Ben Green

Photodynamic therapy in the management of lesions of the head and neck

Photodynamic therapy (PDT) is a promising and effective treatment for lesions of the head and neck. It uses illumination with light of a specific wavelength, which activates a photosensitising drug in the presence of oxygen. It can be used in combination with other treatments or on its own, and results in the cellular destruction of the lesion through a free-radical process. Photosensitisers can be applied topically or given systemically depending on the lesion being treated. Results indicate that PDT is an effective adjunct to standard conventional treatments. We review its use.

Optical diagnostic techniques for use in lesions of the head and neck: review of the latest developments

Optical biopsy systems are a potential adjunct to the histopathological assessment of tissue specimens; they are not invasive and can give an immediate result. We review the most common optical biopsy techniques used to detect lesions of the head and neck: elastic scattering spectroscopy, microendoscopy, narrow band imaging, fluorescence, and optical coherence tomography, and discuss their clinical use.

The surgical management of Treacher Collins syndrome.

Treacher Collins syndrome (TCS), mandibulofacial dysostosis, or Franceschetti-Zwahlen-Klein syndrome, is a rare genetic disorder characterised by dysgenesis of the hard and soft tissues of the first and second branchial arches. Early operations focus on maintaining the airway, protecting the eyes, and supporting auditory neurological development. Later operations include staged reconstruction of the mouth, face, and external ear. Bimaxillary surgery can improve the maxillomandibular facial projection, but correction of malar, orbital rim, and temporal defects may be more difficult. We present a clinical review of the syndrome with a chronological approach to the operations.

The Management of Midline Frontonasal Dermoids: A Review of 55 Cases at a Tertiary Referral Center and a Protocol for Treatment

Background: The incidence of midline frontonasal dermoid cysts is one in 20,000 to one in 40,000. These lesions may have intracranial extension. This is explained by the anatomy and embryology of nasofrontal development. Skin involvement may also be extensive. Incomplete excision frequently leads to recurrence. The authors report their experience and pathway for management of midline dermoids. Methods: Databases were searched to identify patients who had undergone surgery for removal of a dermoid cyst. Preoperative imaging and indications for surgery were reviewed. Cases were grouped according to surgical approach, and outcomes and complications were identified. Results: Fifty-five patients were treated. Magnetic resonance imaging or computed tomography was used to delineate the anatomy, and surgical excision was expedited if there was a history of infection, especially if imaging suggested intracranial extension. Twelve patients were treated endoscopically (one was converted to open). Eleven required transcranial approaches for intracranial extension (20 percent). Of these, one lesion breached the dura. The remaining 32 patients had dermoids excised with an open approach (direct, bicoronal, or rhinoplasty). There were no recurrences in the open group and there was one recurrence in the transcranial group. This was treated by reexcision. Conclusion: Midline dermoid cysts are relatively uncommon. However, knowledge of the pathogenesis of these lesions together with the authors’ experience over 15 years has allowed them to develop a protocol-driven approach, with a low incidence of complications. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Current surgical management of metastases in the neck from mucosal squamous cell carcinoma of the head and neck.

Neck dissection, which is an important method of treatment for metastases from mucosal (and other) squamous cell carcinomas (SCC) of the head and neck, is also useful for staging disease. Since its inception it has changed from a radical to a more conservative procedure, and vital structures are preserved wherever possible. Refinements in methods of imaging to assess involvement in the neck have encouraged alternative approaches that can improve outcomes and reduce morbidity. We look at the reported evidence for the surgical management of metastases in the neck from mucosal SCC.

Craniofacial disorders that have phenotypic overlap with Treacher Collins syndrome

The mandibulofacial dysostoses are congenital disorders that result in abnormalities of the first and second pharyngeal arches. The most well known mandibulofacial dysostosis is Treacher-Collins syndrome (TCS) a disorder of craniofacial morphogenesis (Table 1). TCS is the result of mutations in the gene that encodes the protein Treacle which is needed for neural crest stability. Animal models have postulated that extensive neuroepithelial apoptosis could explain the skeletal and soft tissue deformities seen in TCS. Mandibulofacial Dysostosis with Microcephaly (MFDM) also results in the same craniofacial presentation as TCS but with bilateral zygomatic arch clefting, microcephaly, developmental delay, sensorineural hearing loss, cleft palate, choanal atresia (Table 2). In contrast, the neurocranium in TCS has been found to have normal dimensions in length, height and volume but an abnormal shape. These features identified in MFDM have been reported in the literature in patients diagnosed with TCS but have been genetically tested for Treacle mutations and found to be negative. Nager and Miller syndromes are conditions that also have facial phenotypic overlap with TCS but present

Malignant cutaneous adnexal tumours of the head and neck: an update on management

Adnexal tumours form a heterogeneous group of relatively rare neoplasms. Many of them have a poor prognosis and treatment can sometimes be difficult and controversial. We summarise the latest publications relating to malignant cutaneous adnexal tumours of the head and neck, and give an update on their management. We discuss Merkel cell carcinoma and other rare malignant adnexal tumours including dermatofibrosarcoma protuberans and atypical fibroxanthoma.

Re: The metastatic potential of head and neck cutaneous malignant melanoma: is sentinel node biopsy useful?

Most of the points raised by Main et al1 are salient, but two of them must be questioned. First is the controversy about sentinel lymph node biopsy (SLNB). The essential principle of the procedure is to provide patients with information on prognosis, which they generally find useful, and it is considered the most accurate test to achieve this. Early identification and removal of affected lymph node basins can control local disease and help patients psychologically.2 Most patients (95/98) were glad that they had had the procedure and 89 thought that it had been beneficial. Secondly, the authors argued against its routine use despite recent publication of the results of a trial comparing SLNB with nodal observation, which showed that mean survival in patients with intermediate-thickness and thick melanomas was significantly better (<0.001) in the SLNB group than in the observed group. This suggests that SLNB prolongs diseasefree survival and melanoma-specific survival particularly in patients with confirmed nodal disease.3 The authors are right to question the benefit and the cost of such interventions, but there is no question about the value of accurate prognostic tests for example, when the true depth of a melanoma is not known, the result of SLNB can be the only prognostic information available. In terms of a learning curve, we also agree that such techniques should not be offered in all centres. In particular, it is true that the disease may differ when melanoma occurs in other parts of the body or is a different subtype. Therefore, we agree that to obtain valid results from the test, only trained doctors should be involved in lymphoscintigraphy, harvesting of nodes, dermatopathological analysis, and review by the multidisciplinary team. SLNB is a test that depends on multidisciplinary support and should be offered only in centres where the results can be audited and peer reviewed, or where it is done as part of a trial. It does have a place in the prognosis of patients with malignant melanoma, and they have the right to be fully informed about the tests that are available and where they can be done. Conflict of Interest