Otolaryngologic and head and neck manifestations of acquired immunodeficiency syndrome (AIDS)

Patients with acquired immune deficiency syndrome (AIDS) frequently present with signs and symptoms referable to the head and neck. Three hundred ninety-nine patients with AIDS presented at the University of California, San Francisco and its affiliated hospitals from 1980 to April 1984. One hundred sixty-five patients (41%) with AIDS presented with, or had on initial evaluation, head and neck manifestations. Of that group, 58 (35%) had cutaneous, oral, and pharyngeal lesions of Kaposi's sarcoma; 51 (31%) had oral, pharyngeal, esophageal, or laryngeal candidiasis; 36 (22%) had chronic cough and shortness of breath; 13 (8%) had rapidly enlarging neck masses; and 7 (4%) had herpes simplex lesions. With the increasing number of cases of AIDS it is important for the otolaryngologist to be aware of these presentations.     

Primary Kaposi’s sarcoma of the nasal cavity not associated with AIDS

Kaposi’s sarcoma (KS) is an unusual vascular tumor characterized by multiple reddish blue nodules, which usually present on the skin of the lower and upper extremities. KS may also involve mucosal sites, lymph nodes and visceral organs. During the last two decades, with the large increase in the incidence of this tumor associated with the acquired immune deficiency syndrome (AIDS), there have been increasing number of cases with KS presenting on the skin or mucosa of the head and neck. A review of the literature revealed that only six cases of primary KS of the nasal cavity have previously been published and only one of them presented in a patient not associated with AIDS. We report the case of a 59-year-old woman who presented 4 years ago with nasal obstruction and intermittent minor epistaxes. Physical examination revealed the presence of a fleshy tumor arising from the left nasal septum, which was excised. Histological examination of the tumor showed morphological and immunohistochemical features of KS. A complete physical and laboratory examination revealed no other pathological findings. The patient received no further treatment and 4 years later, she is in excellent condition. In the present study, we report the second case where the primary manifestation of the KS was in the nasal cavity in a patient with an adequate immune system.     

Local treatment of AIDS-associated bulky Kaposi's sarcoma in the head and neck region

Kaposi’s sarcoma (KS) is frequently seen in the head and neck regions of HIV-infected patients. We report two cases of patients with AIDS who consulted the ENT clinic. One patient came to our clinic complaining of abnormal sensations in the pharynx, and dysphasia due to a gross KS in the oropharynx. The excision of the tumor improved the difficulty of swallowing. The other patient complained of masticatory problems and tongue pain due to a bulky KS on the dorsal side of the tongue. We treated the tongue lesion with intralesional chemotherapy. The administration of intralesional vinblastine resulted in a partial response. Unless systemic chemotherapy is effective enough to improve a functional disorder, it is thought that local therapy employing excision or intralesional chemotherapy is one of the common therapeutic option of the otolaryngologist, because this treatment avoids severe side effects caused by systemic chemotherapy or radiotherapy.     

Follicular dendritic cell sarcoma of the head and neck: case report and literature review

Objectives/Hypothesis: This article presents a case of a patient with follicular dendritic cell sarcoma (FDS), a rare neoplasm usually of the head and neck, and reviews the literature. Study Design: Literature review. Methods: A MEDLINE literature search was performed and the literature was reviewed. Results: Our patient presented with an FDS that had been excised from the upper neck and recurred in a level V node. He was treated with neck dissection and postoperative irradiation and remains disease free 5.25 years after salvage treatment. The literature search yielded 67 case reports on FDS of the head and/or neck. Most patients were treated with surgery (94%). Twenty-eight percent of patients received adjuvant radiotherapy; 18% received adjuvant chemotherapy. Fifty percent of patients were alive with no evidence of disease at last follow-up; 9% died from disease. Conclusions: We currently treat head and neck FDS with wide resection and postoperative radiotherapy.     

Otorhinolaryngological findings in AIDS patients: a study of 63 cases

Patients with acquired immunodeficiency syndrome (AIDS) frequently show signs and symptoms involving the head and neck. We reviewed the clinical histories of 63 cases with AIDS, with patients treated from 1982 to December 1985, in our hospital. Findings referable to the head and neck were seen in 43 patients. Comparison with a previous study in San Francisco revealed remarkable differences. We found otolaryngological manifestations in 68% of the patients in contrast to 41% in this latter study. We saw more rapidly increasing neck masses, a greater incidence of shortness of breath and chronic cough, and an increased occurrence of candidiasis. The number of cases with Kaposi's sarcoma lesions was equal in both studies.     

Otorhinolaryngological findings in AIDS patients: a study of 63 cases

Summary Patients with acquired immunodeficiency syndrome (AIDS) frequently show signs and symptoms involving the head and neck. We reviewed the clinical histories of 63 cases with AIDS, with patients treated from 1982 to December 1985, in our hospital. Findings referable to the head and neck were seen in 43 patients. Comparison with a previous study in San Francisco revealed remarkable differences. We found otolaryngological manifestations in 68% of the patients in contrast to 41% in this latter study. We saw more rapidly increasing neck masses, a greater incidence of shortness of breath and chronic cough, and an increased occurrence of candidiasis. The number of cases with Kaposi's sarcoma lesions was equal in both studies.     

Synovial cell sarcoma: diagnosis,treatment, and outcomes

OBJECTIVES/HYPOTHESIS: Synovial cell sarcoma is a mesenchymal tumor predominantly of the lower extremities. Three percent of cases arise in the head and neck region. It is thought that head and neck synovial sarcoma has a better prognosis than tumors of the extremities. Our experience has demonstrated aggressive behavior of this neoplasm in the head and neck. This compelled us to compare our experience with other studies. STUDY DESIGN: Retrospective chart review. METHODS: We obtained the records of patients diagnosed with head and neck synovial sarcoma from the Tumor Registry of the University of Louisville School of Medicine (Louisville, KY) and affiliated hospitals for data compiled between January 1990 and December 2000. Data on patient demographics, clinical findings and symptoms, histological findings, treatment, extent of disease, recurrence, and survival were recorded. The literature was reviewed identifying reports of synovial cell sarcoma. RESULTS: Five consecutive patients with synovial cell sarcoma were assessed at our facility. The median patient age was 28.2 years. All of the patients underwent an aggressive primary surgical excision followed by irradiation. All patients received chemotherapy after recurrence. Four of the five patients had local recurrence, and all five of the patients developed distant metastases. Three of the patients have died, and two are alive with evidence of disease. Novel sites are reported including the ethmoid sinus and the parotid gland. This group demonstrated a 40% 5-year overall survival, which was lower than the 60% 5-year survival reported in the literature for all sites. CONCLUSIONS: Synovial cell sarcoma of the head and neck is a disease of young people and carries a poor prognosis. The aggressive nature of the disease may require modification of accepted treatment modalities and sequence.     

Head and neck presentations of acquired immunodeficiency syndrome

Since December 1980, over 2,000 cases of acquired immunodeficiency syndrome (AIDS) have been reported. The charts of 72 patients admitted to the New York University Medical Center with a diagnosis of AIDS were reviewed with particular emphasis on presenting signs, symptoms and laboratory values. Symptoms tended to be non-specific and most often resembled an upper respiratory infection. Over 95% of the patients presented with either diffuse adenopathy, oral or facial lesions consistent with Kaposi's sarcoma, white oral lesions, or anergy. Laboratory findings included leukopenia, increased erythrocyte sedimentation rate, thrombocytopenia and anemia. The in-hospital mortality rate was 26%. The current status of our knowledge concerning AIDS is reviewed and discussed. The frequency and types of presenting signs and symptoms in the head and neck are reported in order to alert the otolaryngologic community to this entity.     

An evaluation of the uptake of technetium-99m (v) dimercaptosuccinic acid in patients with squamous carcinoma of the head and neck

A new imaging agent, Technetium-99m (Tc99m) (v) Dimercaptosuccinic acid (DMSA), has recently been developed which has been used to evaluate head and neck tumours. Twenty-four patients were studied of whom 21 had histologically proven SCC of the head and neck. The remaining 3 had benign lesions. Planar imaging of patients with primary disease revealed a sensitivity of 83% and a 75% specificity. The results of planar imaging of patients with cervical metastases yielded a 92% sensitivity and 100% specificity. Seven patients also had single photon emission computerized tomography (SPECT) which improved the image quality, spatial resolution and sensitivity of the investigation. Tc99m (v) DMSA imaging provides a cheap and rapid means of investigating head and neck SCC. This study suggests further work is indicated to assess its role in diagnosis and subsequent management.     

Planned neck dissection after concomitant radiochemotherapy for advanced head and neck cancer

OBJECTIVES/HYPOTHESIS: Since 1998, at our academic, multidisciplinary head and neck cancer treatment center, it has been our policy to treat appropriate patients with locoregionally advanced squamous cell carcinoma of the head and neck (SCCHN) with concomitant radiochemotherapy followed within 6 weeks by planned neck dissection(s). Our objective was to investigate the oncologic efficacy of planned neck dissection, to date, in this patient population with a focus on outcomes in the neck. STUDY DESIGN: Retrospective analysis of a cumulative patient database. METHODS: The medical records of all patients who underwent planned neck dissection(s) after concomitant radiochemotherapy for locoregionally advanced SCCHN at Beth Israel Medical Center and The Institute for Head and Neck Cancer in New York City were reviewed. For each patient, preradiochemotherapy primary and neck stage, postradiochemotherapy/preneck dissection clinical and radiographic neck status, type of neck dissection(s) performed, pathologic status of the neck dissection specimen(s), length of follow-up (after planned neck dissection), disease status at last follow-up, and site(s) of recurrence were recorded. Local, regional, and distant disease control rates were calculated by the Kaplan-Meier method. RESULTS: Fifty-one planned neck dissections were performed on 39 radiochemotherapy patients (12 patients had bilateral operations) between early 1998 and October, 2003. Thirty-two (82%) patients had N2 or greater neck disease, with 29 (74%) having T3/T4 disease at various upper aerodigestive tract primary sites. Patients received an average of 6,700 cGy and 6,000 cGy external beam radiation therapy to primary disease sites and involved cervical lymphatics respectively, concomitant with one of three platinum-based chemotherapy schedules. At a mean follow-up time of 24 (range 8-57) months for the entire study population, there has been only one neck recurrence (N2A neck). No patient with N2B (n = 11), N2C (n = 13, with majority of heminecks staged N2B), or N3 (n = 5) disease has recurred in the neck. No recurrences have occurred in the 41 heminecks (in 33 patients) where modified neck dissection (including 24 selective procedures) was performed despite the presence of residual carcinoma in 13 (32%) of these heminecks on pathologic review. Among all heminecks with residual carcinoma present (n = 18) in the neck dissection specimen, there has been only one neck recurrence. There have been no recurrences in the 26 heminecks (in 19 patients) with incomplete clinical response after radiochemotherapy despite the presence of residual carcinoma in 14 (54%) of these necks on pathologic review. The clinical and radiographic absence of residual disease after radiochemotherapy did not always predict a complete pathologic response. Surgical complications have been limited (1 chyle leak, 1 wound breakdown). CONCLUSIONS: The integration of planned neck dissection into the multidisciplinary management of patients with locoregionally advanced SCCHN is highly effective in controlling cervical metastatic disease. Modified and selective neck dissection procedures can be performed in the majority of patients, regardless of the response in the neck subsequent to concomitant radiochemotherapy. We recommend a planned neck dissection(s) in all patients staged (pretreatment) with N2 or greater neck disease and in select N1 cases.     

Kaposi's sarcoma of the head and neck in patients with AIDS

Over a 40 month period, 219 patients with AIDS were seen at St. Mary's Hospital, London. Kaposi's sarcoma, one of the criteria for diagnosing the syndrome, was the presenting feature in 62 patients. Eighty four patients developed Kaposi's sarcoma at some stage of their disease and the head and neck region was involved in 56 of them. Although Kaposi's sarcoma is rarely life threatening in AIDS, potential airway obstruction, pain or cosmetic disfigurement may justify treating the lesion. Whilst cutaneous tumours may be managed by using radiotherapy (16 Gray in four fractions over four days), this treatment produces a sever mucositis when used to treat mucosal disease; we, therefore use a combination of vincristine and bleomycin for this.     

Role of computerized tomography (CT) scan of the chest in patients with newly diagnosed head and neck cancers

Chest metastases and second primaries are not uncommon in patients with head and neck cancer. Early detection of a second site of malignant disease may alter prognosis and management. This study assessed the diagnostic yield of chest radiographs compared with computerized tomography (CT) in a series of patients with head and neck cancer. Forty-four consecutive patients with a head and neck squamous cell carcinoma (SCC) attending the head and neck surgery department of Cumberland Infirmary, Carlisle, between January 2000 and December 2000 were included in this prospective study. Patients with lymphomas and localized cancers of the skin and lip were excluded. Thirty men and 14 women, with a mean age of 67 years, were assessed. All had chest radiographs and chest CT at the same time as the CT scan of the primary site. Only one patient had a true positive finding on chest radiograph. Five patients had an abnormal chest CT. Of these, two had multiple lung metastases, and another patient had biopsy-proved bronchogenic carcinoma and underwent surgical excision. The sensitivity and specificity of CT scan was 100% and 95%, as opposed to 33% and 97% for chest radiograph.     

人类免疫缺陷病毒感染及艾滋病在耳鼻咽喉头颈外科的临床表现

目的 提高对人类免疫缺陷病毒感染者及艾滋病患者在耳鼻咽喉头颈外科临床表现的认识,以便能及时诊治并做好必要的防护.方法 分析55例坦桑尼亚首诊于耳鼻咽喉头颈外科的HIV感染者及艾滋病患者的临床表现及其预后.55例患者中男23例,女32例;年龄3～67岁,中位年龄31岁.结果 55例患者中腮腺肿胀17例次(30.9%);鼻腔、口腔、咽部卡波西肉瘤19例次(34.5%);慢性化脓性中耳炎12例次(21.8%);颈部肿块11例次(20.0%);咽部肿物7例次(12.7%);口腔及咽部黏膜糜烂溃疡6例次(10.9%);口腔白色念珠菌感染2例次(3.6%).HIV感染者或艾滋病患者经治疗后耳鼻咽喉科感染状况可缓解,但易反复发作,且逐渐加重.结论 HIV感染者及艾滋病患者可首诊于耳鼻咽喉头颈外科.对耳鼻咽喉科感染等治疗缓解后反复发作者,应除外是否合并HIV感染或是否为艾滋病患者.

Abstract：

Objective To improve the recognition of clinical manifestation of human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS) in otorhinolaryngology head and neck surgery, and to emphasize the early diagnosis, correct treatment and effective protection. Methods Fifty-five patients with HIV infection and AIDS encountered in the department of otorhinolaryngology head and neck surgery in Tanzania were included in this study. There were 23 males and 32 femals with age ranged from 3 -67 years, medium 31 year. The clinical manifestation and prognosis of the patients were analyzed and summed up. Results Parotid glands swelling was the most commonly seen clinical manifestation in the 55 cases. Among the cases reported here, 17 (30.9%) showed parotid glands swelling, 19(34. 5% ) had Kaposi's sarcoma in nasal cavity or oral cavity or pharynx,12(21.8% ) were accompanied with chronic suppurative otitis media, 11 (20.0%) had masses in the neck,7 ( 12.7% ) had masses in the pharynx, 6 ( 10.9% ) were seen to have ulcer in oral and pharyngeal mucosa,2(3.6% ) showed infection due to candidaalbicans. The infection in most cases could be controlled and symptoms relieved, but recurrence could occur over time and got worse gradually. Conclusions Many patients with HIV infection and AIDS first see a doctor in otorhinolaryngology head and neck surgery.Patients who had the above clinical manifestations in repeated poor results should be observed carefully,early diagnosis and treatment are important to prevent transmission, prolong life and maximize the quality of life of the patients.     

Primary cutaneous lymphoma of the head and neck

One hundred three patients with Stage I and II extranodal primary lymphomas of the head and neck were reviewed. Six patients (5%) presented with cutaneous lesions, five with single site and one with multiple sites of involvement. Histopathology was malignant lymphoma (ML) large cell (3), ML small cleaved cell (1), ML small lymphocytic (1), and ML mixed large and small cell (1). Five of six patients relapsed following initial treatment. Four patients were treated with primary radiation therapy, three of which had relapses outside the treatment area. One patient was treated with intralesional steroid injection and also recurred outside the treated area. One patient was treated with radiation and chemotherapy and recurred outside the treatment area. Three patients are alive without disease, two died of disseminated disease, and one died of unrelated causes. Isolated cutaneous presentation of head and neck lymphoma is uncommon. Radiation therapy appears to have been curative in one patient with localized disease. Four patients recurred outside the radiation portals despite careful staging, suggesting that systemic therapy may be necessary for disease control.     

Kaposi's sarcoma of the intra-parotid lymph nodes in AIDS

Kaposi's sarcoma is the most frequent malignancy associated with AIDS. The occurrence of Kaposi's sarcoma in the parotid region is extremely rare. In this publication we present a case of a 47-year-old male patient who developed a swelling of the left parotid tail that proved to be Kaposi's sarcoma of an intra parotid lymph node. A discussion of the etiological factors, clinical staging and management of KS, as well as the differential diagnosis of the parotid enlargement in AIDS patients, is presented.     

Ewing's sarcoma of the head and neck in children.

OBJECTIVE: The purpose of this paper was to review our experience with Ewing's sarcoma of the head and neck in children. DESIGN: Retrospective chart review. SETTING: The Hospital for Sick Children, Toronto, Ont., Canada. METHODS: Between 1986 and 1996, 70 cases of Ewing's sarcoma were identified. The medical records, roentgenographic and pathology reports were reviewed retrospectively. The gender, age of presentation, location and clinical presentation of the tumor were noted in the cases involving the head and neck. The treatment and follow-up of these patients were recorded. RESULTS: Of the 70 cases of Ewing's, five involved the head and neck (7.1%). The age of presentation ranged from 7.5 to 14 years. An enlarging mass in the mandible was the mode of presentation in three of the five children. Two patients had metastases at initial presentation. All patients received combination treatment regimens with chemotherapy initially, followed by adjuvant surgery and/or radiation. Follow-up ranged from 2 to 11 years. Three of five patients died of metastatic disease. Two are alive and well with no evidence of disease. CONCLUSIONS: Ewing's sarcoma occurs infrequently in the head and neck in children. An enlarging mass in the mandible is the most frequent mode of presentation. This tumor is treated systemically with high dose chemotherapy and locally with surgical excision where possible. In lesions that are initially unresectable and/or show a poor response to chemotherapy, radiation is used for local control. A good prognosis can be expected if the disease has not metastasized.     

Computed tomography--guided needle biopsy of head and neck lesions

OBJECTIVE: To evaluate the diagnostic efficacy of computed tomography (CT)-guided needle biopsies of head and neck lesions. DESIGN: All CT-guided needle biopsies of head and neck lesions performed between September 1994 and February 1999 were included. Cytopathologic and histologic records, along with patient clinical records, were reviewed. SETTING: A tertiary care medical center. PATIENTS: Patients referred for evaluation of lesions inaccessible to routine methods of needle biopsy. RESULTS: Thirty-seven patients underwent 42 CT-guided biopsies. There were included 12 lesions in or adjacent to the skull base and 9 lesions around the pharyngoesophageal or laryngotracheal complex; the other lesions were located in the deep lobe of the parotid gland (n = 7), deep neck area (n = 12), and thyroid gland (n = 2). Diagnostic cytologic biopsy specimens were obtained in 38 (91%) of 42 needle biopsy procedures. The results were supported histologically and/or clinically in 36 cases (95%). Eighteen patients underwent open surgical procedures. Histologic confirmation was found in 86% of cases. Nineteen patients (51%) avoided an open surgical procedure: 11 with benign disease and 8 with recurrent malignancy. There were no false-positive or false-negative results, and no complications were identified. CONCLUSIONS: Computed tomography-guided needle biopsy is a safe and reliable minimally invasive technique for the diagnosis of poorly accessible or deep-seated lesions of the head and neck. Diagnostic needle biopsies allow improved preoperative planning and patient counseling in surgical patients and avoidance of open surgical procedures in patients with benign disease or recurrent malignant neoplasms.     

Positron emission tomography in the evaluation of synchronous lung lesions in patients with untreated head and neck cancer

BACKGROUND: Positron emission tomography (PET) with the glucose analogue fludeoxyglucose F 18 uses the increased glucose uptake that is observed in neoplastic cells. It can differentiate between benign and malignant pulmonary lesions in patients with lung tumors. Applications of PET in extracranial head and neck neoplasms have included evaluating patients with unknown primary lesions, detecting primary and recurrent head and neck tumors, monitoring response to radiotherapy, and evaluating the N0 neck in oral cavity carcinomas. Its role in determining the presence of synchronous lung lesions has not been defined. PATIENTS AND METHODS: A retrospective review of 115 patients who underwent PET between October 1994 and October 1996 was performed to evaluate extracranial head and neck neoplasms. Fifty-nine (51%) previously untreated patients with squamous cell carcinoma of the upper aerodigestive tract were analyzed. RESULTS: Fifteen patients (25%) had PET scans that were positive for synchronous lung lesions. Five patients had a disease process that did not warrant further investigation; they did not have pathological confirmation of their lung lesions. Of these, 3 died of disease within 2 months of the diagnosis of primary head and neck squamous cell carcinoma, 1 was unavailable for follow-up, and 1 had lung lesions that were considered metastatic and no pathological confirmation of lung lesions was obtained. The remaining 10 patients with positive PET scan findings were investigated further: 8 patients had biopsy-confirmed lung lesions; 5 patients had positive findings on chest x-ray films; 8 had positive findings on computed tomographic scans; and 3 had positive findings on bronchoscopy. The results of 2 PET scans were false-positive. The PET scans were important in altering treatment in 3 patients; of these, 3 had negative findings on chest x-ray films, 2 had positive findings on computed tomographic scans, and 1 had positive findings on bronchoscopy. CONCLUSIONS: The overall sensitivity, positive predictive value, and accuracy of PET were 100%, 80%, and 80%, respectively. The overall accuracy of radiography of the chest, computed tomography of the chest, and bronchoscopy was 70%, 90%, and 50%, respectively. The accuracy of PET over bronchoscopy was statistically significant (P<.05). PET appears to be a promising imaging modality for the detection of synchronous lung lesions in patients with negative findings on chest x-ray films.     

Langerhans' cell histiocytosis in the paediatric population: presentation and treatment of head and neck manifestations

Langerhans' cell histiocytosis (LCH) is a rare paediatric disease of unknown etiology affecting 1 to 5 children per 1 million each year. It is characterized by the idiopathic proliferation of Langerhans' cells. The clinical spectrum of disease is quite varied, ranging from a solitary eosinophilic granuloma to diffuse multisystem involvement. The head and neck is the most common site of involvement, occurring in approximately 60% of LCH patients. Head and neck manifestations are diverse and include skull and temporal bone lesions, cervical lymphadenopathy, and skin rash. Diagnosis can be difficult as these lesions mimic other common conditions seen by the otolaryngologist, including otitis externa, acute mastoiditis, and gingivitis. A retrospective study was carried out to study our centre's experience with LCH over the last 10 years. Twenty-one patients were diagnosed between January 1990 and December 1999. Patient's age at time of diagnosis ranged from 6 days to 14 years. Fifty-seven percent of patients had localized bony lesions; the remaining 43% had diffuse multisystem disease. The head and neck was also the most commonly involved site in our study, affecting 67% of our patients. Presentation and diagnosis of these lesions are discussed in detail. Treatment, complications, and patient outcomes will also be discussed.     

Overexpression of the p53 gene in primary and metastatic head and neck carcinomas

The p53 gene has been correlated with disease progression in a number of human malignancies, and p53 abnormalities are found in a high percentage of head and neck squamous cell carcinomas. The objectives of this study were 1. to correlate p53 expression with disease progression in squamous cell carcinoma of the head and neck (SCCHN), and 2. to determine whether there are site-specific differences in p53 expression. Primary lesions and/or lymph node metastases from 147 patients with invasive SCCHN were immunostained for p53 overexpression. Expression of p53 was similar (42% versus 43%) in primary lesions and lymph node metastases. Expression also did not vary significantly by site in the head and neck. In conclusion, increased p53 expression did not correlate with disease progression in our series of patients with invasive SCCHN. The finding of a lack of increased expression with disease spread to lymph nodes supports the belief that p53 alterations occur early in head and neck carcinogenesis.