Thyroglossal duct cyst and sinuses: A 20-year Los Angeles experience and lessons learned

Background

First described in 1920 and later modified in 1928, the Sistrunk procedure substantially reduced the incidence of recurrence of midline neck cysts compared with a local excision or cystectomy. The purpose of this study was to determine if the rate of recurrence was influenced by performing either a ‘classic’ or a ‘modified’ Sistrunk procedure, if the recurrence rate was influenced by the physician's training, how successful we have been in managing patients with a recurrence? Finally, is outpatient surgery safe for Sistrunk procedures?

Methods

We performed a retrospective review of all patients with a thyroglossal duct remnant (TGDR) who were seen at the Children's Hospital Los Angeles (CHLA) from 1990 to 2010. The following data were collected: patient age, gender, presence or absence of a pre-operative infection, imaging studies, type of procedure performed, the attending surgeon's training background, inpatient or outpatient status, and complications.

Results

A total of 128 patients (61% male, 39% female) met the inclusion criteria. The age ranged from 2 months to 14 years (mean of 5.1 years). A total of 137 procedures were performed; 114 (83.2%) for primary and 23 (16.8%) for secondary disease. Complications included post-operative infection (10.9%), recurrence of disease (6.6%), undesirable scar (5.8%), and fistula (2.9%). Surgeons with fellowship-training in pediatric otolaryngology had a recurrence rate of 4.0% and surgeons with fellowship-training in pediatric surgery or pediatric plastic surgery had a recurrence rate of 30.1%. Twenty patients had a ‘classic’ Sistrunk (14.6%) and 117 (85%) had a ‘modified’ procedure. Patients were admitted after surgery in 78 cases (56.9%) and 59 patients (43.1%) had an outpatient (OPD) procedure.

Conclusions

There is no place for cystectomy in the treatment of TGDR. A ‘modified’ Sistrunk procedure is the procedure of choice in both primary and revision cases. Wide local excision of recurrences is required and a ‘classic’ Sistrunk should be considered. Specific training to gain an intimate knowledge of the anatomy in and around the larynx and experience with multiple cases reduces the incidence of recurrence. Outpatient surgery is safe and effective for selected patients who undergo a Sistrunk procedure.     

Regional control after concomitant chemoradiotherapy without planned neck dissection in node-positive head and neck squamous cell carcinomas

Objectives

Although three-weekly high-dose (100 mg/m²) cisplatin (three cycles) chemoradiotherapy has been considered a standard regimen for patients with advanced head and neck squamous cell carcinomas (HNSCC), this protocol is associated with significant acute and late toxicities. Therefore, weekly cisplatin at a dose of 40 mg/m² has been used at our institution since 2006. This retrospective study was aimed at assessing the oncologic efficacy of weekly cisplatin chemoradiotherapy for the control of nodal metastasis.

Methods

We analyzed 28 patients with node-positive HNSCC treated with weekly cisplatin and concurrent radiotherapy. Computed tomography was performed 4–8 weeks after the completion of chemoradiotherapy to evaluate nodal response. If residual neck disease was apparent or suspected, we performed early salvage neck dissection (ND). In cases with a complete response (CR), we took a “wait and see” approach. When no viable tumor cells were observed in the surgical specimens obtained by ND, nodal metastasis was defined as controlled by weekly cisplatin chemoradiotherapy alone.

Results

Nodal metastasis was evaluated as having a CR in 20 patients (71%). Eight patients (29%) underwent early salvage ND. Recurrent primary tumors were observed in the other four patients (14%). Salvage primary resection and associated ND were performed for these four patients. In 7 of 12 patients undergoing ND, no viable tumor cells were observed. In 23of 28 patients, neck diseases were controlled by chemoradiotherapy alone (not including salvage by ND). In 27 of 28 patients, neck diseases were controlled by the overall treatment (including salvage by ND). The rate of nodal control by chemoradiotherapy alone and by the overall treatment was found to be 82.0% and 96.3%, respectively, using the Kaplan–Meier method. The three-year overall and disease free survival rates were 86.8% and 80.8%, respectively.

Conclusion

Concomitant weekly cisplatin at a dose of 40 mg/m² chemoradiotherapy showed a good control rate of not only primary lesions but also neck diseases.     

Modified radical neck dissection for residual neck disease after radiotherapy of nasopharyngeal carcinoma

Objective

Although radical neck dissection is proposed as a standard salvage procedure for the management of radiotherapy-resistant nasopharyngeal carcinoma of the neck, modified radical neck dissection may be appropriate for select patients. This study was designed to evaluate the efficacy of individualized neck dissections based on preoperative imaging studies and intraoperative exploration for the management of radiotherapy-resistant nasopharyngeal carcinoma of the neck.

Methods

The study included 42 consecutive patients who failed radiotherapy or chemo-radiotherapy for nasopharyngeal carcinoma of the neck and underwent a total of 46 radical neck dissections or modified radical neck dissections. Selection of the proper type of neck dissection was based on preoperative imaging studies and intraoperative exploration. The patients’ clinical features, pathologic characteristics, complications, and treatment outcome were estimated and analyzed.

Results

Radical neck dissection and modified radical neck dissection were performed on 19 and 27 necks, respectively. Thirty-three necks (71.7%) had multiple node metastases. Nineteen necks (41.3%) had node metastases at two or more levels. The overall morbidity rate was 11.9%. The 5-year neck control rate (NCR) was 79.1% for 46 necks. The 5-year overall survival and disease free survival for 42 patients were 58.0% and 44.0%, respectively. No statistically significant differences were found in comparing OS, DFS, NCR between the MRND and RND groups.

Conclusions

Individualized neck dissection based on preoperative imaging studies and intraoperative exploration is appropriate for the management of radiotherapy-resistant nasopharyngeal carcinoma of the neck.     

Is elective neck dissection necessary for the surgical management of T2N0 glottic carcinoma?

Objective

Evaluation of neck metastasis incidence in surgically treated T2N0M0 glottic carcinoma patients and discussion the necessity of elective neck dissection in this subset of larynx carcinomas.

Materials and methods

The patients who were staged clinically and radiologically as T2N0M0 glottic carcinoma having surgical intervention for their primary tumor and elective neck dissection between March 1996 and July 2009 with at least 2 years of follow up were included in the study. The recordings of patients were evaluated retrospectively for primary tumor location, vocal cord mobility, type of laryngectomy and neck dissection, results of histopathological examination, number of dissected lymph nodes for each specimen and for local and regional failure during the follow up.

Results

In the 13-year study period, 24 consecutive patients with a mean age of 56.4 were treated surgically with 20 frontolateral, three vertical laryngectomies and one cricohyoido-epiglottopexy; 19 lateral and 5 functional neck dissections were performed for the necks. Histopathological examinations of the neck dissection specimens revealed an average of 32 lymph nodes (8–65) and there was no metastasis in any of these specimens. After an average 58 months of follow-up, only one patient had local failure and no patients had regional failure.

Conclusion

As occult metastasis was not detected in any of the neck dissection specimens in cT2N0M0 patients and no regional failure was experienced during the follow-up period, it was concluded that the neck could be followed up without performing elective neck dissection in the surgical management of cT2N0M0 glottic carcinoma patients.     

Canal wall reconstruction and preservation in the surgical management of cholesteatoma in children with Down's syndrome

Introduction

Down's syndrome is associated with poor Eustachian tube function, and an increased incidence of cholesteatoma. The only previously published case series suggests that ‘canal wall preserving’ procedures are only rarely suitable for the management of cholesteatoma in this population.

Methods

We conducted a retrospective review of the hospital's clinical records database to identify patients with Down's syndrome and cholesteatoma. These patients’ notes were then reviewed.

Results

We identified nine patients with Down's syndrome who had undergone surgical management of cholesteatoma over a twelve year period. Three patients had bilateral disease, meaning twelve ears were treated. Seven ears were initially treated with ‘canal wall down’ procedures. Four out of five of the remaining ears were successfully treated using ‘canal wall preservation’ or ‘canal wall reconstruction’, with one ear requiring subsequent conversion to a ‘canal wall down’ approach.

Conclusion

Canal wall preservation/reconstruction is feasible in patients with Down's syndrome, even when cholesteatoma extends into the mastoid.     

Retrospective analysis of tympanoplasty in children with cleft palate: A 22-year experience: I. Mesotympanic (non-cholesteatomatous) cases

Background

Contradictory data have been published on the outcomes of ear surgeries in cleft patients.

Objectives

To investigate whether there are differences in the short and long term outcomes of tympanoplasty performed due to childhood chronic mesotympanic otitis media in patients without and with cleft palate.

Setting

Tertiary care pediatric medical centre.

Methods

The authors retrospectively analysed the first author's data on pediatric tympanoplasties of the past 22 years with the help of a computer programme developed by the third author. The outcomes of 159 ‘NoCleft’ tympanoplasties (119 patients, 144 ears) were compared to the outcomes of 31 ‘Cleft’ tympanoplasties (21 patients, 27 ears) with the average age of the patients being 10.8 and 10.7 years accordingly.

Results

The preoperative ABG (28.76/28.94 dB, p = 0.468), the best postoperative ABG (12.78/10.04 dB, p = 0.096), the last postoperative ABG (15.59/13.19 dB, p = 0.192), the final hearing gain (13.17/15.75 dB, p = 0.253) and the postoperative ABG deterioration associated with time (2.81/3.15 dB, p = 0.376) were statistically compared in the ‘NoCleft’/’Cleft’ groups. No significant difference was found between the outcomes of the two groups. The same parameters were examined separately after tympanoplasties performed with intact ossicular chain and after those requiring columella ossiculoplasty. The ‘Cleft’ group did not have worse outcomes in this respect, either. The average follow-up period of the patients was more than 3 years in both groups. The graft take rate was 100%, reperforation occurred in 3.5% of the cases in both groups. In their study, grommet insertion was more likely to be necessary in the ‘Cleft’ group.

Conclusion

The authors concluded that there was no significant difference between the expectable outcomes of pediatric tympanoplasties in patients with and without cleft palate regarding mesotympanic cases; therefore, the indications for tympanoplasty are the same in the two groups. They outline the importance of the therapeutic management of cleft patients in the frameworks of a “Cleft Palate Team” and the necessity for their lifelong otorhinolaryngological care due to their vulnerable Eustachian tube function. They are planning to publish the same comparative analysis of their patients with cholesteatoma in a following study.     

Fourth branchial cleft anomaly: Management strategy in acute presentation

Objectives

Branchial malformations are common congenital head and neck lesions usually diagnosed in childhood during the first decade of life. Acute presentation is usually managed with conservative protocols before a definitive surgical procedure although the risk of life-treating septic complications may influence the physician’s decision. Surgery is the treatment of choice with the removal of the lesion alone, nevertheless more aggressive approaches must be considered in complicated cases. Selective neck dissection including the removal of part of the thyroid lobe with the congenital lesion should be considered as the “ultima ratio” treatment to avoid recurrence.

Methods

We reviewed literature and report our experience concerning two patients with fourth branchial cleft sinus.

Results

A three-year-old child with a clinical history of recurrent neck abscess was referred to our department after several drainages performed in another centre. A three-year-old child referred to our department for a left side lower primary neck abscess. In both cases the diagnosis of a complicated fourth cleft remnant was confirmed by rigid endoscopic visualization of the mucosal orifice of the sinus in the pyriform fossa. Surgical management during acute presentation was challenging; in one patient the early fasciitis required an emergency procedure to remove the infected sinus that were strictly adherent to the deep vascular-nervous axis.

Conclusion

Surgery was the definitive treatment in both cases and at 12 and 25 months follow-up respectively no recurrences were observed.     

Pediatric otolaryngology in a field hospital in the Philippines

Background

Major natural disasters adversely affect local medical services and resources. We sought to characterize pediatric patients presenting with otolaryngology-head and neck surgery (OTO-HNS)-related diseases/injuries to a field hospital over 11 days of operation, which was deployed to assist the healthcare facilities in Bogo, the Philippines, in the aftermath of typhoon Haiyan (Yolanda).

Methods

We reviewed charts of pediatric patients aged 0–18 years visiting our field hospital, who presented with OTO-HNS-related diseases/injuries. We also describe the structure of the field hospital, equipment, facilities and capabilities of our service, discuss medical and ethical concerns, and propose several recommendations for future similar missions.

Results

Of the 863 pediatric visits, 91 (11%) presented with OTO-HNS-related diseases/injuries, 3 of them were of recurring patients. Of the 88 included individual patients, 47 (53%) were boys, with an average age of 6.9 ± 4.9 years. Ear-related diseases, mostly acute otitis media (AOM), and neck-related diseases were the most common pathologies (49% and 16% of the patients, respectively). Antibiotic therapy was administered to 36 (41%) patients, mostly to children with AOM. Despite limited resources, we were able to perform surgical interventions on 8 (9%) patients, which included laceration suturing, abscess drainage and neck surgery.

Conclusions

Otolaryngologists have an important role in the treatment of children affected in a disaster area, at a time of an increased demand for healthcare. Unlike ‘acute phase’ missions, where traumatic injuries are the focus for treatment, ‘subacute’ phase missions provide more routine medical and surgical care.     

Managing regional metastasis in patients with cutaneous head and neck melanoma – is selective neck dissection appropriate?

Background

Neck dissection is recommended for patients with head and neck cutaneous melanoma and nodal metastasis. However, there appears to be no clear evidence to guide the extent of nodal resection.

Methods

Loco-regional recurrence (LR), overall survival (OS) and progression free survival (PFS) was retrospectively compared between patients who had Comprehensive neck dissection (CND) and Selective neck dissection (SND).

Results

There was no difference in LR, OS and PFS between CND (n = 18) and SND groups (n = 79). Extra capsular extension (ECE), frontal disease and increasing number of involved nodes resulted in worse OS and PFS but had no impact on LR.

Conclusion

Patients with disease limited to one node without ECE can be effectively treated by SND alone. In patients who have these unfavourable pathological features more extensive nodal resection does not improve outcome if they receive radiotherapy. Extent of neck dissection or adjuvant radiotherapy has no impact on overall survival.     

Thyroid carcinoma uptake of F-Fluorodeoxyglucose in patients with elevated serum thyroglobulin and negative I scintigraphy

Purpose

To determine if FDG-PET results can predict for outcome in thyroid cancer patients with elevated Tg and negative I-131 imaging.

Materials and methods

We conducted a retrospective review of 76 patients who had elevated serum Tg and negative ¹³¹I scintigraphy and who underwent FDG-PET. After FDG-PET, patients underwent neck dissection or radiation.

Results

The 51 patients with positive FDG-PET had a 5-year survival of 63% compared to 100% (p < 0.049) for the 25 patients with negative PET. Patients with FDG-avid disease isolated to the lymph nodes had 5-year CSS of 91% compared to 32% (p = 0.0033) for those with disease outside the regional lymph nodes. Twenty-nine patients with disease isolated to the regional lymph nodes underwent salvage neck dissection and 22 remain NED after 28 months.

Conclusions

Negative FDG-PET with elevated Tg predicts an excellent outcome. FDG-avid disease isolated to the regional lymph nodes had a low likelihood of death due to thyroid cancer.     

Language regression in children with Autism Spectrum Disorders

Objectives

Regression in autism applies to the phenomenon of apparently normal early development followed by the loss of previously acquired skills and manifestation of symptoms of autism. Estimates of the frequency of regression in autism range from 10% to 50%. Although there are tools available to evaluate and diagnose Autism Spectrum Disorders, however, there is no published tool available in Indian context to identify the children with ASD at an early age. The study was aimed to describe the differences in language regression between children with ASD and typically developing children and also to determine the age of regression.

Methods

Regression screening tool, a questionnaire was developed based on Regression Supplement Form (Goldberg et al., 2003). The skills were validated by five Clinical Psychologists. It comprised of 16 skills which included domains like, ‘spoken language and non verbal communication’, ‘social interest and responsiveness’ and ‘play and imagination’. This retrospective study was conducted on a single group. The participants consisted of parents of 30 children with ASD (22 males and 8 females).

Results

The findings revealed a significant regression in children with ASD. The mean regression age is 20.19 months (SD-5.2). The regression profile of the children with ASD revealed regression of language skills occurred at 19.16 months followed by non language skills at 20.5 months.

Conclusions

Based on the findings it can be stated that inclusion of regression screening tool will offer clinicians a convenient tool to examine the phenomena of regression in children with ASD and identify them as early as 21 months of age for early intervention.     

Chyle leak: A rare complication post-hemithyroidectomy. Case report and review of literature

Background

Thyroidectomy is one of the common neck surgeries. Well recognized complications include postoperative bleeding, hypocalcaemia and recurrent laryngeal nerve injury. Chyle leak post-thyroidectomy is extremely rare. Most of the reported cases have had a complete central compartment neck dissection.

Methods and results

This is a case report of a patient who suffered from chyle leak after a left hemithyroidectomy without a complete central compartment neck dissection. The patient was managed conservatively with low fat diet and observation. A protocol for approaching thyroid patients with chyle leak is proposed based on a comprehensive literature review.

Conclusion

Chyle leak post-thyroidectomy for a benign disease is a very rare complication. Nevertheless, head and neck surgeons should consider it in the differential diagnosis of neck swelling post-thyroidectomy.     

Usefulness and pitfall of Narrow band imaging combined with magnifying endoscopy for detecting an unknown head and neck primary site with cervical lymph node metastasis

Objective

Cervical nodal metastasis from clinically undetectable primary squamous cell carcinoma (SCC) accounts for 1–2% of head and neck malignancies. We retrospectively evaluate the ability of Narrow band imaging combined with magnifying endoscopy (NBI-ME) to detect the primary sites of superficial SCC in the head and neck region.

Methods

This was a report of 11 patients. We performed with NBI-ME to detect unknown primary sites in the head and neck.

Results

Among 11 patients, primary sites were detected in eight. Primary sites were detected in the head and neck in 6 (54.5%) of 11 patients on NBI-ME, all 6 primary lesions were a flat lesion. Two patients in whom primary lesions could not be detected on NBI-ME, one had submucosal tumor like lesion, the other featured by a detectable primary lesion 19 months after neck dissection.

Conclusion

NBI-ME can be recommended as an essential procedure for the detection of primary lesions in patients with primary unknown cervical lymph node metastasis.     

Management of neck metastases in T2N0 lip squamous cell carcinoma

Background

Prophylactic neck dissection (PND) is indicated when the chance of occult lymph node metastases from head and neck tumors is significant. There is no consensus regarding which tumor size PND would be indicated in cases of lip cancer.

Methods

A total of 139 patients with surgically treated lip cancer were selected. The size of the lesion (T) and the presence of lymph node metastases (N) were assessed by examining the medical records. For analysis purposes, the T2 group was divided into T2a (2 to 3 cm) and T2b (3 to 4 cm).

Results

The following distribution of incidence of neck metastases was observed in the study groups: 11.7% in T1, 9% in T2a, 43.7% in T2b, and 52.2% in T3 + T4. Statistical comparison of the groups (p) revealed the following results: T2a X T2b = 0.03; T2a X T3 + T4 = 0.001.

Conclusion

PND is indicated for tumors larger than 3 cm.     

Squamous cell carcinoma of the parotid gland: A population-based analysis of 2545 cases

Purpose

Squamous cell carcinoma (SCC) of the parotid gland is an uncommon tumor, which generally affects older patients. In this study, we explore various aspects of this entity using a national population-based database.

Methods

The Surveillance, Epidemiology, and End Results (SEER) registry was used to extract data on frequency, incidence, and disease-specific survival (DSS) from 1973 to 2009. Variables analyzed included age, gender, race, histologic grade, stage and treatment. Cox proportional hazards analysis was conducted.

Results

A total of 2545 cases were identified. Parotid SCC was most common in males (79.8%), whites (92.9%), and patients aged ≥ 75 years (51.4%). Incidence increased slightly over the past three decades (annual percent change 1.90%, p < 0.05). Overall 5-year DSS was 54.4%. Statistically significant poor prognostic factors included black race, age ≥ 75 years, tumor T3 or greater, and higher clinical stage at diagnosis. Elective neck dissection (END) in patients staged N0 was associated with higher DSS (78.3% versus 51.1%, p < 0.0001). The omission of END was associated with a three-fold greater hazard of death (hazard ratio 3.19, 95% confidence interval 1.53–7.26, p = 0.0016), regardless of whether or not radiotherapy was given.

Conclusion

Parotid SCC is uncommon, and data on treatment decisions are limited. Our study profiles the demographic, clinicopathologic, incidence, and survival features of this entity. Perhaps most notably, our results support the practice of END of the N0 neck.     

Recurrence pattern after conservative surgery for papillary thyroid carcinoma

Objective

Risk-based treatment represents the optimal management strategy for papillary thyroid carcinoma; however, the optimal extent of thyroidectomy and neck dissection remains controversial. This study aims to clarify the pattern of recurrence after conservative surgery in patients with papillary thyroid carcinoma.

Methods

We retrospectively reviewed 93 patients with papillary thyroid carcinoma treated with conservative surgery. We analyzed recurrence rate, recurrence pattern, risk factors for recurrence, salvage treatment, and disease-free survival (DFS) in patients stratified according to risk.

Results

The recurrence rate was significantly lower in the low-risk group compared with the high-risk group (14% vs 34%; p < 0.01). The recurrence pattern also differed between the two groups, with ipsilateral lateral neck recurrence being more common in the low-risk group (9%), while contralateral lateral neck recurrence was more common in the high-risk group (18%). Patients with contralateral thyroid lobe metastasis and/or direct contralateral thyroid lobe invasion showed a significantly higher rate of contralateral lateral neck metastasis than patients negative for both these features. The overall 5-year DFS was 81% in all patients. Advanced T and N classification, large primary tumor (≥4 cm), extrathyroidal invasion, and high-risk group were significantly associated with poorer 5-year DFS in univariate analysis.

Conclusion

Conservative surgery may represent a good treatment option for patients with low-risk papillary thyroid carcinoma. Tumor recurrence patterns differ between risk groups, with contralateral thyroid lobe lesions and direct contralateral lobe invasion being risk factors for contralateral lateral neck recurrence.     

Brainstem auditory evoked potentials with the use of acoustic clicks and complex verbal sounds in young adults with learning disabilities

Purpose and background

Acoustic signals are transmitted through the external and middle ear mechanically to the cochlea where they are transduced into electrical impulse for further transmission via the auditory nerve. The auditory nerve encodes the acoustic sounds that are conveyed to the auditory brainstem. Multiple brainstem nuclei, the cochlea, the midbrain, the thalamus, and the cortex constitute the central auditory system. In clinical practice, auditory brainstem responses (ABRs) to simple stimuli such as click or tones are widely used. Recently, complex stimuli or complex auditory brain responses (cABRs), such as monosyllabic speech stimuli and music, are being used as a tool to study the brainstem processing of speech sounds. We have used the classic ‘click’ as well as, for the first time, the artificial successive complex stimuli ‘ba’, which constitutes the Greek word ‘baba’ corresponding to the English ‘daddy’.

Patients and methods

Twenty young adults institutionally diagnosed as dyslexic (10 subjects) or light dyslexic (10 subjects) comprised the diseased group. Twenty sex-, age-, education-, hearing sensitivity-, and IQ-matched normal subjects comprised the control group. Measurements included the absolute latencies of waves I through V, the interpeak latencies elicited by the classical acoustic click, the negative peak latencies of A and C waves, as well as the interpeak latencies of A–C elicited by the verbal stimulus ‘baba’ created on a digital speech synthesizer.

Results

The absolute peak latencies of waves I, III, and V in response to monoaural rarefaction clicks as well as the interpeak latencies I–III, III–V, and I–V in the dyslexic subjects, although increased in comparison with normal subjects, did not reach the level of a significant difference (p < 0.05). However, the absolute peak latencies of the negative wave C and the interpeak latencies of A–C elicited by verbal stimuli were found to be increased in the dyslexic group in comparison with the control group (p = 0.0004 and p = 0.045, respectively). In the subgroup consisting of 10 patients suffering from ‘other learning disabilities’ and who were characterized as with ‘light’ dyslexia according to dyslexia tests, no significant delays were found in peak latencies A and C and interpeak latencies A–C in comparison with the control group.

Conclusions

Acoustic representation of a speech sound and, in particular, the disyllabic word ‘baba’ was found to be abnormal, as low as the auditory brainstem. Because ABRs mature in early life, this can help to identify subjects with acoustically based learning problems and apply early intervention, rehabilitation, and treatment. Further studies and more experience with more patients and pathological conditions such as plasticity of the auditory system, cochlear implants, hearing aids, presbycusis, or acoustic neuropathy are necessary until this type of testing is ready for clinical application.     

Current management strategy of hypopharyngeal carcinoma

Objectives

Squamous cell carcinoma (SCC) of the hypopharynx represents a distinct clinical entity among other cancers of the head and neck region. Despite recent advances in chemoradiotherapy, surgery remains the preferred therapeutic option for locally advanced disease and salvage for failure after chemo-radiotherapy. In this article, several aspects of surgical and non-surgical approaches in the management of hypopharyngeal cancer are discussed.

Methods

A search in pubmed was made for publications with regard to the management of hypopharyngeal carcinoma.

Results

In early-staged hypopharyngeal cancer, the overall and disease-specific survival rates after organ-preserving radiotherapy is comparable to that after surgery. However, for advanced staged disease, the results initial surgery with post-operative adjuvant radiotherapy was superior to chemoradiotherapy alone. The incidence of occult nodal metastasis is found to be more than 20%. Selective neck dissection removing cervical lymph node level II–IV is the procedure of choice for patients with clinically N0 neck. Contralateral nodal clearance may also be considered in tumors involving the medial wall of the pyriform recess, post-crioid region or the posterior wall, and those with ipsilateral palpable nodal metastasis and clinical stage IV disease. Transoral robotic surgery (TORS) has the potential value as the minimally invasive procedure for the management of carcinoma of the hypopharynx.

Conclusions

The treatment strategy for carcinoma of the hypopharynx has been evolving with time. Organ preserving chemoradiotherapy has been the treatment of choice for early stage disease, with surgical resection and reconstruction reserved for advanced and recurrent tumors.     

Diffuse large B-cell lymphoma of the sinonasal tract: Analysis of survival in 852 cases

Purpose

Diffuse large B-cell lymphomas (DLBCLs) are rare tumors of the head and neck that often have non-specific presentations and significant morbidity and mortality. In this analysis we use a large cohort to compare the demographic and disease-specific parameters affecting survival and incidence of DLBCLs.

Methods

The United States National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) registry was utilized to extract data regarding sinonasal diffuse large B-cell lymphoma between 1973 and 2009. A total of 852 cases of sinonasal DLBCLs were found. Presenting symptoms, demographics, disease specific survival, relative survival and survival by treatment modality were described for this rare tumor.

Results

Overall disease specific survival (DSS) at 1-year was 84.7% and at 5 years was 68.0%. DSS was significantly lower for those not treated with radiation therapy, with 1- and 5-year survival rates of 77.3% and 62.5%, versus those treated with radiation therapy, with 1- and 5-year rates of 89.2% and 71.5% (p < 0.05). Prognosis was significantly better for patients treated with radiation therapy (HR 0.6, p < 0.05) while it was poorer for patients with involvement of multiple sinuses (HR 1.5, 1.8, p < 0.05).

Conclusions

DLBCLs of the sinonasal tract are rare tumors of the head and neck. Survival is significantly improved for those treated with radiation therapy while the involvement of multiple sinuses is a negative prognostic indicator.     

Sentinel node biopsy for oral and laryngopharyngeal squamous cell carcinoma: a retrospective study of 177 patients in Japan

Objective

Sentinel node (SN) biopsy in the head and neck region has not been widely used in Japan, except at a few facilities. However, almost all these facilities perform preoperative localization and intraoperative diagnosis by frozen section analysis of SN to select patients who must undergo neck dissection in a one-stage procedure. The objective of this study was to determine the actual status of SN biopsy at those facilities in Japan that have actively conducted this procedure, and to elucidate the usefulness and drawbacks of this technique in head and neck cancer.

Methods

We retrospectively reviewed 177 patients who had undergone SN biopsy at 7 facilities. The underlying pathology was laryngeal or hypopharyngeal cancer in 20 patients from one hospital, while the remaining 157 patients had oral cancer. Preoperative localization of SN was determined using conventional lymphoscintigraphy with or without single photon emission computed tomography with CT (SPECT-CT). Intraoperative localization and diagnosis of SN were performed by gamma probe and frozen section analysis.

Results

Conventional lymphoscintigraphy detected a mean of 2.6 SNs per patient in 137 patients with oral cancer, compared to 2.7 in 71 patients using SPECT-CT and 2.9 in 154 patients using the gamma probe. No significant differences were apparent between techniques. Forty of the 520 SNs (7.7%; 33 in oral cancer and 7 in laryngeal or hypopharyngeal cancer) were pathologically positive in the final diagnosis. Of these, 3 were not processed for frozen sectioning and were diagnosed only with hematoxylin and eosin staining. Among the others, 32 (86.5%) were diagnosed intraoperatively as showing metastasis. In terms of the false-negative rate, 144 patients were determined by SN biopsy to have no positive SNs. Of these, 2 patients had non-SN metastases found in their dissected neck and 8 patients without neck dissection showed late nodal recurrence. The false-negative rate was thus 6.9%.

Conclusion

Frozen section analysis, particularly multislice sectioning, offers a relatively reliable intraoperative diagnostic method. We were able to perform immediate neck dissection based on the results of multislice sectioning as a single-stage procedure.