Benedict Panizza

Results of a prospective study of positron emission tomography–directed management of residual nodal abnormalities in node‐positive head and neck cancer after definitive radiotherapy with or without systemic therapy

The purpose of this study was to present our prospectively evaluated positron emission tomography (PET)‐directed policy for managing the neck in node‐positive head and neck squamous cell carcinoma (N+HNSCC) after definitive radiotherapy (RT) with or without concurrent systemic therapy.

DETECTING AND DEFINING THE ANATOMIC EXTENT OF LARGE NERVE PERINEURAL SPREAD OF MALIGNANCY: COMPARING TARGETED MRI WITH THE HISTOLOGIC FINDINGS FOLLOWING SURGERY

The accurate preoperative identification of the extent of perineural spread (PNS) of malignancy along a cranial nerve is vital to the design of an appropriate surgical resection. Our purpose was to determine the sensitivity of targeted MRI in predicting the presence of disease and the anatomic extent of spread when compared with histologic findings.

Anterior approaches in juvenile nasopharyngeal angiofibromas with intracranial extension

Although surgery is regarded as the mainstay of treatment for juvenile nasopharyngeal angiofibromas (JNAs), ancillary treatment modalities such as radiotherapy and on rare occasions chemotherapy are still recommended by many for intracranial extension with apparent radiologic involvement of the cavernous sinus and internal carotid artery. Further, most authors undertaking surgical excision of this subgroup of patients would recommend a lateral or combined frontal and lateral approach for its removal. In a series of 49 cases of JNA, 14 were found during surgery to have intracranial extradural extension; the anterior approach was used for their removal. Although in these cases, on radiography the cavernous sinus often looked to be invaded and the internal carotid artery was displaced superolaterally, there was no difficulty in establishing a plane of dissection. Total removal was achieved in 11 of the 14 cases with a single-stage procedure. Of the 3 cases with residual tumor, only 1 occurred intracranially. Removal was achieved by a subtemporal approach in this case. For the extracranial residual tumors 1 required a midface degloving and the other, with a 1-cm residual tumor in the nasopharynx, has been treated conservatively for 6 years with no evidence of growth. No deaths or significant complications have occurred, and radiotherapy has not been required. We conclude that JNAs are tumors with a predilection for spread but that rarely invade dura, acting instead to displace it. We believe that surgery is the method of choice for treating these lesions and that an anterior surgical approach with microsurgical techniques should be used in the first instance. In the last 2 cases we preferred a midface degloving technique to avoid facial scarring and because this approach allows a widening of the surgical field if needed by the performance of bilateral maxillary free bone flaps. On the rare occasion that a lateral approach, with its attendant permanent conductive hearing loss, is found to be necessary for total tumor removal, this can be done as a staged procedure. This may be necessary when the tumor has spread lateral to the horizontal internal carotid artery.

Surgical resection for clinical perineural invasion from cutaneous squamous cell carcinoma of the head and neck

Perineural invasion (PNI) in cutaneous squamous cell carcinoma of the head and neck (SCCHN) is associated with decreased survival. Patients with large nerve or clinical PNI present with clinical signs and symptoms or MRI evidence of cranial nerve involvement. These patients often succumb to disease that spreads into the brainstem. In our experience, when the disease extends up to the Gasserian or Geniculate ganglion, surgical resection with negative margins provides the best chance for cure. Herein we review our experience to validate our clinical observations.

Sphenoid Sinus Fungal Balls

Objectives: We sought to examine the nature of fungal balls of the sphenoid sinus, in particular the exposure of adjacent skull base structures and the potential for surgical morbidity. Methods: We retrospectively reviewed our series of 17 cases of sphenoid sinus fungal balls seen between 1998 and 2005 with reference to their diagnosis, radiologic changes, histopathology, and surgical management. Results: Exposed structures included the pituitary fossa, cavernous sinus, and cavernous internal carotid artery, but this exposure did not result in an increase in perioperative complications. Sclerotic thickening of the sinus walls persisted, probably representing a chronic osteitis in response to concurrent bacterial infection. This appeared to be protective against further sinus wall erosions. Wall erosions did not heal. One patient demonstrated what appeared to be invasive fungal disease from a fungal ball. Conclusions: Sphenoid sinus fungal balls can occur with minimal symptoms in a mainly elderly population and require surgical removal. Sphenoid sinus fungal balls have a low rate of operative morbidity and should be effectively managed by transnasal endoscopic sphenoidotomy alone.

Vestibular schwannoma: an understanding of growth should influence management decisions.

Background Treatments for vestibular schwannomas include surgical removal and radiotherapy. Observation is a reasonable alternative, given the slow growth of these tumors. The goal of this study was to determine the 5-year no-growth rate in patients managed initially by observation in attempts to define indications for treatment. Study Design Retrospective chart analysis of prospectively collected patient database. Methods Patients with unilateral vestibular schwannomas who presented in the last 10 years were reviewed. Those managed initially by observation were reviewed. At least 2 consecutive imaging studies were required. The following information was recorded from the charts: age, sex, tumor size at presentation and subsequent follow-up sessions, treatment in the event of growth, and time interval between presentation and last imaging available. The institutional ethics committee approved the study. Results One hundred ten patients were included. There were 65 male patients and 45 female patients. The mean age was 62.4 years (range, 32-91 yr). The mean follow-up was 31.4 months (range, 6-156 mo). Twenty-three patients demonstrated evidence of growth, with an overall 5-year no-growth rate of 70.6%. Despite growth, the 5-year no-intervention rate was 81.3%. Interestingly, 11 patients (10%) demonstrated tumor regression. Patients with intracanalicular tumors had a 5-year no-growth rate of 89.8% compared with 73.9% and 45.2% for Grade I and Grade II or larger tumors, respectively. The difference between intracanalicular and Grade II or larger tumors was statistically significant (p = 0.0196). Conclusion Our data suggest that treatment can be delayed in a large proportion of vestibular schwannoma patients and that this is particularly true in patients with small tumors. Despite growth, only a small percentage of patients require intervention. Thus, we recommend a period of observation to determine the need for treatment in patients without indications for urgent intervention.

Balance, mobility and gaze stability deficits remain following surgical removal of vestibular schwannoma (acoustic neuroma): an observational study.

QUESTION Are there residual deficits in balance, mobility, and gaze stability after surgical removal of vestibular schwannoma? DESIGN Observational study. PARTICIPANTS Twelve people with a mean age of 52 years who had undergone surgical removal of vestibular schwannoma at least three months previously and had not undergone vestibular rehabilitation. Twelve age- and gender-matched healthy people who acted as controls. OUTCOME MEASURES Handicap due to dizziness, balance, mobility, and gaze stability was measured. RESULTS Handicap due to dizziness was moderate for the clinical group. They swayed significantly more than the controls in comfortable stance: firm surface eyes open and visual conflict (p < 0.05); foam surface eyes closed (p < 0.05) and visual conflict (p < 0.05); and feet together: firm surface, eyes closed (p < 0.05), foam surface, eyes open (p < 0.05) and eyes closed (p < 0.01). They displayed a higher rate of failure for timed stance and gaze stability (p < 0.05) than the controls. Step Test (p < 0.01), Tandem Walk Test (p < 0.05) and Dynamic Gait Index (p < 0.01) scores were also significantly reduced compared with controls. There was a significant correlation between handicap due to dizziness and the inability to maintain balance in single limb and tandem stance (r = 0.68, p = 0.02) and the ability to maintain gaze stability during passive head movement (r = 0.78; p = 0.02). CONCLUSION A prospective study is required to evaluate vestibular rehabilitation to ameliorate dizziness and to improve balance, mobility, and gaze stability for this clinical group.

Perineural Invasion of Head and Neck Skin Cancer: Diagnostic and Therapeutic Implications

Perineural invasion of head and neck skin cancer is a poorly understood and often misdiagnosed pathological entity. Incidental or microscopic perineural invasion is identified by the pathologist and often leads to confusion as to how the patient should be further treated. The less common but more aggressive clinical perineural spread presents with a clinical deficit, which is too commonly misinterpreted by the clinician. This review will try to clarify the terminology that exists in the literature and explore the mechanisms of invasion and spread. It will look at the recent advances in diagnosis and comment on the limitations inherent in current classification schemes. A review of outcomes will be included and current treatment strategies utilized discussed.

Access to the parapharyngeal space: an anatomical study comparing the endoscopic and open approaches.

A subtemporal preauricular approach to the infratemporal fossa and parapharyngeal space has been the traditional path to tumors of this region. The morbidity associated with this procedure has lead to the pursuit of less invasive techniques. Endoscopic access using a minimally invasive transmaxillary/transpterygoid approach potentially may obviate the drawbacks associated with open surgery. The anatomy of the parapharyngeal space is complex and critical; therefore, a comparison of the anatomy exposed by these different approaches could aid in the decision making toward a minimally invasive surgical corridor.

Outcomes after surgery and postoperative radiotherapy for perineural spread of head and neck cutaneous squamous cell carcinoma

Queensland, Australia, has the highest rates of cutaneous squamous cell carcinoma (SCC). Perineural invasion (PNI) is associated with reduced local control and survival.