Jens Pfeiffer

Descending necrotizing mediastinitis: contemporary trends in etiology, diagnosis, management, and outcome.

Objective:To evaluate contemporary trends in etiology, diagnosis, management, and outcome of descending necrotizing mediastinitis (DNM) and to draw the clinicians attention on this probably underappreciated disease. Summary of Background Data:An uncommon but one of the most serious forms of mediastinitis is DNM which is caused by downward spread of deep neck infections and arises as a major complication of “banal” odontogenic, pharyngeal, or cervicofacial foci. As most studies are based on small patient populations, current data on risk factors, etiology, and outcome vary significantly. Also, the optimal form of treatment remains controversial. Methods:This retrospective study, which is the largest single-center study since 1960, is based on the management of 45 patients with DNM treated over a period of 12 years. Additionally, a meta-analysis of 26 studies on DNM published between 1999 and 2008 was performed and compared with own data and 2 previous meta-analyses covering the interval from 1960 to 1998. Results and Conclusions:Today DNM most commonly arises from pharyngeal foci and mixed polymicrobial aerobic and anaerobic infections. Reduced tissue oxygenation and impaired immune function promotes its development. Most cases of DNM are limited to the upper mediastinum and can be adequately drained by a transcervical approach. Formal thoracotomy should be reserved for cases extending below the plane of the tracheal bifurcation. Although DNM remains an aggressive infection with high morbidity, a favorable outcome can now be obtained in 85% of patients, even with this selective approach. Early diagnosis and surgical intervention are crucial.

Severe deep neck space infections and mediastinitis of odontogenic origin: clinical relevance and implications for diagnosis and treatment.

Conclusions. Early diagnosis and aggressive antimicrobial and surgical treatment are essential to successfully treat extensive cervico-mediastinal abscesses of odontogenic origin. Patient management should be performed by experienced clinicians well trained in managing possible complications. We recommend close clinical and radiological postoperative follow-up investigations with early surgical re-intervention if necessary. Objectives. While neck infections affecting the perimandibular space have a high prevalence and their clinical aspects have repeatedly been discussed, further spread of the inflammation and life-threatening situations have rarely been described. The objective was to determine clinical, diagnostic, and therapeutic aspects of severe neck infections of odontogenic origin. Emphasis was placed on grave descending deep neck space infections, sometimes resulting in mediastinitis as a life-threatening complication. Patients and methods. We reviewed 10 patients with severe odontogenic abscesses treated during an 8-year interval in a single center. Results: The submandibular space was the most frequently encountered location of deep neck space infections. Mediastinitis was found in five patients. The most frequent causative bacteria were Streptococcus and Bacteroides species. All patients underwent intravenous antibiotic treatment and surgical therapy. Mediastinotomy was inevitable in five cases and thoracotomy in one case. All patients survived.

ULTRASOUND-GUIDED CORE-NEEDLE BIOPSY IN THE DIAGNOSIS OF HEAD AND NECK MASSES: INDICATIONS, TECHNIQUE, AND RESULTS

Unclear cervicofacial masses are common presentations that often require tissue sampling to guide therapy. While open biopsy is invasive, fine‐needle aspiration cytology includes a high rate of nondiagnostic samples.

Serial [18F]-fluoromisonidazole PET during radiochemotherapy for locally advanced head and neck cancer and its correlation with outcome.

PURPOSEnThe aim was to assess changes of tumour hypoxia during primary radiochemotherapy (RCT) for head and neck cancer (HNC) and to evaluate their relationship with treatment outcome.nnnMATERIAL AND METHODSnHypoxia was assessed by FMISO-PET in weeks 0, 2 and 5 of RCT. The tumour volume (TV) was determined using FDG-PET/MRI/CT co-registered images. The level of hypoxia was quantified on FMISO-PET as TBRmax (SUVmaxTV/SUVmean background). The hypoxic subvolume (HSV) was defined as TV that showed FMISO uptake ⩾1.4 times blood pool activity.nnnRESULTSnSixteen consecutive patients (T3-4, N+, M0) were included (mean follow-up 31, median 44months). Mean TBRmax decreased significantly (p<0.05) from 1.94 to 1.57 (week 2) and 1.27 (week 5). Mean HSV in week 2 and week 5 (HSV2=5.8ml, HSV3=0.3ml) were significantly (p<0.05) smaller than at baseline (HSV1=15.8ml). Kaplan-Meier plots of local recurrence free survival stratified at the median TBRmax showed superior local control for less hypoxic tumours, the difference being significant at baseline and after 2weeks (p=0.031, p=0.016).nnnCONCLUSIONSnFMISO-PET documented that in most HNC reoxygenation starts early during RCT and is correlated with better outcome.

Solitary Fibrous Tumors in the Head and Neck: New Insights and Implications for Diagnosis and Treatment

Objectives: The solitary fibrous tumor (SFT) is a potentially malignant spindle cell neoplasm of mesenchymal origin that was originally described as a thoracic lesion originating from pleural tissue. Recently, numerous extrapleural sites of origin have been described, frequently affecting the head and neck region. The purpose of this article is to focus on a formerly underestimated neoplasm and to highlight its appearance in the head and neck region. Methods: The authors present 2 illustrative cases, including what is probably the first reported case of an SFT arising in the human tonsillar fossa, and give a clinical and pathological literature review. Results: The clinical, histologic, and radiologic features are presented, and the surgical treatment is described. The international medical literature concerning SFTs in general and SFTs of the head and neck in particular is reviewed, and the changing concept of SFTs and hemangiopericytomas is discussed on the basis of the updated World Health Organization classification of soft tissue tumors. Conclusions: It is nowadays recognized that the large majority of lesions formerly classified as hemangiopericytomas are, in fact, variants of SFTs. Although still a rare occurrence, SFTs have become increasingly recognized, and clinicians should be aware of their presentation.

PRIMARY EWING SARCOMA OF THE PETROUS TEMPORAL BONE: AN EXCEPTIONAL CAUSE OF FACIAL PALSY AND DEAFNESS IN A NURSLING

Primary Ewing sarcoma affecting the skull base in general and the petrous bone in particular is extremely rare with only 4 reports of Ewing sarcoma arising in the petrous temporal bone in the international medical literature.

Radiation-induced leiomyosarcoma of the oropharynx

Leiomyosarcoma is a malignant mesenchymal tumor originating from smooth muscle cells, which most frequently develops in the myometrium and in the gastro-intestinal tract. Reviewing the international literature, radiation-induced sarcoma arise in 0.035 to 0.2 % of all irradiated patients. Especially in the head and neck region, radiation-induced leiomyosarcoma is an extremely rare lesion. The authors report a case of a radiation-induced leiomyosarcoma of the tonsillar region of the oropharynx in a 51-year-old male patient, who had undergone radiation therapy of this region 38 years before. The lesion was treated by radical surgery. Diagnostic steps, histological presentation and therapy are described in detail and the literature concerning radiation induced malignancies in general as well as radiation induced leiomyosarcoma in particular is reviewed. The highlights of this case are an extremely uncommon location and a rare pathological entity of radiation induced malignancies.

Head and neck cancer in young adults and nonsmokers: Study of cancer susceptibility by genome-wide high-density SNP microarray mapping

Abstract Conclusion. Our results raise the question as to whether specific patterns of ‘germline loss of heterozygosity (LOH)’ could contribute to the genetic susceptibility for head and neck squamous cell carcinoma (HNSCC). Objectives. HNSCC usually occurs in older individuals with a history of smoking. However, about 5% of HNSCC patients have never used tobacco or develop this disease at an exceptionally young age. Therefore, genetic susceptibility must contribute significantly to HNSCC risk. The objective was to introduce a novel approach that might help to unveil candidate genes contributing to cancer predisposition and to identify individuals at risk for HNSCC, and to present our observations with this method in a specific group of patients. Methods: High-resolution SNP (single-nucleotide polymorphism) microarray mapping for homozygous stretches in germline DNA was performed in 12 patients who appeared particularly susceptible to develop HNSCC, because they were exceptionally young or never users of tobacco. Results: We could identify strings of consecutive homozygous SNPs that were much longer than would be expected to appear by chance alone, indicating regions of DNA deletions that we named germline LOH.

Malignant peripheral nerve sheath tumour of the paranasal sinuses and the anterior skull base

BACKGROUNDnMalignant peripheral nerve sheath tumours (MPNSTs) are highly aggressive neoplasms with a marked propensity for local recurrence and metastatic spread. The management of MPNSTs continues to challenge pathologists and surgeons. As MPNSTs of the paranasal sinuses and the skull base are rare, prognostic factors and treatment modalities have not been consistently identified.nnnPATIENTS AND METHODSnWe present a case of MPNST of the anterior skull base and provide an overview of all MPNSTs reported since 1970, in which the tumour location was the anterior skull base or the paranasal sinuses.nnnRESULTSnLiterature review revealed 33 well-documented cases of MPNSTs in this anatomic location. These cases were analysed with emphasis on age, gender, affected site, therapy, outcome, presence of neurofibromatosis, local recurrence and metastases.nnnCONCLUSIONSnDespite multimodal therapy and advances in surgical techniques, the prognosis of MPNST located in the paranasal sinuses and the anterior skull base remains dismal. Outcome is mainly a function of local control by surgical resection. Adjuvant radiochemotherapy has shown no benefit. It may therefore be advisable to abstain from radiochemotherapy in order to improve chances for surgical intervention in case of recurrent disease. Close follow-up investigations are indispensable.

An elderly woman with increasing dyspnoea after a fall.

An otherwise healthy 92-year-old woman was admitted to our department with shortness of breath and dysphagia 10 h after a fall in her bathroom. Medical checkup at another institution had not uncovered the causation of the complaints. Clinical and radiological examinations at our department then revealed an expanding retropharyngeal and prevertebral haematoma. Because of increasing dyspnoea, a lateral cervical approach was used to remove the haematoma and to achieve haemostasis. The authors could demonstrate that the source of bleeding was a minor injury of the anterior longitudinal ligament. Retropharyngeal haematoma is a potentially life-threatening condition because it can rapidly progress to airway obstruction. Large retropharyngeal haematoma after minor blunt head and neck trauma is not a well-recognised condition. This case, however, illustrates that precarious retropharyngeal haematoma can occur after low-energy trauma even without anticoagulation therapy. A high index of suspicion for this airway collapse is advisable in older patients.