Necrotizing fasciitis of the pharynx following adenotonsillectomy.

Necrotizing fasciitis is a rare clinical entity in the head and neck region. We report a case of necrotizing fasciitis following adenotonsillectomy in a previously healthy 2-year-old girl. The child presented in a septic state with impending airway compromise. Computed tomography (CT) showed massive soft tissue widening with air in the retropharyngeal, parapharyngeal and retromandibular spaces. Intraoperative exploration showed necrosis of the posterior pharyngeal wall from the skull base to the cricoid, with extension into the parapharyngeal and retropharyngeal spaces. Cultures from the debrided tissues grew two aerobes and three anaerobes. Management involved airway support, surgical debridement, broad spectrum antibiotic coverage and nutritional support. The patient ultimately developed nasopharyngeal and oropharyngeal stenosis requiring tracheostomy and gastrostomy tube placement. This case report highlights an extremely rare complication of adenotonsillectomy.     

Lack of association of CT findings and surgical drainage in pediatric neck abscesses

OBJECTIVE: To evaluate the relationship between neck abscess characteristics on computerized tomography (CT) scan and surgical drainage in pediatric patients. METHODS: Retrospective data warehouse review identified 43 children younger than 19 years admitted to a tertiary care pediatric hospital during the first quarters of 2000 through 2003 who underwent CT imaging for suspicion of head and neck abscesses involving the neck; face; and peritonsillar, retropharyngeal, and parapharyngeal spaces. A total of 45 scans were graded by a radiologist blinded to management. Thickness of the prevertebral soft tissue; location, dimensions, and degree of enhancement of the abscess; patient age; steroid and preadmission antibiotic use; and surgical intervention were recorded. RESULTS: Surgical drainage was performed in 32 of 43 patients (74%). We found no significant correlation between prevertebral soft tissue thickness, abscess dimensions or enhancement on CT scan, and surgical drainage. There was no significant association between surgical drainage and patient age, administration of steroids, or preadmission antibiotic use. CONCLUSIONS: Neck abscess appearance on CT scan did not predict surgical drainage, although prevertebral soft tissue thickness and abscess dimensions may be important features. Abscess enhancement, patient age, and the use of steroids and prehospitalization antibiotics were not found to correlate with surgical drainage.     

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.     

Computed tomography of cervical lymph nodes. Staging and management of head and neck cancer

Forty patients with head and neck cancer had a computed tomographic (CT) scan followed by lymphadenectomy and pathologic confirmation. The overall accuracy of clinical examination of the neck was 70% vs 93% by CT. The CT correctly "upstaged" the neck in nine patients. One was upstaged from NO to N1, and four each from NO to N2 and N1 to N2. It correctly "downstaged" the neck in one patient (from N2 to N1). Eight patients had extranodal disease on CT confirmed by pathology. The CT findings were correct in ten of 11 previously treated patients. Because CT is more accurate than the clinical examination, it should be included in the staging of not only the primary tumor but also nodal disease of the neck. It can have an important role in the management of head and neck cancer.     

Profile of neck cellulitis—Clinician's dilemma

Cellulitis neck may be the only presenting feature of an underlying disease in the upper aerodigestive tract. Inflammation in the head and neck region spreads through potential neck spaces to the surface by direct extension or by lymphatic spread. Four cases of cellulitis neck who presented in the emergency department and progressed with variable clinical course are reported in this paper. After initial treatment with parenteral broad spectrum antibiotics, investigations revealed underlying disease and appropriate treatment was instituted. The importance of detailed clinical examination, investigations and key management protocols are highlighted.     

Computed tomography and ultrasonographic evaluation of metastatic cervical lymph nodes with surgicoclinicopathologic correlation

The detection of cervical lymph nodal metastasis and carotid artery invasion by metastatic lymph nodes is an important issue in the management of head and neck malignancies. This study compared the evaluation of metastasis by palpation, ultrasonography (USG) and computed tomography (CT) in patients with known head and neck malignancies. Twenty-five consecutive patients with head and neck malignancy were prospectively evaluated for the presence of cervical lymphadenopathy and carotid artery invasion. All patients underwent clinical examination (palpation), USG and CT examination. A modified CT criteria was employed which yielded acceptable results for the detection of metastatic nodes. Radical neck dissection was performed for 26 neck sides, and the results of pre-operative evaluation were confirmed by the surgical and histopathological findings. Palpation, ultrasound and CT have comparable sensitivity in the determination of metastasis involving cervical lymph nodes. Thus palpation should be employed as the primary method of assessment of secondaries in the neck. However, palpation is less sensitive than CT and USG in the detection of carotid artery involvement, hence the clinical suspicion of arterial invasion should be confirmed by either CT or USG which have similar accuracy in the detection of carotid artery invasion.     

A prospective study of PET-FDG imaging for the assessment of head and neck squamous cell carcinoma

The main aim of the study was to evaluate the use of positron emission tomography using fluoro-deoxyglucose (PET-FDG) imaging for the detection of squamous cell carcinoma of the head and neck. Fifty-four consecutive patients with malignancies involving the head and neck were studied prospectively. Thirty-one patients presented with primary disease and 23 were suspected of recurrent or residual disease. All patients underwent full clinical staging, PET-FDG scans and anatomical imaging, 37 underwent computed tomography (CT), 13 magnetic resonance (MR) and four had both CT and MR. Clinical assessment, CT/MR, PET-FDG and histological examination were all evaluated independently of each other. All 31 primary head and neck malignant tumours were detected by PET-FDG. Based on 16 patients who underwent neck dissections, the sensitivity and specificity of PET-FDG for detecting nodal disease was 67% and 100% respectively, compared with clinical assessment of 58% and 75% and CT/MR of 67% and 25%. In all 12 patients, PET-FDG correctly identified the presence or absence of recurrent or residual disease. PET-FDG staged 13 post-treatment necks with an accuracy of 100%, as compared to CT/MR which was accurate in 7 of 13 and clinical assessment which was accurate in eight. Three sites of abnormal tracer uptake unrelated to malignancy were recorded as incidental findings (mandibular osteomyelitis, 1; post glossectomy site, 2). PET-FDG was more accurate than CT/MR for identifying primary and recurrent tumours as well as metastatic lesions in the neck. If these diagnostic properties of PET-FDG are confirmed in further prospective studies, it could prove a valuable adjunct for the management of head and neck cancer.     

Head and neck surgery in the elderly: a maturing problem

The number of elderly patients requiring oncologic head and neck surgery is increasing as this proportion of the population continues to grow. To establish the specific problems and relative risks, 100 patients, 70 years of age and over have been examined to determine post-operative mortality and morbidity. Results do not show these to be significantly increased in the elderly and support an aggressive approach to head and neck cancer management in these patients.     

Air in the neck

Air in the neck is normally found in the pharynx, larynx and trachea. Free air may enter the neck by direct opening of potential fascia spaces, dissection within the fascia spaces from the head or mediastinum and by injury to the upper respiratory or alimentary tracts. The sources for free air in the neck are numerous and varied and range from the rectum to the sinuses. The otolaryngologist should have a thorough knowledge of the differential diagnosis for air in the neck since the definitive therapy depends on the etiology.     

Diagnostic utility of positron emission tomography-computed tomography for predicting malignancy in cystic neck masses in adults

OBJECTIVES: Combined positron emission tomography and computed tomography (PET-CT) is used for the diagnostic evaluation and staging of squamous cell carcinoma of the head and neck (SCCHN). By superimposing anatomic localization of CT with the physiologic data of PET, occult primary and metastatic neoplasms might be identified. Because the diagnostic algorithm for cystic neck masses in adults often overlaps with the work-up of cancer of unknown primary site, we evaluated the utility of PET-CT scans to identify the presence of malignancy and the location of primary tumor. STUDY DESIGN: Single-institution retrospective case review series. METHODS: We reviewed the PET-CT imaging of cystic neck masses occurring in five patients over 40 years of age with significant risk factors for SCCHN and correlated this information with histopathology. RESULTS: In each patient in our series, the PET portion of a combined PET-CT was misleading, whereas the CT examination was more suggestive of the correct pathology. Ultimately, clinical judgment and endoscopic evaluation, guided by CT findings, were most valuable for distinguishing malignant versus benign processes and identifying the primary tumor sites. CONCLUSIONS: PET-CT may not be a reliable modality for identifying malignancy in adults with suspicious cystic neck masses. A thorough clinical evaluation by an experienced head and neck surgeon, in conjunction with contrast-enhanced CT, may be sufficient to facilitate the optimal management of such patients.     

Magnetic resonance imaging and computed tomography in pediatric head and neck masses

Fifty-three magnetic resonance imaging (MRI) and 25 computed tomography (CT) studies of 53 head and neck masses in pediatric patients were reviewed retrospectively. All lesions had pathologic proof except for 2 metastatic and 2 recurrent lesions, which only had prior pathologic confirmation at their primary sites. These included 12 malignant tumors, 23 benign tumors, 6 inflammatory masses, and 12 congenital lesions. The MRI performance ranged predominantly from good to excellent in detection of the lesion and the extent of involvement and in contrast to the surrounding tissue; when CT comparison was available, MRI proved to be equal to or better than it in detection of these factors and in preoperative diagnosis. Our results suggest that MRI should be the method of choice for the initial evaluation of the pediatric head and neck region, especially in those patients requiring multiple examinations. However, CT and MRI should be used conjunctively in complicated cases, especially those possibly involving lesions with calcifications or bony involvement.     

French ENT Society (SFORL) guidelines for the management of immunodeficient patients with head and neck cancer of cutaneous origin

ObjectivesThe French ENT Society (SFORL) created a workgroup to draw up guidelines for the management of immunodeficient patients with head and neck cancer of cutaneous origin. The present guidelines cover diagnostic and therapeutic management and prevention of head and neck cancer of cutaneous origin in immunodeficient patients, and in particular in transplant patients and those with HIV infection.Materials and methodsThe present guidelines were based on a critical multidisciplinary reading of the literature. Immunosuppression and its varieties are defined. The usual risk factors for skin cancer and those specific to immunodeficiency are presented. The prevention, assessment and management of cutaneous carcinoma, melanoma, Kaposi's sarcoma and lymphoma are dealt with. The level of evidence of the source studies was assessed so as to grade the various guidelines. When need be, expert opinions are put forward.ResultsImmunodeficient patients are at higher risk of head and neck skin tumors. The level of risk depends on the type of deficiency; there is an especially high risk of squamous cell carcinoma in transplant patients and of Kaposi's sarcoma in HIV-positive subjects. Various viruses are associated with skin cancers. Skin tumors are often evolutive in case of immunodeficiency, requiring rapid treatment. Management is generally the same as in immunocompetent subjects and should be discussed in a multidisciplinary team meeting. Immunosuppression may need to be modulated. In organ transplant patients, the only class of immunosuppressants with proven antitumoral efficacy are mTOR inhibitors, particularly in cutaneous squamous cell carcinoma. The rhythm of clinical surveillance should be adapted according to the risk of recurrence. Preventive measures should be undertaken.ConclusionSkin cancers in immunodeficiency are highly evolutive, requiring the earliest possible treatment. Immunosuppression may need modulating. As the risk of recurrence may be elevated, careful surveillance should be implemented. Preventive measures should also be undertaken.     

脱氧葡萄糖-正电子发射计算机断层显像对颈淋巴结转移癌的诊断价值

目的：探讨脱氧葡萄糖-正电子发射计算机断层[^18F-FDG-PET／CT（PET／CT）]融合显像对颈淋巴结转移癌的诊断价值。方法：对照颈淋巴结清扫术后病理结果,回顾性对比分析20例头颈癌患者颈部正电子发射断层（PET）、CT及PET／CT资料。结果：PET对颈淋巴结转移癌的诊断敏感性、特异性及准确度分别为92.3％、85.7％、90.0％,CT分别为77.0％、57.1％、70.0％,PET／CT分别为92.3％、100.0％、95.0％,PET／CT的诊断准确度显著高于CT（P〈0．05）、略优于PET。13例鼻咽癌放疗后患者,CT诊断正确7例,PET／CT诊断正确12例。7例N。患者颈淋巴结清扫术后病理证实4例存在颈淋巴结转移,术前PET／CT均诊断正确。结论：PET／CT融合显像对颈淋巴结转移癌的诊断价值优于单独的PET及CT,尤其对于治疗后的患者,其诊断优势更加突出,有望作为是否需行颈淋巴结清扫术的指征。     

Cavernous hemangioma of the infratemporal fossa

Cavernous hemangiomas are most commonly found in the head and neck region. We report a case of infratemporal fossa cavernous hemangioma. Extensive workup included CT scan, MRI, and angiography. Treatment involved surgical excision using the Weber-Ferguson approach. Successful excision of the tumor was possible because of accurate preoperative localization of the mass, as well as morphologic examination that ruled out those infratemporal fossa tumors requiring different surgical approaches.     

Complications of space infections of the head and neck.

Life threatening infections of odontogenic or upper airway origin may extend to potential spaces formed by fascial planes of the lower head and upper cervical area. The incidence of these “space infections” has been greatly reduced by modern antibiotic therapy. However, serious morbidity and even fatalities continue to occur. Two cases of deep neck infection, (one of odontogenic and one tonsillar in origin) with subsequent mediastinitis, empyema, pericarditis and ultimate survival are reported. One case of deep neck infection, (of odontogenic etiology) and suppurative thrombophlebitis of the internal jugular vein with ultimate fatal outcome is also reviewed. Review of the literature reveals only one previous case report of a survivor of an odontogenic deep neck infection complicated by mediastinitis, empyema and pericarditis. The anatomy, etiology and treatment of complications of these “space infections” of the head and neck are briefly reviewed.     

Indications for PET/CT in the head and neck

PET/CT has revolutionized the evaluation of patients with head and neck cancer by allowing more accurate staging, more focused treatment modalities, earlier detection of recurrent disease, and identification of incurable disease. In some clinical scenarios, PET/CT is clearly useful, while in others the cost may not be warranted. In this chapter, the authors review the literature on the use of PET/CT in head and neck cancers (in particular squamous cell carcinoma) and provide an evidence-based approach to the use of PET/CT for staging, treatment planning, monitoring of treatment response, and surveillance of treated patients with squamous cell carcinoma. They also briefly address the use of PET/CT for thyroid cancer, lymphoma, and melanoma. At the end of each section, key points are summarized in a box for quick reference.     

Comparative studies of diagnosis with US or CT of the cervical lymph node metastases in head and neck cancer

Correct assessment of lymph node metastasis in the head-neck region is very important for management of head and neck cancer. 233 lymph nodes were removed by radical neck dissection from 12 cases with cancer in the head and neck region, who did not undergo any preoperative treatment, and the materials were histopathologically examined. The histopathological findings were compared with preoperative US and CT findings. Histopathologically, 26 lymph nodes were found positive for metastasis and the remaining 207 lymph nodes, negative. US detected 45 (19%) of 233 lymph nodes before operation, and 40 of the 45 lymph nodes (89% : 40/45) were qualitatively correctly diagnosed. CT detected 21 lymph nodes (19%), 16 of which were qualitatively correctly diagnosed (76% : 16/21). Of 26 lymph nodes which were histopathologically involved, 19 lymph nodes were correctly diagnosed by US and 11 by CT. Possible reasons explaining the superiority of US to CT in terms of diagnostic reliability are the following: 1) US demonstrates more clearly the existence of lymph nodes than CT. 2) US is more reliable for measuring sizes of lymph nodes than CT. In literature, CT has been often reported to be useful to diagnose cervical lymph node involvement in individual cases. However, we insist that it is necessary to diagnose individual lymph nodes strictly for correct assessment of the reliability of image diagnosis.     

Metastatic neck disease. A clinical/radiographic/pathologic correlative study

The concept of treating prophylactically the neck of the patient with head and neck cancer is based on the presence of neck metastases in a large number of cases, even if not always detected by physical examination. A modality that could reveal abnormal nodes accurately would change this management attitude so that a number of necks could be left untreated. A retrospective comparative study was undertaken to determine whether high-resolution computed tomographic (CT) scanning might play this role, and whether it has any advantage over physical examination. The radiographic findings of 79 patients with head and neck cancer who had undergone a total of 100 neck dissections were compared with the findings of physical and histopathologic examinations. This study shows similar sensitivity rates for both physical examination and CT scanning (61.55% and 59.6%, respectively) and slight superiority of the positive predictive values of physical examination (91.4%) over those of CT scanning (81.6%). The study suggests that CT offers no advantage over physical examination and should therefore not be used for neck management decisions. Measuring the size of involved lymph nodes showed that occult nodes fall within the same range as normal nodes and thus cannot be differentiated from normal nodes by size alone.     

Waiting times during the management of head and neck tumours

The waiting times incurred during the management of 75 consecutive head and neck oncology patients attending for post-treatment follow-up were reviewed. Data were gleaned from general practitioner (GP) referral letters, patient case-notes as well as radiology and histology reports. The mean time for GP referral to ENT was 5.1 weeks. From ENT to endoscopy was 3.1 weeks, to histology 3.5 weeks, to computed tomography (CT) scan 5.6 weeks, to magnetic resonance scan (MR) 4.1 weeks, to primary radiotherapy 10.3 weeks and to surgery 5.5 weeks. The mean symptom duration prior to referral was 4.9 months. Our results compare unfavourably with the standards recommended by the BAO-HNS. Local modifiations may improve matters, but significant increases in funding, manpower and equipment are required to achieve the stipulated standards. Moreover, criteria for referral have to be re-emphasized and patient education has to be addressed as these appear to contribute the longest delay in the diagnosis of head and neck tumours.     

Head and neck cancer surgery in the elderly

BACKGROUND: The literature on management of advanced head and neck cancer in the elderly is limited. Diagnostic and treatment decisions may be implicated by advanced age itself. METHOD: Treatment outcomes of head and neck cancer in elderly patients were reviewed in the literature. The results should serve as a basis for an individualized treatment strategy. RESULTS: A comparison of data shows that chronologic age alone should not be a contraindication to adequate oncologic surgery. An aggressive approach to head and neck cancer management with curative intention can be also considered in high aged patients with advanced cancer. Surgical therapy of head and neck cancer can be as effective in elderly patients as in younger patients without a significant increase in mortality and complications. CONCLUSIONS: Head and neck cancer patients of all age groups should have a treatment of equal quality regardless of whether the expected outcome is cure or palliation.