W. Frederick McGuirt

A comparative diagnostic study of head and neck nodal metastases using positron emission tomography

A prospective study was conducted to compare the accuracy of clinical examination, computed tomography (CT), and positron emission tomography (PET) in identifying head and neck squamous cell carcinoma metastatic to cervical lymph nodes. The findings in the necks of 49 patients evaluated by clinical examination and CT were compared to the findings in the same necks by PET, a newly available metabolic imaging modality. Pathology specimens were available for 45 of the necks. The findings of PET and CT correlated in 84% of cases. In the cases that did not correlate, CT proved correct in four of five cases. PET (82%) and CT (84%) were comparable and were both better than clinical examination (71%) in correctly identifying the presence or absence of metastatic disease.

Pet scanning in head and neck oncology: A review

The objective of this study was to review and describe the usage of fluorine‐labeled deoxyglucose (FDG) and positron emission tomography (PET) in the diagnosis and management of head and neck cancer.

Tracheobronchial foreign bodies

A retrospective review of 88 cases of foreign body aspiration was undertaken. The patients ranged in age from 5 months to 73 years; the peak incidences of foreign body aspiration occurred in children less than 3 years of age and in adults older than 50 years. Sixty‐one of the 88 patients were male. Physical examination was abnormal in 61% of patients. The most common radiographic abnormality was inspiratory‐expiratory abnormality, seen in 27% of patients. Rigid endoscopy under general anesthesia was the preferred method for removal of the aspirated material. Multiple foreign bodies were found in 5% of the patients. Tracheobronchial foreign bodies should, therefore, be strongly suspected in susceptible patient populations who present with a suggestive history, even when no physical or radiographic evidence can be seen. Patients should be carefully examined for multiple foreign bodies at the time of rigid endoscopic removal.

Intracranial complications of acute and chronic infectious ear disease: A problem still with us.†

Among 334,884 admissions to the North Carolina Baptist Hospital from 1963 through 1982, 100 patients had central nervous system (CNS) complications of middle ear disease. The complications occurred predominantly in young patients, 85 of the 100 being less than 20 years of age. Meningitis occurred in 76 patients; the acute form was more prevalent (63 cases). The less common nonmeningitic complications included brain abscess (n=6), effusion (n=5), lateral sinus thrombosis (n=5), otitic hydrocephalus (n=5), and empyema (n=3). Overall mortality was 10%. One patient with brain abscess died; 9 of the 76 patients with meningitis died (12%), with 4 of those deaths occurring among the 13 patients with chronic meningitis (31%). Because these complications have declined markedly since the advent of antibiotics, many contemporary otolaryngologists have been unexposed to these complications. However, as this series shows, they do still occur, their natural history remains the same, and the resulting mortality is still alarmingly high. A plea is made for otolaryngologists to maintain an awareness of these complications and to work with pediatricians and neurosurgeons for the best team care of patients with CNS complications of middle ear disease.

Can post RT neck dissection be omitted for patients with head and neck cancer who have a negative PET scan after definitive radiation therapy

PURPOSE A prospective, single institution study was conducted to evaluate the role of positron emission tomography with fluoro-deoxyglucose (FDG) before and after definitive radiation therapy for patients with head-and-neck cancer. Correlation with CT or MRI imaging and pathologic findings at the time of planned neck dissection was made. METHODS AND MATERIALS Twelve patients with AJCC Stages III-IV cancer of the head and neck received CT or MRI and PET imaging before treatment with definitive radiation therapy. One month after completion of treatment, repeat CT or MRI and PET imaging was obtained. All images were reviewed independently by radiologists who were blind to the results of the other modality. Patients then underwent planned neck dissection. Pathologic correlation with posttreatment scans allowed calculation of the sensitivity, specificity, negative predictive value, and the positive predictive value for both CT/MRI and PET. RESULTS Comparison of CT/MRI to PET obtained before definitive RT revealed both primary tumor and nodal disease were detected by both modalities in all cases where primary tumor was known. After RT, comparison of CT/MRI imaging to findings of neck dissection revealed a sensitivity of 90%, specificity of 100%, positive predictive value of 100%, and negative predictive value of 50%. Comparison of PET imaging with pathologic findings demonstrated sensitivity of 45%, specificity of 100%, positive predictive value of 100%, and a negative predictive value of 14%. CONCLUSIONS In this small series of patients, the presence of a positive PET 1 month after RT accurately indicated the presence of residual disease in all cases; however, a negative PET indicated absence of disease in only 14%. Further investigation is warranted before FDG-PET should be used to determine whether post-RT neck dissection should be omitted.

Multiple simultaneous tumors in patients with head and neck cancer. A prospective, sequential panendoscopic study

A prospective panendoscopic study (bronchoscopy, laryngoscopy, esophagoscopy) was carried out in 81 consecutively seen, untreated patients newly diagnosed as having a mucosal neoplasm in the upper aerodigestive tract, to determine how many had a synchronous second primary lesion of the aerodigestive tract. Fourteen patients (17%) proved to have multiple primary lesions (14 second‐primary and two third‐primary lesions). Three lesions were hypopharyngeal, six esophageal, three pulmonary, two laryngeal, and two oropharyngeal. Two of the additional lesions were found during routine head and neck examination, nine lesions would have been found with a single routine symptom‐ or roentgenogram‐directed endoscopic examination; five, because of their location or small size, would not have been found without panendoscopy, even after chest roentgenography, indirect laryngoscopy, and barium esophagography had been done. The most productive endoscopic examinations for detecting second primary lesions were esophagoscopy and laryngoscopy, the former detecting six lesions, the latter five lesions. The yield of chest roentgenograms was low (1/79). No complications resulted from this prospective panendoscopic protocol study. These findings should reinforce the belief that head and neck cancer is a panmucosal disease of the aerodigestive tract, that silent second synchronous primary lesions are not uncommon, and that every effort should be made to find all primary sites before treatment of the index tumor is begun.

Occult primary tumors of the head and neck

Patients who present with squamous cell carcinoma metastatic to cervical lymph nodes and no clinically apparent primary site present a therapeutic dilemma. Positron emission tomography imaging with 2‐[F‐18]fluoro‐2‐deoxy‐D‐glucose (FDG‐PET) has been shown to be useful for the examination of known primary tumors. This study was undertaken to determine whether FDG‐PET imaging improves detection of occult primary tumors in patients with metastatic squamous cell carcinoma in the lymph nodes of the head and neck.

Preoperative identification of benign versus malignant parotid masses: A comparative study including positron emission tomography

Various diagnostic tools were used in 26 patients with parotid masses to determine their value in preoperative malignant or benign categorization. These tools were positron emission tomography (PET), clinical examination, fine‐needle aspiration biopsy (FNAB), computed tomography (CT), and magnetic resonance imaging (MRI). PET identified all 26 lesions and all 12 malignant lesions, but made the correct categorization in only 69% of cases. Thus, it was not as good as the more conventional diagnostic methods, their correct categorizations being 85% (clinical), 87% (CT/MRI), and 78% (FNAB) in the same patients.

Positron emission tomography in the evaluation of laryngeal carcinoma.

Positron emission tomography (PET) is a relatively new radiologic imaging technique based on glucose analog uptake and metabolism in tumor tissue. In this study, PET was used in evaluating 38 patients with laryngeal cancer. Twenty-five patients were examined with PET prior to treatment to study the reliability of PET in identifying the primary tumor and assessing regional nodal status; 13 patients who had previously received irradiation with curative intent and who represented differential diagnostic problems were imaged to differentiate between irradiation effects and recurrent or residual cancer. Findings for both groups were compared to results of clinical evaluation and those of computed tomography (CT) and magnetic resonance imaging (MRI). The PET results were essentially identical to those of CT, MRI, and clinical evaluation in identifying metastatic lesions (82% correct), and were as reliable as CT and MRI for correctly identifying primary tumors (88%). Positron emission tomography was most helpful in differentiating recurrent tumor from postirradiation tissue sequelae. However, its lack of anatomic detail made PET less valuable for primary staging and therapeutic planning. It may enhance the diagnostic accuracy of CT and MRI where anatomic distortions occur or where diagnostic criteria for CT and MRI are ambiguous.

Voice Analysis of Patients with Endoscopically Treated Early Laryngeal Carcinoma

Endoscopic laser resection of early (T1) laryngeal carcinoma has been advocated as an alternative to radiotherapy. Heretofore, the voice characteristics following this procedure have been addressed in only one review, which included patients treated by irradiation and laser resection. We present the first review of voice findings in 22 patients treated only by endoscopic laser resection of their vocal cord carcinomas. Laser resection of selected vocal cord carcinomas produced voice function results acceptable to the patients and was rated by them to be normal to almost normal. Speech pathologists rated the voices to be near-normal to mildly abnormal. Voices after laser resection of vocal carcinoma exhibited a slightly higher fundamental frequency, a decrease in intensity and phonatory duration, and markedly higher laryngeal airway resistance. The percentage of voicing showed little deviation from normal, as did mean percentage of perturbations.