Barton F. Branstetter

The changing face of malignant (necrotising) external otitis: clinical, radiological, and anatomic correlations

Malignant (necrotising) external otitis is an invasive infection of the external auditory canal. Although elderly patients with diabetes remain the population most commonly affected, immunosuppressed individuals (eg, from HIV infection, chemotherapy, etc) are also susceptible to malignant external otitis. Pseudomonas aeruginosa is isolated from the aural drainage in more than 90% of cases. The pathophysiology is incompletely understood although aural water exposure (eg, irrigation for cerumen impaction) has been reported as a potential iatrogenic factor. The typical patient presents with exquisitely painful otorrhoea. If untreated, cranial neuropathies (most commonly of the facial nerve) can develop due to subtemporal extension of the infection. The diagnosis of malignant external otitis is based on a combination of clinical findings, an increased erythrocyte sedimentation rate, and radiographic evidence of soft tissue with or without bone erosion in the external canal and infratemporal fossa. Treatment consists of prolonged administration (6-8 weeks) of an antipseudomonal agent (typically an orally administered quinolone). With the introduction and widespread use of both oral and topical quinolones, there are reports of less severe presentation of malignant external otitis and even the emergence of ciprofloxacin resistance. Reservation of systemic quinolones for the treatment of invasive ear infections is recommended.

Stereotactic Body Radiotherapy for Recurrent Squamous Cell Carcinoma of the Head and Neck: Results of a Phase I Dose-Escalation Trial

PURPOSE To evaluate the safety and efficacy of stereotactic body radiotherapy (SBRT) in previously irradiated patients with squamous cell carcinoma of the head and neck (SCCHN). PATIENTS AND METHODS In this Phase I dose-escalation clinical trial, 25 patients were treated in five dose tiers up to 44 Gy, administered in 5 fractions over a 2-week course. Response was assessed according to the Response Evaluation Criteria in Solid Tumors and [(18)F]-fluorodeoxyglucose standardized uptake value change on positron emission tomography-computed tomography (PET-CT). RESULTS No Grade 3/4 or dose-limiting toxicities occurred. Four patients had Grade 1/2 acute toxicities. Four objective responses were observed, for a response rate of 17% (95% confidence interval 2%-33%). The maximum duration of response was 4 months. Twelve patients had stable disease. Median time to disease progression was 4 months, and median overall survival was 6 months. Self-reported quality of life was not significantly affected by treatment. Fluorodeoxyglucose PET was a more sensitive early-measure response to treatment than CT volume changes. CONCLUSION Reirradiation up to 44 Gy using SBRT is well tolerated in the acute setting and warrants further evaluation in combination with conventional and targeted therapies.

Induction Docetaxel, Cisplatin, and Cetuximab Followed by Concurrent Radiotherapy, Cisplatin, and Cetuximab and Maintenance Cetuximab in Patients With Locally Advanced Head and Neck Cancer

PURPOSE We incorporated cetuximab, a chimeric monoclonal antibody against the epidermal growth factor receptor (EGFR), into the induction therapy and subsequent chemoradiotherapy of head and neck cancer (HNC). PATIENTS AND METHODS Patients with locally advanced HNC, including squamous and undifferentiated histologies, were treated with docetaxel 75 mg/m2 day 1, cisplatin 75 mg/m2 day 1, and cetuximab 250 mg/m2 days 1, 8, and 15 (after an initial loading dose of 400 mg/m2), termed TPE, repeated every 21 days for three cycles, followed by radiotherapy with concurrent cisplatin 30 mg/m2 and cetuximab weekly (XPE), and maintenance cetuximab for 6 months. Quality of life (QOL) was assessed using Functional Assessment of Cancer Therapy-Head and Neck. In situ hybridization (ISH) for human papillomavirus (HPV), immunohistochemistry for p16, and fluorescence ISH for EGFR gene copy number were performed on tissue microarrays. RESULTS Of 39 enrolled patients, 36 had stage IV disease and 23 an oropharyngeal primary. Acute toxicities during TPE included neutropenic fever (10%) and during XPE, grade 3 or 4 oral mucositis (54%) and hypomagnesemia (39%). With a median follow-up of 36 months, 3-year progression-free survival and overall survival were 70% and 74%, respectively. Eight patients progressed in locoregional sites, three in distant, and one in both. HPV positivity was not associated with treatment efficacy. No progression-free patient remained G-tube dependent. The H&N subscale QOL scores showed a significant decrement at 3 months after XPE, which normalized at 1 year. CONCLUSION This cetuximab-containing regimen resulted in excellent long-term survival and safety, and warrants further evaluation in both HPV-positive and -negative HNC.

Deferring Planned Neck Dissection Following Chemoradiation for Stage IV Head and Neck Cancer: The Utility of PET-CT†

Objective: To determine whether combined positron emission tomography and computed tomography (PET‐CT) may be of value in deferring planned neck dissections for patients with advanced head and neck squamous cell carcinoma (HNSCC).

Phase II Trial of Pemetrexed and Bevacizumab in Patients With Recurrent or Metastatic Head and Neck Cancer

PURPOSE We hypothesized that bevacizumab, a monoclonal antibody against vascular endothelial growth factor (VEGF), will potentiate the activity of pemetrexed, a multitargeted antifolate, in squamous cell carcinoma of the head and neck (SCCHN). PATIENTS AND METHODS Patients with previously untreated, recurrent, or metastatic SCCHN were treated with pemetrexed 500 mg/m(2) and bevacizumab 15 mg/kg given intravenously every 21 days with folic acid and B(12) supplementation until disease progression. Primary end point was time-to-progression (TTP). DNA was isolated from whole blood samples for the detection of polymorphisms in thymidylate synthase, methylenetetrahydrofolate reductase (MTHFR), and VEGF. RESULTS Forty patients were enrolled. The median TTP was 5 months, and the median overall survival (OS) was 11.3 months. In 37 evaluable patients, the overall response rate was 30%, including a complete response rate of 5%, and the disease control rate was 86%. Grade 3 to 5 bleeding events occurred in six patients (15%): four were grade 3, and two were fatal. Other serious toxicities in 10% or more of patients included neutropenia (10%) and infection (12.5%). One patient died of sepsis after receiving eight cycles of therapy. For the MTHFR A1298C (rs1801131) single nucleotide polymorphisms, homozygote patients with AA had worse OS (P = .034). CONCLUSION The addition of bevacizumab to pemetrexed resulted in promising efficacy outcomes in SCCHN. Bleeding events were frequent but some may have been due to natural history of disease. Polymorphisms in MTHFR may offer potential for treatment individualization.

Appearance of Normal Cranial Nerves on Steady-State Free Precession MR Images

As radiologic imaging technology improves and more intricate details of the anatomy can be evaluated, images provide more precise diagnostic information and allow better localization of abnormalities. For example, standard T2-weighted magnetic resonance (MR) imaging sequences adequately depicted only the larger cranial nerves, whereas current steady-state free precession (SSFP) sequences are capable of depicting the cisternal segments of all 12 cranial nerves. SSFP sequences provide submillimetric spatial resolution and high contrast resolution between cerebrospinal fluid and solid structures, allowing the reconstruction of elegant multiplanar images that highlight the course of each nerve. These sequences have become a mainstay in the evaluation of the cerebellopontine angles and inner ear. Usually referred to by their trade names or acronyms (eg, constructive interference steady state, or CISS, and fast imaging employing steady-state acquisition, or FIESTA), SSFP sequences allow precise differentiation between branches of the facial and vestibulocochlear nerves, accurate detection of small masses in the cerebellopontine angles and internal auditory canals, and detailed evaluation of endolymph and perilymph within the inner ear. To take full advantage of these imaging sequences, radiologists must be familiar with the appearances of similar anatomic details of all 12 cranial nerves on SSFP MR images.

Current use of 18F-fluorodeoxyglucose positron emission tomography and combined positron emission tomography and computed tomography in squamous cell carcinoma of the head and neck.

The history and physical examination, computed tomography (CT) and magnetic resonance imaging are the cornerstones for identifying new and recurrent cancers of the head and neck. The advent of positron emission tomography (PET) and combined PET/CT imaging technology is a promising development. These modalities have the potential to help stage patients presenting with head and neck cancer, identify responses to nonsurgical therapy, and allow earlier detection of recurrence in the hope of improving survival. The following paper provides a brief history of PET and PET/CT imaging. The current PET and PET/CT literature for squamous cell carcinoma of the head and neck is reviewed, and specific recommendations for its use are provided.

Vidian canal: analysis and relationship to the internal carotid artery.

Objectives: The purpose of this study is to describe the anatomy and relationships of the vidian canal to known endonasal and skull base landmarks. This will allow the endoscopic skull base surgeon to safely approach the anterior genu of the petrous carotid artery during expanded endonasal approaches to the skull base.

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.

Frequency of a dental source for acute maxillary sinusitis

To identify radiographic features of odontogenic acute maxillary sinusitis and to determine the frequency of a causative dental infection in patients with radiographic evidence of maxillary sinus fluid.