- Email: [email protected]
Hypopharyngeal desmoid tumor (aggressive fibromatosis)
OtolaryngologyRead and Neck Surgery Volume 121 Number 2
that LAUP for the treatment of snoring is time limited, requiring further treatment in some patients. Methods: LAUP was performed in the outpatient setting using the CO 2 laser and local anesthesia in all patients. A 5year follow-up sleep questionnaire was completed by two thirds of patients with a recurrence of snoring. Results: Results of our study are based on a 5-year experience from June 1993 to June 1998. A total of 409 patients were treated with LAUP for snoring and obstructive sleep apnea. A recurrence of snoring occurred in 15 (3.7%) patients. Conclusion: LAUP is a relatively new procedure for the treatment of snoring and obstructive sleep apnea with no longterm follow-up reported in the literature. Conclusions from this 5-year experience with 409 patients are that 3.7% of patients treated with LAUP had recurrence of snoring and that there are no patient characteristics that predict the recurrence of snoring. 165
Conversion of Posterior Semicircular Canal BPPV to Horizontal SCC for Canalith Repositioning PETER C WEBER MD; SIMON WATSON MD; KEITH MEETZE MD; Charleston SC
Objective: Benign paroxysmal positional vertigo (BPPV) is classically thought of as vertical associated with rotary nystagmus seen on Hallpike's maneuvers. The theory of canalolithiasis is the proposed etiology. The success rate of treating BPPV with a canalith repositioning procedure (CRP) has been reported by many to be 90% to 95%. Our own results are similar, but we have recently noticed a new finding occurring during CRP. Recently, the use of a mastoid oscillator was introduced with the CRP. In the first 2 months we noticed 5 patients who developed conversion from horizontal rotary nystagmus to pure horizontal nystagmus. Methods: During CRP, 5 patients converted from horizontal rotary nystagmus to pure horizontal, indicating a change from posterior semicircular canal BPPV to lateral canal BPPV. Continuation of the classic CRP or maneuver of Epley did not relieve these symptoms. Treatment for lateral semicircular canal canalolithiasis was then implemented. Results: The symptoms of all 5 of the patients treated in this manner resolved. Conclusions: We will describe the mechanism we believe to be the culprit for this phenomenon and also how to recognize and treat this conversion. 166
Cytokines in Allergic and Nonallergic Rhinosinusitis MICHAEL DAMM MD; SUSANNE WEND; MARKUS JUNGEHUELSING MD; HANS EDMUND ECKEL MD; Cologne Germany
Objectives: Distinct pathophysiologic mechanisms of recruit-
Scientific Posters P255
ment and survival of eosinophils have been supposed in allergic versus nonallergic chronic polypoid rhinosinusitis (CPR). The purpose of this study was to characterize and to compare the cytokine expression and cellular infiltrates in polyps of patients with allergy and nonallergic patients suffering from CPR. Methods: The subjects of this study were 40 patients with CPR undergoing functional endoscopic sinus surgery (FESS). Diagnoses of CPR were established by CT scans and nasal endoscopy. Allergy skin tests and allergen-specific IgE levels were performed before surgery to distinguish patients with allergy (group 1, n = 20) from those without allergy (group 2, n = 20). Tissue specimens of nasal polyps were obtained during FESS. Histological examinations were performed to count eosinophils and lymphocytes. Cytokine concentrations (IL1~, IL-2, IL-4, IL-5, IL-6, IL-10, IL-12, IL-13, interferon-T [IFN~/], tumor necrosis factor-~x [TNFot], and granulocytemacrophage colony-stimulating factor [GM-CSF]) of tissue homogenates were measured by ELISA and related to the total protein contents. Results: Histological examinations revealed an eosinophilic-dominated chronic inflammation in all biopsy specimens. IL-4 and GM-CSF were detectable in only 20% of all nasal polyp samples. All other cytokines were detected in the majority of specimens (group 1: IL-1]], 2.2; IL-2, 66.7; 1L-5, 22.6; 1L-6, 1.9; IL-12, 7.5; IL-13, 18.7; IFN7, 3.5; TNF~x, 8.5; and group 2: IL-1[~, 4.8; IL-2, 53.8; IL-5, 28.6; IL-6, 2.8; IL12, 9.9; IL-13, 23.8; IFNT, 3.5; TNFc~, 10.6 [median of cytokine concentration related to total protein content in picograms per milligram]). Statistical analyses revealed no significant differences of cytokine tissue levels between allergic and nonallergic subjects (Mann-Whitney U test). Conclusion: The inflammation of CPR involves the production of several cytokines. On the basis of our results, we conclude no different mechanism of tissue eosinophilia in patients with allergy and nonallergic subjects suffering from CPR. However, the mechanisms of recruitment and survival of eosinophils in CPR remain unclear up to now. Further studies are necessary to clarify the interaction between allergic inflammation and CPR.
167
Hypopharyngeal Desmoid Tumor (Aggressive Fibromatosis) TIMOTHY D ANDERSON MD; GREGORY S WEINSTEIN MD; JOHN HARWICK MD; DAVID I ROSENTHAL MD, Philadelphia PA; Philadelphia PA; Allentown PA; Philadelphia PA
Objectives: Desmoid tumors are locally aggressive spindle cell lesions that most often present in the abdominal wall. The supraclavicular region is the most common head and neck site, but a few sinonasal, oral, and parotid cases have been reported. Recurrence rates of simple excision are estimated to be 25% to 75% due to the infiltrative nature of these tumors. The rarity of the tumor (2-4 per I million) precludes con-
P256
OtolaryngologyHead and NeckSurgery August T999
Scientific Posters
trolled studies. Both surgery and radiation therapy (XRT) have been advocated as treatment methods. We report a unique hypopharyngeal desmoid tumor controlled with XRT and review the literature. Methods: Case report with 1-year posttreatment follow-up. No previous similar case was identified with a careful MEDLINE search. Results: The patient is a 33-year-old man who presented with a 1-month history of neck fullness and dysphagia. Imaging revealed a 5-cm hypopharyngeal mass with significant narrowing of the upper airway. Direct laryngoscopy, tracheotomy, gastrostomy, and biopsy were performed. Pathologic examination revealed a moderately cellular spindle cell lesion. Desmoid tumor was diagnosed. Complete surgical resection would have required total pharyngolaryngectomy with cervical esophagectomy and may have left residual disease at the carotid arteries. Radiation therapy was recommended. After a total dose of 60 Gy, the patient was decannulated and resumed a normal diet. He had a complete clinical and radiographic response, remains free of disease after 1-year follow-up, and has normal speech and swallowing function. Conclusion: We report the first case of a hypopharyngeal desmoid tumor. Primary XRT resulted in regression of the tumor, avoiding total pharyngolaryngectomy. XRT remains an attractive management option either in place of or after surgery for selected high-risk cases. 168
Nonlnvasive Imaging of Oral Precancer Using Optical Coherence Tomography W MAI-rHEW WHITE BS; NIKOS S SOUKOS DDS PHD; BREI"[ B E BOUMA PHD; GARY TEARNEY MD PHD; R ROX ANDERSON MD; RICHARD L FABIAN MD; Boston MA
Objectives: This work investigated the capability of a noninvasive imaging device, optical coherence tomography (OCT), to screen for malignant conversion in precancer of the oral cavity (leukoplakia, erythroplakia, and oral lichen planus). Methods: OCT is similar to ultrasound imaging, except that it uses light rather than acoustic waves. The resulting images are in gray scale of vertical sections to a depth of 1.5 mm in mucosal tissues with a resolution of 10 ~tm. OCT images of normal and pathological epithelium were obtained from 15 patients with oral precancer. A biopsy was taken from the site of the lesion that was imaged for histopathologic comparison. Results: We will present OCT images obtained for the first times of normal epithelium, premalignant lesions and conditions, and tumors of the oral cavity along with their corresponding histopathologic correlations. OCT imaging was able to delineate the microscopic architecture characteristics of the above-mentioned tissues. Conclusion: The ability of OCT to provide high-resolution in situ imaging suggests the potential of this system for screening malignant conversion in oral precancer.
169
Upper Jugular Lymph Nodes (Submuscular Abscess) in Non-SCC of the Head and Neck YOAV P TALMI MD; MICHAEL WOLF MD; ZEEV HOROWIIZ MD; LEV BEDRIN MD; MICHAEL PELEG DDS; JONA KRONENBERG MD; RAN YAHALUM DDS; Tel Hashomer Israel
Objectives: Cervical lymphadenectomy of level II encompasses lymph nodes associated with the upper internal jugular vein and the spinal accessory nerve (SAN). Removal of tissue superior to the SAN (submuscular recess [SMR]) was recently shown to be inordinate in selected cases of squamous cell cancer (SCC). Methods: 30 patients with non-SCC of the head and neck treated with cervical lymphadenectomy were prospectively evaluated. Thirty-two neck dissection (ND) specimens were histologically analyzed for the number of lymph nodes involved with cancer. At the time of surgery, level II was separated into the supraspinal accessory nerve component (IIa) and the component anterior to the SAN (IIb). Results: NDs were most commonly done for cancer of the thyroid gland (14), followed in frequency by the parotid gland (7), skin (melanoma) (5), basal cell cancer (2), and other sites (4). Twenty-one NDs were selective procedures, and 11 were either radical or modified radical NDs. Twenty-five necks were clinically N+, and 7 were NO. Histological staging was N+ in 27 ND specimens. Level lib contained an average of 11.7 nodes, and the Ha component contained an average of 5.5 nodes. Level II was with metastatic disease in 23 of 27 nodepositive specimens (85%). Level Ha was involved with cancer in 6 cases (19%), 5 of which were preoperatively staged as N+. Three level IIa-positive cases involved cancer of the parotid gland, comprising 43% of this subgroup of patients. Conclusion: Incidence of involvement of the SMR in nonSCC cases seems more common than in cases of SCC. The additional time required and morbidity associated with dissection of the supraspinal accessory nerve component of level II are probably justified when performing ND in cancer of the thyroid gland. The SMR should be excised in cancer of the parotid gland. These data justify performing prospective controlled studies with long-term follow-up periods. 170
Changing Patterns of Buccal Manifestations Observed in AIDS IVAN DIEB MIZIARA MD; MARIO VALENTINI JR MD; Sao Paulo Brazil
Objectives: To review the different disorders that may affect the buccal cavity in HIV patients treated with antiviral drugs in the last 2 years. Methods: Fifty-seven patients interned or showed in consultations at the ENT department of the Hospital das Clinicas (Sao Paulo University Medical School), between January 1996 and November 1998, with buccal lesions were included
that LAUP for the treatment of snoring is time limited, requiring further treatment in some patients. Methods: LAUP was performed in the outpatient setting using the CO 2 laser and local anesthesia in all patients. A 5year follow-up sleep questionnaire was completed by two thirds of patients with a recurrence of snoring. Results: Results of our study are based on a 5-year experience from June 1993 to June 1998. A total of 409 patients were treated with LAUP for snoring and obstructive sleep apnea. A recurrence of snoring occurred in 15 (3.7%) patients. Conclusion: LAUP is a relatively new procedure for the treatment of snoring and obstructive sleep apnea with no longterm follow-up reported in the literature. Conclusions from this 5-year experience with 409 patients are that 3.7% of patients treated with LAUP had recurrence of snoring and that there are no patient characteristics that predict the recurrence of snoring. 165
Conversion of Posterior Semicircular Canal BPPV to Horizontal SCC for Canalith Repositioning PETER C WEBER MD; SIMON WATSON MD; KEITH MEETZE MD; Charleston SC
Objective: Benign paroxysmal positional vertigo (BPPV) is classically thought of as vertical associated with rotary nystagmus seen on Hallpike's maneuvers. The theory of canalolithiasis is the proposed etiology. The success rate of treating BPPV with a canalith repositioning procedure (CRP) has been reported by many to be 90% to 95%. Our own results are similar, but we have recently noticed a new finding occurring during CRP. Recently, the use of a mastoid oscillator was introduced with the CRP. In the first 2 months we noticed 5 patients who developed conversion from horizontal rotary nystagmus to pure horizontal nystagmus. Methods: During CRP, 5 patients converted from horizontal rotary nystagmus to pure horizontal, indicating a change from posterior semicircular canal BPPV to lateral canal BPPV. Continuation of the classic CRP or maneuver of Epley did not relieve these symptoms. Treatment for lateral semicircular canal canalolithiasis was then implemented. Results: The symptoms of all 5 of the patients treated in this manner resolved. Conclusions: We will describe the mechanism we believe to be the culprit for this phenomenon and also how to recognize and treat this conversion. 166
Cytokines in Allergic and Nonallergic Rhinosinusitis MICHAEL DAMM MD; SUSANNE WEND; MARKUS JUNGEHUELSING MD; HANS EDMUND ECKEL MD; Cologne Germany
Objectives: Distinct pathophysiologic mechanisms of recruit-
Scientific Posters P255
ment and survival of eosinophils have been supposed in allergic versus nonallergic chronic polypoid rhinosinusitis (CPR). The purpose of this study was to characterize and to compare the cytokine expression and cellular infiltrates in polyps of patients with allergy and nonallergic patients suffering from CPR. Methods: The subjects of this study were 40 patients with CPR undergoing functional endoscopic sinus surgery (FESS). Diagnoses of CPR were established by CT scans and nasal endoscopy. Allergy skin tests and allergen-specific IgE levels were performed before surgery to distinguish patients with allergy (group 1, n = 20) from those without allergy (group 2, n = 20). Tissue specimens of nasal polyps were obtained during FESS. Histological examinations were performed to count eosinophils and lymphocytes. Cytokine concentrations (IL1~, IL-2, IL-4, IL-5, IL-6, IL-10, IL-12, IL-13, interferon-T [IFN~/], tumor necrosis factor-~x [TNFot], and granulocytemacrophage colony-stimulating factor [GM-CSF]) of tissue homogenates were measured by ELISA and related to the total protein contents. Results: Histological examinations revealed an eosinophilic-dominated chronic inflammation in all biopsy specimens. IL-4 and GM-CSF were detectable in only 20% of all nasal polyp samples. All other cytokines were detected in the majority of specimens (group 1: IL-1]], 2.2; IL-2, 66.7; 1L-5, 22.6; 1L-6, 1.9; IL-12, 7.5; IL-13, 18.7; IFN7, 3.5; TNF~x, 8.5; and group 2: IL-1[~, 4.8; IL-2, 53.8; IL-5, 28.6; IL-6, 2.8; IL12, 9.9; IL-13, 23.8; IFNT, 3.5; TNFc~, 10.6 [median of cytokine concentration related to total protein content in picograms per milligram]). Statistical analyses revealed no significant differences of cytokine tissue levels between allergic and nonallergic subjects (Mann-Whitney U test). Conclusion: The inflammation of CPR involves the production of several cytokines. On the basis of our results, we conclude no different mechanism of tissue eosinophilia in patients with allergy and nonallergic subjects suffering from CPR. However, the mechanisms of recruitment and survival of eosinophils in CPR remain unclear up to now. Further studies are necessary to clarify the interaction between allergic inflammation and CPR.
167
Hypopharyngeal Desmoid Tumor (Aggressive Fibromatosis) TIMOTHY D ANDERSON MD; GREGORY S WEINSTEIN MD; JOHN HARWICK MD; DAVID I ROSENTHAL MD, Philadelphia PA; Philadelphia PA; Allentown PA; Philadelphia PA
Objectives: Desmoid tumors are locally aggressive spindle cell lesions that most often present in the abdominal wall. The supraclavicular region is the most common head and neck site, but a few sinonasal, oral, and parotid cases have been reported. Recurrence rates of simple excision are estimated to be 25% to 75% due to the infiltrative nature of these tumors. The rarity of the tumor (2-4 per I million) precludes con-
P256
OtolaryngologyHead and NeckSurgery August T999
Scientific Posters
trolled studies. Both surgery and radiation therapy (XRT) have been advocated as treatment methods. We report a unique hypopharyngeal desmoid tumor controlled with XRT and review the literature. Methods: Case report with 1-year posttreatment follow-up. No previous similar case was identified with a careful MEDLINE search. Results: The patient is a 33-year-old man who presented with a 1-month history of neck fullness and dysphagia. Imaging revealed a 5-cm hypopharyngeal mass with significant narrowing of the upper airway. Direct laryngoscopy, tracheotomy, gastrostomy, and biopsy were performed. Pathologic examination revealed a moderately cellular spindle cell lesion. Desmoid tumor was diagnosed. Complete surgical resection would have required total pharyngolaryngectomy with cervical esophagectomy and may have left residual disease at the carotid arteries. Radiation therapy was recommended. After a total dose of 60 Gy, the patient was decannulated and resumed a normal diet. He had a complete clinical and radiographic response, remains free of disease after 1-year follow-up, and has normal speech and swallowing function. Conclusion: We report the first case of a hypopharyngeal desmoid tumor. Primary XRT resulted in regression of the tumor, avoiding total pharyngolaryngectomy. XRT remains an attractive management option either in place of or after surgery for selected high-risk cases. 168
Nonlnvasive Imaging of Oral Precancer Using Optical Coherence Tomography W MAI-rHEW WHITE BS; NIKOS S SOUKOS DDS PHD; BREI"[ B E BOUMA PHD; GARY TEARNEY MD PHD; R ROX ANDERSON MD; RICHARD L FABIAN MD; Boston MA
Objectives: This work investigated the capability of a noninvasive imaging device, optical coherence tomography (OCT), to screen for malignant conversion in precancer of the oral cavity (leukoplakia, erythroplakia, and oral lichen planus). Methods: OCT is similar to ultrasound imaging, except that it uses light rather than acoustic waves. The resulting images are in gray scale of vertical sections to a depth of 1.5 mm in mucosal tissues with a resolution of 10 ~tm. OCT images of normal and pathological epithelium were obtained from 15 patients with oral precancer. A biopsy was taken from the site of the lesion that was imaged for histopathologic comparison. Results: We will present OCT images obtained for the first times of normal epithelium, premalignant lesions and conditions, and tumors of the oral cavity along with their corresponding histopathologic correlations. OCT imaging was able to delineate the microscopic architecture characteristics of the above-mentioned tissues. Conclusion: The ability of OCT to provide high-resolution in situ imaging suggests the potential of this system for screening malignant conversion in oral precancer.
169
Upper Jugular Lymph Nodes (Submuscular Abscess) in Non-SCC of the Head and Neck YOAV P TALMI MD; MICHAEL WOLF MD; ZEEV HOROWIIZ MD; LEV BEDRIN MD; MICHAEL PELEG DDS; JONA KRONENBERG MD; RAN YAHALUM DDS; Tel Hashomer Israel
Objectives: Cervical lymphadenectomy of level II encompasses lymph nodes associated with the upper internal jugular vein and the spinal accessory nerve (SAN). Removal of tissue superior to the SAN (submuscular recess [SMR]) was recently shown to be inordinate in selected cases of squamous cell cancer (SCC). Methods: 30 patients with non-SCC of the head and neck treated with cervical lymphadenectomy were prospectively evaluated. Thirty-two neck dissection (ND) specimens were histologically analyzed for the number of lymph nodes involved with cancer. At the time of surgery, level II was separated into the supraspinal accessory nerve component (IIa) and the component anterior to the SAN (IIb). Results: NDs were most commonly done for cancer of the thyroid gland (14), followed in frequency by the parotid gland (7), skin (melanoma) (5), basal cell cancer (2), and other sites (4). Twenty-one NDs were selective procedures, and 11 were either radical or modified radical NDs. Twenty-five necks were clinically N+, and 7 were NO. Histological staging was N+ in 27 ND specimens. Level lib contained an average of 11.7 nodes, and the Ha component contained an average of 5.5 nodes. Level II was with metastatic disease in 23 of 27 nodepositive specimens (85%). Level Ha was involved with cancer in 6 cases (19%), 5 of which were preoperatively staged as N+. Three level IIa-positive cases involved cancer of the parotid gland, comprising 43% of this subgroup of patients. Conclusion: Incidence of involvement of the SMR in nonSCC cases seems more common than in cases of SCC. The additional time required and morbidity associated with dissection of the supraspinal accessory nerve component of level II are probably justified when performing ND in cancer of the thyroid gland. The SMR should be excised in cancer of the parotid gland. These data justify performing prospective controlled studies with long-term follow-up periods. 170
Changing Patterns of Buccal Manifestations Observed in AIDS IVAN DIEB MIZIARA MD; MARIO VALENTINI JR MD; Sao Paulo Brazil
Objectives: To review the different disorders that may affect the buccal cavity in HIV patients treated with antiviral drugs in the last 2 years. Methods: Fifty-seven patients interned or showed in consultations at the ENT department of the Hospital das Clinicas (Sao Paulo University Medical School), between January 1996 and November 1998, with buccal lesions were included