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Risk of thyroid malignancy following an index head and neck squamous cell carcinoma: A population-based study

December 7, 2016  |  Jason Y. Chan, MBBS; Zhen Gooi, MBBS; Wojciech K. Mydlarz, MD; Nishant Agrawal, MD


To evaluate the incidence of a subsequent primary thyroid malignancy in patients with an index head and neck squamous cell carcinoma (HNSCC), we analyzed the National Cancer Institute's Surveillance, Epidemiology, and End Results database to identify a cohort of patients who had been diagnosed with a primary HNSCC from 1973 through 2004. The study population was made up of 60,323 patients of all ages, roughly three-quarters of whom were male. A total of 60 patients (0.1%) developed a subsequent thyroid malignancy-not a statistically significant finding. The overall standard incidence ratio (SIR) for a subsequent thyroid malignancy was 1.58 (p < 0.05). The highest SIRs were seen during in the first 5 years after diagnosis of the original primary (SIR: 3.05; p < 0.05), more specifically in 2 to 11 months after diagnosis (SIR: 7.11; p < 0.05). Further analyses demonstrated that SIRs were significantly higher in males (SIR: 1.71), in patients aged 60 through 79 years (SIR: 1.71), in whites (SIR: 1.55), in patients who had undergone external-beam radiotherapy for their index primary (SIR: 1.84), in those whose tumor was initially staged as regional (SIR: 1.96), and in patients whose index primary was in the oral cavity (SIR: 1.71) or larynx (SIR: 1.88) (p < 0.05 for all). We conclude that the incidence of a subsequent primary thyroid malignancy in patients with an HNSCC is highest during the first 5 years after diagnosis of the index primary, reflecting the benefit of continued surveillance.

Facial reanimation according to the postresection defect during lateral skull base surgery

December 7, 2016  |  John P. Leonetti, MD; Sahar Nadimi, MD; Sam J. Marzo, MD; Douglas Anderson, MD; Darl Vandevender, MD


The vast majority of benign tumors of the cerebellopontine angle, temporal bone, and parotid gland can be successfully resected without permanent injury to the facial nerve. Malignant tumors or recurrent disease may require facial nerve sacrifice, especially if preoperative facial paresis is present. This article will present case examples of the various methods to reconstruct facial animation after lateral skull base resections that require sacrifice of cranial nerve VII, and the associated mimetic facial musculature. Facial mimetic outcome after reanimation was graded using the House-Brackmann scale. Primary neurorrhaphy or interposition grafting may be performed when both the proximal and distal portions of the facial nerve are available and viable facial musculature is present. If only the distal facial nerve and viable facial musculature are available, a split hypoglossal to facial nerve anastomosis is used. A proximal facial nerve to microvascular free flap is performed when the proximal facial nerve is available without distal nerve or viable musculature. A cross-facial to microvascular free flap is performed when the proximal and distal facial nerve and facial musculature are unavailable. The above methods resulted in a House-Brackmann score of III/VI in all case examples postoperatively. The method of facial reanimation used depends on the availability of viable proximal facial nerve, the location of healthy, tumor-free distal facial nerve, and the presence of functioning facial mimetic musculature.

Rare primary mucosal melanoma of the larynx

December 7, 2016  |  Adam Blanchard, MD; Jeremy B. Nguyen, MD; Philip Daroca, MD; Paul Friedlander, MD; Eleanor Lewin, MD; James Vu, MD, MBA; Enrique Palacios, MD, FACR


Few cases of primary mucosal melanoma of the larynx have been documented in the literature, so only a limited amount of data exists regarding its diagnosis and treatment. The prognosis is poor, as patients often present at a late stage with regional or distant metastases. We describe the case of a 66-year-old man who presented with hoarseness and dysphagia. Laryngoscopy identified a dark discoloration of the supraglottic larynx and incomplete mobility of the right vocal fold; an excisional biopsy confirmed the diagnosis. We discuss the epidemiology, clinical features, diagnosis, interpretation of imaging findings, and management of this rare malignant melanoma.

Primary solitary intralabyrinthine schwannoma: A report of 7 cases and a review of the literature

December 7, 2016  |  Avi Shupak, MD; Yehuda Holdstein, MD; Margalit Kaminer, MSc; Itzhak Braverman, MD


Intralabyrinthine schwannomas (ILSs) are uncommon benign tumors that originate in the Schwann cell sheath of the intralabyrinthine distal branches of the vestibulocochlear nerve. They have no initial involvement in the internal auditory canal, although that might develop later. These lesions can arise inside the cochlea, originate in the vestibule or, in rare cases, develop in the semicircular canals. From these sites, spread might take place via the anatomic connections between the perilymphatic spaces in the scala vestibuli and the anterior vestibule. Thus, ILSs centered in the cochlea might involve the vestibule, and those originating in the vestibular end organs would reach the cochlea. Presenting signs and symptoms include a progressive or sudden sensorineural hearing loss (which occurs in more than 95% of patients), as well as tinnitus and vertigo. Magnetic resonance imaging characteristics include sharp circumscription and hypointensity on thin, heavily T2-weighted 3D images and strong enhancement after gadolinium administration on T1-weighted images. We describe a series of 7 cases of primary ILS that were managed at two of our institutions. We also discuss the need for a comprehensive otoneurologic evaluation that encompasses the functional derangement and the tumor location as delineated by MRI, and we describe the treatment options.

Undifferentiated pleomorphic sarcoma of the vocal fold

December 7, 2016  |  Chang-Yeong Jeong, MD; Choung-Soo Kim, MD


Undifferentiated pleomorphic sarcoma, previously called malignant fibrous histiocytoma, usually arises in the extremities and retroperitoneum. Primary laryngeal undifferentiated pleomorphic sarcoma is very rare, with only 63 cases having been reported in the literature as of 2015. The disease has a poor prognosis because of problems with local recurrence and metastasis. Wide resection has been recommended as a treatment modality in previous reports. We report a case of undifferentiated pleomorphic sarcoma of the vocal fold in a 64-year-old man presenting with rapid growth. The lesion was treated with type III microlaryngeal surgery followed by radiation therapy. The patient's voice was good enough for social communication, and there was no evidence of recurrence on regular examination.

Surgical management of parapharyngeal space tumors: The role of cervical and lateral skull base approaches

December 7, 2016  |  Arturo Mario Poletti, MD; Siba P. Dubey, MS; Giovanni Colombo, MD; Giovanni Cugini, MD


We conducted a retrospective study to analyze the role of the cervical and lateral skull base approaches in the surgical excision of parapharyngeal space (PPS) tumors. Our study population was made up of 34 patients-15 males and 19 females, aged 13 to 73 years (mean: 50.6)-who had presented to us with a PPS tumor during a 9-year period. The 34 cases included 23 benign tumors and 11 malignancies. The 23 benign tumors consisted of 11 pleomorphic adenomas, 5 schwannomas, 2 paragangliomas, 2 Warthin tumors, 1 oncocytoma, 1 hamartoma, and 1 osteochondroma. The 11 malignancies included 3 cases of recurrent nasopharyngeal carcinoma, 2 cases of mucoepidermoid carcinomas, and 1 case each of carcinoma ex pleomorphic adenoma, liposarcoma, lymph node metastasis from nasopharyngeal carcinoma, lymph node metastasis from follicular thyroid carcinoma, rhabdomyosarcoma, and cranial nerve (CN) X neurofibrosarcoma. Among the benign tumors, 14 were removed via the transparotid approach, 3 via the transcervical approach, 3 via the transcervical-transparotid approach, 2 via the petro-occipital-trans-sigmoid approach, and 1 via the Fisch type A infratemporal fossa approach. During postoperative follow-up, 5 of the 23 patients with a benign tumor exhibited facial nerve paresis, 2 developed CN IX to XII palsy, and 1 each developed Frey syndrome and CN X palsy. In the malignant tumor group, 4 of the 11 patients were treated via the transcervical-transparotid approach, 3 via the Fisch type C infratemporal fossa approach, 3 via the transcervical-transmandibular approach, and 1 via the transcervical-lateral petrosectomy approach. The neural deficits observed during the postoperative period were more extensive among the patients with a malignant tumor. We conclude that the transparotid and transcervical approaches were adequate for excising most benign tumors. For malignant tumors, large tumors, and tumors with skull base involvement and transcranial extension, the transparotid-transcervical, transcervical-transmandibular, infratemporal fossa, and petro-occipital-trans-sigmoid approaches were necessary.

Evaluation of the efficacy of curcumin in experimentally induced acute sinusitis in rats

December 7, 2016  |  Leman Birdane, MD; Cemal Cingi, MD; Nuray Bayar Muluk, MD; Turhan San, MD; Dilek Burukoglu, MD


We investigated the possible beneficial effects of curcumin (CMN) in the treatment of sinusitis. An experimentally induced sinusitis model was created in rats, and the results were evaluated histologically. Thirty-two healthy, female Sprague Dawley rats weighing 270 to 310 g each, were randomly divided into four groups. Group 1 was the control group. In Groups 2 to 4, experimentally induced acute sinusitis was developed, and the rats in those groups were given saline, sulbactam-ampicillin, and CMN, respectively, for 10 days. Then all rats were dissected, and samples of sinus mucosa were taken. Histologic examination was performed via light microscopy. In the sinusitis + antibiotic group, values of inflammation, vascular congestion, vascular dilatation, and subepithelial glandular atrophy were significantly higher; and values of mucosal damage and cilia loss, and hyperplasia of goblet cells, were not significantly different from those in the control group. In the sinusitis + CMN group, values of inflammation, vascular congestion, and vascular dilatation were significantly higher; and values of mucosal damage and cilia loss, hyperplasia of goblet cells, and subepithelial glandular atrophy were not significantly different from those of the control group. Histologic examination revealed that in the sinusitis + CMN group, a nearly normal appearance of the epithelial tissue and reduced cellular inflammation in connective tissue were observed. Minimal vascular congestion in connective tissue remained. The efficacy of CMN in acute sinusitis may be related to its potent anti-inflammatory effects on modulation of various inflammatory cytokines. When low side effects are taken into account, CMN therapy may be a promising option in the treatment of acute sinusitis.

Sclerotic effect of oxytetracycline on the submandibular gland: An experimental model

December 7, 2016  |  Oguz Guclu, MD; Asli Muratli, MD; Deniz Arik, MD; Kazim Tekin, MD; Halil Erdogan, MD; Fevzi Sefa Derekoy, MD


Oxytetracycline has been suggested as an alternate therapy for chronic recurrent sialadenitis and sialorrhea. We conducted an experimental study to investigate the sclerotic effect of this drug on the submandibular gland by histopathologic methods. Our subjects were 20 New Zealand white rabbits, which were divided into two groups of 10. The right submandibular gland of the rabbits in the active-treatment group was injected with 0.3 ml of oxytetracycline (100 mg/ml), and that of the controls was injected with saline. Four weeks after the injections, all the glands were removed. Histopathologic studies, including hematoxylin and eosin and Masson trichrome staining, were carried out. The glands were evaluated for tissue inflammation, congestion, fibrosis, edema, lipomatosis, and atrophy. To investigate apoptosis, terminal deoxynucleotidyl transferase-mediated dUTP-digoxigenin nick-end labeling (TUNEL) immunohistochemical staining was used. In the study group, inflammation (n = 9), congestion (n = 9), fibrosis (n = 6), edema (n = 6), and lipomatosis (n = 4) were observed; in the sham group, only lipomatosis was seen (n = 5). The TUNEL assay results for acinar cells were 4.51 ± 1.41% in the oxytetracycline group and 2.08 ± 1.76% in the control group (p = 0.006); the corresponding figures for the duct cells were 7.05 ± 0.87% and 3.10 ± 2.26% (p = 0.001). Based on our findings, we conclude that oxytetracycline might be a viable alternative for the treatment of chronic recurrent sialadenitis and sialorrhea. However, more research in this area is needed.

Nasal gouty tophus

December 7, 2016  |  Pei-Hsun Liao, MD; Kuo-Ping Chang, MD

Surgical removal of gouty tophi is generally indicated when the lesions grow and cause symptoms or lead to cosmetic problems.

Effect of a corticosteroid (triamcinolone) and chlorhexidine on chemotherapy-induced oxidative stress in the buccal mucosa of rats

December 7, 2016  |  Sami G&uuml;m&uuml;&scedil;, MD; Murat Yar&inodot;kta&scedil;, MD; Mustafa Naz&inodot;ro&gbreve;lu, PhD; Abd&uuml;lhadi Cihangir U&gbreve;uz, PhD; Giray Aynali, MD; &Scedil;irin Ba&scedil;p&inodot;nar, MD


Oral mucositis manifests as erythematous and ulcerative lesions of the oral mucosa. Among its various causes, cancer treatment (e.g., chemotherapy with or without radiation therapy) is one of the more well known. It has been widely mentioned that oxidative stress parameters such as lipid peroxidation levels increase during the cancer process. Glutathione is one of the major intracellular enzymes used to detoxify oxidant molecules; it exists in both a reduced and oxidized state. Reduced glutathione is used as a substrate to synthesize glutathione peroxidase. We conducted a study to investigate and compare the effects of triamcinolone (a synthetic steroid) and chlorhexidine (a chemical antiseptic) on 5-fluorouracil (5-FU; a chemotherapeutic agent)-induced oral mucositis in the buccal mucosa of 36 rats. Oral mucositis was induced through a combination of 5-FU treatment and mild abrasion of the cheek pouch with a wire brush. The rats were treated with one of four regimens: saline placebo (group I), 5-FU only (group II), 5-FU plus triamcinolone (group III), and 5-FU plus chlorhexidine (group IV). Three rats in the triamcinolone group died of unknown causes on days 7 and 8, and 3 rats in the chlorhexidine group died on days 7 and 9. On day 9, the remaining 30 rats were sacrificed and examined. Buccal mucosa lipid peroxidation levels were significantly higher in the 5-FU-only group than in the control group and significantly higher in the control group than in the triamcinolone group (p < 0.05 for both). Levels of reduced glutathione were significantly lower in the 5-FU-only group than in both the triamcinolone group and the chlorhexidine group (p < 0.05). Glutathione peroxidase activity was significantly higher in the triamcinolone group than in the 5-FU-only group (p < 0.01). Histopathologic analysis revealed that treatment with triamcinolone significantly reduced 5-FU-induced inflammatory cell infiltration and ulceration (p < 0.001); no such reduction was seen with chlorhexidine. In conclusion, we observed that triamcinolone and chlorhexidine treatment modulated chemotherapy-induced oxidative injury in rat oral mucositis. However, only triamcinolone histopathologically ameliorated 5-FU-induced oral mucositis. These findings suggest that triamcinolone is a useful agent for the management of experimental oxidative injury and oral mucositis caused by 5-FU chemotherapy.