Why do patients with head and neck squamous cell carcinoma experience distant metastases: can they be prevented?

PURPOSE OF REVIEW: This article will examine recent publications that enhance our understanding of this process, and current areas of investigation for therapeutic intervention in preventing and treating metastatic disease. RECENT FINDINGS: Recent investigations have led to insights into the mechanisms of cellular adhesion, invasion, and angiogenesis. E-cadherin, integrins, and selectins are all pivotal in cell-cell adhesion and communication. Recent advances in the area of tumor angiogenesis have led to our discovery of endostatin, an anti-angiogenic peptide that has potential in treating metastatic head and neck cancer. Current trials looking at sentinel node mapping may allow us to evaluate the nodal status of early head and neck cancer and identify a subset of patients at risk for distant metastasis. SUMMARY: As our understanding of metastatic disease increases, so will our ability to intervene in the various pathways involved in metastatic evolution. Metastatic cells are likely to respond differently to chemotherapeutic agents. Agents inhibiting specific aspects of invasion, adhesion, and angiogenesis will need to be combined to intervene at these key steps. Continued investigation into the biology of the epidermal growth factor receptor has led to an increased understanding of the mechanisms of abrogation of apoptosis, increased cellular motility, and metastasis. Inhibition of the epidermal growth factor receptor pathway with the monoclonal antibody C-255 has been shown to inhibit these processes and will likely be effective in reducing the development of distant metastasis.     

Measuring the density of the fissula antefenestram and the section of the basal turn of the cochlea: Are they useful in the radiological diagnosis of otosclerosis?

IntroductionThe role of objective parameters in terms of improvement of the accuracy of high-resolution computed tomography (HRCT) of the temporal bone in the diagnosis of otosclerosis remains unclear.ObjectivesTo investigate the relationship between the density of the fissula antefenestram (FAF) and of the width of the transversal section of the basal turn of the cochlea (BTC), and the diagnosis of otosclerosis.MethodsThis is a retrospective study in which preoperative HRCT data from ears of patients submitted to stapedotomy due to otosclerosis (case group) were evaluated. For the control group, normal hearing ears having undergone HRCT for other purposes were included. Case and control HRCT images were objectively assessed by an experienced blinded radiologist. During this evaluation, measurements of the relative radiological density of the FAF and of the transversal section of the BTC were obtained. The results were compared between the groups. Also, a receiver operating characteristic curve was created and the area under the curve (AUC) was calculated for each variable. Significance level was set at .05.Results40 ears were included in each group. Case ears presented reduced values for the relative radiological density on the FAF (p-value<0.0001). Moreover, ears with otosclerosis (p-value: 0.022) presented lower transversal section of the BTC. The AUC for these variables reached 0.929 and 0.646, respectively.ConclusionsOtosclerotic ears present reduced radiological density on the FAF and narrower BTC. The relative density of the FAF also shows a great diagnostic power in the context of this disease.     

Does parental experience of the diagnosis and intervention process differ for children with auditory neuropathy?

ObjectivesThis study compared parental experience of the audiological diagnosis and intervention process in children with auditory neuropathy spectrum disorder and sensory neural hearing loss.MethodsA matched group survey was used with parents of children with auditory neuropathy spectrum disorder (ANSD) matched with a control group of parents and children with sensorineural hearing loss (SNHL). The two groups were matched in terms of the child's gender, age, amplifications used, social background and utilisation of private or public health care sectors. An interview questionnaire, consisting of 45 questions in six categories (1. biographic information, 2. experiences of audiological diagnosis, 3. hearing aid benefit, 4. parental experience of the rehabilitation decision making process, 5. parental needs for emotional support and 6. parental needs for information) using a 5-point Likert scale for categories 2–7, was administered by the same audiologist.ResultsChildren with ANSD experienced a significantly longer waiting period from diagnosis to hearing aid fitting (p = 0.025) and/or cochlear implantation (p = 0.036). Parents of children with ANSD reported significantly different experiences of the diagnostic process (p = 0.001) with poorer understanding of the diagnosis and reporting insufficient time allowed for asking questions. During the rehabilitation decision-making process 47% of parents with ANSD children (vs. 0% of parents with SNHL children) reported receiving conflicting information. Parents of children with ANSD were also less likely to recommend hearing aids to other parents. Information needs were similar between groups.ConclusionsParents of children with ANSD have different experiences and greater uncertainty during the diagnostic and rehabilitation process. Providing regular consultation and structured timelines through the diagnostic process and decision-making process may facilitate this process with less uncertainty.     

The AAO-HNS Committee on Hearing and Equilibrium guidelines for the diagnosis and evaluation of therapy in Menière's disease: have they been applied in the published literature of the last decade?

To assess how effectively the American Academy of Otolaryngology-Head and Neck Surgery Committee on Hearing and Equilibrium (AAO-HNS CHE) guidelines for the diagnosis and evaluation of therapy in Meniere's disease have been applied in the last 11 years of published literature. This was a MedLine-based review. Some 79.7% of papers attempted to use the AAO-HNS CHE guidelines. However, only 50% of these publications managed to use the AAO-HNS CHE criteria in the diagnosis and evaluation of therapy correctly. In order to advance our understanding of this condition, improved application of the AAO-HNS CHE guidelines by authors and editors alike is required in the reporting of results of the therapy of Meniere's disease.     

Cystic lymphangioma in adults: can trauma be the trigger?

Cystic lymphangioma is a rare congenital anomaly of the lymphatic system. Most lesions present in infancy or early childhood with a swelling in the head and neck region. We report the case of a lady who presented with a cystic swelling in the suprascapular region that appeared after a fall on outstretched hands. Repeated aspiration and depomedrone injection failed to prevent recurrence. Surgical excision achieved complete removal, and histology showed the lesion as cystic lymphangioma, a rare condition to appear on the shoulder in an adult after trauma.     

Patients with neck lumps: can they be managed in a 'one-stop' clinic setting?

The present government has stated its intentions to expand the application of "one-stop" assessments for out-patients. To decide if this is an appropriate strategy for managing patients with neck lumps, we prospectively assessed 110 patients referred to the Neck Lump Clinic of the Otolaryngology Department of a teaching hospital. Patients were assessed clinically and with immediately reported fine needle aspiration cytology (FNAC). The accuracy of immediately reported FNAC was later compared with a final report and histology, when available. A "one-stop" visit was defined as patients who were discharged, or placed on a waiting list, after a single consultation. Eight-three (76%) patients did not have to return to the outpatient department, of which 59 (54%) were discharged. No changes occurred from immediate to final FNAC reports. If certain criteria are met, patients with neck lumps can be successfully managed in a "one-stop" setting.     

The current status of hearing care: can we change the status quo?

The members of the profession of audiology often express concern that the services and products that have been developed to provide benefit to the hearing impaired are not sought after or delivered to the majority of those diagnosed with hearing loss. A critical look at the status quo of hearing care delivery in the United States is needed to verify this assumption and to develop strategies to improve the situation. A key concern is the lack of a comprehensive high-quality scientific database upon which to build continuous improvements in the effectiveness of the services and products that are provided to the hearing impaired.     

The allergic march: can we prevent allergies and asthma?

The allergic march is a progression of atopic disease from eczema to asthma, and then to allergic rhinoconjunctivitis. It appears to be caused by a regional allergic response with breakdown of the local epithelial barrier that initiates systemic allergic inflammation. Genetic and environmental factors predispose to developing the allergic march. There are data to support 4 possible interventions to prevent the allergic march from progressing to asthma: (1) supplements of dietary probiotics, (2) exclusive breast feeding during the first few months of life, or, alternatively (3) use of extensively hydrolyzed infant formulas, (4) treatment with inhalant allergen immunotherapy by either subcutaneous or sublingual methods.     

The validity of functional assessments of communication and the Activity/Participation components of the ICIDH-2: do they reflect what really happens in real-life?

This paper aims to provide a better understanding of the nature of functional communication activities so that assessment and treatment efforts are based on a theoretical framework and empirical data. Three sources of information are discussed. The first is the Activity/Participation dimensions of the World Health Organization's International Classification of Functioning, Disability, and Health. The second source is existing assessments of functional communication. The final source is data obtained from observational studies conducted in our research unit. The studies have observed the everyday communication of people with aphasia, people with Traumatic Brain Injury (TBI), and patients in hospital. The simplification of real-life communication in the WHO classification scheme, the variability of item sampling in existing assessments, and the complexity of communication observed in real-life settings has led to the conclusion that there are three levels of functional communication assessment: generic, population-specific, and individualized. Clinicians may choose which level suits their purpose. When clinicians routinely choose from a range of sophisticated functional assessments to inform their therapy, the seed that Martha Taylor Sarno planted and nourished for the past 30 years or more will truly flourish throughout the world of speech-language pathology. Learning outcomes: As a result of this activity, participants will (1) understand the theoretical framework and data base that motivates assessment and treatment of functional communication activities, (2) be able to discuss the World Health Organization's Classification of Functioning, Disability and Health and (3) gain information about functional assessment and observational sampling of real world communication activities across three levels.     

Pediatric rhabdomyosarcoma of the head and neck: is there a place for surgical management?

OBJECTIVE: To review and evaluate the place of surgical treatment in the management of rhabdomyosarcoma of the head and neck in children. DESIGN: Retrospective analysis of patient charts from January 1, 1972, to December 31, 1998. SETTING: Tertiary pediatric referral center. PATIENTS: Twenty-nine consecutive children with nonorbital head and neck rhabdomyosarcoma. INTERVENTIONS: Surgery, chemotherapy, and radiotherapy. MAIN OUTCOME MEASURES: Disease-free survival and long-term morbidity from treatment. RESULTS: Twenty patients had parameningeal and 9 had nonparameningeal head and neck tumors. All were treated with chemotherapy. For 18 patients, diagnostic biopsies were performed and they received radiotherapy. Eleven patients underwent surgery as definitive therapy. Using the Intergroup Rhabdomyosarcoma Study (IRS) staging system, 5 of these 11 patients had complete resection of tumor (IRS group I) and avoided radiotherapy. The other 6 patients required radiation because of compromised, regional, or incomplete resection of tumor. One had undergone regional resection with nodal involvement, and 2 had compromised resections with microscopic residual disease (IRS group II). Three had incomplete resections with gross residual tumor (IRS group III). Only 1 patient who underwent surgery ultimately died from recurrence at 2.7 years after an incomplete resection. The other 10 patients were relapse free at a median follow-up of 3.7 years (range 0.8-21.0 years). Long-term surgical morbidity was seen in 36% (4/11) of the patients and included facial nerve paralysis, trismus, and cosmetic deformity. CONCLUSIONS: Children with localized disease of the head and neck are able to undergo complete surgical resection, with low long-term surgical morbidity. By undergoing complete surgical resection, these children are able to avoid radiotherapy and its long-term complications, with no compromise in survival.     

Delayed peripheral facial palsy in the stapes surgery: can it be prevented?

PURPOSE: The aim of this study was to evaluate poststapedectomy-delayed facial palsy etiopathogenesis, risk factors, evolution, and prevention. MATERIALS AND METHODS: Seven hundred six stapedectomies performed in 580 patients were reviewed. In all patients who developed delayed facial palsy, the dates of onset and subside of facial palsy, the anatomic and pathologic predisposing factors, and a possible history for recurrent labial herpetic lesions were considered. The House-Brackmann (H-B) grading system was used to evaluate the facial function. Virus-specific immunoglobulin (Ig) G and IgM antibodies against herpes simplex virus type 1 (HSV-1) were determined by enzyme-linked immunosorbent assay (ELISA) 3 weeks after the onset of the paralysis. The results were compared with a control group without a history of recurrent herpes labialis. RESULTS: Poststapedectomy facial palsy developed in 7 out of 706 procedures. All 7 patients referred a history of recurrent labial herpetic lesions. One patient showed a facial palsy H-B grade II, 2 a grade III, and 3 a grade IV. After acyclovir therapy, 6 subjects recovered completely, whereas 1 maintained an H-B grade II. An increased IgG antibody titer was found in 6 of the patients with delayed facial palsy and in 1 out of 7 controls. Mean IgG titer was 1:14,050 in the subjects with delayed facial palsy and 1:2,300 in controls (P <.001). CONCLUSIONS: Poststapedectomy-delayed facial palsy is likely caused by a reactivation of HSV-1, latent within the geniculate ganglion. The activation of the latent virus is more frequent in patients with a history of herpes labialis and can be prevented by an adequate acyclovir therapy.     

Progress in head and neck cancer immunotherapy: can tolerance and immune suppression be reversed?

The incidence of squamous cell carcinoma of the head and neck (SCCHN) is greater than 40,000 cases per year in the United States, and approximately 500,000 cases annually worldwide. Despite significant advances in detection, ablation, and reconstruction, survival has not improved appreciably over the past few decades. Therefore, novel approaches are necessary to provide head and neck oncologists with a more effective armamentarium against this challenging disease. Cancer immunotherapy describes various approaches to expand and activate the immune system to control tumor growth in vivo. So far, immunotherapy appears to have had applicability in conjunction with other therapeutic interventions that treat residual tumor cells after therapy or to reduce the occurrence of second primary tumors. In particular, diseases such as SCCHN are attractive candidates for novel therapeutic approaches, since the standard treatments have not yet successfully controlled this disease with sufficiently high success rates. This article reviews adjuvant immunotherapeutic strategies currently in trials or under development for SCCHN patients, including vaccination or cytokine immunostimulation.     

Obstruction of the eustachian tube orifice and pressure changes in the middle ear: are they correlated?

OBJECTIVES: We performed a cross-sectional study to investigate whether the obstruction of the eustachian tube orifice due to adenoid hyperplasia changes the pressures in the middle ear. METHOD: Fifty consecutive children 2 to 12 years of age with nasal obstruction were examined from May to October 2005. Adenoid size and status of the eustachian tube orifice were assessed with nasal flexible fiberoptic endoscopy. Tympanometry was used to evaluate the middle ear. RESULTS: In children with occlusion of the eustachian tube orifice by adenoid tissue, 87% had abnormal pressure in the middle ear according to tympanograms. When orifices were not occluded, 86% of the tympanograms were normal (p < .001). CONCLUSIONS: Obstruction of the eustachian tube orifice by adenoid tissue was associated with tympanograms suggestive of abnormal pressure in the middle ear. Future studies with a larger sample size are necessary to clarify this association.     

Micrometastases in cervical lymph nodes from patients with squamous carcinoma of the head and neck: should they be actively sought? Maybe

Techniques are now being developed, which allow ever smaller metastatic deposits in regional lymph nodes to be detected; the question is, should they be sought, or does their presence convey no additional information for treatment of head and neck carcinoma patients at this time? Preliminary findings have suggested that the presence of micrometastases may carry with it some prognostic information, and as a consequence, the search for micrometastases would, for the foreseeable future, appear to be a fertile ground for investigation. To bring some uniformity to this project, it is suggested that these definitions be adopted: a micrometastasis measures greater than 0.2 mm but less than 2.0 mm in diameter, and smaller deposits should be designated as isolated tumor cells, which, in turn, are subdivided into those isolated tumor cells detected by light microscopy, immunohistochemistry, or molecular methods. At this juncture, the import of such micrometastases remains in the realm of the clinical investigator--it remains an open question whether the identification of micrometastases (however they may ultimately come to be defined) will prove to have an impact on the care of head and neck cancer patients.