had multiple cutaneous nodules. An incidence of malignant transformation was documented in 3.5% of the cases. Management of benign neurofibromatosis must be individualized for each patient and ranges from incisional biopsy to wide local excision. In every case, the risk of severe neurologic deficit must be weighted against the benefits of surgical resection, which is usually incomplete. Genetic counseling is advised for all patients with this disease, since no cure is available.     

Pilomatrixoma of the head and neck

Pilomatrixoma is an uncommon neoplasm which occurs most frequently in the head and neck region. It usually presents as a slowly growing dermal or subcutaneous mass. Unfamiliarity with this lesion may lead the physician to mistake it for more common infectious or neoplastic processes. Most pilomatrixomas are benign and are adequately treated by local excision. Since a spectrum of clinical and histologic aggressiveness (pilomatrixoma carcinoma) has been noted in some lesions, a more aggressive surgical approach for such tumors is recommended. Two patients with pilomatrixoma are presented to emphasize the diagnostic confusion that can occur.     

Chondrosarcomas of the head and neck

Chondrosarcomas of the head and neck are uncommon. Over a 35-year period (1950–1985) at our institution, 557 patients had an established diagnosis of chondrosarcoma. In 28 (5%) of these patients, the tumor was located in the head and neck region. A retrospective analysis was performed in an attempt to accurately define clinical characteristics, management, and outcome in these 28 patients. The patient population consisted of 15 males and 13 females whose ages ranged from 10 to 72 years, with a median of 38 years. Ten (36%) patients were untreated and 18 (64%) previously treated patients were referred for further management. The primary sites were maxilla (11), cervical vertebrae (7), mandible (3), skull (2), sphenoid and ethmoid sinuses (2), frontal sinus (1), nasal septum (1), and orbit (1). Lesions arising in the larynx were excluded from this study. The most common presenting symptom was a painless mass. Surgery was the definitive treatment in all patients. However, adjuvant radiation therapy or chemotherapy was utilized for residual disease in almost half of the cases (13 patients). Follow-up ranged from 5 to 35 years. Twelve (43%) of the 28 patients were known to be alive and free of disease more than 5 years after surgery. The most common cause of death was uncontrollable local disease (88%). However, only 3 of the 10 previously untreated patients developed local recurrence. For all patients, the median interval from time of first recurrence until death was 25 months (range 6 to 70 months). Positive margins in 8 of 12 patients resulted in local recurrence and eventual death. Distant metastases were documented in 18% of patients, most often involving the lungs. Analysis of a subgroup of patients treated more recently (1975–1985) reveals 7 (78%) of 9 patients to be alive and free of disease at 5 years postoperatively.

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Resumen Los condrosarcomas de la cabeza y el cuello son neoplamas raros. En un período de 35 años (1950–1985) se atendieron 557 pacientes con el diagnóstico de condrosarcoma en nuestra institución. En 28 de los pacientes (5%) el tumor estaba ubicado en la región de la cabeza y el cuello. Se realizó un análisis retrospectivo con el objeto de definir las características clínicas, el manejo y el resultado obtenido en estos 28 pacientes. El grupo incluyó 15 hombres y 13 mujeres con edades entre 10 y 72 años y una edad media de 38 años. Diez pacientes (36%) no fueron tratados y 18 pacientes (64%) que habían sido tratados previamente fueron referidos para terapia adicional. Los sitios primarios fueron el maxilar (11), las vértebras cervicales (7), la mandibula (3), el cráneo (2), los senos esfenoidales y etmoidales (2), los senos frontales (1), el septo nasal (1) y la órbita (1). Las lesiones originarias en la laringe fueron excluidas de este estudio. El síntoma más común de presentación fue una masa indolora. La cirugía constituyó el tratamiento definitivo en la totalidad de los casos. Sin embargo, se utilizó radioterapia o quimioterapia adyuvantes por enfermedad residual en casi la mitad (13 pacientes). El seguimiento varió entre cinco y 35 años. Doce de los 28 pacientes (43%) estaban vivos y libres de enfermedad a los 5 o más años de seguimiento. La causa de muerte más común fue la extensión incontrolada de la enfermedad local (88%). Sin embargo, sólo 3 de 10 pacientes no previamente tratados desarrollaron recurrencia local. El intervalo medio de sobrevida entre la primera recurrencia y la muerte fue de 25 meses (rango 6 a 70 meses) para el grupo total. Margénes positivos dieron como resultado recurrencia local y eventualmente muerte en 8 de 12 pacientes. Metástasis distantes fueron detectadas en 18% de los casos, siendo más frecuente en los pulmones. El análisis del subgrupo de pacientes tratados más recientemente, en el período 1975–1985, reveló que 7 de 9 pacientes (78%) se hallaban vivos y libres de enfermedad a los 5 años.

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Résumé La localisation au niveauds la tête et du cou du chrondrosarcome est rare. Entre 1950–1985 (30 ans), dans notre institution, le diagnostic de chrondosarcome a été établi chez 557 patients. Chez 28 de ces patients (5%), la tumeur était localisée dans la région de la tête et du cou. Par une analyse rétrospective, on a défini les caractéristiques cliniques, le traitement, et l'évolution de ces 28 patients. Il s'agissait de 15 hommes et de 13 femmes dont les âges allaient de 10 à 72 ans (médiane=38 ans). Dix patients (36%) n'avaient pas eu de traitement antérieur alors que 18 (64%) avaient déja été traités ailleurs et avaient été adressés chez nous pour traitement complémentaire. Les localisations principales étaient le maxillaire supérieur (n=11), les vertèbres cervicales (n=7), le mandibule (n=3), le crâne (n=2), les sinus sphénoïde et éthmoïde (n=2), le sinus frontal (n=1), le septum nasal (n=1) et l'orbite (n=1). Les lésions du larynx ont été exclues de cette etude. Le symptôme principal était la découverte d'une masse indolore. Le traitement définitif proposé a été la chirurgie dans tous les cas. La radiothérapie ou la chimiothérapie adjuvante ont été utilisées pour traiter des résidus tumoraux chez environ la moitié des patients (n=13). Pour l'ensemble des patients, le suivi est allée de 5 et 35 ans. Au moins 12 des 28 patients (43%) sont en vie sans récidive à plus de 5 ans. La cause de décès la plus fréquente a été la récidive locale noncontrôlable (88%). Cependant, seulement trois des 10 patients n'ayant pas eu de traitement antérieur ont récidivé localement. Pour l'ensemble des patients, l'intervalle (valeur médiane) entre les premiers signes de récidive et la mort a été de 25 mois (extrêmes 6 à 70 mois). Huit des 12 patients ayant eu des marges des sécurité envahies ont eu une récidive locale et sont morts. Les métastases à distance ont été observées chez 18% des patients, le plus souvent au niveau des poumons. L'analyse d'un sous-groupe de patients (n=9) traités plus récemment (1975–1985) montre que 7 (78%) sont en vie sans maladie évolutive à 5 ans.

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Presented at the Société Internationale de Chirurgie and the Collegium Internationale Chirurgiae Digestivae in Stockholm, Sweden, August, 1991.     

Melanoma of the head and neck

Cutaneous melanoma of the head and neck accounts for approximately 20 per cent of all melanomas. Variation in the incidence of melanoma by sex and by subsites within the head and neck is related to exposure to sunlight. Study of the precursor skin lesions of individuals and families at high risk for melanoma are providing new insights into the biology of melanoma. The clinical importance of such information is earlier diagnosis and treatment. With microstaging techniques it has become apparent that in many instances the primary tumor can be excised safely with narrower margins than were thought necessary in the past. The role of elective lymph-node dissection remains controversial, but when it is performed a complete dissection is recommended. Improvement in adjunctive methods of treatment is needed, but significant palliation can be achieved, with occasional long-term survival.     

Imaging of the head and neck

Imaging is increasingly being used in the evaluation of patients presenting with a neck mass or with a ‘hot’ neck and has an established role in the staging of head and neck cancer. Plain radiographs have a very limited role and the workhorses of neck imaging are ultrasound, computed tomography (CT) and magnetic resonance imaging with an increased demand, more recently, for positron emission tomography-CT. Contrast studies, videofluoroscopy, angiography and nuclear medicine have a limited but important role in selected cases. This article will discuss the role of some of these imaging modalities in evaluating the soft tissues of the neck.