Paul D. Righi

Comparison of ultrasound-fine needle aspiration and computed tomography in patients undergoing elective neck dissection

Ultrasound of the neck with fine needle aspiration (US‐FNA) of suspicious lymph nodes has potential advantages over other radiologic techniques as a screening method for the N0 neck in head and neck cancer.

The Value of Ultrasound With Ultrasound-Guided Fine-Needle Aspiration Biopsy Compared to Computed Tomography in the Detection of Regional Metastases in the Clinically Negative Neck

PURPOSE Head and neck oncologists have not reached consensus regarding the role of contemporary imaging techniques in the evaluation of the clinically negative neck in patients with head and neck squamous cell carcinoma (HNSCC). The purpose of the present study was to compare the accuracy of ultrasound with guided fine-needle aspiration biopsy (UGFNAB) and computed tomography (CT) in detecting lymph node metastasis in the clinically negative neck. METHODS AND MATERIALS Sixty-four neck sides of patients with HNSCC were examined preoperatively by ultrasound/UGFNAB and CT at one of five participating tertiary care medical centers. The findings were correlated with the results of histopathologic examination of the neck specimen. RESULTS Ultrasound with guided fine-needle aspiration biopsy was characterized by a sensitivity of 48%, specificity of 100%, and overall accuracy of 79%. Three cases had nondiagnostic aspirations using UGFNAB and were excluded. CT demonstrated a sensitivity of 54%, specificity of 92%, and overall accuracy of 77%. UGFNAB detected two additional metastases not visualized on CT, whereas CT detected no metastases not seen on UGFNAB. The results of UGFNAB were similar between the participating centers. CONCLUSIONS Approximately one half of the clinically occult nodal metastases in our patient group were identified by both CT and UGFNAB. Overall, UGFNAB and CT demonstrated comparable accuracy. The sensitivity of CT was slightly better than UGFNAB, but the latter remained characterized by a superior specificity. The results of CT and UGFNAB did not appear to be supplementary. The choice of imaging modality for staging of the clinically negative neck depends on tumor site, T-stage, and experience and preference of the head and neck oncologist. If CT is required for staging of the primary tumor, additional staging of the neck by UGFNAB does not provide significant additional value.

Sinonasal undifferentiated carcinoma: A 10-year experience

PURPOSE Sinonasal undifferentiated carcinoma (SNUC) is a rare and aggressive malignancy of the paranasal sinuses and nasal cavity. Of the few reported series, most indicate a dismal prognosis. In this report, the clinical presentation, histopathologic criteria used for diagnosis, mode of treatment, and outcome are evaluated in seven patients with SNUC. MATERIALS AND METHODS Seven patients with SNUC treated at the University of Cincinnati between 1983 and 1993 were analyzed retrospectively. RESULTS Most of the patients presented with extensive local disease, and two patients also had cervical metastases. All except one were treated using a multimodality approach. Four of the seven patients died of disease (DOD), with a mean survival of only 11.5 months following treatment. Inability to eradicate local disease was responsible for treatment failure in all cases. Three patients have achieved short-term control of disease following combined therapy, but one is at high risk for recurrence. CONCLUSION SNUC was associated with an overall poor prognosis in our series despite aggressive treatment. Control of local disease was the central therapeutic consideration. Intensive multimodality therapy is recommended for all patients with SNUC.

Zenker's diverticulum: Analysis of surgical complications from diverticulectomy and cricopharyngeal myotomy

Objective: To identify risk factors for postoperative complications in patients undergoing diverticulectomy and cricopharyngeal (CP) myotomy for Zenkers diverticulum. Study Design: Retrospective. Materials and Methods: A chart review was conducted of all patients with a Zenkers diverticulum who were treated with diverticulectomy and cricopharyngeal myotomy at three tertiary care centers in central Indiana between 1988 and 1998. Results: Of the 24 patients identified, 9 developed postoperative complications (2 medical and 7 surgical). Statistical analysis of multiple potential risk factors revealed that only diverticulum size greater than 10 cm2 at surgery placed the patient at increased risk for postoperative surgical complications. To our knowledge, this is the first report that has specifically addressed diverticulum size as an independent risk factor for postoperative surgical complications following diverticulectomy and CP myotomy. Conclusions: Given our findings, we recommend considering diverticulopexy rather than diverticulectomy in a patient with a Zenkers diverticulum greater than 10 cm2 in size if a cervical approach is the selected treatment. Key Words: Zenkers diverticulum, cricopharyngeal myotomy, surgical complications, diverticulectomy.

Radiologic percutaneous gastrostomy: Results in 56 patients with head and neck cancer†

Objective: The establishment of a direct enteral feeding route is critical in the overall treatment of many patients with head and neck cancer. Use of radiologic percutaneous gastrostomy (RPG), the newest technique for gaining enteral access, has not been studied in such patients extensively. This study evaluated the indications, technique, success rate, and complications associated with RPG in patients with head and neck cancer. Study Design: Retrospective. Methods: A comprehensive chart review was undertaken of 56 patients with head and neck cancer treated at a tertiary care institution who had undergone successful or attempted RPG at some point during their treatment course. Results: Most study patients had advanced oropharyngeal squamous cell carcinoma. The most frequent indications for RPG were dysphagia/aspiration following tumor resection (n = 26) and dysphagia following completion of single‐ or combined‐modality therapy (n = 22). The success rate of attempted RPGs was 98.2%. The overall complication rate for RPG was 12.7% (10.9% minor and 1.8% major). Conclusions: RPG is a valuable tool for establishing enteral nutrition in patients with head and neck cancer. Advantages of RPG include high success rate despite obstructing lesions, low complication rate, time efficiency and scheduling ease compared with intraoperative percutaneous gastrostomy (PEG) by a second team, no reported tumor seeding of the tube site, and the fact that postoperative RPG allows for more accurate selection of patients who require a gastrostomy tube.

Predictive Factors for Functional Recovery after Free Tissue Transfer Oromandibular Reconstruction

BACKGROUND Recovery of upper aerodigestive tract function after reconstruction of segmental oromandiblectomy defects is frequently incomplete. The purpose of this study was to quantitate postreconstruction function and define variables that predict functional outcome in this population. METHODS A prospective study of 21 patients who underwent microvascular free tissue transfer reconstruction of segmental oromandibular defects was performed. Measures of swallowing, speech, bite, and oral intake were performed preoperatively and at 1, 3, 6, and 12 months postoperatively or until plateau. Preoperative versus maximal postoperative measures were compared and correlated with nine potentially predictive variables. Univariate and multivariate analyses were performed to determine the most significant predictive factors. RESULTS Baseline function in the study population was abnormal. Postoperative bite force improved, but swallowing, speech, and oral intake were worse than preoperative. Significant (univariate) predictors of outcome included diagnosis of cancer, tongue resection, pharynx resection, and flap skin paddle area. Only tongue resection remained significant in multivariate analysis. CONCLUSIONS Increasing need for oropharyngeal lining replacement, especially after tongue resection, is the most important predictor of functional outcome in reconstruction of segmental mandible defects.

The pectoralis major myofascial flap : Clinical applications in head and neck reconstruction

PURPOSE The pectoralis major myofascial (PMMF) flap, a simple variant of the pectoralis major myocutaneous (PMMC) flap, has been underemphasized as a reconstructive method in head and neck surgery. MATERIALS AND METHODS In the present study, we review our experience using 18 PMMF flaps for a variety of reconstructive purposes in 15 head and neck cancer patients treated at a tertiary care hospital. Twelve of the study patients were undergoing surgical salvage of a recurrent cancer, and 10 had received previous radiation. RESULTS The overall rate of flap complications in our series was 22%, and the incidence of major flap complications requiring surgical revision was 11%. CONCLUSION In our experience, the use of the PMMF flap for a variety of reconstructive tasks in the head and neck has been associated with a high overall success rate with avoidance of some of the limitations of the PMMC flap.

Craniofacial resection of a nasoseptal chondrosarcoma: case report and review of the literature.

BACKGROUND Chondrosarcoma of the nasal septum is a rare, malignant neoplasm. A case is presented that illustrates the evaluation and treatment of this malignancy, reviews the relevant literature, discusses surgical approaches, and assesses adjuvant, nonsurgical therapy. METHODS A craniofacial approach using an extended, bifrontal craniotomy and lateral rhinotomy with medial maxillectomy resulted in gross total resection at surgery. Because permanent sections of bone margins after decalcification were positive, conformal external beam radiation was used. RESULTS The patient made a complete recovery, returned to work, and is disease-free 26 months after treatment. CONCLUSIONS Surgical therapy using an anterior craniofacial resection is the preferred approach. External beam radiation therapy is potentially indicated for the following: positive or close surgical margins on permanent histopathology, extensive tumor with known residual at operation, or local recurrence not amenable to resection. Because of late local recurrence, lifelong follow-up is required.

Wound Complications Associated With Brachytherapy for Primary or Salvage Treatment of Head and Neck Cancer

Brachytherapy can be employed in the primary or salvage treatment of head and neck cancer. The advantage of brachytherapy is the stereotactic limitation of radiation exposure to noninvolved tissues. Wound complications associated with brachytherapy have been discussed only sporadically in the literature. This retrospective study examines 28 patients, 20 for initial treatment and eight for salvage, with varying site and stage head and neck cancer treated with brachytherapy in addition to external beam radiation therapy and/or surgery. The overall complication rate was 50% (14/28), with infection and minor flap breakdown being the most common problems. Tumor site in the primary treatment group was the only significant factor in wound complications. In the salvage group complications were minor and primarily related to flap coverage of brachytherapy catheters.

Case study of well-differentiated carcinoid tumor of the larynx and review of laryngeal neuroendocrine tumors.

in 1969. Since then, approximately 450 cases have been reported in the English language literature, 2 of which only 13 have involved well-differentiated carcinoid tumors. The clinical behavior and overall prognosis associated with these tumors vary widely between the different tumor types. The current World Health Organization classification scheme for neuroendocrine tumors of the larynx is presented in Table 1. 3 In this article we describe a rare case of a well-differentiated carcinoid tumor of the larynx and summarize the current literature regarding identification, treatment, and prognosis of these unusual tumors.