In scalp reconstruction, soft tissue and osseous defects frequently coexist. The purpose of this study was to compare outcomes of simultaneous scalp and calvarial reconstruction to scalp only reconstruction.

A review of microsurgical scalp reconstruction with or without cranioplasty over a 10-year period was performed.

One hundred thirty-eight scalp reconstructions were performed, of which 48 involved concurrent cranioplasty. The overall rate of perioperative complications was 21.0%, whereas the rate of late recipient site complications was 11.6%. No significant differences in perioperative (p = .56) or late (p = .42) recipient site complications were observed between patients undergoing scalp and calvarial versus scalp only reconstruction. In terms of complications, muscle free flaps with skin grafts were as reliable as free flaps with skin paddles (p = .36).

Simultaneous scalp and calvarial reconstruction is associated with success rates equivalent to scalp only reconstruction. Muscle flaps covered with skin grafts and flaps with a skin paddle seem to be equally reliable. © 2012 Wiley Periodicals, Inc. Head Neck, 2012

Nevoid basal cell carcinoma syndrome (NBCCS) is a rare, inheritable, multisystem disorder characterized by numerous basal cell carcinomas (BCCs), maxillary keratocyst, and musculoskeletal malformations. Occasionally, it is associated with malignancies like rhabdomyoma, melanoma, and sinonasal undifferentiated carcinoma, to name a few.

A patient presented with NBCCS with a medullary thyroid carcinoma. Clinical, surgical details, and germline genetic analysis are herein described.

A 32-year-old woman was referred to our department with suspicion of medullary thyroid carcinoma, which was confirmed by histopathological examination. The patient was diagnosed as also having NBCCS. Germline mutation analysis indicated wild-type genes PTCH1 and RET. DNA copy number analysis by high resolution microarray comparative genomic hybridization (CGH) revealed a small interstitial loss at chromosomal band 2q37.3.

To our knowledge, this is the first described patient with NBCCS carrying a medullary thyroid carcinoma and a 2q37 deletion, which confirms that this syndrome can be associated with many different malignancies. © 2012 Wiley Periodicals, Inc. Head Neck, 2012

The voice impact of treatment for nonlaryngeal head and neck primary sites remains unknown.

We conducted a prospective study of a consecutive sample of patients undergoing chemoradiation for nonlaryngeal head and neck cancer. The Voice Symptom Scale (VoiSS) was completed, and voice recordings were made at 3 time-points.

Of 42 recruited patients, 34 completed the measures before and in the early posttreatment phase (mean 16.5 weeks), while 21 patients were assessed at the final time-point (mean, 20.4 months). VoiSS scores showed statistically significant progressive deterioration in the total score (p = .02) and impairment subscale (p < .0001) through to the final assessment. Acoustic measures and perceptual ratings deteriorated significantly (p < .001) in the early posttreatment weeks and improved at the final assessment, but not to the baseline. Interrater agreement was excellent for expert measures.

To the best of our knowledge, this is the first prospective study to show that chemoradiation therapy for nonlaryngeal head and neck cancer has a significant effect on the patients' self-reported voice quality, even in the long term. © 2012 Wiley Periodicals, Inc. Head Neck, 2012

Patients with head and neck squamous cell cancer (HNSCC) are at risk of developing second primary lung cancer (SPLC).

Among 61,883 patients with HNSCC from the Surveillance, Epidemiology and End Results (SEER) database, 4522 developed SPLC (any histology) ≥2 months after HNSCC. We correlated risk with demographic and tumor-related parameters.

The risk of SPLC after HNSCC was 5.8%, 11.4%, and 16.4% at 5, 10, and 15 years, respectively. From Cox regression, significantly adverse (p < .0001) risk factors for SPLC included: regional versus localized HNSCC stage (hazard ratio [HR] = 1.16), hypopharyngeal or supraglottic laryngeal site (HR = 1.57), increased age (HR = 1.26/decade), black race (HR = 1.27), and male sex (HR = 1.26). Glottic (HR = 0.75) and tonsillar or oral cavity sites (HR = 0.80) were associated with significantly (p < .0001) lower risks of SPLC.

From population-based actuarial analyses, HNSCCs with more aggressive clinicopathologic features were more apt to develop SPLC, suggestive of similar environmental and/or host factors for these cancers. © 2012 Wiley Periodicals, Inc. Head Neck, 2012

The purpose of the present study was to determine normal values of epithelial thickness within the oral cavity by using optical coherence tomography (OCT).

In a total of 143 healthy test persons, epithelial thickness of the oral mucosa was determined with the help of OCT separately for each side at 7 different locations. Special attention was directed to those sites having the highest incidence for the development of dysplasias and carcinomas.

The epithelium demonstrated a varying thickness depending on its location within the oral cavity. The highest values were found in the region of the buccal mucosa (294 μm) and the hard palate (239 μm), whereas the thinnest epithelium was measured at the floor of the mouth (99 μm).

Our data serve as reference values for detecting oral malignancy and determining the approximate grade of dysplasia. In this circumstance, a differentiated view of the different regions is important due to a variation in thickness of the epithelium within the oral cavity. © 2012 Wiley Periodicals, Inc. Head Neck, 2012

The purpose of this study was to evaluate the counts and percentages of differential leukocytes as prognostic indicators in patients with nasopharyngeal carcinoma (NPC).

This study consisted of 1410 cases identified from an established prospective cohort of 1533 patients with NPC between October 2005 and October 2007 in the Sun Yat–Sen University Cancer Center. Multivariate Cox proportional hazards analyses were applied.

A high percentage of lymphocyte was significantly associated with a favorable prognosis of NPC (highest vs lowest quartile, hazard ratio [HR], 95% confidence interval [CI] for overall and progression-free survival, HR, 0.71; 95% CI, 0.48–1.06; HR, 0.61; 95% CI, 0.43–0.86, respectively), whereas a high neutrophil percentage (HR, 1.62; 95% CI, 1.06–2.46; HR, 1.55; 95% CI, 1.10–2.18, respectively), and a neutrophil/lymphocyte ratio (NLR; HR, 1.57; 95% CI, 1.04–2.39; HR, 1.68; 95% CI, 1.19–2.38, respectively), were significantly related to a poor prognosis of NPC.

Pretreatment NLR and percentages of lymphocyte and neutrophil are independent prognostic factors and may serve as clinically convenient and useful biomarkers for survival of patients with NPC. © 2012 Wiley Periodicals, Inc. Head Neck, 2012

The purpose of this study was to assess the factors influencing swallowing and phonatory results after partial laryngectomy.

We carried out a medical chart review of patients who underwent partial laryngectomies between June 2003 and November 2010, focusing on functional outcomes.

Thirty-two patients were enrolled. No statistically significant difference was found in the comparison of phonatory outcomes of patients with preservation of both arytenoids; the results of the Yanagihara classification were significantly different (p = .015) in patients with an atypical neoglottis; radiotherapy statistically significantly influenced only the mean fundamental frequency (p = .035). The type of partial laryngectomy does not seem to affect the deglutition results; radiotherapy statistically significantly affected the dysphagia score (DS; p = .03), penetration aspiration (p = .02), and MD Anderson Dysphagia Inventory (MDADI; p = .02).

Horizontal supraglottic laryngectomy and supracricoid partial laryngectomy give the same swallowing results. The presence of both arytenoids does not influence the final outcome compared to patients in whom only 1 arytenoid is preserved. Postoperative radiotherapy only influences the swallowing function. © 2012 Wiley Periodicals, Inc. Head Neck, 2012

The purpose of this study was to evaluate the prognostic impact of the sixth edition of the Union Internationale Contre le Cancer (UICC) classification and different TNM-based stage groupings for malignant tumors of the ethmoid sinuses and the nasal cavity.

We conducted a retrospective analysis of 98 patients with malignant tumors of the ethmoid sinuses and the nasal cavity between 1967 and 2003. The UICC classification of the sixth edition and the T and N Integer Score (TANIS) and Hart were tested for their prognostic significance.

In univariate analysis, all stage groupings revealed discriminatory power for overall survival (OS; p < .05), however, in multivariate analysis only the UICC-stage grouping (p = .033) and the TANIS-8 scheme (p = .044) predicted OS. The TANIS did not have a better prognostic quality than the sixth edition of the UICC classification.

The UICC-stage grouping of the sixth edition is a good prognostic index for malignant tumors of the ethmoid sinuses and the nasal cavity. © 2012 Wiley Periodicals, Inc. Head Neck, 2012

Neuroendocrine tumors are rare neoplasms arising from neural and epithelial origin.

The case records of 4 patients with the diagnosis of neuroendocrine laryngeal tumor were retrospectively reviewed. In this analysis of our medical records, we describe a series of 4 men with neuroendocrine laryngeal tumors treated in our department since 1994, including the first extremely aggressive and lethal laryngeal paraganglioma reported in the English-language literature. We also discuss the classification, the macro and microscopical characteristics, clinical and pathologic findings, and treatment of these neoplasms.

Although neuroendocrine laryngeal tumors account for approximately 1% of all neoplasms in the larynx, its majority represents very aggressive tumors showing a capacity for metastasis and portending poor outcome. © 2012 Wiley Periodicals, Inc. Head Neck, 2012

The aim of this article was to assess the management of the neck and regional recurrence for squamous cell carcinoma of the maxillary alveolus and hard palate (n = 43) and compare that to the rest of the oral cancer sites (n = 465).

This is a retrospective report through database and case note review.

The incidence of nodal metastases (pathologic node–positive necks added to regional recurrence for clinical N0 and pathologic N0) was 37% (16/43) for maxillary alveolus and hard palate compared with 40% (187/465) for the oral cavity in general. Regional recurrence occurred in 26% (11/43) in the maxillary alveolus and hard palate compared with 7% (31/465) in the remaining oral cavity sites (p = .001).

Squamous cell carcinoma arising in the maxillary alveolus and hard palate has a similar risk of regional metastasis as the rest of the oral cavity, and a lower propensity for selective neck dissection is resulting in higher regional recurrence and lower survival rates. © 2012 Wiley Periodicals, Inc. Head Neck, 2012

Bleeding within the supraglottic region can be a lethal complication after CO₂ laser microsurgery. Our aim was to propose endoluminal anatomical landmarks to locate the superior laryngeal vessels resulting in a safer microsurgery.

Endoluminal dissections were made in 22 larynges without laryngeal disease.

The neurovascular structures were in the superior third of a triangle defined by the vocal process, the anterior commissure, and the epiglottic attachment of the aryepiglottic fold. They overlapped in 4 different ways: pattern I (70.4%): superior laryngeal vein (SLV), superior laryngeal artery (SLA), and internal laryngeal nerve (ILN); pattern II (13.6%): SLA, SLV, ILN; pattern III (4.6%): SLV, ILN, and SLA; pattern IV (4.6%): SLA, ILN, and SLV.

Microsurgery in the supraglottic region may be safer if surgeons are aware of the superior third of the above-defined triangle, “danger area”, where the vascular elements of this region are located. © 2012 Wiley Periodicals, Inc. Head Neck, 2012

The prognostic significance of volume-based metabolic parameters measured by ¹⁸F-fluorodeoxyglucose positron emission tomography/CT (¹⁸F-FDG PET/CT) is not established. We evaluated the prognostic value of metabolic parameters in patients with squamous cell carcinoma (SCC) of the tonsil.

We enrolled a total of 69 patients with SCC of the tonsil who underwent pretreatment ¹⁸F-FDG PET/CT. We measured maximum standardized uptake value (SUV_max), metabolic tumor volume (MTV), total lesion glycolysis (TLG), and asymmetry indices (of SUV_max, MTV, and TLG). The prognostic significance of these parameters and clinical variables was assessed by Cox proportional hazards regression analysis.

Multivariate analyses with adjustments for age, sex, and American Joint Committee on Cancer stage showed that only TLG (hazard ratio = 1.020, 95% confidence interval 1.003–1.037, p = .023) was an independent predictive factor associated with decreased overall survival.

TLG is a significant independent metabolic prognostic factor for overall survival in patients with SCC of the tonsil. © 2012 Wiley Periodicals, Inc. Head Neck, 2012

Lipoleiomyosarcoma is a rare tumor consisting of well-differentiated liposarcoma and leiomyosarcoma. The ear–nose–throat location of lipoleiomyosarcoma has not been previously described.

A 37-year-old man with a dysphagia had a dyspnea after an endoscopy. A large tumor was exteriorized from the man's mouth. The lesion was pedicled to the epiglottis. A histologic examination determined that the tumor was a lipoleiomyosarcoma. MDM2 and CDK4 gene amplification were positive. Due to the risk of recurrence, a second intervention was performed to complete the excision.

These tumors develop in cavities slowly and gradually. The treatment of this lesion is surgical with a sufficient resection margin. © 2012 Wiley Periodicals, Inc. Head Neck, 2012

The purpose of this study was to determine the expression pattern of the Merkel cell polyomavirus (MCPyV) large T-protein antigen in patients with Merkel cell carcinoma.

A tissue microarray (TMA) containing 30 specimens was constructed and stained for the MCPyV large T protein. Immunohistochemical expression was determined semiquantitively and was compared to patients' outcome.

Nuclear expression of MCPyV large T protein was detected in 29 of 30 specimens (97%). In particular, 60% to 100%, 30% to 60%, and 10% to 30% of tumor cells were positive in 27 specimens (90%), 1 (3%), and 1 (3%), respectively. There was no difference in positivity between primary and metastatic lesions. Clinical data could not be correlated to MCPyV large T-protein expression.

MCPyV large T protein was significantly overexpressed in 97% of all specimens. Although we could not demonstrate a predictive effect, MCPyV large T protein may represent a molecular marker with utility in pathological diagnosis as well as a potential new therapeutic target in patients with Merkel cell carcinoma. © 2012 Wiley Periodicals, Inc. Head Neck, 2012

Ethmoid sinus osteomas are uncommon, benign, osteogenic tumors. The purpose of this retrospective study was to describe their usual clinical presentation and to discuss their surgical management.

The medical records of 25 patients treated for ethmoid osteoma between March 2001 and December 2010 were retrospectively reviewed.

The average tumor size was 18.5 ± 14 mm. Only 3 patients were asymptomatic, 14 had a history of frontal sinusitis (complicated with orbital cellulitis in 4 cases), and 4 patients presented with diplopia. An endoscopic approach was performed in 19 cases, a coronal approach in 4 cases, and a combined approach (endoscopic + coronal) in 2 cases. No recurrence was reported.

Ethmoid sinus osteoma can be asymptomatic and detected incidentally on CT scans, but often causes frontal sinusitis and orbital complications. The endoscopic approach offers the possibility of safe removal with cosmetic advantages compared to coronal approach. © 2012 Wiley Periodicals, Inc. Head Neck, 2012

Patients with a first head and neck carcinoma have a high risk of successive neoplasms, many of which appear again in the head and neck. Second head and neck tumors have a poorer prognosis than first tumors, but data about the prognosis of third and fourth tumors in the head and neck are lacking.

We carried out a retrospective study of 4298 patients with a primary head and neck carcinoma. Survival and the characteristics of the first tumor, second tumor, and any successive tumors in the head and neck were analyzed.

Second and successive tumors showed a tendency to appear more frequently in the oral cavity and oropharynx and had a lower stage than that of index tumors. Five-year survival rates after a first, second, third, and fourth tumors in the head and neck were 67.6%, 56.1%, 45.0%, and 32.1%, respectively.

Survival decreased progressively with every new head and neck tumor. © 2012 Wiley Periodicals, Inc. Head Neck, 2012

Parapharyngeal space (PPS) tumors are rare, accounting for 0.5% of all head and neck neoplasms. PPS tumors are difficult to diagnose due to limited presenting signs and symptoms and because of their location deep within the neck.

A 60-year-old woman presented with complaints of otalgia, which appeared to be consistent with a temporomandibular disorder (TMD). Due to disproportionate symptoms, an MRI of the temporomandibular joints was ordered. The MRI revealed a mass within the PPS, which was later diagnosed as a mucoepidermoid carcinoma. A literature search failed to reveal otalgia, and facial pain, thought to be related to a TMD, as the primary presenting symptoms of a PPS neoplasm.

Patients presenting with disproportionate signs and symptoms of a TMD should be evaluated with advanced imaging to rule out occult pathology. © 2012 Wiley Periodicals, Inc. Head Neck, 2012

We describe a novel surgical technique for resection of squamous cell carcinoma in the setting of a massive tongue lymphovascular malformation (LVM).

A 75-year-old man with a history of long-standing massive LVM of the tongue presented with a 4-cm squamous cell carcinoma of the involved oral tongue. Given the aberrant vascular anatomy of this lesion, traditional surgical treatment could not be undertaken. Therefore, serial suture ligation was performed over a 2-week period, allowing complete excision of the squamous cell carcinoma and a large portion of the tongue LVM with minimal morbidity. Return to preoperative functional status was likewise achieved.

Serial suture ligation glossectomy is a simple and effective technique for treating the uncommon case of squamous cell carcinoma of the tongue in the setting of a massive LVM. © 2012 Wiley Periodicals, Inc. Head Neck, 2012

The appropriate management of the neck in patients with regionally advanced head and neck cancer remains controversial. The purpose of this study was to retrospectively analyze our institutional experience with up-front neck dissection followed by definitive chemoradiotherapy.

Fifty-five patients with radiographic evidence of large or necrotic lymph nodes underwent up-front neck dissection followed by definitive chemoradiation.

The 5-year overall survival (OS) and progression-free survival (PFS) rates were estimated at 71.3% and 64.7%, respectively. There were 2 failures in the dissected neck, for a control rate of 96.7%. There were 7 locoregional failures and 12 distant failures, for locoregional and distant control rates of 87.3% and 78.2%, respectively.

Up-front neck dissection followed by chemoradiotherapy resulted in excellent locoregional control, OS, and PFS. Utilization of this strategy should be considered in carefully selected patients with regionally advanced head and neck cancer. © 2012 Wiley Periodicals, Inc. Head Neck, 2012

Salivary gland carcinosarcoma is a rare and aggressive malignant mixed tumor in which carcinomatous and sarcomatous elements coexist and metastasize together. The tumor may occur in the background of a preexisting pleomorphic adenoma or may arise de novo. We report a case of a woman presenting with a carcinosarcoma de novo of the parotid gland.

Our patient underwent surgical resection and adjuvant radiotherapy and demonstrates no evidence of recurrence at 14 months posttreatment.

Review of the literature supports combined modality, surgery with postoperative radiation, as the standard of care for this malignancy, although the long-term prognosis for these patients is unclear. © 2012 Wiley Periodicals, Inc. Head Neck, 2012

The epidermal growth factor receptor (EGFR) and vascular endothelial growth factor receptor (VEGFR) have been implicated as therapeutic targets for head and neck squamous cell carcinoma (HNSCC). Vandetanib is a small-molecule tyrosine kinase inhibitor (TKI) with dual specificity for EGFR and VEGFR. Here we characterize the phenotypic and biochemical effects of vandetanib on various HNSCC cell lines.

In vitro models were used for studying tumor cell viability, invasion, and signaling as well as in vivo xenograft models.

Treatment with vandetanib reduced viability, invasion, and tumor growth of HNSCC cell lines. Phosphorylation levels of mitogen-activated protein kinase (MAPK) and signal transducer and activator of transcription 3 (STAT3) were reduced in vandetanib-treated HNSCC cells. Additionally, vandetanib abrogates EGF-induced STAT3 activity and STAT3 target gene expression.

We demonstrated that vandetanib inhibits the growth of head and neck cancer cell lines. The antitumor effects of vandetanib appear to be exerted via the EGFR inhibitory effect of the compound. © 2012 Wiley Periodicals, Inc. Head Neck, 2012

The purpose of this study was to determine whether the incidence of bilateral neck disease tonsillar cancer is rising.

We reviewed tonsillar cancer incidence data from the Surveillance, Epidemiology, and End Results (SEER) Program of the National Cancer Institute.

The annual incidence of advanced neck disease (≥N2) with small primary tonsillar cancer is increasing (annual percent change [APC]; p < .05) during 2 evaluable time frames (1988–2003 and 2004–2008). The increase for small primary tonsillar cancer from 2004 to 2008 is associated with increased ipsilateral disease (ie, T1-2N2a–b, APC 10.6%; p < .05) rather than bilateral neck disease (T1-2N2c, APC 5.9%, APC = NS). The increase in bilateral neck disease is less than the overall rise in T1 to 2 tonsillar cancer (APC 7.2%; p < .05).

In the human papillomavirus (HPV) era, bilateral neck disease is increasingly common. This seems to be a consequence of the increasing incidence of tonsillar cancer rather than a new biologic behavior. © 2012 Wiley Periodicals, Inc. Head Neck, 2012

Superficial temporal artery (STA) aneurysms are an uncommon entity and mostly described in case studies. The purpose of this review was to show the studied clinical presentation, diagnostic modalities, and treatment modalities of STA aneurysms.

A review was performed of reports on STA aneurysms published until December 2010, using the MEDLINE and Cochrane databases.

One hundred sixty-six pseudoaneurysms and 20 true aneurysms were described. The majority of patients presented with a painless pulsatile mass. Historically, angiography was most often used, but ultrasound scan, CT, and MRI may be superior. Surgical resection was performed in 128 pseudoaneurysms and 20 true aneurysms with 1 recurrence and few complications. Endovascular approaches were used in 13% of pseudoaneurysms with an 80% success rate.

Pseudoaneurysms are mostly the result of blunt trauma as opposed to true aneurysms which usually occur spontaneously. Surgical resection is a safe treatment modality, but endovascular treatment might be considered in a selected group of patients. © 2012 Wiley Periodicals, Inc. Head Neck, 2012

The ultrasonic scalpel is a recently introduced device in head and neck surgery. Total thyroidectomy is the most common endocrine procedure performed by surgeons.

This was an open, phase IV, multicenter, randomized controlled trial (RCT) that compared the use of an ultrasonic scalpel with a conventional technique in patients who underwent total thyroidectomy. The outcomes were surgical complication rate, operative time, drainage volume, postoperative pain, and costs.

In all, 261 patients were included in 11 centers. There was a mean difference of 17% of operative time in favor of the ultrasonic scalpel group. There were no differences in postoperative complications. There was a difference in costs of 14% in favor of the ultrasonic scalpel group, but it was not statistically significant.

The use of an ultrasonic scalpel was as safe as that of the conventional technique and had the advantage of a shorter operative time and lower postoperative drainage. Costs were not different between groups. © 2012 Wiley Periodicals, Inc. Head Neck, 2012

Mandibular osteoradionecrosis (ORN) is a well-known complication of head and neck radiotherapy; however, ORN of the cervical spine is rarely reported.

Herein, we present a patient with a history of tonsillar carcinoma treated with chemoradiation who developed acute, severe progressive neck pain due to cervical spine collapse as a result of ORN. We also discuss diagnosis and treatment of cervical ORN based on a review of the literature.

The patient was successfully treated with antibiotics and surgical debridement and fixation.

Delayed diagnosis of cervical ORN can result in marked disability and pain due to spinal cord compression, as well as serious deformity and instability requiring surgical intervention, and even death. It is important for otolaryngologists who treat head and neck malignancies to be aware of this potential complication so that patients may be diagnosed as early as possible and treated with conservative measures. © 2012 Wiley Periodicals, Inc. Head Neck, 2012

Hyperparathyroidism–jaw tumor (HPT-JT) syndrome is a rare autosomal dominant multiple tumor syndrome characterized by hyperparathyroidism due to single or multiple-gland parathyroid tumor(s). Since it was first described in 1990, the genetics underlying the syndrome have been elucidated and typical clinical presentations are becoming clarified as literature describing this rare entity amasses.

A 22-year-old man presented with a 2-year history of fatigue, weight loss, nausea, and vomiting. Anemia workup indicated severe hypercalcemia. Investigations were consistent with a diagnosis of HPT-JT. The patient underwent a total 4-gland parathyroidectomy with single gland reimplantation.

HPT-JT is a complex syndrome with phenotypic manifestations that can seem physiologically and temporally unrelated. The risk of parathyroid carcinoma is elevated in patients with HPT-JT, necessitating rapid treatment and complete tumor resection to reduce the morbidity and mortality associated with intractable hypercalcemia due to local recurrence or metastatic disease. © 2012 Wiley Periodicals, Inc. Head Neck, 2012

The purpose of this study was to report the incidence of venous thromboembolism (VTE) in patients with head and neck cancer after surgery.

This was a single-institution, retrospective cohort: 134 patients underwent resection and simultaneous microvascular reconstruction. The primary endpoint was identification of confirmed or suspicious VTE within 30 days of surgery.

Two subjects (1.4%) with confirmed VTE (1 pulmonary embolism, 1 deep venous thrombosis) and 6 subjects (4.4%) with suspicious VTE (1 acute respiratory failure, 1 sudden cardiac arrest, and 4 cases of leg edema without imaging) were identified. The strongest predictors of possible VTE were prior VTE (p = .004; odds ratio [OR], 25.11; 95% confidence interval [CI], 1.13–556.40), red cell transfusion (p = .009; OR, 1.80; 95% CI, 1.16–2.80), high body mass index (p = .015, OR, 1.29, 95% CI, 1.05–1.58), and older age (p = .046; OR, 1.10; 95% CI, 1.00–1.19).

The incidence of VTE in patients with head and neck cancer after resection and microvascular reconstruction ranged from 1.4% to 5.8%. © 2012 Wiley Periodicals, Inc. Head Neck, 2012

Hyalinizing clear cell adenocarcinoma (HCCA) is a rare salivary gland malignancy. To our knowledge, there are no published reports of primary clear cell carcinoma of the vallecula.

A 59-year-old man with progressive dysphagia and otalgia underwent direct laryngoscopy with biopsy of a vallecular mass. The pathology results returned as clear cell adenocarcinoma. He underwent a wide local excision for his T₂N₀M₀ stage II tumor.

Clear cell adenocarcinoma of the oropharynx typically presents as a painless neck mass and it can be difficult to distinguish from other clear cell malignancies.

Immunohistochemical staining is essential for narrowing the differential diagnosis of these lesions. Treatment is controversial but usually consists of wide local excision and possibly a neck dissection. © 2012 Wiley Periodicals, Inc. Head Neck, 2012

Juvenile nasopharyngeal angiofibromas (JNAs) with significant skull base involvement and intracranial extension are challenging tumors. We evaluated our experience in the treatment of extensive JNAs through resection followed by radiosurgery.

From 1999 to 2007, 10 advanced JNAs (Andrews grade IV) were treated by primary surgical resection followed by gamma knife radiosurgery of residual tumor. Tumor control and treatment morbidity were evaluated.

Six months after radiosurgery and annually thereafter, an imaging study was done that revealed decrement in tumor size in 3 patients and no change in 7 patients, after a 3-year minimum follow-up. Clinically, patients are asymptomatic.

An efficient strategy in the management of extensive JNAs is the use of a multimodality approach, in which surgical resection is followed by the treatment with radiosurgery in critical locations. These therapeutic schemes are safe and offer long-term tumor control. © 2012 Wiley Periodicals, Inc. Head Neck, 2012

Endosonography has been successfully used in staging gastrointestinal cancer, but its value is as yet undetermined in laryngology.

This prospective study includes 84 patients undergoing microlaryngoscopy for laryngeal cancer. The results of endosonography were compared with those of CT and MRI in the 76 surgical cases.

In the assessment of laryngal cancer, endosonography was superior to current imaging techniques, whereas CT and MRI showed similar results (accuracy of 89% vs 77% and 77%, respectively).

This study confirms that endosonography is highly effective in staging laryngeal cancer. Therefore, the latter may constitute a complementary diagnostic tool in these tumors and additionally may assist in choosing an adequate treatment. © 2012 Wiley Periodicals, Inc. Head Neck, 2012

We analyzed tissue incorporation, immune response, and neovascularization of AlloDerm and DermaMatrix in a rat model of postparotidectomy reconstruction.

In 8 male Sprague–Dawley rats, 3-dimensionally folded AlloDerm implants were placed in the left postparotidectomy bed and 3 in the anterior dorsum as controls. The same was done for DermaMatrix on the right side and posterior dorsum. Two animals were euthanized at 4, 8, and 12 days. A blinded pathologist assessed the degree of fibroblast proliferation, neovascularization, and inflammation.

When compared with the dorsum, DermaMatrix implants in the parotid bed had significantly higher numbers of inflammatory cells at 8 and 12 days (p = .049 and .0046). AlloDerm acted more consistently between the postparotidectomy bed and dorsum.

AlloDerm reacts similarly when comparing the postparotidectomy bed to the dorsum. DermaMatrix induces a more marked inflammatory reaction in the postparotidectomy bed when compared with the dorsum. © 2012 Wiley Periodicals, Inc. Head Neck, 2012

Irradiation-induced signaling via the 2 pathways, Raf-MEK-ERK and PI3K-Akt, is known to be closely associated with a limited response to radiotherapy. In the present study we analyzed the relevance of constitutively active K-Ras for postradiogenic pathway stimulation and the option of coordinated inhibition to overcome these rescue mechanisms.

We used 2 epithelial tumor cell lines as a model system, one of them harboring a G12S K-Ras mutation. Cells were irradiated and the effect of combined treatment with ionizing radiation and inhibitors on the expression of pERK and pAkt was determined by Western blotting. Additionally, clonogenic assays were performed to functionally analyze survival of the cell lines.

Compared with the nonmutated cells we observed the G12S cell line showing a clearly reduced response to inhibitor treatment under irradiation. In the case of pharmacologic inhibition of 1 of the pathways a compensatory upregulation of the second cascade leading to increased clonogenic survival seems feasible. However, there was a good functional response of this cell line to double inhibition with both compounds represented by minimized colony forming ability. The activation of ERK and Akt after irradiation was confirmed in xenotransplants showing elevated postradiogenic protein levels.

With our data we confirmed our hypothesis of postradiogenic constitutive activation of the 2 pathways both required for Ras-mediated radioresistance in epithelial cells. If this effect should prove itself as a general mechanism in Ras-mutated tumors, application of specific inhibitors to block both cascades in parallel could contribute to enhance radiosensitivity in these types of cancer. © 2012 Wiley Periodicals, Inc. Head Neck, 2012

We report a rare case of a mediastinal goiter confined to the thoracic inlet and cavity presenting with ventricular tachycardia as the sole clinical manifestation.

The patient did not have any of the typical features of a mediastinal goiter such as neck swelling, dysphagia, or respiratory difficulty, but instead had spontaneous onset of wide-complex tachycardia requiring emergency treatment. This atypical presentation led to initial misinterpretation of imaging studies and delayed diagnosis of the mediastinal mass. The large, completely intrathoracic thyroid goiter abutted the cardiac muscle and required a combined transcervical and median sternotomy approach for removal. The arrhythmia resolved postoperatively.

To our knowledge, this case represents the first documented presentation of ventricular tachycardia as a unique and sole feature of mediastinal goiter. © 2012 Wiley Periodicals, Inc. Head Neck, 2012

The role of sentinel node biopsy in head and neck cancer is currently being explored. Patients with positive sentinel nodes were investigated to establish if additional metastases were present in the neck, their distribution, and their impact on outcome.

In all, 109 patients (n = 109) from 15 European centers, with cT1/2,N0 tumors, and a positive sentinel lymph node were identified. Kaplan–Meier and univariate and multivariate logistic regression analysis were used to identify variables that predicted for additional positive nodes and their position within the neck.

A total of 122 neck dissections were performed in 109 patients. Additional positive nodes were found in 34.4% of cases (42/122: 18 same, 21 adjacent, and 3 nonadjacent neck level). Additional nodes, especially if outside the sentinel node basin, had an impact on outcome.

The results are preliminary but suggest that both the number and the position of positive sentinel nodes may identify different prognostic groups that may allow further tailoring of management plans. © 2012 Wiley Periodicals, Inc. Head Neck, 2012

Oroantral fistulas are pathologic connections between the oral cavity and the maxillary sinus. Arteriovenous fistulas are abnormal connections between an artery and a vein with no intervening capillary network.

We present an extremely rare case of barotrauma-related oroantral fistula with an associated arteriovenous fistula between the internal maxillary artery and the ophthalmic venous system.

The patient developed an oroantral fistula from barometric pressure changes in the setting of sinusitis. After closure and revision of the oroantral fistula, he developed proptosis and chemosis. Angiography revealed an arteriovenous fistula between the internal maxillary artery and the ophthalmic venous drainage system in the area of the oroantral fistula, which was treated with endovascular embolization.

Arteriovenous fistulas may accompany oroantral fistulas created by trauma or surgery and should be considered in patients presenting with chemosis and proptosis. Treatment with embolization should be performed before surgical intervention. © 2012 Wiley Periodicals, Inc. Head Neck, 2012

Minor salivary gland tumors of the sinonasal region are rare. Minor salivary gland tumors of this region behave differently from other subsites in the head and neck. The objective of our study was to analyze the survival and prognostic factors in patients with minor salivary gland tumors of the sinonasal region.

We carried out a retrospective review of patients with minor salivary gland tumors of the sinonasal region. All slides were reviewed by an independent pathologist. Survival was analyzed using the Kaplan–Meier method and Cox multivariate regression to identify prognostic factors.

In all, 163 patients were identified from our registry. The 5-year disease-free and overall survival rates were 48.3% and 83.3%, respectively. Tumor grade, nodal status, and adjuvant radiotherapy were significant predictors of disease-free survival (DFS), on multivariate analysis.

Minor salivary gland tumors have a good overall survival in spite of high recurrence rates. Tumor grade, nodal status, and adjuvant radiotherapy are independent predictors of DFS. © 2012 Wiley Periodicals, Inc. Head Neck, 2012

Reconstruction after partial cricotracheal resection is technically demanding and is seldom reported in literature. The purpose of this study was to report a technique of reconstruction of such a defect with a radial forearm flap supported by a titanium mesh.

A 75-year-old man who was diagnosed with a case of papillary carcinoma thyroid, underwent excision of the tumor with a partial cricotracheal resection. The defect was reconstructed with a free radial forearm flap with fascia suspended on a titanium mesh.

At a follow-up of 6 months after treatment, the patient has normal nasal breathing and an acceptable voice.

This reconstructive technique enabled us to maintain the integrity of the subglottic airway. Our technique was unique in that we used the skin-lined part of the radial forearm flap to line the airway and the fascia to cover the titanium mesh outside, thereby preventing plate exposure. © 2012 Wiley Periodicals, Inc. Head Neck, 2012

Reconstruction of moderate-sized mucosal defects of the oral cavity/oropharynx represents a surgical challenge. The most widely used reconstructive techniques are skin grafts, local or regional pedicled flaps, and free flaps, but they do not provide mucosal sensitivity, mobility, volume, or texture similar to that of native tissue. The cheek myomucosal flaps seem to provide “ideal reconstruction” because they carry a thin, mobile, well-vascularized, and sensitive tissue, like those excised or lost. The purpose of this retrospective analysis was to evaluate the indications for the advantages and disadvantages of 6 types of buccinator myomucosal flaps which are possible to raise from the cheek mucosa.

Sixty-nine buccinator myomucosal flaps were performed on 66 patients with moderate-sized postoncologic and posttraumatic oral and oropharyngeal defects.

In all cases except 1, flaps were successfully used with excellent oncological and functional results.

Buccinator myomucosal flaps can be considered “ideal flaps” for three-dimensional oral and oropharyngeal reconstructions. © 2012 Wiley Periodicals, Inc. Head Neck, 2012

The parotid is the commonest site of cutaneous metastases in the head and neck. The role and extent of neck dissection in patients with parotid metastatic cutaneous malignancy remains controversial.

We reviewed the lymphoscintigraphy and single photon emission CT (SPECT) of patients with melanoma who had a sentinel node in the parotid to determine the second tier cervical lymph nodes.

Levels II and III cervical nodes make up 82% of second tier lymph nodes for the parotid, and levels IV and V, 12% and 4%, respectively. Second tier lymph nodes isolated to levels I, IV, or V, bypassing levels II and III, occurred in only 2% of cases.

The risk of harboring occult metastasis in levels I, IV, and V when levels II and III are negative is low. Levels II and III neck dissection is likely to be an effective staging procedure in patients with isolated parotid metastases. © 2012 Wiley Periodicals, Inc. Head Neck, 2012

The purpose of this study was to discuss the appropriate management options for parathyroid carcinomas, which is still a subject of controversy.

A retrospective chart review of 16 patients with parathyroid carcinoma was undertaken to determine the clinical outcome.

All patients were initially treated with surgery, and 11 patients received adjuvant radiotherapy. The 5- and 10-year disease-specific survival rates were 100% and 80%, respectively; the 5- and 10-year disease-free survival rates were 69% and 43%, respectively. The 5- and 10-year locoregional control rates were 69% and 52%, respectively; the 5- and 10-year distant control rates were 89% and 74%, respectively. In this cohort, none of the clinicopathologic parameters could be defined as a predictor.

In patients with parathyroid carcinoma, definition of prognostic factors and the role of adjuvant radiation treatment has still to be elucidated. Nevertheless, angioinvasion and positive resection margins are critical factors regarding disease-free survival in patients with parathyroid carcinomas. © 2012 Wiley Periodicals, Inc. Head Neck, 2012

The purpose of this study was to investigate clinical features and prevalence of germline mutations of patients with head/neck paragangliomas.

Genetic analysis on known susceptibility genes for paragangliomas (VHL, RET, SDHB, SDHC, SDHD, and SDHAF2) was performed in 17 consecutive patients with head/neck paraganglioma (age range, 14–82 years) and 17 relatives.

Head/neck paragangliomas were usually symptomatic with “mass effect” (88.2%), without family history (82.3%), often multifocal (41.2%), never functioning, and malignant. Germline mutations were detected in 7 of 17 patients (41%; 6 SDHD and 1 SDHB). Patients with mutations were younger, with head/neck paragangliomas usually multifocal and with higher biologic aggressiveness than wild-type subjects. To date, 4 families have been studied and the prevalence of carriers was elevated (58.8%). These mutated relatives (age range, 17–71 years) were disease-free, except 4 patients in whom multiple head/neck paragangliomas were detected.

Adequate morpho-functional screening and follow-up and, if possible, genetic testing is advisable in patients with head/neck paraganglioma. © 2012 Wiley Periodicals, Inc. Head Neck, 2012

This study was carried out to explore the use of an intraoperative shunt during surgical resection of complicated carotid body tumors (CBTs).

Of the 47 patients who underwent surgical resection for CBT, an intraoperative shunt was performed in 10 patients with complicated CBTs involving the carotid artery wall between January 2005 and August 2010, and their clinical materials were respectively reviewed.

No severe complications occurred intraoperatively and postoperatively in all the 10 patients with complicated CBTs involving the carotid artery wall. No recurrence and metastasis occurred during follow-up period for a mean of 35.3 months (range, 12–60 months).

An intraoperative shunt maintained cerebral circulation, decreased the size of tumor by excluding the vascular supply of the external carotid artery, and guided the resection of CBT. The intraoperative shunt was a safe and effective way during surgical resection of complicated CBTs. © 2012 Wiley Periodicals, Inc. Head Neck, 2012

Chyle fistulas may occur after left neck dissections that include level IV, due to injury of the thoracic duct or of 1 of its major branches. Despite being unusual, this complication carries substantial postoperative morbidity and even mortality. So far, no effective intraoperative maneuver has been reported to detect this fistula at the end of a neck dissection. In this cohort study, we sought to describe a simple new maneuver, intraoperative abdominal compression, which can effectively help to identify an open major lymphatic duct on level IV at the end of a neck dissection.

From March 1989 to September 2010, 206 patients underwent neck dissections involving left level IV, and underwent intraoperative abdominal compression. There were 119 men and 87 women, with ages ranging from 18 to 81 years (median, 52 years). One hundred forty-four patients had squamous cell carcinomas, 54 had thyroid carcinomas, 5 had malignant melanomas, and 3 had salivary cancers. Distribution by type of left neck dissection was: selective including levels II, III, and IV (73 cases; 35.4%), selective including levels II, III, IV, and V (55 cases; 26.6%), selective including levels I, II, III, and IV (12 cases; 5.8%), modified radical (47 cases; 22.8%), and radical (19 cases; 9.2%). In all cases, at the end of the procedure, the endotracheal tube was temporarily disconnected from the ventilator. Keeping the dissected level IV area under clear visualization, an abdominal compression was performed. At this moment, any detected lymphatic leak was carefully clamped and tied with nonabsorbable sutures. After ventilating the patient, the intraoperative abdominal compression was repeated to reassure complete occlusion of the lymphatic vessel.

In 13 cases (6.3%), a chyle leak was detected after performing the intraoperative abdominal compression. All leaks except for 2 were successfully controlled after 1 attempt. In these 2 patients, a patch of muscle and fat tissue was applied with fibrin glue on the top. In 1 of these patients, another chyle leak in a different location was detected only at the second intraoperative abdominal compression, and was also effectively closed. Postoperatively, there were 2 (1%) chyle fistulas, both among these 13 cases, and all were successfully managed with clinical measures only. No fistulas occurred among the remaining 193 patients in whom intraoperative abdominal compression did not demonstrate lymphatic leak.

To our knowledge, this is the first description of a specific maneuver to actively detect a lymphatic fistula at the end of a left neck dissection involving level IV. In this study, intraoperative abdominal compression was able to detect an open lymphatic vessel in 6.3% of the cases, as well as to assure its effective sealing in the remaining 93.7% of the patients. Moreover, no life-threatening high-volume fistula was noted in this study. © 2012 Wiley Periodicals, Inc. Head Neck, 2012

The purpose of this study was to show the investigated prevalence rate of brownish spots of early cancer under narrow band imaging (NBI) in different sites/types of the epithelium.

In all, 125 adults with early mucosal cancer underwent NBI examination. Four types of epithelium were categorized: keratinized thick stratified squamous (type 1), nonkeratinized thin (type 2a) or very thick (type 2b) stratified squamous, and pseudo-stratified ciliated columnar epithelium (type 3).

The prevalence rate of brownish spots in early cancer of the nasopharynx, oral cavity, oropharynx, hypopharynx, and epiglottis were 11.1%, 15.9%, 21.4%, 100%, and 100%, respectively. Type 2a epithelium (odds ratio [OR], 76.45; 95% confidence interval [CI], 9.26–631.14) was a significant predictive factor for the brownish spots.

The brownish spots have higher reliability for screening in early cancer of the mouth floor, hypopharynx, and epiglottis, but not in other mucosal sites. Mucosal sites with type 2a epithelium have a higher tendency of demonstrating brownish spots. © 2012 Wiley Periodicals, Inc. Head Neck, 2012

Glucocorticoids (GCs) not only regulate metabolic and inflammatory mechanisms, but also are known to suppress tumor growth. Despite previous detection of glucocorticoid receptors (GRs) in juvenile angiofibromas, their distribution and function have not further been studied.

Juvenile angiofibroma tissue (n = 30), nasal mucosa specimens (n = 10), subepithelial stroma of nasal mucosa (n = 20), and primary fibroblasts from juvenile angiofibroma (n = 6) and nasal mucosa samples (n = 6) were analyzed by quantitative reverse transcriptase-polymerase chain reaction (RT-PCR) and immunofluorescence staining. The antiproliferative effect of GCs (dexamethasone, prednisolone, and hydrocortisone) in vitro was assessed using a bromdeoxyuridine (BrdU) assay.

An upregulation of GR transcripts and protein was shown in juvenile angiofibroma tissue and primary mesenchymal cells compared to nasal mucosa. Application of GCs resulted in a significantly higher antiproliferative effect on juvenile angiofibroma versus nasal mucosa fibroblasts in vitro.

Expression of GRs and antiproliferative effects of GCs on juvenile angiofibroma fibroblasts offer novel options for the treatment of this unique fibrovascular tumor. © 2012 Wiley Periodicals, Inc. Head Neck, 2012

While a large body of literature exists involving normative measurements for the craniofacial skeleton, few have analyzed the necessary dimensions that are pertinent in reconstruction using microvascular free flaps.

Cephalometric analysis was performed using 3-dimensional CT scans from 70 adults. Relevant dimensions of the fibula were obtained from a subset of 20 patients.

Normative cephalometric values, including various distances and angles, for the mandible and maxilla were obtained and compared to the dimensions of the fibula. Comparisons were made between measurements from men and women, and patients with full dentition and edentulous patients. Schematics for designing mandibular and maxillary reconstructions are presented.

When premorbid craniofacial anatomy cannot be discerned in the setting of extensive trauma or tumor involvement, normative dimensions may be a helpful guide for flap design and should be in the armamentarium of surgeons engaged in complex head and heck reconstruction. © 2012 Wiley Periodicals, Inc. Head Neck, 2012

Interstitial photodynamic therapy (iPDT) can be an option in the management of locally recurrent base of tongue cancer after (chemo)radiation treatment. The purpose of the current study was to develop a technique to implant light sources into the tumor tissue.

Twenty patients with previously irradiated locally recurrent base of tongue cancers who were not candidates for salvage surgery or reirradiation or refused these therapies were included in this study. The treatment planning was done on MRI. The light sources were implanted using modified brachytherapy techniques.

The iPDT could be conducted in all patients without short-term complications. At 6 months, 9 patients had complete response with 4 patients still free of disease (46–80 months). Long-term complications included pharyngocutaneous fistula in 6 patients, serious bleeding in 1 patient, and cutaneous metastasis in 2 patients.

The initial results are encouraging. There is room for improvement to control the destructive potential of iPDT through planning and monitoring tools. © 2012 Wiley Periodicals, Inc. Head Neck, 2012

Spleen tyrosine kinase (Syk) is a nonreceptor tyrosine kinase and often aberrantly expressed in human cancers. However, Syk expression pattern has not yet been investigated in nasopharyngeal carcinoma (NPC).

Samples of 223 NPC tissues were immunohistochemically stained for Syk expression and survival analysis was then performed. Interaction and co-localization of Syk with Epstein–Barr virus encoded latent membrane protein 2A (LMP2A) was explored.

High expression of Syk was detected in 24% of NPC cases, and correlated significantly with T classification, local recurrence, a lower 5-year survival rate, and a lower 5-year disease-free survival (DFS) rate. Syk expression was a significant, independent prognosis predictor for patients with NPC. LMP2A induced Syk expression in NPC and LMP2A high expression correlated with Syk high expression in NPC clinical samples.

High expression of Syk, which results partly from LMP2A expression in NPC, is associated with tumor recurrence and poor prognosis of patients with NPC. © 2012 Wiley Periodicals, Inc. Head Neck, 2012

Low serum levels of vitamin D, measured as serum 25-hydroxy-vitamin D (S-25-OHD), have been observed in several cancers.

Sixty-five adult patients with head and neck cancer, 50 men, median age 61 years (range, 33–77 years), were enrolled in this prospective cohort study. Concentrations of S-25-OHD and plasma calcium (Ca) and phosphate (Pi) were measured before cancer treatment.

The mean S-25-OHD was 42.0 (SD 22) nmol/L. Hypovitaminosis D (37.5–50 nmol/L) was found in 20% of the patients and vitamin D deficiency (<37.5 nmol/L) in 45% of the patients. No seasonal variation was seen. Subnormal plasma Ca and Pi levels were found in 11% and 9% of the patients, respectively.

Subnormal vitamin D levels were found in a significant proportion of the patients. Because vitamin D deficiency may pose these patients to increased risk of therapy-related morbidity, special attention should be paid to correction of this nutritional deficiency. © 2012 Wiley Periodicals, Inc. Head Neck, 2012

Recent studies have indicated hedgehog pathway plays a role in carcinogenesis of certain cancers. We investigated the clinical significance of its signaling components, including Sonic hedgehog (Shh), Patched (Ptch), and Gli-1, in oral squamous cell carcinoma (OSCC).

By immunohistochemistry, we determined Shh, Ptch, and Gli-1 expression in surgical specimens from 40 patients with OSCC. The relationship between expression of these molecules and clinicopathologic variables were assessed by chi-square analysis. Statistical difference of survival was compared using log-rank test.

Ptch overexpression was associated with lymphatic metastasis (p = .028). Nuclear Gli-1 overexpression correlated with primary tumor size (p = .001), lymphatic metastasis (p = .011), and tumor recurrence (p = .008). Overexpression of Ptch (p = .020) or Gli-1 (p = .002) in OSCC indicated poor prognosis in the univariate survival analysis.

Our results suggest sonic hedgehog (Shh) pathway plays an important role in OSCC progression and should be considered a potential therapeutic target. © 2012 Wiley Periodicals, Inc. Head Neck, 2012

Scapular tip osteomyogenous free flaps have been described for complex palate reconstruction. Minimal osteotomies are needed because of the similar shapes of the scapula and palate. We compared the bony morphology of the palate and scapular tip to determine the suitability of the scapular tip for palate reconstruction.

We analyzed facial and chest CT images of 10 patients, comparing the morphology of 3 simulated palate resection specimens (total palate, subtotal palate, and hemipalate) with corresponding simulated scapular tip bone flaps from the same patient.

Conformance distances between palates and simulated flaps were small, indicating close shape similarity. Median conformance distances were 3.44 mm for hemipalatectomy, 3.56 mm for subtotal palatectomy, and 3.71 mm for total palatectomy. Six outlier observations accrued from 2 patients.

Based on this analysis, there is close similarity between the shapes of the palate and the scapular tip. This similarity supports use of the scapular tip flap for selected palate defects. © 2012 Wiley Periodicals, Inc. Head Neck, 2012

Resident training in emergency airway management is not well described. We quantified training and exposure to airway emergencies among graduating Otolaryngology–Head and Neck Surgery and Anesthesiology residents.

The methods used for this study were a national web-based survey of chief residents.

The response rate was 52% (otolaryngology) and 60% (anesthesiology). More otolaryngology residents rotated on anesthesiology than anesthesia residents on otolaryngology (33% vs 8%). More anesthesiology chiefs never performed an emergency surgical airway than otolaryngology (92% vs 18%). The most common self-rating of competency was “9,” with 82% overall self-rating “8” or higher (10 = “totally competent”).

Otolaryngology and anesthesiology emergency airway management experience/training is heterogeneous and nonstandardized. Many chief residents graduate with little exposure to airway emergencies, especially surgical airways. Resident confidence levels are high despite minimal experience. This high confidence-low experience dichotomy may reflect novice overconfidence and suggests the need for improved training methods. © 2012 Wiley Periodicals, Inc. Head Neck, 2012

We performed a pilot study using Trojan vaccines in patients with advanced squamous cell carcinoma of the head and neck (SCCHN). These vaccines are composed of HLA-I and HLA-II restricted melanoma antigen E (MAGE)-A3 or human papillomavirus (HPV)-16 derived peptides, joined by furin-cleavable linkers, and linked to a “penetrin” peptide sequence derived from HIV-TAT. Thirty-one patients with SCCHN were screened for the trial and 5 were enrolled.

Enrolled patients were treated with 300 μg of Trojan peptide supplemented with Montanide and granulocyte-macrophage colony-stimulating factor (GM-CSF) at 4-week intervals for up to 4 injections.

Following vaccination, peripheral blood mononuclear cells (PBMCs) from 4 of 5 patients recognized both the full Trojan constructs and constituent HLA-II peptides, whereas responses to HLA-I restricted peptides were less pronounced.

This treatment regimen seems to have acceptable toxicity and elicits measurable systemic immune responses against HLA-II restricted epitopes in a subset of patients with advanced SCCHN. © 2012 Wiley Periodicals, Inc. Head Neck, 2012

Carcinoma ex pleomorphic adenoma (Ca ex-PA) is defined as a carcinoma arising from a primary (de novo) or recurrent benign pleomorphic adenoma (PA).

We present a parotid myoepithelial carcinoma ex pleomorphic adenoma in a 38-year-old man with a t(3;8)(p21;q13) as the only chromosomal alteration by cytogenetic and spectral karyotypic analysis (SKY).

The finding of this translocation in a subset of PA and in the present case suggests a critical role for this event in the malignant transformation of PA.

Collectively, both the cytogenetic and the molecular studies suggest the concept that PA lacking alterations pursue a benign behavior, whereas those with the t(3;8) translocation may progress to carcinoma. © 2012 Wiley Periodicals, Inc. Head Neck, 2012

The purpose of this study was to evaluate the viability of skin grafts used for correction of cicatricial ectropion resulting from previous ablative surgery and radiotherapy for head and neck cancer and to report overall outcomes of cicatricial ectropion repair.

This is a retrospective, noncomparative case series of all consecutive patients with head and neck cancer who had been exposed to high-dose radiation therapy in their periocular region and had surgical correction of their lower eyelid cicatricial ectropion through placement of a full-thickness skin graft and a lower eyelid tightening procedure by the same surgeon. The primary outcome measure was skin graft viability. Secondary outcome measures comprised postoperative complications, the overall outcome of ectropion repair as judged by improvement in symptoms of exposure keratopathy, and dependence on lubricating eye drops and ointments, as well as cosmetic improvement measured through a grading scale based on the degree of inferior scleral show and/or tarsal conjunctival eversion.

Twenty-five patients were eligible for the study. Nineteen men and 6 women had a median age of 63 years (range, 20–84 years). All 25 patients had high-dose radiation therapy for their head and neck cancer. All but 1 patient had major cancer ablative surgery performed before radiation therapy. Thirteen of 25 patients also received chemotherapy. There was 100% viability of the skin grafts used for the repair of lower eyelid cicatricial ectropion. There were a few postoperative complications including the need for revision surgery to correct residual ectropion in the lower eyelid in 2 patients, and a third patient required a revision surgery due to upper eyelid retraction and lagophthalmos after harvest of skin graft from the upper eyelid. Improvement was noted in the subjective symptoms in 22 of 25 patients (88%), whereas 17 patients (68%) were noted to have improvement in their clinical findings on slit lamp examination. All 20 patients, for whom good quality photos were available, had improvement in the degree of cicatricial lower eyelid ectropion as measured by the amount of inferior scleral show and tarsal conjunctival eversion, although 11 patients had some residual ectropion. All 20 had either good or excellent results in the appearance of their skin grafts.

Our findings suggest that full-thickness skin grafts are a nice option for correction of cicatricial lower eyelid ectropion in a previously radiated field; 100% of the grafts survived. The majority of patients had improvement of ocular surface damage and symptoms, with a decreased dependence on topical lubricants. All evaluable patients had improvement in the degree of cicatricial lower eyelid ectropion, although close to one-half of patients had some mild residual ectropion. The majority of patients had excellent appearance of the skin graft. © 2012 Wiley Periodicals, Inc. Head Neck, 2012

We postulated that disruptions of the canonical transforming growth factor-beta (TGF-β)/Smad signaling pathway might contribute to the development of head and neck squamous cell carcinoma (HNSCC).

A cohort of 798 HNSCC tumor samples from 346 patients were analyzed by immunohistochemistry (IHC) to define the pattern of expression of (phospho)Smad2, (phospho)Smad3, and Smad4.

We found that 19%, 40%, and 12% of HNSCC specimens failed to express pSmad2, pSmad3, or Smad4, respectively. Loss of Smad2/3 activation was observed in 8.5% of specimens. In addition, 4% of specimens failed to express only Smad4. Moreover, patients with pSmad2/3-negative tumors had a significantly better overall survival than that of those whose tumors expressed activated Smad2/3. In contrast, loss of Smad4 expression did not have prognostic significance.

Our results indicate that HNSCC in which Smad2/3 are inactivated or in which Smad4 expression is lost represent 2 distinct tumor subtypes with different clinical outcomes. © 2012 Wiley Periodicals, Inc. Head Neck, 2012

Most of the reports about lymph node (LN) metastasis in papillary thyroid carcinoma (PTC) are retrospective studies.

We prospectively evaluated the pattern and predictive factors of LN metastasis of 176 patients with PTC who underwent total thyroidectomy and bilateral central LN dissection with or without therapeutic lateral LN dissection.

Ipsilateral central LNs were involved even in early T classification, and contralateral central LNs were infrequently involved even in late T classification. Most of the lateral LN metastases were in levels II, III, and IV. Male sex was predictive of LN metastasis. Ipsilateral central LN metastasis and central LN metastasis were associated with contralateral central LN metastasis and lateral LN metastasis, respectively.

Ipsilateral central neck dissection is recommended for all PTC patients. Careful inspection for LN metastasis should be performed when evaluating male patients with PTC, and if central LNs are involved, carefully inspect lateral LNs. © 2012 Wiley Periodicals, Inc. Head Neck, 2012

There are limited data on the role of laser-assisted surgery for early glottic cancer in elderly patients.

This retrospective study was conducted on a series of 130 consecutive cases of early glottic carcinoma occurring in elderly patients (>65 years old) treated with CO₂ laser surgery.

The overall and disease-specific survival rates were 87.7% and 99.2%, respectively. The rates of local disease control after primary laser surgery, ultimate local control with laser alone, and laryngeal preservation were 84.6%, 93.8%, and 96.9%, respectively. A shorter disease-free survival (DFS) was associated with the involvement of 1 or more specific laryngeal regions (arytenoids, ventricle, anterior commissure, vocal muscle, subglottis) (p = .01) and the status of the surgical margins (p = .002); on multivariate analysis, only the latter remained prognostically significant vis-à-vis the DFS (p = .002).

Even in elderly patients with early glottic carcinoma, endoscopic laser surgery is an effective treatment. © 2012 Wiley Periodicals, Inc. Head Neck, 2012

The seventh edition of the American Joint Committee on Cancer (AJCC) Staging Manual introduced a more detailed system to stage regional lymph node metastases for disease with cutaneous squamous cell carcinoma (SCC). The purpose of this study was to determine if the inclusion of disease staged N2 and N3 together with disease staged M1 is an appropriate grouping within stage IV.

A retrospective multicenter analysis was conducted of 603 patients with metastatic cutaneous SCC to compare survival data for regional (N2 and N3) versus distant metastases.

Disease specific survival (DSS) and overall survival (OS) were much poorer for patients with distant disease compared to those with different stages of regional disease. After 5 years, only 25% of patients with N2 disease and 35% of patients with N3 disease died from their cancer compared with 89% of patients with distant metastases.

Our results indicate that in cutaneous SCC, stage IV represents a very heterogeneous group. Therefore, N2 and N3 disease should not be grouped with M1 together within AJCC stage IV. © 2012 Wiley Periodicals, Inc. Head Neck, 2012

The treatment results of buccal squamous cell carcinoma before and after 2002 were compared.

Two hundred forty-five patients with buccal cancer who underwent curative treatment were retrospectively reviewed.

The 5-year overall survival rate was 30.0% before 2002 and 53.5% after 2002 (p = .004). On multivariate analysis, T classification, surgical margins, and treatment modality significantly affected overall survival, and N classification and histologic grade had trends to affect it. Invasion depth had a trend to influence locoregional control. For patients with early-stage disease without adverse factors, the locoregional control was similar between surgery alone group and surgery + radiotherapy group.

The survival of patients with buccal cancer was improved after 2002, which represented the start of intensity-modulated radiotherapy (IMRT) in our institute. Ipsilateral neck alone irradiation was recommended for T1-2N0-1 and small T3N0 disease, and bilateral neck irradiation could be reserved for advanced disease. © 2012 Wiley Periodicals, Inc. Head Neck, 2012

Patients with head and neck cancer have similar risk factors to patients with carotid disease. Patients with head and neck cancer should be screened with vascular consultations obtained as indicated. Identification of significant carotid artery disease before surgical treatment of head and neck cancer is important in order to prevent perioperative and future strokes.

Eleven patients underwent carotid duplex ultrasound followed by vascular consultation for significant asymptomatic and symptomatic carotid stenosis. Carotid endarterectomy was performed during an oncologic resection of head and neck cancer between the years of 1996 and 2011.

There were no local or regional recurrences. There were no perioperative deaths or strokes. Two-year and 5-year survival were 70% and 29%, respectively, with a median survival of 51 months.

Collaboration of head and neck surgeons with vascular surgeons provides the patient with an oncologic resection and revascularization with a low perioperative risk of stroke. This improves the patient's quality of life by lessening the possibility of a stroke postoperatively. © 2012 Wiley Periodicals, Inc. Head Neck, 2012

The objective of the present study was to relate the dimensions and the intraluminal pressure of the pharyngoesophageal segment (PES) to the voice and speech proficiency of total laryngectomees with a tracheoesophageal prosthesis (TEP).

Twenty total laryngectomees with secondary TEP insertion underwent evaluation of voice and speech, manometry, and videofluoroscopy.

Most laryngectomees (65%) were moderate speakers. The poorer speakers presented a lower intraluminal pressure in the PES at rest (4.44 mmHg) and a higher value (40.46 mmHg) during phonation. Good speakers presented a significant difference in the anteroposterior distance between prominence of the PES and the posterior pharyngeal wall (PPES-PPW) in the rest (6.09 mm) to phonation (3.24 mm).

The poorer speakers presented a lower intraluminal pressure in the PES at rest and a higher value during phonation compared with moderate speakers. Good speakers showed a significant difference in the PPES-PPW dimension. © 2012 Wiley Periodicals, Inc. Head Neck, 2012

This study aimed to test the safety of using perioperative high-dose-rate brachytherapy (PHDRB) in resected head and neck cancer.

From 2000 to 2008, 97 patients received PHDRB after complete macroscopic resection. Group 1 (previously irradiated patients) received 32 to 40 Gray (Gy) of PHDRB in 8 to 10 twice-daily (bid) treatments (R0–R1 resections). Group 2 (unirradiated patients) received 16 to 24 Gy of PHDRB in 4 to 6 bid treatments (R0–R1 resections) followed by external beam irradiation (EBRT) of 45 Gy/25 daily fractions ± concomitant chemotherapy.

The median follow-up was 4.3 years. The cumulative hazard of 2-year grade ≥ 3 complications in group 1 was 45.9%, and the rate of grade ≥ 3 complications in group 2 was 24.6%. Actuarial locoregional control at 2 and 5 years for group 1 was 60.9% and for group 2, 84.1% and 79.4%.

Complications and locoregional failure rates were similar to those reported in the reference standards despite a much smaller treatment volume. © 2012 Wiley Periodicals, Inc. Head Neck, 2012

Minor salivary gland malignancies in children are rare and data on treatment and outcomes are limited.

A retrospective chart review of all pediatric patients with the pathologic diagnosis of minor salivary gland malignancy at a tertiary care cancer hospital was used to conduct this review.

From 1952 to 2006, 35 children with minor salivary gland cancers were treated at The University of Texas MD Anderson Cancer Center. Mean age was 15.2 +/- 2.9 years with a slight female predominance. Recurrence occurred in 4 patients and was significantly associated with positive margins, advanced stage, and high histologic grade. Overall survival (OS) and disease-specific survival (DSS) were 89.3% and 88.4%, respectively, at 5 years. Advanced stage, positive margins, and high grade were associated with adverse survival.

Minor salivary gland malignancies in children are rare. Surgical resection with clear margins yields excellent outcomes in patients with low-intermediate grade and early stage tumors. Patients with high-grade malignancies do poorly despite multimodality therapy. © 2012 Wiley Periodicals, Inc. Head Neck, 2012

To assess volumetric changes of human papillomavirus (HPV)-related lymph nodes (LN) before, during, and after a course of intensity-modulated radiation therapy (IMRT) ± chemotherapy.

Each “pathologic” LN (≥1 cm) was contoured on the available diagnostic/planning CTs before, during each week, and after treatment.

Seventy-nine LNs in 50 patients were identified. Beyond the first week of treatment, 3 patterns of LN change were recorded: consistently shrinking LN (n = 33; 41.8%), inconsistently shrinking LN with temporary enlargement limited to the first week (n = 14; 17.7%), or also during the subsequent weeks (n = 32; 40.5%). Nodal density at planning is highly predictive of group assignment, with a larger mean density for consistently over inconsistently shrinking LNs (p = .009). Also, this grouping predicts the response at the end of treatment.

HPV-related LN behavior during IMRT is extremely variable but somewhat predictable on the basis of nodal density at planning. © 2012 Wiley Periodicals, Inc. Head Neck, 2012

Apoptosis induced by Fas/FasL system has been proposed as a gene therapy methold for various cancers.

We used adeno-associated virus–expressing enhanced green fluorescent protein (EGFP)-human FasL (AAV-EGFP-hFasL) to deliver FasL into Hep-2 cells, cytotoxicity was detected by MTS assay , apoptosis was confirmed by flow cytometry. We also treated the xenograft of Hep-2 tumor in nude mice with intratumoral injection of AAV-EGFP-hFasL. The size of the xenograft, the apoptosis in the xenograft, and the survival rate of the inoculated mice were then evaluated.

Hep-2 cells infected with AAV-EGFP-hFasL showed increased apoptosis rate and killing effect compared with AAV-EGFP–infected cells. In addition intratumoral injections of AAV-EGFP-hFasL into Hep-2 xenografts induced significant growth suppression of tumors.

Our findings suggest that the introduction of FasL into head and neck squamous cell carcinoma may induce significant apoptosis, and adeno-associated virus may be a useful vehicle for gene therapy. © 2012 Wiley Periodicals, Inc. Head Neck, 2012

The purpose of this study was to evaluate a new surgical method, plastic cordotomy for treatment of bilateral vocal fold immobility.

We used cadaver experiments on 20 larynges to measure the widening of the glottis after bilateral plastic cordotomy. We conducted a prospective study of 21 female patients operated on with bilateral plastic cordotomy.

Bilateral plastic cordotomy enlarged the width of glottis to 9.55 (range, 8.3–10) mm in men and 8.5 (range, 7.4–8.8) mm in women and the area of glottis to 110.5 mm² (range, 88–149 mm²) in men and to 84.5 mm² (range, 59–107 mm²) in women. Clinical study revealed that the mean of peak inspiratory flow increased from 1.09 (0.41) L/seconds before surgery to 2.85 (0.67) L/seconds in long-term.

Plastic cordotomy is an effective, anatomically based method to alleviate obstruction in bilateral vocal fold immobility patients. The main advantage of plastic cordotomy is long-term stability of results due to prevention of restenosis. © 2012 Wiley Periodicals, Inc. Head Neck, 2012

The purpose of this study was to describe the incidence of nodal disease in sebaceous carcinoma and its impact on survival.

Data from the 17 registries of the Surveillance, Epidemiology, and End Results (SEER) database was retrospectively collected for sebaceous carcinoma from 1973 to 2007. Information on location, histologic grade, stage of disease, and survival was gathered.

One thousand eight hundred thirty-six sebaceous carcinomas were diagnosed during the time period: 633 (34.5%) in the eyelid and 786 (42.8%) in the extraocular head and neck skin. Eyelid sebaceous carcinomas had higher histologic grade compared with tumors in extraocular sites (p < .001). Ocular sebaceous carcinomas had a higher incidence of regional or distant metastases at presentation (4.4%) compared with extraocular head and neck sites (0.9%; p = .03). There was a high incidence of N+ disease in poorly differentiated ocular sebaceous carcinomas (15.2%).

The incidence of nodal disease was higher with eyelid tumors. Sentinel lymph node biopsy can be considered for eyelid tumors, but not for non-eyelid head and neck tumors. © 2012 Wiley Periodicals, Inc. Head Neck, 2012

Demands for organ preservation and increasing knowledge in molecular tumor biology have lead to the development of molecular targeting agents. These substances have also been incorporated into concomitant and sequential chemoradiation protocols.

This study was conducted using a systematic literature review.

In head and neck squamous cell carcinoma (HNSCC), the inhibition of epidermal growth factor receptor (EGFR) signaling as a central step in carcinogenesis, progression, and metastasis is the predominant approach. Although EGFR targeting substances are commonly used, the specific influence of molecular targeting therapies on patient outcome remains unclear. In this review, results from recent clinical trials in the area of primary chemoradiation in the combination with EGFR targeting agents are discussed.

Encouraging results from recent trials need to be confirmed in larger patient cohorts and cost-effectiveness analyses have to be undertaken. Phase III studies need to confirm these results before, time and again, new phase II studies are initiated. © 2012 Wiley Periodicals, Inc. Head Neck, 2012

Little information has been reported on regional and time trends of human papillomavirus (HPV) prevalence rates of oropharyngeal cancer (OPC) and non-OPC.

The study consisted of a systematic review and meta-analysis using random effects logistic regression models.

Overall HPV prevalence in OPC (47.7%; 95% confidence interval [CI], 42.9–52.5%) increased significantly over time: from 40.5% (95% CI, 35.1–46.1) before 2000, to 64.3% (95% CI, 56.7–71.3) between 2000 and 2004, and 72.2% (95% CI, 52.9–85.7) between 2005 and 2009 (p < .001). Prevalence increased significantly in North America and Europe, and the significant gap between them that existed before 2000 (50.7% vs 35.3%, respectively, p = .008) has now disappeared (69.7% vs 73.1%, respectively, p = .8). Prevalence in non-OPC (21.8%; 95% CI, 18.9–25.1%) has not increased over time (p = .97)

The sharp increase in the proportion of HPV-positive OPC over the last decade has occurred at a faster rate in Europe compared with that in North America. In contrast, the relatively low prevalence of HPV in non-OPC remains unchanged. © 2012 Wiley Periodicals, Inc. Head Neck, 2012

High rates of positive surgical margins are reported after a maxillectomy. A large part of tumors that are preoperatively considered “operable” can thus not be resected with tumor-free margins.

This was a retrospective study on medical files of 69 patients that underwent maxillectomy as primary treatment for a squamous cell carcinoma.

More than one third (39%) of all resections performed is incomplete, with dorsal or dorsocranial-positive surgical margins in two thirds. Correlation of tumor extension on preoperative imaging to surgical margins status revealed that dorsal and cranial tumor extension were significant prognostic factors for tumor positive surgical margins (p = .006 and p = .031, respectively). Positive margins were associated with a 2-fold increased risk of death (hazard ratio, 2.4; 95% confidence interval, 1.2–4.9).

Cranial or dorsal tumor extension on preoperative imaging was a significant risk factor for positive surgical margins after maxillectomy with significant negative influence on overall survival. © 2012 Wiley Periodicals, Inc. Head Neck, 2012

The purpose of this study was to analyze the relationship between cytologic features, clinical features, and recurrence of papillary thyroid cancer (PTC). We hoped to predict prognosis preoperatively.

We retrospectively studied cytologic features by using computerized morphometry and clinical data of 118 patients with usual-type PTC without initial metastasis, including 34 patients with cancer recurrence in 10 years after surgery and 84 patients who did not have recurrence for more than 10 years after surgery. Another 24 patients were recruited for validation.

Multivariate logistic analysis indicated that nucleus-to-cell ratio, variation of nuclear area, tumor size, and patient age were significantly related to recurrence. Cox regression analysis showed that hazard ratios were 3.34, 1.53, 1.77, and 2.6, respectively.

Cytologic features of PTC analyzed with computerized morphometry significantly correlated with recurrence. It helped to predict prognosis preoperatively and may be helpful for planning further treatment. © 2012 Wiley Periodicals, Inc. Head Neck, 2012

The diagnostic role of cyclooxygenase-2 (COX-2) expression in laryngeal atypical hyperplasia, vocal fold nodule, and laryngeal squamous cell carcinoma was examined.

Specimens obtained from patients diagnosed with vocal fold nodule (n = 35), atypical hyperplasia (n = 35), laryngeal squamous cell carcinoma (n = 35), and clinical parameters were evaluated retrospectively.

Although no staining was observed in patients with vocal fold nodules, staining was noted in laryngeal atypical hyperplasia and squamous cell carcinoma. The percentage of COX-2 staining was the highest in the carcinoma group.

It was determined that COX-2 staining was significantly associated with laryngeal squamous cell carcinoma. It should be noted that overexpression of COX-2, a potentially important factor in the evolution of carcinogenesis in precancerous lesions, might be an indicator of the development of carcinoma. © 2012 Wiley Periodicals, Inc. Head Neck, 2012

We assessed the effectiveness of cevimeline 30 mg 3 times daily in patient-reported oral health (Oral Health Impact Profile [OHIP-49]) and quality of life (QOL) in patients with xerostomia.

In our investigator-initiated, multicenter, randomized, double-blind, placebo-controlled study, patients who received >40 Gy of radiation therapy to the head and neck including at least 3 major salivary glands were randomized to cevimeline 30 mg or placebo orally 3 times daily for 6 weeks. Patients had to have grade 1 or 2 xerostomia and be >16 weeks posttreatment. Clinical data were collected and questionnaires administered at baseline and week 6. The primary outcome was change in OHIP-49 total score from baseline to week 6.

No statistically significant differences in oral health or QOL were observed. During the 6 weeks of the study, the severity of xerostomia decreased from baseline.

Xerostomia is a significant sequela of treatment of head and neck cancer that may improve with time. The role of oral parasympathetic muscarinic secretogogues in alleviating patient symptoms and complaints remains unclear. © 2012 Wiley Periodicals, Inc. Head Neck, 2012

Cricopharyngeus is the only muscle for which electromyography is used in the differential diagnosis of swallowing disorders. Because of some practical difficulties, electrophysiologic tests for this muscle are not performed routinely. Thus we aimed to describe an alternative topographic way to reach the muscle easily.

On 10 cadavers, a spinal needle (20 G) and on 37 patients a concentric needle electrode (26 G) were used. The needle was inserted percutaneous at the level of the superior border of the cricoid cartilage, anterior to the anterior border of the sternocleidomastoid muscle at 60 degrees angle to the frontal plane in the posteromedial direction.

We reached the muscle in all cadavers. In all of the patients, the needle entered the muscle on the first attempt; that was confirmed by electromyographic responses.

Our results show that this method can be useful for the practical application of cricopharyngeus muscle electromyography. © 2012 Wiley Periodicals, Inc. Head Neck, 2012

Tissue imprinting can generate molecular marker maps of tumor cells at deep surgical margins. The purpose of this study was to evaluate the feasibility of this method for detection of residual head and neck squamous cell carcinoma (HNSCC).

Paired fresh tissue and nitrocellulose membrane imprints of tumor and deep margins were collected from 17 HNSCC resections. DNA was amplified using quantitative methylation-specific polymerase chain reaction (qMSP) for p16, DCC, KIF1A, and EDNRB. Levels of methylation in tumors and deep margins were compared.

DNA from imprints was adequate for qMSP. Hypermethylation of target genes was present in 12 of 17 tumors and in 8 deep margins. Methylation level was better from margin imprints than tissue. During follow-up (median, 13 months), local or regional recurrences occurred in 6 cases of which 5 had molecularly positive margins.

Tissue imprinting is feasible for molecular detection of residual tumor at deep surgical margins and may correlate with locoregional recurrence. © 2012 Wiley Periodicals, Inc. Head Neck, 2012

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.

We identified patients with large nerve PNI from cutaneous SCCHN between January 1996 and 2006 from a prospectively collected database. Patients who underwent surgical resection as their primary mode of therapy were included. Clinical and demographic variables were recorded. Survival analysis was performed with Kaplan-Meier curves, and the log-rank test was used for significance testing between groups.

Twenty-one patients were identified. The mean age was 60 (range, 38–86) years, with 15 men and 6 women. Nineteen patients had a formal skull base resection, whereas 2 patients had a subcranial resection. We had 3 complications in our series: extradural hemorrhage (n = 1), cerebrospinal fluid leak (n = 1), and wound infection (n = 1). None of the patients who underwent a formal skull base resection to include the lateral cavernous sinus (ie, Gasserian ganglion) suffered ocular palsies or permanent morbidity when the orbit was preserved (n = 11). We had no surgical deaths. The average length of stay was 9 days (SD 6.3 days). The 5-year disease specific survival rate for the entire group was 64.3%. V3 involvement resulted in lower, although not significant, 5-year disease-free survival rates— 0% for those patients with involvement (n = 4) versus 66.8% for no involvement of V3 (n = 17).

Appropriately planned surgical resection of PNI in cutaneous SCCHN up to the ganglion as dictated by the disease extent may improve survival without significant added morbidity. © 2011 Wiley Periodicals, Inc. Head Neck 2011

Squamous cell carcinoma of the head and neck can present as a cervical metastasis from an unknown primary site. The standard diagnostic workup includes panendoscopy and directed biopsies but this will fail to identify a portion of unknown primary tumors.

Herein, we present a case report of a male patient with an unknown primary tumor in which the da Vinci surgical robot was used to evaluate the tongue base.

Clinical evaluation, imaging, and panendoscopy with directed biopsies failed to detect the primary tumor site. Robot-assisted biopsy of a broad area of the tongue base, incorporating submucosal tissue, identified the primary tumor with minimal postoperative morbidity.

Failure to localize an unknown primary tumor often results in widespread irradiation of the upper aerodigestive tract, inducing significant morbidity. Robot-assisted biopsies of the tongue base may identify unknown primaries that would otherwise have been missed through standard directed biopsy techniques. © 2011 Wiley Periodicals, Inc. Head Neck, 2011

Indications for thyroidectomy during laryngectomy are controversial. We examined whether clinicopathologic features can predict thyroid gland involvement, and the prognostic effect of thyroid gland involvement in patients undergoing total laryngectomy.

The study set out to review preoperative assessment, operation findings, pathologic findings, and follow-up data.

Thyroid gland involvement was found in 11 of 53 patients (21%) undergoing total laryngectomy and thyroidectomy. Preoperative work-up failed to predict thyroid gland involvement. Thyroid gland involvement was associated with salvage procedures (p = .025), paratracheal metastases (p = .003), and poor overall survival (hazard ratio = 2.74, p = .008).

Thyroid gland involvement in patients undergoing total laryngectomy is frequent and is associated with poor prognosis. Preoperative assessment failed to predict thyroid gland involvement. We believe that thyroidectomy should be considered in cases with paratracheal lymphatic spread irrespective of tumor location within the larynx. © 2011 Wiley Periodicals, Inc. Head Neck, 2011

The prognosis for patients with mucosal malignant melanoma (MMM) of the nasal cavity is very poor because of the radioresistance of melanoma cells.

We present the first case report of the efficacy of superselective intra-arterial cisplatin (CDDP) infusion concurrent with hypofractionated radiotherapy (RT) for MMM of the nasal cavity.

A pink, polypoid mass, histopathologically diagnosed as an amelanostic melanoma, occupied the right nasal cavity. After the treatment, a nasal tumor disappeared, leaving only a small bulge in the medial wall of the middle turbinate. Histopathologic examination revealed scattered degenerated melanoma cells, remaining only in the small restricted area in the medial surface of the excised middle turbinate. Twelve months after the treatment, the patient has not experienced any local recurrence or regional and distant metastasis.

The superselective intra-arterial CDDP infusion concurrent with hypofractionated RT might be useful for the management of nasal MMM. © 2011 Wiley Periodicals, Inc. Head Neck, 2011

We planned a phase I study of weekly arterial infusion of docetaxel and cisplatin via a superficial temporal artery for recurrent head and neck cancer to determine the optimal dose.

The dose of cisplatin was fixed and the dose of docetaxel was escalated from 8 mg/m², with an increase of 2 mg/m² per step, to identify the maximum tolerated dose (MTD). In total, 4 courses of weekly chemotherapy were administered.

Twelve patients were recruited to this trial. The MTD of docetaxel was 14 mg/m². At this dose level, dose-limiting toxicity was observed in 2 of 3 patients. One patient experienced grade 3 leukopenia, while the other experienced grade 3 leukopenia. Myelosuppression was the dose-limiting toxicity for this regimen.

The recommended dose for weekly arterial infusion of docetaxel was identified as 12 mg/m² combined with weekly cisplatin at 40 mg/m², with 4 courses of each. © 2011 Wiley Periodicals, Inc. Head Neck, 2011

This phase II study tested the addition of the oral epidermal growth factor receptor gefitinib to multiagent concurrent chemoradiotherapy regimen in head and neck squamous cell cancer (HNSCC).

Patients with stage III–IV HNSCC received hyperfractionated radiation (72–74.4 Gy at 120 cGy twice daily), with concurrent 96-hour infusions of cisplatin 20 mg/m²/day and fluorouracil 1000 mg/m²/day given during weeks 1 and 4. Daily gefitinib 250 mg was started on day 1 of radiation and continued for 2 years. Results were retrospectively compared with our previous study using identical chemoradiotherapy without gefitinib.

Sixty patients were enrolled in the study; 80% had stage IV disease and 68% had oropharyngeal primary tumors. The full course of gefitinib was not tolerated by 42%; there were 5 treatment-related deaths (8%). With a median follow-up of 54 months, 2- and 3-year overall survival estimates were 80% and 71%, respectively. Projected distant metastatic control at 2 and 3 years was 88%. When compared with our historical cohort, acute toxicities including renal dysfunction and unplanned rehospitalization were worse in the study patients. Projected outcome estimates did not differ between the 2 cohorts.

Addition of gefitinib to concurrent chemoradiotherapy was difficult to complete, did not improve outcomes, and increased toxicity. © 2011 Wiley Periodicals, Inc. Head Neck, 2011

Negative pressure drainage has been shown to be an effective treatment of chyle fistula. However, the optimal level of negative pressure has not been determined. We therefore conducted a prospective randomized trial to address this issue.

In all, 21 patients with chyle fistula were randomly assigned to a high negative pressure suction (HNPS) group (−600 mmHg, n = 10) or low negative pressure suction (LNPS) group (−125 mmHg, n = 11). The duration of drain leakage and hospital stay, and the incidence of complications were compared between the 2 groups.

All patients were successfully treated with conservative management without surgical intervention. The median durations of chyle leakage and hospital stay were significantly shorter in the HNPS group compared with the LNPS group: 4 versus 7 days (p = .0048) and 5 versus 11 days (p = .0107), respectively.

Negative suction was demonstrated to be highly effective in the management of chyle fistula, and HNPS appeared to be more efficient than LNPS. © 2011 Wiley Periodicals, Inc. Head Neck, 2011

Oral squamous cell carcinoma (OSCC) is the sixth most common type of carcinoma worldwide. The pathogenic pathways involved in this cancer are mostly unknown; therefore, a better characterization of the OSCC gene expression profile would represent a considerable advance. The public availability of gene expression datasets was meant to obtain new insights on biological processes.

We integrated 4 public microarray datasets on OSCC to evaluate the degree of consistency among the biological results obtained in these different studies and to identify common regulatory pathways that could be responsible for tumor growth.

Twelve altered cellular pathways implicated in OSCC and 4 genes altered in the extracellular matrix (ECM) receptor pathway were validated by quantitative real-time polymerase chain reaction (qRT-PCR).

Using 4 expression array datasets, we have developed a robust method for analyzing pathways altered in OSCC. © 2011 Wiley Periodicals, Inc. Head Neck, 2011

Few human papillomavirus (HPV)(+) head and neck squamous cell carcinoma (HNSCC) cell lines exist. We established University of Michigan-squamous cell carcinoma-104 (UM-SCC-104), a new HPV(+) HNSCC cell line from a recurrent oral cavity tumor, and characterized it for the presence of cancer stem cells (CSCs).

Tumor cells were tested for biomarker expression by immunohistology, and the presence of HPV was assessed by several methods.

UM-SCC-104 has a unique genotype, contains HPV-16, and expresses E6/E7. Inoculation of aldehyde dehydrogenase (ALDH)(+) and ALDH(−) cells in an immunocompromised mouse resulted in tumor growth from the ALDH(+) cells after 6 weeks that recapitulated the histology of the primary, whereas ALDH(−) cells did not produce tumors.

UM-SCC-104, a new HPV-16, CSC-containing HNSCC cell line will aid in studying recurrent HPV(+) tumors. The aggressive nature of this tumor is consistent with high uniform expression of epidermal growth factor receptor (EGFR) and a functionally significant proportion of ALDH(+) CSCs. © 2011 Wiley Periodicals, Inc. Head Neck, 2011

Adenoid cystic carcinoma (ACC) of the salivary gland frequently develops lung metastases. In cases in which chemotherapy is indicated, resistance is a common phenomenon. New drugs, such as cetuximab, have been chosen to avoid this chemoresistance.

A 54-year-old man was diagnosed with ACC of the right submandibular gland. He underwent a submandibular gland resection with adjuvant radiotherapy. Three years later, bilateral lung metastases were diagnosed and treated with various chemotherapy schedules, including paclitaxel without success. We obtained radiographic response, followed by disease stabilization for more than 1 year with the addition of cetuximab to paclitaxel administered at low weekly doses (metronomic schedule).

This case demonstrates for the first time a reversion of primary resistance to chemotherapy in ACC that is currently considered chemoresistant by use of a combination of metronomic chemotherapy with new targeted agents such as cetuximab. Metronomic chemotherapy was also well tolerated and achieved long-term response. © 2011 Wiley Periodicals, Inc. Head Neck, 2011