Head and Neck

Condyloma acuminatum of the buccal mucosa

June 8, 2014     Rashmi Jaiswal, PhD; Manoj Pandey, MS; Mridula Shukla, DipNB; Mohan Kumar, MD
article

Abstract

Condyloma acuminatum is a human papillomavirus (HPV)-induced disease. It is usually transmitted sexually, and it frequently occurs in the anogenital area. A finding of condyloma acuminatum in the oral cavity is rare. Besides HPV, other risk factors for oral condyloma include chewing betel quid and smoking. We report the case of a 52-year-old man who presented with a 2 x 2-cm verrucous white patch on his buccal mucosa. He was habituated to both betel quid and cigarette smoking. A biopsy of the lesion identified it as a verrucous hyperplasia of the squamous epithelium with HPV-related koilocytic changes. The lesion was excised, and further histopathology identified it as condyloma acuminatum. The patient was disease-free 9 months postoperatively. The possibility of condyloma acuminatum should be considered in the differential diagnosis of an oral white lesion. The most common treatments are surgical excision, cryosurgery, electrocautery, and laser excision. There is no known role for antiviral therapy.

Metastatic ovarian sex-cord stromal tumor with annular tubules in a patient without Peutz-Jeghers syndrome

June 8, 2014     Kimi Dart, DO; Ted Schwartzenfeld, DO; Warren Brandes, DO; Anthony D'Errico, DO; Michael Stender, MD
article

Abstract

Sex-cord stromal tumors (SCSTs) with annular tubules (SCTATs) are a small class of ovarian lesions that possess histologic features of both Sertoli and granulosa cells. Approximately one-third of patients with SCTAT also have Peutz-Jaghers syndreome, which makes these cases especially rare. Patients with non-PJS-associated SCTAT make up the remaining two-thirds; 20% of these cases have a metastatic presentation. Metastasis of these tumors to the head and neck region has only been reported in a few instances. In this article we report a case of a 25-year-old woman who presented with “a lump in her throat” and was ultimately diagnosed with SCTAT. We also discuss the current protocols in the diagnosis and treatment of this entity.

Rhabdomyosarcoma of the supraglottis in an adult

June 8, 2014     Alex Fernandez, MS; Reena Gupta, MD; Hootan Zandifar, MD
article

Primary laryngeal rhabdomyosarcoma is an extremely uncommon malignant neoplasm in adults, accounting for relatively few documented cases compared with squamous cell carcinoma.

Extensive basal cell carcinoma of the face: An extreme case of denial

June 8, 2014     Soroush Zaghi, MD; Pedram Ghasri, MD; Paul Busse, MD, PhD; John Clark, MD; Kevin Emerick, MD
article

Abstract

Patients with head and neck cancer are particularly susceptible to using denial as a coping mechanism. While some forms of denial may help patients achieve better levels of physical functioning, persistent denial can serve as a major barrier to treatment. We report a case of extreme denial by a 60-year-old woman with an extensive basal cell carcinoma of the face that had been neglected for more than 20 years. We present this case to raise awareness of the potential danger of denial, and we discuss strategies that physicians can undertake to properly manage patients who engage in it. Since the diagnosis and treatment of head and neck cancer can result in profound psychological trauma, gaining an appreciation for how patients cope with it is an important part of the comprehensive care of head and neck oncology patients.

Sebaceous carcinoma of the parotid gland: A case report and review of the literature

June 8, 2014     Alexander Manteghi, DO; Seth Zwillenberg, MD; Vivian Arguello-Guerra, MD
article

Abstract

Sebaceous carcinoma is a rare malignancy primarily affecting the periocular sebaceous glands. Sebaceous carcinoma of the parotid gland is exceedingly rare, with only 30 cases reported in the literature. Our case brings this total to 31. We present a case involving a 57-year-old man with a slowly enlarging, right tail-of-parotid mass abutting the ear lobule with overlying skin discoloration. Excision of the mass with superficial parotidectomy was performed, and microscopic examination demonstrated sebaceous carcinoma with positive margins. Subsequently, the patient underwent a completion parotidectomy and inferior auriculectomy with no evidence of residual tumor. Six months after postoperative adjuvant radiotherapy, the patient remains tumor-free. The clinical and morphologic features of this tumor are discussed.

Endoscopic management of spontaneous CSF rhinorrhea with septal graft and middle turbinate rotational flap technique: A review of 31 cases

June 8, 2014     Shawky M. Elmorsy, MD; Yasser W. Khafagy, MD
article

Abstract

Spontaneous cerebrospinal fluid (CSF) rhinorrhea poses a major challenge to rhinologists. Much controversy attends its cause, pathophysiology, management, and prognosis. It has been suggested that endoscopic placement of a septal graft with a middle turbinate rotational flap may represent the ideal approach to closing skull base defects. We conducted a retrospective chart review to compile the results of this approach in 31 patients with spontaneous CSF rhinorrhea-22 women and 9 men, aged 18 to 67 years (mean 38.5 ± 8.96) at diagnosis. After one surgery, success had been achieved in 27 of these patients (87.1%). The remaining 4 patients underwent a second surgery, and 2 of them experienced a successful closure. In the remaining 2 patients, a third surgery was still unsuccessful, and they were referred to the neurosurgical team for a shunt procedure. Thus, the overall success rate with the septal graft and a middle turbinate rotational flap was 93.5% (29/31). Septal grafts and middle turbinate flaps are easy to harvest and easy to place. Accurate localization of the defect, meticulous surgical technique, and cerebral dehydrating measures may improve outcomes. Further study of spontaneous CSF rhinorrhea to better evaluate its pathophysiology and prognostic factors is warranted.

Postoperative shoulder function after different types of neck dissection in head and neck cancer

May 7, 2014     Adil Sheikh, MBBS; Hussain Shallwani, MBBS; Shehzad Ghaffar, FCPS, FRCS
article

Abstract

Reported complications of neck dissection surgery have included decreases in shoulder muscle power and range of motion, drooping shoulder, and shoulder pain. We conducted a cross-sectional study to assess postoperative shoulder function following three different types of neck dissection surgery that were performed at Aga Khan University Hospital and to determine how various treatment factors and patient characteristics affected postoperative shoulder function. Our study population included 70 patients-51 men and 19 women, aged 18 to 70 years (mean: 48.6 ± 11.6)-who had undergone a total of 92 neck dissections (22 patients underwent bilateral procedures). Patients were assessed by physical examination and questionnaire responses. The physical examination included objective assessments of shoulder muscle power against resistance, active range of motion, maximum possible forward flexion, the length of time needed to repeat active shoulder flexion 5 times, and shoulder abduction. The questionnaire covered shoulder mobility during activities of daily living, the results of physiotherapy (and exercise), postoperative radiation status, and shoulder pain. Of the 92 neck dissections, 17 were selective (18.5%), 64 were modified radical (69.6%), and 11 were radical (12.0%). We found that patients who had undergone a nerve-sparing procedure (i.e., selective neck dissection or a modified radical neck dissection) exhibited significantly better shoulder function than did patients who had undergone radical neck dissections (p < 0.01). In addition, increasing age (p < 0.001) and a history of diabetes (p = 0.003) were associated with worse shoulder function, and postoperative physiotherapy was associated with better shoulder function (p = 0.002). Neither sex, weight, the side of the neck operated on (left or right), the administration of postoperative radiation, the length of time between surgery and shoulder function assessment, comorbidities such as hypertension and ischemic heart disease, nor the status of the level V lymph nodes had any statistically significant association with shoulder function.

Chronic lymphocytic thyroiditis (Hashimoto thyroiditis)

May 7, 2014     Lester D.R. Thompson, MD
article

Appropriate management requires lifelong thyroid hormone replacement therapy, resulting in decreased thyroid antibody levels, although complications of therapy may be seen.

Massive pleomorphic adenoma of the parotid gland: Surgical considerations

May 7, 2014     Alex Fernandez, MS; Ryan F. Osborne, MD, FACS; Jason S. Hamilton, MD, FACS
article

Preservation of the facial nerve and its branches requires special consideration when dealing with a large parotid mass. The traditional approach of anterograde dissection of the facial nerve proves ineffective in patients with large lesions that effectively obstruct the field of view and origin of the nerve trunk

Metastatic cervical carcinoma from an unknown primary: Literature review

May 7, 2014     Rodrigo Arrangoiz, MS, MD; Tom J. Galloway, MD; Pavlos Papavasiliou, MD; John A. Ridge, MD, PhD; Miriam N. Lango, MD
article

Abstract

Carcinoma of an unknown primary (CUP) encompasses a heterogeneous group of tumors for which no primary site can be detected following a thorough history, physical examination, and noninvasive and invasive testing. CUP presenting with metastasis to the neck (metastatic cervical carcinoma from an unknown primary [MCCUP]) has been an enigma since von Volkmann first described it in 1882 as a cancer arising in a branchial cleft cyst. Genetic studies have shed some light on this unusual entity. In most cases, clinical features, imaging studies, and a meticulous assessment of the upper aerodigestive tract should assist in identifying the source of disease. Molecular testing of cytologic specimens for Epstein-Barr virus and human papillomavirus (HPV) can facilitate identification of the primary site in the nasopharynx and oropharynx. At least 25% of MCCUPs are directly attributable to HPV-related malignancies, and this number can be expected to increase. Minimally invasive transoral mucosal sampling can identify an otherwise clinically and radiologically occult cancer. We performed a literature review with the objective of discussing the history, epidemiology, clinical presentation, diagnostic workup, and management of MCCUP.

Endoscopic transnasal transsphenoidal approach for craniopharyngioma: Report of 6 cases

May 7, 2014     Chan-Soon Park, MD; Byung-Guk Kim, MD; Ji-Hyeon Shin, MD; Jin-Hee Cho, MD
article

Abstract

We conducted a retrospective study to evaluate outcomes in patients with a craniopharyngioma who were managed via a transnasal transsphenoidal approach. Craniopharyngiomas exhibit histologically benign but “clinically malignant” features. Our study group was made up of 5 patients who underwent a total of 6 operations. The study population included 1 female and 5 males, aged 14 to 50 years (mean: 29.2). The overall rate of near-total tumor removal was 67%, but all patients eventually experienced a recurrence. Revision surgery to correct any severe postoperative complications was not required in any case. We found that the endoscopic transnasal transsphenoidal approach could be a safe and less invasive surgical option for the removal of craniopharyngiomas, although we were unable to remove all tumor or prevent recurrences.

Parathyroid adenoma in a woman with secondary hyperparathyroidism

May 7, 2014     Darrin V. Bann, PhD; Neerav Goyal, MD, MPH; David Goldenberg, MD, FACS
article

For surgical treatment of secondary hyperparathyroidism, a common approach is the removal of three and one-half glands (subtotal parathyroidectomy), leaving the remaining half gland in place with an intact vascular pedicle. Alternatively, a total parathyroidectomy may be performed, and one-half of one gland may be minced and reimplanted into shallow pockets created in the sternocleidomastoid or brachioradialis muscles.

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