Showing papers in "Laryngoscope in 2000"

Salvage surgery for patients with recurrent squamous cell carcinoma of the upper aerodigestive tract: when do the ends justify the means?

Abstract: Objectives/Hypotheses: Salvage surgery is widely viewed as a “double-edged sword.” It is the best option for many patients with recurrent cancer of the upper aerodigestive tract, especially when original therapy included irradiation, yet it may provide only modest benefit at high personal cost to the patient. The stakes are high because alternatives are of limited value. The primary objective of this study was to fully assess the value of salvage surgical procedures in the treatment of local and regional recurrence. The following hypotheses were developed to focus the study design and data analysis. 1) The efficacy of salvage surgery correlates recurrent stage, recurrent site, and time to presalvage recurrence. 2) The economic and noneconomic costs of salvage surgery increase with higher recurrent stage. 3) Information relating the value of salvage surgery to recurrent stage and recurrent site will be useful to these patients and the physicians who treat them. Study Design: Two complimentary methods of investigation were used: a meta-analysis of the published literature and a prospective observational study of patients undergoing salvage surgery for recurrent cancer of the upper aerodigestive tract. Methods: The meta-analysis combined 32 published reports to obtain an estimate of average treatment effect for salvage surgery with regard to survival, disease-free survival, surgical complications, and operative mortality. The prospective observational study included detailed data in 109 patients who underwent salvage surgery. In addition to parameters studied in the meta-analysis, we obtained baseline and interval quality of life data (Functional Living Index for Cancer [FLIC] scores), baseline and interval performance status evaluations (Performance Status Scale for Head and Neck Cancer Patients [PSS head and neck scores]), length of hospital stay, and hospital and physician charges, and related this data primarily to recurrent stage, recurrent site, and time to presalvage recurrence. Results: The weighted average of 5-year survival in the meta-analysis was 39% in 1,080 patients from 28 different institutions. In the prospective study, median disease-free survival was 17.9 months in 109 patients, and this correlated strongly with recurrent stage, weakly with recurrent site, and not at all with time to presalvage recurrence. Noneconomic costs for patients and economic costs correlated with recurrent stage, but not with site. Baseline FLIC and PSS head and neck scores correlated with recurrent stage, but not with site. After salvage surgery the percentage of patients reaching or exceeding baseline was 51% for FLIC scores, and this differed significantly with recurrent stage. Postoperative interval “success” in PSS head and neck subscale scores for diet and eating in public also correlated with recurrent stage. Conclusions: Overall, the expected efficacy for salvage surgery in patients with recurrent head and neck cancer was surprisingly good, but success was limited and costs were great in stage III and, especially, in stage IV recurrences. A strong correlation of efficacy and noneconomic costs with recurrent stage allowed the creation of expectation profiles that may be useful to patients. Additional systematic clinical research is needed to improve results. In the end, the decision to undergo salvage surgery should be a personal choice made by the patient after honest and compassionate discussion with his or her surgeon.

Transnasal endoscopic repair of cerebrospinal fluid rhinorrhea: a meta-analysis.

Abstract: Objectives/Hypothesis Trauma and surgery are the most common causes of cerebrospinal fluid (CSF) rhinorrhea. Surgical repair is recommended for patients with CSF leaks that do not respond to conservative measures, traumatic CSF leaks that require transcranial surgery for associated brain injuries, and iatrogenic defects that are discovered intraoperatively. The purpose of our study was to ascertain the outcome after transnasal endoscopic repair of CSF leaks and to identify factors regarding the patient, CSF fistula, and treatment that may influence the results of the repair. Methods We performed a meta-analysis of all studies published in English between 1990 and 1999 that reported a minimum of five patients with CSF fistulae that were repaired using an endoscopic approach. We analyzed data that included type of graft and technique used during the repair, surgical complications, the use of packing, and the use of lumbar drains and antibiotics. The success rate was monitored and correlated with the other variables. The meta-analysis database was compared with and added to a database comprising our own patients. Results Fourteen studies comprising 289 CSF fistulae met the inclusion criteria. Endoscopic repair of CSF leaks was successful in 90% (259/289) of the cases after a first attempt. Seventeen of 30 persistent leaks (52%) were closed after a second attempt. Thus ultimately 97% (276/289) of the leaks were repaired using an endoscopic approach. The success rate of repairs using any of the reported techniques and materials was high and not statistically different. The incidence of major complications such a meningitis, subdural hematoma, and intracranial abscess was less than 1% for each complication. Conclusion The endoscopic approach is highly effective and is associated with low morbidity. The literature supports the endoscopic approach using a variety of techniques and materials for the repair of CSF leaks.

Importance of Comorbidity in Head and Neck Cancer

Abstract: Objectives/Hypothesis Patients with head and neck cancer are staged according to the morphology of the tumor with little or no attention given to the importance of the other diseases, illnesses, or conditions. These other conditions are generally referred to as comorbidities. Although not a feature of the cancer itself, comorbidity is an important attribute of the patient with cancer. Comorbidity has direct impact on the care of patients, selection of initial treatment, and evaluation of treatment effectiveness. The objective of this thesis is to demonstrate the importance of comorbidity in head and neck cancer. Specifically, the aims are 1) to demonstrate the burden of comorbidity among head and neck cancer patients by comparing the incidence of none, mild, moderate, and severe comorbidity among patients with head and neck cancer to patients with cancers of the colorectum, lung, breast, gynecological sites, or prostate, 2) to demonstrate the independent impact of comorbidity on overall survival, and 3) to demonstrate the importance of comorbidity in the assessment of initial treatment effectiveness. Study Design This was a prospective cohort study of the impact of comorbidity on head and neck cancer patients presenting for treatment between January 1995 and December 1996. Methods In 1994, the author trained cancer registrars at an academic teaching hospital to code comorbidity from the medical record of new patients using a standard comorbidity index. Standard statistical techniques, including multivariable analysis, were used to compare and contrast the burden of comorbidity for patients with different cancers. Life survival techniques and multivariable logistic regression analysis were used to assess the independent prognostic impact of comorbidity. Further, the technique of conjunctive consolidation was used to augment the TNM system with comorbidity information, to more completely assess the impact of different initial treatments for patients with head and neck cancers. Results The cohort consisted of 3,378 patients with cancers of the head and neck (341), colorectum (307), lung (655), breast (483), gynecological sites (482), and prostate (1,110). The percentage of head and neck cancer patients with moderate to severe comorbidity was 21%; this degree of comorbidity burden was second only to patients with lung (40%) and colorectal (25%) cancer. There was a significant relationship between severity of comorbidity and overall survival (log-rank test, ξ2 = 15.75;P < .0013). For cancers of the head and neck, lung, breast, and prostate the prognostic significance of comorbidity remained even after controlling for other factors, such as age and TNM stage. Conclusions The results of this study show that comorbidity is an important feature of patients with head and neck cancer. Valid instruments exist to measure and classify the overall severity of comorbidity. The scientific evaluation of treatment and the care of patients are impeded by a rigid adherence to a staging system based solely on morphological descriptions of the cancer while ignoring suitable descriptions of the patient. The author believes that the addition of comorbidity information will improve the value of cancer statistics and the care of cancer patients.

Obstructive sleep apnea syndrome: a comparison between Far-East Asian and white men.

Abstract: Objectives To investigate the possible differences between Far-East Asian men and white men in obstructive sleep apnea syndrome (OSAS). Study Design Prospective nonrandomized controlled study. Methods This study compared consecutive Far-East Asian men with OSAS (n = 50) with two selected groups of White men with OSAS (n = 50 in each group). One group of white men was controlled for age, respiratory disturbance index (RDI), and minimum oxygenation saturation (LSAT). Another group was controlled for age and body mass index (BMI). Cephalometric analysis was performed on all subjects. Results The majority of the Far-East Asian men were found to be nonobese (mean BMI, 26.7 ± 3.8) but had severe OSAS (mean RDI, 55.1 ± 35.1). When controlled for age, RDI, and LSAT, the white men were substantially more obese (mean BMI, 29.7 ± 5.8, P = .0055). When controlled for age and BMI, the white men had less severe illness (RDI, 34.1 ± 17.9, P = .0001). Although the posterior airway space and the distance from the mandibular plane to hyoid bone were less abnormal in the Far-East Asian men, the cranial base dimensions were significantly decreased. Conclusions The majority of the Far-East Asian men in this study were found to be nonobese, despite the presence of severe OSAS. When compared with white men, Far-East Asian men were less obese but had greater severity of OSAS. There may be differences in obesity and craniofacial anatomy as risk factors in these two groups.

Development of a staging system for inverted papilloma

Abstract: Objectives Inverted papillomas of the nose and sinuses are uncommon neoplasms. In the past decade there has been a trend toward the use of endoscopic surgical techniques in the management of these tumors, in contrast to the extensive open procedures recommended previously. This trend has not been without controversy, given the association of inverted papillomas with malignancy. It has been difficult to compare surgical approaches to these neoplasms, because of the absence of a uniformly applied staging system representing the extent of disease. It was the purpose of this study to develop such a system that could be easily applied in outcomes research. Study Design This study involved an integrated literature review and a synthesis of findings from a number of studies. Methods Previous and current clinical studies examining the treatment of inverted papilloma were reviewed. Findings were organized, and a staging system was framed based on this review. Results A simple, easily applied staging system was developed based on the extent of tumor involvement noted on endoscopic examination of the nasal cavity and computed tomography (CT) scan evaluation. Conclusions Stage I disease is limited to the nasal cavity alone. Stage II disease is limited to the ethmoid sinuses and medial and superior portions of the maxillary sinuses. Stage III disease involves the lateral or inferior aspects of the maxillary sinuses or extension into the frontal or sphenoid sinuses. Stage IV disease involves tumor spread outside the confines of the nose and sinuses, as well as any malignancy.

Redefining the survival of the fittest: communication disorders in the 21st century.

Abstract: Objectives: To determine the economic effect on the US economy of the cost of caring for people with communication disorders as well as the cost of lost or degraded employment opportunities for people with such disorders, including disorders of hearing, voice, speech, and language. Study Design: Survey of available historical and contemporary governmental and scholarly data concerning work force distribution and the epidemiology of disorders of hearing, voice, speech, and language. Method: Analysis of epidemiological and economic data for industrialized countries, North America, and the United States. Results: Communication disorders are estimated to have a prevalence of 5% to 10%. People with communication disorders may be more economically disadvantaged than those with less severe disabilities. The data suggest that people with severe speech disabilities are more often found to be unemployed or in a lower economic class than people with hearing loss or other disabilities. Communication disorders may cost the United States from $154 billion to $186 billion per year, which is equal to 2.5% to 3% of the Gross National Product. Conclusions: Communication disorders reduce the economic output of the United States, whose economy has become dependent on communication-based employment. This trend will increase during the next century. The economic cost and the prevalence rates of communication disorders in the United States indicate that they will be a major public health challenge for the 21st century.

Clinical study and literature review of nasal irrigation

Abstract: Objectives/Hypothesis Nasal disease, including chronic rhinosinusitis and allergic rhinitis, is a significant source of morbidity. Nasal irrigation has been used as an adjunctive treatment of sinonasal disease. However, despite an abundance of anecdotal reports, there has been little statistical evidence to support its efficacy. The objective of this study was to determine the efficacy of the use of pulsatile hypertonic saline nasal irrigation in the treatment of sinonasal disease. Study Design A prospective controlled clinical study. Methods Two hundred eleven patients from the University of California, San Diego (San Diego, CA) Nasal Dysfunction Clinic with sinonasal disease (including allergic rhinitis, aging rhinitis, atrophic rhinitis, and postnasal drip) and 20 disease-free control subjects were enrolled. Patients irrigated their nasal cavities using hypertonic saline delivered by a Water Pik device using a commercially available nasal adapter twice daily for 3 to 6 weeks. Patients rated nasal disease–specific symptoms and completed a self-administered quality of well-being questionnaire before intervention and at follow-up. Results Patients who used nasal irrigation for the treatment of sinonasal disease experienced statistically significant improvements in 23 of the 30 nasal symptoms queried. Improvement was also measured in the global assessment of health status using the Quality of Well-Being scale. Conclusions Nasal irrigation is effective in improving symptoms and the health status of patients with sinonasal disease.

Screening for Distant Metastases in Patients With Head and Neck Cancer

Abstract: Objectives The detection of distant metastases at initial evaluation may alter the selection of therapy in patients with head and neck squamous cell carcinoma (HNSCC) In this study the value of screening for distant metastases is evaluated Study Design Retrospective analysis Methods The results of screening for distant metastases were retrospectively analyzed in 101 consecutive HNSCC patients with high-risk factors who were scheduled for major surgery All patients had computed tomography (CT) scan of the thorax, bone scintigraphy, examination of the liver by ultrasound and/or CT scan, and blood tests Results Distant metastases were found in 17% of the patients Patients with four or more clinical lymph node metastases or low jugular lymph node metastases had the highest incidence of distant metastases (33%) CT scan of the thorax detected in 12 patients, lung metastases; in 4, mediastinal lymph node metastases; and in 2, primary lung tumors Bone scintigraphy detected in four patients bone metastases; in all four patients lung or mediastinal lymph node metastases were also found Ultrasound and/or CT scan of the liver revealed one patient with metastases Blood tests did not show any significant difference between patients with or without bone or liver metastases Conclusions Screening in patients with three or more lymph node metastases, bilateral lymph node metastases, lymph nodes of 6 cm or larger, low jugular lymph node metastases, locoregional tumor recurrence, and second primary tumors revealed distant metastases in 10% or more CT scan of the thorax is currently the single most important diagnostic technique for screening of distant metastases

Eosinophilic mucin rhinosinusitis: a distinct clinicopathological entity.

Abstract: Background Allergic fungal sinusitis (AFS) was recognized in 1981. Since 1983, a form of sinusitis histologically similar to AFS except for the absence of fungal hyphae has also been noted. The designation “eosinophilic mucin rhinosinusitis (EMRS)” is proposed. Its relationship to AFS is controversial and problematic. Objective To determine whether distinctive clinical and immunological differences exist to differentiate the histological entity of EMRS from AFS. Study Design Literature review and comparison of cases of AFS (n = 418) to EMRS (n = 40) from the literature, as well as cases of AFS (n = 13) and EMRS (n = 29) accrued in the present study. Results A total of 431 AFS patients were compared with 69 EMRS patients. The mean age of patients with AFS was significantly younger than patients with EMRS (30.7 y compared with 48.0 y, respectively;P < .001). Male-to-female ratios were 1.03:1 and 1.26:1 for AFS and EMRS, respectively, and were not significantly different. Forty-one percent of patients with AFS were asthmatic compared with 93% of patients with EMRS (P < .0001). Thirteen percent of patients with AFS were aspirin sensitive compared with 54% of patients with EMRS (P < .0001). Polyp occurrence was almost 100% in both groups. Eighty-four percent of patients with AFS had allergic rhinitis (AR), while only 63% of patients with EMRS had AR (P = .004). Fifty-five percent of AFS patients had bilateral disease, in contrast to the 100% of EMRS patients with bilateral disease (P < .0001). Although average total immunoglobulin E (IgE) was elevated in both groups, it was significantly more elevated in AFS patients (range, 12–13,084 mg/dL; mean, 1,941 mg/dL) compared with EMRS patients (range, 14–1,162 mg/dL; mean, 267 mg/dL;P < .001). Total immunoglobulin G (IgG) and IgG subclasses were seldom reported in the cases available from the literature of either AFS or EMRS. However, in the present series of EMRS, IgG1 deficiency occurred in 50% of evaluated patients (mean, 475 ± 175 mg/dL; range, 250–869 mg/dL; normal, 422 to 1,200 mg/dL) but in no cases of AFS reported in the literature. Conclusions Significant clinical and immunological differences exist to distinguish AFS from EMRS. It is postulated that AFS is an allergic response to fungi in predisposed individuals, while EMRS occurs because of a systemic dysregulation of immunological controls. Because EMRS is a systemic disease, unilateral disease is not seen. In contrast, AFS, an allergic response to fungi, may occur unilaterally or bilaterally depending on the antigenic stimulation. EMRS also has a significantly higher association with asthma, an increased incidence of aspirin sensitivity, and an increased incidence of IgG1 deficiency. Therapy with a systemic steroid, a potent and indiscriminant anti-inflammatory agent, is a useful adjunct in both disorders. Fungal immunotherapy following surgical extirpation of AFS is useful in preventing AFS recurrence. It is predicted that fungal immunotherapy and antifungal agents will be ineffective in patients with EMRS. It is important to differentiate these two similar histopathological entities in future trials assessing therapeutic efficacy. Inclusion of both entities in a study could obscure recognition of the true effectiveness of intervention, because of the possible variable response differences between the two entities. This study shows that significant clinical and immunological differences exist between EMRS and AFS. The future awaits an exploration of the pathophysiological basis of these differences.

Long-term quality of life of patients with head and neck cancer.

Abstract: Objectives: To describe prospectively the long-term changes of quality of life and mood in patients with squamous cell carcinoma of the head and neck treated with surgery and/or radiotherapy Patients and Methods: One hundred seven patients completed the European Organization for Research and Treatment of Cancer (EORTC) Core Questionnaire, the EORTC Head and Neck Cancer Module, and the Center for Epidemiological Studies Depression Scale before treatment, and 6, 12, 24, and 36 months later Results: There was limited deterioration of physical and role functioning and of many head and neck symptoms at 6 months, with improvement thereafter After 36 months only physical functioning, taste/smell, dry mouth, and sticky saliva were significantly worse, compared with baseline Female sex, higher cancer stage, and combination treatment were associated with more symptoms and worse functioning Despite physical deterioration, there was a gradual improvement of depressive symptomatology and global quality of life Conclusion: Treatment for head and neck cancer results in short-term morbidity, most of which resolves within 1 year Despite an initially high level of depressive symptomatology, there is gradual improvement of psychological functioning and global quality of life over the course of 3 years In this prospective study, the impact of the disease and its treatment in long-term survivors seems to be less severe than it is often assumed to be

Anterior distribution of human olfactory epithelium.

Abstract: Objectives/Hypothesis To functionally investigate the distribution of the olfactory epithelium in humans by means of the electro-olfactogram (EOG) and anatomically located biopsy specimens. Study Design Prospective, nonrandomized, investigational. Methods Supra-threshold EOG recordings were made on 12 healthy, trained volunteers (6 women, 6 men; age range, 21–48 y). Vanillin was used as the stimulus, since it exclusively excites olfactory receptor neurons. The EOG was recorded with tubular electrodes that were placed using thin-fiber endoscopic guidance. Biopsy specimens were obtained of anterosuperior nasal cavity mucosa in the same regions as the positive EOGs in 15 smell-tested patients (7 women, 8 men; age range, 22–60 y) during routine nasal and sinus surgery. This biopsied tissue was histologically processed and stained for olfactory and neural proteins. Results Viable responses to EOG testing were obtained in 7 of 12 subjects. In these seven subjects it was possible to identify nine sites above or below the anterior middle turbinate insertion where EOGs were obtained. The biopsy results showed mature olfactory receptor neurons in this same area. Conclusions Human olfactory epithelium appears to be distributed more anteriorly than previously assumed.

Pediatric tracheotomies: changing indications and outcomes.

Abstract: Objective/Hypothesis: To study the outcomes and complications associated with pediatric tracheotomy, as well as the changing trend in indications and outcomes since 1970. Study Design: Retrospective chart review at a major tertiary care children's hospital. Methods: On children who underwent tracheotomy at Children's Hospital of the King's Daughters (Norfolk, VA) between 1988 and 1998, inpatient and outpatient records were reviewed. Of 218 tracheotomies, sufficient data were available on 204. Indications for tracheotomy were placed into the following six groups: craniofacial abnormalities (13%), upper airway obstruction (19%), prolonged intubation (26%), neurological impairment (27%), trauma (7%), and vocal fold paralysis (7%). Results: The average age at tracheotomy was 3.2 ± 0.6 years. Although the prolonged intubation group was significantly younger than all others, the neurological impairment and trauma groups were significantly older. Decannulation was accomplished in 41%. Time to decannulation was significantly higher in the neurological impairment and prolonged intubation groups, but was significantly shorter in the craniofacial group. Complications occurred in 44%. Overall mortality was 19%, with a 3.6% tracheotomy-related death rate. Comparison of our series to other published series of pediatric tracheotomies since 1970 shows fewer being performed for airway infections and more for chronic diseases, with a corresponding increase in duration of tracheotomy and decreased decannulation rates. Conclusions: Tracheotomy is a procedure performed with relative frequency at tertiary care children's hospitals. While children receiving a tracheotomy have a high overall mortality, deaths are usually related to the underlying disease, not the tracheotomy itself.

Effects of dietary restriction and antioxidants on presbyacusis.

Abstract: Objectives/Hypothesis: The premise of this study is that the membrane hypothesis of aging, also known as the mitochondrial clock theory of aging, is the basis for presbyacusis. Furthermore, it is proposed that treatment with antioxidants or dietary restriction can attenuate age-related hearing loss. Many studies have demonstrated a reduction in blood flow to specific tissues, including the cochlea, with aging. Hypoperfusion leads to the formation of reactive oxygen metabolites (ROM). ROM are highly toxic molecules that directly affect tissues including inner ear structures. In addition, ROM can damage mitochondrial DNA (mtDNA), resulting in the production of specific mtDNA deletions (mtDNA del 4977 [human] or mtDNA del 4834 [rat]; also known as the common aging deletion]. Previous corroborating data suggest that the common aging deletion mtDNA 4834 may be associated not only with aging but also with presbyacusis, thus further strengthening the basis of the current studies. In this study, experiments provide compelling evidence that long-term treatment with compounds that block or scavenge reactive oxygen metabolites attenuate age-related hearing loss and reduce the impact of associated deleterious changes at the molecular level. Study Design: Prospective randomized study. Methods: One hundred thirty rats were randomly assigned to one of six groups with appropriate controls. Animals were divided into the following treatment arms: group 1, 30% caloric restriction; group 2, vitamin E oversupplementation; group 3, vitamin C oversupplementation; group 4, melatonin treatment; group 5, lazaroid treatment; and group 6, placebo. In addition, 10 animals were used to determine the appropriate caloric restriction. All subjects underwent baseline and every-3-month testing until their health failed (range, 18‐28 mo; average, 25 mo). This testing included auditory sensitivity studies using auditory brainstem response (ABR) testing, as well as tissue analysis for mtDNA deletions using molecular biological techniques. At the conclusion of the study, animals underwent a final ABR test and were tested for mtDNA deletions in brain and inner ear tissues, and the opposite ear was used for histological analysis. Results: Results indicated that the 30%-caloricrestricted group maintained the most acute auditory sensitivities, the lowest quantity of mtDNA deletions, and the least amount of outer hair cell loss. The antioxidant-treated subjects had improved auditory sensitivities, and a trend for fewer mtDNA deletions was observed compared with the placebo subjects. The placebo subjects had the poorest auditory sensitivity, the most mtDNA deletions, and the greatest degree of outer hair cell loss. Conclusions: Intervention designed to reduce reactive oxygen metabolite damage appears to protect against age-related hearing loss specifically and aging in general. This is reflected by an overall reduction in mtDNA deletions. These data also suggest that the common aging deletion appears to be associated with presbyacusis, as demonstrated by an increased frequency of the mtDNA del 4834 in the cochleae with the most signifi

Raman spectroscopy for early detection of laryngeal malignancy: preliminary results.

Abstract: Objective Raman spectroscopy, the analysis of scattered photons after monochromatic laser excitation, is well established in nonbiological sciences. Recently this method has been used to differentiate premalignant and malignant lesions from normal tissue. Its application for early diagnosis has been explored in a variety of sites (e.g., esophagus, cervix), but not, to date, in laryngeal cancer. The objective of this study was to perform a feasibility study of the use of Raman spectroscopy for early diagnosis of laryngeal malignancy. Methods Biopsy specimens were snap-frozen, and top sections were sent for histopathological analysis. Only homogenous samples with clearly defined pathological findings were used in this study: seven histologically normal samples, four exhibiting dysplasia, and four with carcinoma. Samples were defrosted and placed under a Renishaw (Wotton-Under-Edge, UK) System 1000 Raman microspectrometer for analysis. Between 5 and 12 spectra were acquired from each sample, with an excitation wavelength of 830 nm. Average characteristic spectra for each disease or condition were compared. Further multivariate statistical analysis of the data was carried out to evaluate and maximize the differences in the spectra for each disease or condition. Results The most visible differences in the spectra occur between 850 and 950 cm−1 and 1200 and 1350 cm−1. The later peaks are directly related to protein conformation and C-H bond stretch in nucleic acid bases. The relative intensity of the nucleic acid peak increases with progression to malignancy. Use of linear discriminant analysis made it possible to separate the spectra with disease to a greater degree of accuracy than using empirical peak ratio methods alone. Classification results obtained from cross-validation of the discriminant model showed prediction sensitivities of 83%, 76%, and 92% and specificities of 94%, 91%, and 90% for normal, dysplastic, and squamous cell carcinoma of the larynx, respectively. Conclusions There was strong evidence to support spectral identification of malignancy and earlier abnormal changes. More substantive studies of the spectral differences between malignant and non-neoplastic tissue are warranted. Raman spectroscopy may become a useful adjunct to pathological diagnosis allowing directed or guided biopsies and assessment of adequacy of resection margins.

Identification of Genes Overexpressed in Head and Neck Squamous Cell Carcinoma Using a Combination of Complementary DNA Subtraction and Microarray Analysis

Abstract: Objectives/Hypothesis To discover unique genes specific for squamous cell carcinoma of the head and neck for eventual development as tumor markers and vaccine candidates. Study Design Molecular biological analysis of fresh-frozen head and neck squamous cell cancer (HNSCC). Methods A subtractive library was made from two HNSCC and six normal tissues using a polymerase chain reaction (PCR)–based approach. Genes from this library were PCR amplified and placed on a microarray glass slide. RNA was prepared or obtained from 16 fresh-frozen HNSCC and 22 normal tissue sources. Fluorescent probes were made from the polyA+ RNA derived from the tumor and normal tissues. The probes were hybridized to the glass slides and excited by a tuneable laser. One hundred seven of the genes showing the highest differential fluorescence value between tumor and normal tissue were identified by sequence analysis. Results Thirteen independent genes were found to be overexpressed in tumor tissues. Of these, nine were previously known: keratins K6 and K16, laminin-5, plakophilin-1, matrix metalloproteinase-2 (MMP), vascular endothelial growth factor, connexin 26, 14–3-3 sigma, and CaN19. The level of polyA+ RNA of these genes in the tumors was significantly different from the levels in normal tissue (P < .05). Four previously unidentified genes were also discovered to have increased expression in tumor tissue. Comparing the total tumor group (n = 16) to the normal group (n = 22), only one of these genes showed significant overexpression. Conclusion We report the identification of nine known genes that are significantly overexpressed in HNSCC as compared to normal tissue using subtractive and microarray technology. In addition, we present four previously unidentified genes that are overexpressed in a subset of tumors. These genes will be developed as tumor markers and vaccine candidates.

Prospective, randomized outcome study of endoscopy versus modified barium swallow in patients with dysphagia

Abstract: Objective Aspiration pneumonia is a significant cause of morbidity and mortality in both acute and long-term care settings. While there are many reasons for patients to develop aspiration pneumonia, there exists a strong association between difficulty swallowing, or dysphagia, and the development of aspiration pneumonia. The modified barium swallow test (MBS) and endoscopic evaluations of swallowing are considered to be the most comprehensive tests used to evaluate and manage patients with dysphagia in an effort to reduce the incidence of pneumonia. The purpose of this study was to provide an initial investigation of whether flexible endoscopic evaluation of swallowing with sensory testing (FEESST) or MBS is superior as the diagnostic test for evaluating and guiding the behavioral and dietary management of outpatients with dysphagia. FEESST combines the standard endoscopic evaluation of swallowing with a technique that determines laryngopharyngeal sensory discrimination thresholds by endoscopically delivering air pulse stimuli to the mucosa innervated by the superior laryngeal nerve. Study Design Randomized, prospective cohort outcome study in a hospital-based outpatient setting. Methods One hundred twenty-six outpatients with dysphagia were randomly assigned to either FEESST or MBS as the diagnostic test used to guide dietary and behavioral management (postural changes, small bites and sips, throat clearing). The outcome variables were pneumonia incidence and pneumonia-free interval. The patients were enrolled for 1 year and followed for 1 year. Results Seventy-eight MBS examinations were performed in 76 patients with 14 patients (18.4%) developing pneumonia; 61 FEESST examinations were performed in 50 patients with 6 patients (12.0%) developing pneumonia. These differences were not statistically significant (ξ2 = 0.93, P = .33). In the MBS group the median pneumonia-free interval was 47 days; in the FEESST group the median pneumonia-free interval was 39 days. Based on Wilcoxon's signed-rank test, this difference was not statistically significant (z = 0.04, P = .96). Conclusion Whether dysphagic outpatients have their dietary and behavioral management guided by the results of MBS or of FEESST, their outcomes with respect to pneumonia incidence and pneumonia-free interval are essentially the same.

Chronic sinusitis and anosmia: pathologic changes in the olfactory mucosa.

Abstract: Objectives To evaluate histological changes in the olfactory mucosa of patients with chronic rhinosinusitis. These results are analyzed in light of current understanding of the pathophysiology of anosmia secondary to nasal and sinus disease. Study Design Prospective study of olfaction on patients undergoing sinus surgery for the management of chronic rhinosinusitis. Methods Thirty patients, aged 22 to 39 years, underwent olfactory biopsy at the time of surgery with evaluation by a pathologist. Inflammatory changes were graded as mild (normal), moderate, or severe. Clinical olfactory function was evaluated using the University of Pennsylvania Smell Identification Test (UPSIT). The results correlated with the degree of olfactory dysfunction. Results Of the 30 patients 19 had unequivocal olfactory mucosa in the biopsy specimen. Eleven had only respiratory or indeterminate mucosa. Nine patients demonstrated normal olfactory mucosa and normal olfactory function (UPSIT >35). Ten patients demonstrated pathological changes in the olfactory mucosa with an influx of lymphocytes, macrophages, and eosinophils. Of these 10 patients, 7 had olfactory deficits as determined by UPSIT. The remaining three patients had normal olfactory function despite moderate chronic inflammation. These studies indicate that the olfactory mucosa is capable of mounting an inflammatory response similar to that seen in the respiratory mucosa of patients with chronic sinusitis. These data suggest that the olfactory deficits in these patients may be the result of inflammatory changes within the olfactory mucosa in addition to any alteration in airflow to the olfactory cleft.

Pain, Quality of Life, and Spinal Accessory Nerve Status After Neck Dissection

Abstract: Objective To assess quality of life (QOL) in patients with head and neck cancer who underwent neck dissection and to compare QOL scores for patients in whom the spinal accessory nerve (CN XI) was resected or preserved. Setting and Design and Outcomes Measures Three hundred ninety-seven patients who had undergone treatment for head and neck cancer completed the University of Michigan Head and Neck Quality of Life (HNQOL) instrument, the Medical Outcomes Study SF-12 General Health Survey, and questions on “pain despite pain medications” and headaches. Results Of the 397 patients, 222 had no neck dissection, 46 had neck dissections resecting CN XI, and 129 had dissection sparing CN XI. Of the latter group, 68 patients had dissections sparing level V and 61 dissections included level V. Age, sex, primary site distribution, and T stage were not different between the groups. Patients who had neck dissections sparing CN XI had better scores on the HNQOL pain domain (P = .002), had less shoulder or neck pain (P = .003), and took pain medications less frequently (P = .0004) compared with patients who had neck dissections sacrificing CN XI. When CN XI was preserved, patients who had no level V dissection had better pain domain scores (P = .03) and eating domain scores (P = .007) on the HNQOL, had less shoulder or neck pain (P = .006), and had less physical problems (P = .03) than patients who had level V dissected. On multivariate analysis, pain-related QOL scores after neck dissection were significantly better (P < .01) if patients had dissections with preservation of CN XI and if level V was not dissected. Conclusion Neck dissections sparing CN XI are associated with better pain scores on the HNQOL, less shoulder and neck pain, and less need for medications. When CN XI is spared, not dissecting level V of the neck is associated with better HNQOL pain scores, less shoulder or neck pain, and fewer physical problems.

Hearing results after primary cartilage tympanoplasty.

Abstract: Objectives/Hypothesis: Cartilage-perichondrium grafting of the tympanic membrane has been used in an effort to reduce recurrence or progression of middle ear disease. The rigidity of cartilage has obvious benefit in preventing tympanic membrane retraction, but concern has been raised regarding its sound conduction properties. Few studies in the literature address hearing results after cartilage tympanoplasty. The purpose of this study was to investigate the hearing results after primary cartilage tympanoplasty and compare them with results after primary tympanoplasty with temporalis fascia. Study Design: A retrospective review of all ear surgeries using cartilage between 1994 and 1999 was performed. Methods: Only primary cases in which the ossicular chain was intact and no mastoid surgery was performed were included. Indications for surgery included tympanic membrane perforation, retraction, and cholesteatoma. Pre- and postoperative speech reception thresholds and air-bone gaps at 500 Hz, 1000 Hz, 2000 Hz, and 4000 Hz were compared. Results: Eleven patients comprised the cartilage study group, and there were 11 age- and temporally matched control subjects. The mean improvement in speech reception threshold for both the study group and the control group was 10 dB. The majority of patients in both groups had ABG closure to within 10 dB at all frequencies examined. There were no statistically significant differences in speech reception threshold improvement or air-bone gap closures between the two groups. Conclusions: These results demonstrate that hearing results after cartilage tympanoplasty are comparable to those after temporalis fascia tympanoplasty. Therefore, when indicated, a cartilage-perichondrium graft can be used for prevention of disease recurrence or progression without fear of impairing hearing.

Natural history of acoustic neuromas.

Abstract: Objectives/Hypothesis 1) Develop a computerized technique to accurately compare acoustic neuroma size on routine computed tomography and magnetic resonance imaging (MRI) scans; 2) use this technique to determine the growth pattern in a large series of patients with acoustic neuroma who were conservatively managed; 3) describe the natural history of patients with acoustic neuromas who did not receive surgical intervention and those who underwent subtotal resection; 4) correlate the size and growth rate of acoustic neuromas to clinical presentation and auditory and vestibular testing; and 5) recommend guidelines for the management of patients with acoustic neuromas. Study Design A retrospective study from 1974 to 1999 of patients with unilateral acoustic neuromas who had conservative treatment by serial imaging studies (80 patients) or subtotal resection (49 patients). Methods All patient charts were evaluated for presenting symptoms, reasons for the type of management given, and clinical outcome. Charts were also reviewed with respect to serial audiological assessment, electronystagmography, and brainstem auditory evoked response. Imaging studies were analyzed using a computer technique so that serial studies could be compared to determine growth rates. Results Rigorous computer analysis of tumor size and growth rate was statistically the same as the radiologist's description of the tumor size and growth rate. Of 70 patients who were older than 65 years of age old at the time their tumor was discovered, 4 (5.7%) required intervention and 18 (26%) were dead of unrelated causes. These patients had a mean follow-up of 4.8 years (range, 0.01–17.2 y). Overall, growth rate for nonsurgical patients was 0.91 mm per year. Nonsurgical tumors did not grow or regressed in 42.3%. Overall postoperative growth rate for surgical subtotal resection patients was 0.35 mm per year. Surgical tumors did not grow or regressed after subtotal resection of acoustic neuroma in 68.5% of patients. Three patients (6.1%) required revision surgery because of tumor growth or the development of symptoms. Neither auditory nor vestibular testing was a reliable measure for determining tumor growth. Conclusion Measurement of the maximal tumor diameter on MRI scans is a reliable method for following acoustic neuroma growth. There is no need to perform a rigorous analysis of tumor size to determine whether the tumor is growing significantly. The vast majority of patients older than 65 years with acoustic neuromas do not require intervention. The indications for intervention should be based on a combination of rapid tumor growth with the development of symptoms.

Connexin26 mutations associated with nonsyndromic hearing loss.

Abstract: Objective Mutations in the GJB2 gene are a major cause of autosomal recessive and sporadic types of congenital deafness. The 35delG mutation is the most frequent type of mutation in white populations. However, several other forms were reported, such as 167delT among Ashkenazi Jews and R143W in Africans. The present study investigated the mutations of connexin26 (Cx26) found in patients with nonsyndromic hearing loss (NSHL) and newborns in the Korean population. Study Design The sequencing data for 147 unrelated patients with congenital NSHL and 100 audiologically screened newborns were included in this prospective study. Methods Genomic DNA samples from all patients and newborns were sequenced in both directions for detection of Cx26 mutations. Results Thirteen different types of mutations were found in the patients and newborns. V27I and E114G are the popular types of polymorphic mutations in both groups. 235delC—deletion and frameshift—was detected in patients (15 in 294 alleles) and newborns (1 in 200 alleles). 35delG was rarely found in both group. In addition to above mutations, several types of mutations—S85P, K41R, S72C, V84A, 176-191del, and 299-300del—were identified. The family study of the 235delC showed a typical autosomal recessive trait of NSHL in their audiological evaluation of hearing threshold. Conclusion The frequency of 235delC allele showed much higher in the patients (5%) than in newborns (0.5%). We rarely found 35delC mutant in both groups. These results suggest that the different types of Cx26 mutations affect autosomal recessive NSHL according to ethnic background.

Long-term experience with endoscopic diagnosis and treatment of salivary gland inflammatory diseases.

Abstract: Objectives To assess the efficacy of the sialoendoscopic technique for treatment of inflammatory salivary gland diseases. This report documents the authors' long-term experience with sialoendoscopy and discusses the long-term results of the procedure, technical issues, and varieties that they have utilized, as well as the advantages and limitations of this modality. Study Design Retrospective clinicopathologic study of 236 patients who were endoscopically treated from 1994 to 1999 for suspected salivary gland obstructive disease. Methods Endoscope employed was the third generation sialoendoscope (Nahlieli Sialoendoscope, Karl Storz, Tuttlingen, Germany). Results Ten sialoendoscopies were immediate failures as a result of technical problems. In the remaining 226 glands, 170 had obstructions and 56 had sialadenitis without evidence of obstructions. The success rate was 83%. Multiple endoscopic findings were encountered. No severe complications were noted. Conclusion This report demonstrates the efficacy and safety of sialoendoscopy as a promising new method for use in the diagnosis, removal, and postoperative management of sialolithiasis, sialadenitis, and other obstructive salivary gland diseases.

Microvascular angiogenesis and apoptosis in the survival of free fat grafts.

Abstract: Objectives/Hypothesis Autologous fat is an ideal material for augmentation in plastic surgery because of its minimal tissue reaction and easy availability, but its long-term graft survival is somewhat unpredictable. This study was conducted to determine how fat grafts get their vascular supply from the recipient bed and why they keep reducing in volume and weight. Study Design Experimental study using animal models. Methods The expression of vascular endothelial growth factor (VEGF) in grafted fat tissue was examined by using immunohistochemical staining, and apoptotic cell death in the grafted fat was studied by using terminal deoxynucleotidyl transferase (TdT)–mediated deoxy-uridine triphosphate (dUTP)-biotin nick end-labeling method. Twenty-five Wistar rats were used as models of free fat grafts. Fat tissue taken from inguinal fat pads was grafted to the back skin with an 18-gauge needle injection. Results The weight of the injected fat was significantly reduced on the 180th day compared with the original weight (32% ± 10%). VEGF+ cells were observed in fibrous connective tissue of the grafts on days 7 and 30 but not after day 90. Apoptotic cells were also observed on days 7 and 30. Conclusions Angiogenic factors including VEGF started to revascularize the graft around day 7, and the extent of the vasculature was not reduced after the revascularization. In addition to necrosis in the graft's early stages, apoptosis induced by many factors in the graft's environment is also, at least in part, a cause of long-term volume reduction of the fat graft. Thus clinical application of angiogenic factors such as VEGF to fat grafts and control of apoptosis may contribute to improvements in fat-grafting techniques.

Temperature profile in the nasal cavity.

Abstract: Objectives/hypothesis Inspired air is heated and moistened as it passes the nasal cavity. The temperature increase should be similar to a heated tube model, depending on the airflow. Study design Intranasal temperature values of 50 volunteers were measured after inspiration at different locations: nasal vestibule, nasal valve area, anterior to the head of the middle turbinate, and the nasopharynx. Temperature values were related to nasal airway resistance data. Methods Intranasal temperature measurements were made with a miniaturized thermocouple. Nasal airway resistance was detected by active anterior rhinomanometry. Results A logarithmic increase of air temperature from the anterior segment of the nose to the posterior part was noted. In the nasopharynx temperature was approximately 34 degrees C. The highest increase in temperature was observed in the nasal valve area. Conclusions The temperature increase of ambient air in the nasal airways can be compared with a logarithmic curve of the heating of air passing a heated tube. As the heating of air is important for water transport, the space between the nasal valve and the middle turbinate is of special functional importance. No correlation to the results of rhinomanometry was found.

Osteoplastic frontal sinus surgery with fat obliteration: technique and long-term results using magnetic resonance imaging in 82 operations.

Abstract: Objective To evaluate the intraoperative and late complications of osteoplastic sinus surgery with fat obliteration with long-term magnetic resonance imaging (MRI) follow-up. Methods The operative records of all patients who underwent osteoplastic frontal sinus surgery with fat obliteration between January 1, 1986 and December 31, 1997 were reviewed and the postoperative clinical course and magnetic resonance imaging (MRI) scans were analyzed if available. MRI analyses revealed that changes in the distribution of fatty and fibrous tissue, the development of necrosis or oil cysts, recurrences, inflammatory complications, and mucoceles were time-dependent occurrences. Results Eighty-two operative records were evaluated and 59 patients were followed 1 to 12 years after surgery. Eighty-six MRI scans in 51 patients were available for analysis. The most frequent intraoperative complications were exposure of orbital fat (19.5%), unintentional fracture of the anterior wall (19.5%), incorrect placement of the anterior wall (17%), and dural injury (9.8%). Persistent changes of the frontal contour (embossment, depression) occurred in 10.2% and the esthetic result was unfavorable in 5.1% of the cases. Mucoceles could be detected in 5 of 51 cases (9.8%). The amount of adipose tissue detectable in the last scan was less than 20% in the majority of cases (53%), and more than 60% in only 18% of the cases. The amount of adipose tissue decreased significantly with time (the median half-life was 15.4 mo). Conclusions Osteoplastic frontal sinus surgery with fat obliteration is very useful and successful in patients in whom the frontal sinus is not accessible via an endonasal approach or the natural drainage cannot be reestablished. MRI is currently the most valuable diagnostic tool to evaluate the frontal sinus after obliteration with adipose tissue. The method has some limitations with regard to detection of small recurrent mucoceles and differentiating vital adipose tissue from fat necroses in the form of oil cysts. In these difficult cases, long-term MRI follow-up is necessary.

Sentinel lymph node radiolocalization in head and neck squamous cell carcinoma.

Abstract: Objectives: To determine the feasibility of sentinel node radiolocalization in stage N0 in head and neck squamous cell carcinoma and to gain insight as to whether the sentinel node could be prognostic of regional micrometastatic disease. Study Design: A prospective report on the application sentinel node radiolocalization in eight patients with N0 squamous cell carcinoma of the head and neck region. Methods: For each patient a peritumoral submucosal injection of filtered technetium (99mTc) prepared with sulfur colloid was performed immediately following intubation. After at least 30 minutes, focal areas of accumulation corresponding to a sentinel node were marked on the skin surface. Complete neck dissections were performed, and the sentinel nodes were identified for later histological evaluation and comparison to the remaining lymphadenectomy specimen. Results: Sentinel node radiolocalization accurately identified two or more sentinel lymph nodes in all eight cases. In one patient, two of the three lymph nodes containing micrometastatic disease were sentinel lymph nodes. There was no instance in which sentinel node was negative for micrometastatic disease while being positive in a nonsentinel lymph node. Conclusions: Accurate localization of the sentinel lymph node using radiolabeled sulfur-colloid is feasible in patients with squamous cell carcinoma of the head and neck region. Although sentinel node radiolocalization in head and neck squamous cell cancer may potentially reduce the time, cost, and morbidity of regional lymph node management, more experience with technique is required before its role can be determined.

Engineering autogenous cartilage in the shape of a helix using an injectable hydrogel scaffold.

Abstract: Objective Previous successful efforts to tissue engineer cartilage for an auricle have used an immunocompromised nude mouse xenograft model. Subsequent efforts in an immunocompetent autogenous animal model have been less successful because of an inflammatory response directed against the foreign scaffold polymer used to provide an auricular shape. We studied an alternative polymer material and surgical technique to engineer autogenous cartilage in the shape of a human ear helix using injectable hydrogel scaffolding, Pluronic F-127 (polyethylene oxide and polypropylene oxide). Subject Yorkshire swine. Material and Methods Fresh autogenous chondrocytes were suspended in a biodegradable, biocompatible co-polymer hydrogel, Pluronic F-127, at a concentration of 3 × 107 cells/mL. To support the contour of the implant, a skin fold channel in the shape of the helix of a human ear was created in the skin in three sites on the ventral surface of the animal. The cell-hydrogel suspension was injected through the skin fold channel. For controls, injections were made into identical channels using either cells alone or the Pluronic F-127 without cells. After 10 weeks, the specimens were excised and examined both grossly and histologically. Results Grossly, all implants retained a helical-like shape. Excised specimens possessed flexible characteristics consistent with elastic cartilage. The specimens could be folded and twisted and on release of mechanical pressure would instantly return to the original shape. Histological evaluation of the implants using H&E, Safranin O, trichrome blue, and Verhoeff's stains demonstrated findings consistent with mature elastic cartilage. Control injection of hydrogel alone demonstrated no evidence of cartilage formation and control injection of chondrocytes alone showed evidence only of disassociated elastic cartilage. Conclusion Injection of autologous porcine auricular chondrocytes suspended in a biodegradable, biocompatible hydrogel of Pluronic F-127 resulted in the formation of cartilage tissue in the approximate size and shape of a human ear helix. This preliminary method extends the concept of auricular tissue engineering from an immunocompromised xenograft animal model to an immunocompetent autologous animal model.

Accuracy, utility, and cost of frozen section margins in head and neck cancer surgery.

Abstract: Objectives Intraoperative frozen section analysis of surgical margins is widely used in head and neck cancer surgery. This study evaluates frozen section accuracy relative to permanent controls and final margins from the entire specimen, the rate at which frozen sections impact intraoperative management, and the resultant cost. Study Design Retrospective. Methods From 1997 to 1999 the frozen section results, permanent controls, and final tumor margins from 80 consecutive patients undergoing 420 intraoperative frozen section margins for head and neck malignancy were reviewed. Results A 98.3% accuracy rate (sensitivity, 88.8%; specificity, 98.9%) was found compared with permanent sections of the same tissue. However, 40% (8 of 20) of patients with positive final margins on the resection specimen, and 100% (15 of 15) with close (<5 mm) margins were not detected by frozen section analysis. The overall accuracy of frozen section in the evaluation of close or positive final margins was 71.3% (sensitivity, 34.3%; specificity, 100%). In addition, 5% (4 of 80) of patients potentially benefited from intraoperative frozen section by virtue of immediate margin revision. The estimated cost of intraoperative frozen section averaged as much as $3123 per patient, with a cost-benefit ratio of 20:1. Conclusions Intraoperative frozen section margins are accurate, but they are costly and cannot reliably eradicate positive final margins. Patients with early-stage lesions and those undergoing re-resection for recurrence or salvage surgery after radiation failure derived the greatest potential benefit from frozen section margins.

Positron emission tomography with fluorodeoxyglucose for suspected head and neck tumor recurrence in the symptomatic patient.

Abstract: OBJECTIVE: To analyze the impact of positron emission tomography with fluorodeoxyglucose (FDG-PET) in the treatment of patients suspected of having head and neck cancer recurrence. STUDY DESIGN: Prospective and consecutive inclusion of 44 patients presenting with clinical symptoms suggestive of head and neck tumor recurrence. METHODS: FDG-PET was compared with combined computed tomography (CT) plus magnetic resonance imaging (MRI) procedures for the differential diagnosis between tumor recurrence and benign post-therapeutic changes. For FDG-PET, the potential additional value of semiquantitative indexes was studied. The impact on patient treatment (i.e., their ability to accurately select patients for panendoscopic exploration) was analyzed retrospectively for both CT+MRI and PET workups. RESULTS: The diagnostic accuracy was found higher for PET than for combined CT+MRI: sensitivity ranged from 96% to 73%, specificity from 61% to 50%, and accuracy from 81% to 64% for PET and CT+MRI, respectively. The accuracy of FDG-PET was the highest (94%) in patients included more than 12 weeks after the end of therapy. In 15 discordant cases, PET was correct in 11 and CT+MRI in 4. Patient selection for panendoscopic exploration and biopsy was correct in 79% and 50% of patients with FDG-PET and CT+MRI, respectively. Quantification of FDG uptake had no additional value over visual analysis alone, although we found that a SUVlbm (standardized uptake value corrected for lean body mass) threshold of 3 could be helpful in patients scanned less than 12 weeks after the end of therapy. CONCLUSION: FDG-PET has a major additional diagnostic value to CT+MRI for the evaluation of the symptomatic patient suspected of having head and neck cancer recurrence. PET could have a direct impact on management by correctly selecting patients in whom a panendoscopic exploration with biopsy is indicated.

Basaloid squamous cell carcinoma of the head and neck.

Abstract: Objective/Hypothesis Basaloid squamous cell carcinoma (BSCC), an uncommon tumor with predilection for the upper aerodigestive tract, is a distinct variant of squamous carcinoma, because of its unique histological features and ominous clinical behavior. This study reviews the experience in treating BSCC from two institutions. Study Design Retrospective. Methods H&E-stained sections from 20 patients with BSCC of the head and neck were reviewed and clinical follow-up was obtained for all patients. Results The study group consisted of 14 male and 6 female patients. Their ages ranged from 43 to 85 years, with a mean age of 62 years. Sites of origin included the laryn- (4), tongue (3), pyriform sinus (3), nose (2), floor of mouth (2), mastoid (1), tonsil (1), epiglottis (1), nasopharyn- (1), trachea (1), and palate (1). Pain was the most common presenting symptom (5 cases), followed by hoarseness and bleeding (3 cases each). Tobacco and alcohol abuse was noted in 17 patients. Treatment modalities included surgery with or without chemotherapy or radiotherapy in 13 patients, chemotherapy with irradiation in 2, chemotherapy alone in 2, and radiotherapy alone in 3. Clinical follow-up revealed no evidence of disease in 11 patients. Four were alive with disease at the time of writing and five died of disease. Conclusion BSCC is a highly aggressive malignant tumor that presents in elderly patients who have a history of abuse of tobacco or alcohol, or both. Greater number of patients must be studied and compared with age-matched and stage-matched controls of conventional squamous cell carcinoma to determine whether the poor clinical outcome is related more to high-stage presentation or to the tumor's high-grade malignant cytological features.