Faculty Bibliography

BACKGROUND: Postoperative swallowing function may be influenced by a number of treatment variables; this study examines the relationship of various treatment factors to measures of swallow function. METHODS: Swallowing was examined with the modified barium swallow procedure in 144 patients surgically treated for oral or oropharyngeal cancer 3 months after healing. Univariate and multivariate correlations were used to examine the relationship between swallowing function and treatment. RESULTS: Percent tongue base resected and total volume resected were most often correlated with swallowing function in the univariate analyses. Multivariate analyses identified the following combinations with the strongest correlations: (1) percent tongue base resected and closure type for liquids; (2) percent tongue base resected and unreconstructed mandible for pastes; (3) total volume resected, percent lateral floor of mouth resected, and postoperative radiotherapy dose for masticated boluses. CONCLUSIONS: Total volume resected and percent tongue base resected had a profound impact on postoperative swallowing function. Combinations of percent tongue base resected with other surgical variables had the strongest relationships with overall swallowing function

BACKGROUND: The term collision tumor represents the proximal coexistence of two histologically distinct tumors. Collision tumors within the thyroid are extremely rare, and reported cases are usually of mixed histologies of papillary and medullary carcinomas. Metastatic disease to the thyroid is also an uncommon scenario but may develop after long disease-free intervals. Carcinomas, most commonly renal cell carcinoma, are the likeliest group of neoplasms to metastasize to the thyroid. Soft tissue sarcomas metastasize to the thyroid with a much lower frequency. METHODS: We are reporting this highly unusual case of metastatic liposarcoma from the thigh to thyroid, which harbored a collision tumor of papillary thyroid carcinoma. This 86-year-old woman had undergone an initial resection for liposarcoma of the thigh two decades before being seen with a thyroid mass. RESULTS: Histologically, the thyroid mass was a metastatic myxoid liposarcoma, identical to the primary neoplasm. Papillary thyroid carcinoma was present within this metastasis and in the adjacent thyroid. CONCLUSION.: For any patient seen with a thyroid mass with a history of prior malignancy, no matter how remote, metastatic disease should be considered in the differential diagnosis

OBJECTIVES: To examine the long-term effect of nasoalveolar molding and gingivoperiosteoplasty (modified Millard type) on midface growth at prepuberty. PROCEDURES: In this retrospective study, 20 consecutive patients with a history of complete unilateral cleft lip and palate were evaluated. Ten patients had nasoalveolar molding and gingivoperiosteoplasty performed at lip closure; 10 control patients had nasoalveolar molding but no gingivoperiosteoplasty because of late start in treatment or poor compliance. A single surgeon (C.B.C.) performed all surgical procedures. Standardized lateral cephalometric radiographs were evaluated at two time periods: T1 at pre-bone-grafting age and T2 at prepuberty age. Superimposition and cephalometric analysis were undertaken to investigate the two groups. Two cephalometric reference planes, sella-nasion and basion-nasion, were used to assess the vertical and sagittal relations of the midface (ANS-PNS). The reference landmarks were procrustes fitted. The mean location and variance of ANS and PNS landmarks were computed. All results were analyzed by permutation test. RESULTS: No significant difference in mean location or variance of ANS-PNS in both vertical and sagittal planes at both T1 and T2 periods were found between the two groups (p > .05). CONCLUSIONS: The results suggested that midface growth in sagittal or vertical planes (up to the age of 9 to 13 years) were not affected by presurgical alveolar molding and gingivoperiosteoplasty (Millard type).

OBJECTIVE: To review the management of cerebrospinal fluid leak after vestibular schwannoma removal reported in the literature and to present a novel approach to management of recalcitrant cases. DATA SOURCES: MEDLINE and PubMed literature search using the terms 'cerebrospinal fluid leak' or 'cerebrospinal fluid fistula' and 'acoustic neuroma' or 'vestibular schwannoma' covering the period from 1985 to present in English. A review of bibliographies of these studies was also performed. STUDY SELECTION: Criteria for inclusion in this meta-analysis consisted of the availability of extractable data from studies presenting a defined group of patients who had undergone primary vestibular schwannoma removal and for whom the presence and absence of cerebrospinal fluid leakage was reported. Studies reporting combined approaches were excluded. No duplications of patient populations were included. Twenty-five studies met the inclusion criteria. DATA EXTRACTION: Quality of the studies was determined by the design of each study and the ability to combine the data with the results of other studies. All of the studies were biased by their retrospective, nonrandomized nature. DATA SYNTHESIS: Significance (p < 0.05) was determined using the chi test. CONCLUSIONS: Incisional cerebrospinal fluid leakage responded well to local management and lumbar drainage. Rhinorrhea often necessitated surgical intervention. No specific reoperation techniques correlated exclusively with better reoperation outcomes. The transaural/transnasal approach presents an alternative for surgical management of cerebrospinal fluid rhinorrhea

OBJECTIVE: We studied the hearing results and outcomes after transcrusal craniotomy. STUDY DESIGN: We conducted a retrospective review. SETTING: This study was conducted at a tertiary care hospital. PATIENTS: We studied 10 consecutive patients, including two men and eight women, who underwent transcrusal craniotomy for petroclival masses or tumors. INTERVENTION: The intervention consisted of therapeutic removal of petroclival meningioma. MAIN OUTCOME MEASURE: The main outcome measure of this study was hearing preservation as measured by standard audiogram. RESULTS: There were six meningiomas, one eighth nerve schwannoma, one fifth nerve schwannoma, one chordoma, and one midbasilar artery aneurysm. Postoperative hearing was measured according to the AAOHNS criteria. Complications and further therapies were recorded. Postoperative hearing was measured in eight. The cochlear nerve was severed in one patient. One was unavailable for follow up. Eight patients retained hearing at or near preoperative levels, seven with SRT within 10 dB and speech discrimination within 10% of preoperative levels. Four patients presented with trigeminal symptoms, one with third nerve palsy and two with facial weakness. Postoperative deficits included fourth, sixth, seventh, and eighth nerve palsies in three patients. Complications included one wound infection, two cerebrospinal fluid leak, and two cases of meningitis, both of which were sterile. There were secondary procedures in five patients-three radiosurgery, two shunts, one tracheotomy, and one g-tube. CONCLUSIONS: Transcrusal craniotomy is a safe and effective approach to the petroclival region. Excellent hearing results can be expected with this technique.

Paragangliomas are neuroendocrine tumors derived from the extra-adrenal paraganglia of the autonomic nervous system. Within the head and neck, they are generally defined and named according to their site of origin, and may be found frequently neighboring vascular structures. Physiologic activity is rare in these neoplasms and they may exhibit patterns of inheritance which predispose their occurrence in families, often with multicentricity. These tumors generally exhibit a slow rate of growth, most often presenting asymptomatically as a space occupying mass lesion noted clinically or radiographically. The most common paraganglioma of the head and neck is the carotid body tumor followed by the jugulo-tympanic and vagal varieties. Other rare sites where this tumor may occur include; the larynx, sinonasal chambers and orbit. Diagnosis is generally made through a combination of clinical findings and radiographic studies. Magnetic resonance represents the most important imaging modality for the evaluation and characterization of suspected head and neck paraganglioma. Definitive management for these lesions should be carefully considered in relation to both tumor and patient-oriented factors, especially in regard to the potential morbidity of treatment. Surgery and radiation therapy represent the main treatment modalities for paraganglioma. The selection of treatment depends on the size, location, and biologic activity of the tumor as well as the overall fitness of the patient. Although radiotherapy may be effective in arresting growth of these tumors, rarely is the neoplasm eliminated without surgical resection. Surgery may be associated with significant morbidity, primarily as a consequence of incurring major cranial nerve injury. Patient selection (relative to age and medical condition) should be carefully considered prior to recommending aggressive surgery for paragangliomas of head and neck, especially in those patients at risk for disabling surgical morbidity

OBJECTIVE: To determine whether children with a clinical assessment suggestive of obstructive sleep apnea (OSA) but with negative polysomnography (PSG) have improvement in their clinical assessment score after tonsillectomy and adenoidectomy (T&A) as compared with similar children who do not undergo surgery. METHODS: In a prospective, randomized, investigator-blinded, controlled trial, 59 otherwise healthy children (mean age: 6.3 years [3.0]; 31 boys, 28 girls) with a clinical diagnosis of OSA (clinical assessment score 40) were recruited from the pediatric otolaryngology and pediatric pulmonary private offices and clinics of a tertiary care, academic medical center. A standardized assessment was performed on all patients, including history, physical examination, voice recording, tape recording of breathing during sleep, lateral neck radiograph, echocardiogram, and PSG. A clinical assessment score was assigned. Children with positive PSG (n = 27) were scheduled for T&A, whereas children with negative PSG (n = 29) were randomized to T&A (n = 15) or no surgery (n = 14). Children were reassessed in an identical manner at a planned 6-month follow-up. RESULTS: Follow-up was available for 21 patients with positive PSG, 11 patients with negative PSG randomized to T&A, and 9 nonsurgery patients. In the randomized subjects, the median reduction in clinical assessment score was 49 (range: 32-61) for the T&A patients as compared with 8 (range: -9 to 29) for the nonsurgery patients. Nine (82%) of the T&A patients were asymptomatic (clinical assessment score <20) compared with 2 (22%) of the nonsurgery patients. CONCLUSION: Children with a positive clinical assessment of OSA but negative PSG have significant improvement after T&A as compared with observation alone, thus validating the clinician's role in diagnosing upper airway obstruction

The presence of regional nodal metastases represents a significant adverse prognostic factor for patients with squamous cell carcinoma of the head and neck. Early-stage head and neck cancers, localized to the primary site without regional lymph node metastases have excellent cure rates with either surgery or radiation therapy. The presence of regional metastases results in cure rates that are approximately half of those obtainable in early-stage disease. Therefore, due to the significant adverse impact of neck metastases on prognosis, the treatment of the neck remains a vital part of the decision-making process in determining therapy for head and neck cancer

Clinicopathological variables used at present for prognostication and treatment selection for papillary thyroid carcinomas (PTCs) do not uniformly predict tumor behavior, necessitating identification of novel prognostic markers. Complicating the assessment is the long natural history of PTC and our rudimentary knowledge of its genetic composition. In this study we took advantage of differences in clinical behavior of two distinct variants of PTC, the aggressive tall-cell variant (TCV) and indolent conventional PTC (cPTC), to identify molecular prognosticators of outcome using complementary genome wide analyses. Comparative genome hybridization (CGH) and cDNA microarray (17,840 genes) analyses were used to detect changes in DNA copy number and gene expression in pathological cPTC and TCV. The findings from CGH and cDNA microarray analyses were correlated and validated by real-time PCR and immunohistochemical analyses on a series of 100 cases of cPTC and TCV. Genes identified by this approach were evaluated as prognostic markers in cPTC by immunohistochemistry on tissue arrays. CGH identified significant differences in the presence (76 versus 27%; P = 0.001) and type of DNA copy number aberrations in TCV compared with cPTC. Recurrent gains of 1p34-36, 1q21, 6p21-22, 9q34, 11q13, 17q25, 19, and 22 and losses of 2q21-31, 4, 5p14-q21, 6q11-22, 8q11-22, 9q11-32, and 13q21-31 were unique to TCV. Hierarchical clustering of gene expression profiles revealed significant overlap between TCV and cPTC, but further analysis identified 82 dysregulated genes differentially expressed among the PTC variants. Of these, MUC1 was of particular interest because amplification of 1q by CGH correlated with MUC1 amplification by real-time PCR analysis and protein overexpression by immunohistochemistry in TCV (P = 0.005). Multivariate analysis revealed a significant association between MUC1 overexpression and treatment outcome, independent of histopathological categorization (P = 0.03). Analysis of a validation series containing a matched group of aggressive and indolent cPTCs confirmed the association between MUC1 overexpression and survival (relative risk, 2.3; 95% confidence interval, 1.1-5.5; P = 0.03). Our data suggest that MUC1 dysregulation is associated with aggressive behavior of PTC and may serve as a prognostic marker and potential therapeutic target in this disease