Search

Eagle's syndrome is a rare disease responsible for polymorphic head and neck symptoms, often resulting in delayed diagnosis. The diagnosis of Eagle's syndrome is based on the presence of suggestive clinical signs associated with pain on palpation of the styloid process in the tonsillar fossa, a positive lidocaine test and elongation of the styloid process on 3D CT scan. The most commonly proposed curative treatment is styloidectomy, which allows complete resolution of symptoms in the great majority of cases. This procedure can be performed via a transoral approach or a transcervical approach. After briefly reviewing the embryology and anatomy of the styloid diaphragm region, the authors describe the transcervical styloidectomy technique performed in their department. This simple technique is based on anatomical imperatives designed to limit the operating time and avoid damage to neurovascular structures.

Introduction: Orofacial and cervical pain are a frequent reason for neurology consultations and may be due to multiple pathological processes. These include Eagle syndrome (ES), a very rare entity whose origin is attributed to calcification of the stylohyoid ligament or elongation of the temporal styloid process. We present a series of five patients diagnosed with ES. Methods: We describe the demographic and clinical characteristics and response to treatment of 5 patients who attended the headache units of 2 tertiary hospitals for symptoms compatible with Eagle syndrome. Results: The patients were 3 men and 2 women aged between 24 and 51, presenting dull, intense pain, predominantly in the inner ear and the ipsilateral tonsillar fossa. All patients had chronic, continuous pain in the temporal region, with exacerbations triggered by swallowing. Four patients had previously consulted several specialists at otorhinolaryngology departments; one had been prescribed antibiotics for suspected Eustachian tube inflammation. In all cases, the palpation of the tonsillar fossa was painful. Computed tomography scans revealed an elongation of the styloid process and/or calcification of the stylohyoid ligament in 3 patients. Four patients improved with neuromodulatory therapy (duloxetine, gabapentin, pregabalin) and only one required surgical excision of the styloid process. Conclusions: Eagle syndrome is a rare and possibly underdiagnosed cause of craniofacial pain. We present 5 new cases that exemplify both the symptoms and the potential treatments of this entity. Resumen: Objetivos: El dolor orofacial y cervical es un motivo de consulta frecuente, que puede deberse a múltiples procesos patológicos. Entre ellos se encuentra el síndrome de Eagle, entidad muy infrecuente cuyo origen se atribuye a una osificación del ligamento estilohioideo o una elongación de la apófisis estiloides. Presentamos una serie de cinco pacientes con dicho diagnóstico. Material y métodos: Se describen las características demográficas y clínicas de cinco pacientes atendidos en las Unidad de Cefaleas de dos hospitales terciarios por un cuadro compatible con síndrome de Eagle, y su respuesta a distintos tratamientos. Resultados: Se trata de 3 varones y 2 mujeres, de entre 24 y 51 años, con dolor de localización predominante en un oído y la región amigdalina ipsilateral, de cualidad sorda y de gran intensidad. En todos ellos el patrón temporal era crónico y continuo, con exacerbaciones desencadenadas por la deglución. Cuatro pacientes habían realizado múltiples consultas en servicios de otorrinolaringología, y uno de ellos había recibido tratamiento antibiótico ante la sospecha de tubaritis. En todos los casos la palpación de la fosa amigdalina resultó dolorosa. En tres de los pacientes se demostró elongación de la apófisis estiloides y/o calcificación del ligamento estilohioideo mediante tomografía computarizada. Cuatro mejoraron con tratamiento neuromodulador (duloxetina, gabapentina, pregabalina) y sólo uno precisó cirugía con escisión de la apófisis estiloides. Conclusiones: El síndrome de Eagle es una causa de dolor cráneo-facial poco frecuente, y posiblemente infradiagnosticada. Aportamos cinco nuevos casos que permiten delimitar tanto la semiología como los posibles tratamientos.

Highlights • The average dose to 95% of initial PTV volume was 70.7 Gy for standard plans vs. 58.5 Gy for adaptive plans. • MRI-guided adaptive approach resulted in decrease dose to normal tissue compared with standard plans. • NTCP of post-treatment dysphagia, feeding tube, and hypothyroidism were reduced using the adaptive approach., Purpose We aim to determine the feasibility and dosimetric benefits of a novel MRI-guided IMRT dose-adaption strategy for human papillomavirus positive (HPV+) oropharyngeal squamous cell carcinoma (OPC). Materials/methods Patients with locally advanced HPV+ OPC underwent pre-treatment and in-treatment MRIs every two weeks using RT immobilization setup. For each patient, two IMRT plans were created (i.e. standard and adaptive). The prescription dose for the standard plans was 2.12 Gy/fx for 33 fractions to the initial PTV. For adaptive plans, a new PTVadaptive was generated based on serial MRIs in case of detectable tumor shrinkage. Prescription dose to PTVadaptive was 2.12 Gy/fx to allow for maximum dose to the residual disease. Any previously involved volumes received minimally a floor dose of 50.16 Gy. Uninvolved elective nodal volumes were prescribed 50.16 Gy in 1.52 Gy/fx. Dosimetric parameters of organs at risk (OARs) were recorded for standard vs. adaptive plans. Normal tissue complication probability (NTCP) for toxicity endpoints was calculated using literature-derived multivariate logistic regression models. Results Five patients were included in this pilot study, 3 men and 2 women. Median age was 58 years (range 45–69). Three tumors originated at the tonsillar fossa and two at the base of tongue. The average dose to 95% of initial PTV volume was 70.7 Gy (SD,0.3) for standard plans vs. 58.5 Gy (SD,2.0) for adaptive plans. The majority of OARs showed decrease in dosimetric parameters using adaptive plans vs. standard plans, particularly swallowing related structures. The average reduction in the probability of developing dysphagia ≥ grade2, feeding tube persistence at 6-month post-treatment and hypothyroidism at 1-year post-treatment was 11%, 4%, and 5%, respectively. The probability of xerostomia at 6-month was only reduced by 1% for adaptive plans vs. standard IMRT. Conclusion These in silico results showed that the proposed MRI-guided adaptive approach is technically feasible and advantageous in reducing dose to OARs, especially swallowing musculature.

Current grading systems may not allow clinicians to reliably document and communicate adenotonsillar size in the clinical setting. A validated endoscopic grading system may be useful for reporting tonsillar size in future clinical outcome studies. This is especially important as tonsillar enlargement is the cause of a substantial health care burden on children.To propose and validate an easy-to-use flexible fiberoptic endoscopic grading system that provides physicians with a more accurate sense of the three-dimensional relationship of the tonsillar fossa to the upper-airway.50 consecutive pediatric patients were prospectively recruited between February 2015 and February 2016 at a pediatric otolaryngology outpatient clinic. The patients had no major craniofacial abnormalities and were aged 1 to 16years. Each patient had data regarding BMI, Friedman palate position, OSA-18 survey results collected. For each child, digital video clips of fiberoptic nasopharyngeal, oropharyngeal and laryngeal exams were presented to 2 examiners. Examiners were asked to independently use the proposed Endoscopic tonsillar grading system, the Brodsky tonsillar grading scale, the Modified Brodsky tonsillar grading scale with a tongue depressor, and the Parikh adenoid grading system to rate adenotonsillar hypertrophy. Cohen's Kappa and weighted Kappa scores were used to assess interrater reliability for each of the four grading scales. The Spearman correlation was used to test the associations between each scale and OSA-18 scores, as well as Body Mass Index (BMI).50 pediatric patients were included in this study (mean age 6.1years, range of 1year to 16years). The average BMI was 20. The average OSA-18 score was 61.7. The average Friedman palate position score was 1.34. Twelve percent of the patients had a Friedman palate position score≥3, which made traditional Brodsky grading of their tonsils impossible without a tongue depressor. All four scales showed strong agreement between the two raters. The weighted Kappa was 0.83 for the Modified Brodsky scale, 0.89 for the Brodsky scale, 0.94 for the Parikh scale to 0.98 for the Endoscopic scale (almost perfect agreement). The Endoscopic scale showed the most consistent agreement between the raters during the study. There was a moderate association between the Parikh adenoid grading system with OSA-18 scores (Spearman's ρ=0.58, p0.001) compared to a low association of the tonsillar grading systems with OSA- 18 scores. None of the scales correlated with patient BMI.The proposed Endoscopic tonsillar grading system is as reliable of a method of grading tonsillar size as conventional grading systems. It offers the advantage of allowing for critical evaluation of the tonsils without any anatomic distortion which may occur with the use of a tongue blade. This new validated endoscopic grading system provides a tool for communicating the degree of airway obstruction at the level of the oropharynx regardless of Friedman palate position and may be used in future outcomes projects.

Objective To evaluate and compare the efficacy of postoperative control with digital photographs and physical examination for children who underwent tonsillectomy? Methods In this prospective study, 86 children (46 boys (53.5%) and 40 girls (46.5%) were enrolled for postoperative clinical visit and for obtaining photographs of the tonsillar bed with a digital camera at clinic control. Results No difference in tonsillar fossa healing was observed between the two methods 2 weeks after surgery. Conclusions Digital photographs proved to be a safe method for postoperative control of pediatric patients who underwent tonsillectomy. Adding control with outpatient follow-up will be useful for minimizing postoperative complications.

Background The aim of this study was to describe the potential advantages of the 3D endoscope-assisted anterior tonsillar fossa approach to elongated styloid process. Methods A 58 years-old woman was reported to our Department with one-year history of odynophagia, latero-cervical pain on the left side, and ipsilateral foreign body sensation. Pain was dull and intermittent in nature. The patient had visited different clinics, she had a physiatric and maxillo-facial evaluation with two dental extraction without any relief of the symptoms. On physical examination a hard-bony consistency area was palpated over left-sided tonsillar fossa, evocating severe pain. Three-dimensional computed tomography (CT) confirmed an anomalous length of the left styloid process and a diagnosis of Eagle's syndrome (ES) was made. After careful surgical and anesthesiology evaluation, we decided to proceed with the partial excision of the styloid process with a 3d endoscope-assisted transoral anterior tonsillar fossa approach (Reddy et al., 2020). Results The patient was relieved of her symptoms after the surgery and was discharged after 1 day. Postsurgical healing was uneventful, pharyngodynia was observed for the first 48 h and treated with anti-inflammatory medication. No early or late postoperative complications, including massive bleeding, neurovascular injury or infection, were encountered. At 1 year follow up visit the patient was still asymptomatic and the CT scan did not show any abnormalities. The 3D endoscope provided a high-quality magnification of the tonsillar fossa, which allow us to correctly identify the site of incision. Styloid process was identified through digital palpation. After sufficient dissection of the tip, the distal part of the elongated styloid process was osteotomised and retrieved with a curved instrument. Local hemostasis was achieved and wound was closed in layers. Conclusion Some authors suggested novel surgical approach for ES like transoral robotic surgery (Rizzo-Riera et al., 2020 [ 2 ]). We present the 3D endoscope-assisted anterior tonsillar fossa approach as a feasible alternative for the surgical management of ES. Our experience with this approach has been outstanding, guaranteeing an optimal vision and depth of the surgical field with safe manipulation of the instruments which avoided injuries to healthy tissue. Furthermore, 3d endoscope was a great didactic tool. In our opinion is not necessary to remove all the styloid process, as other authors suggest (Lisan et al., 2019 [ 3 ]), but is sufficient a partial styloidectomy after cutting the stylohyoid ligament.

A questionnaire-based study was conducted to assess long-term patient reported outcomes (PROs) following definitive IMRT-based treatment for early stage carcinomas of the tonsillar fossa.Participants had received IMRT with or without systemic therapy for squamous carcinoma of the tonsillar fossa (T1-2 and N0-2b) with a minimum follow-up of 2years. Patients completed a validated head and neck cancer-specific PRO instrument, the MD Anderson Symptom Inventory-Head and Neck module (MDASI-HN). Symptoms were compared between treatment groups of interest and overall symptom burden was evaluated.Of 139 participants analyzed, 51% had received ipsilateral neck IMRT, and 62% single modality IMRT alone (no systemic therapy). There were no differences in mean severity ratings for the top-ranked individual symptoms or symptom interference for those treated with bilateral versus ipsilateral neck IMRT alone. However, 40% of those treated with bilateral versus 25% of those treated with ipsilateral neck RT alone reported moderate-to-severe levels of dry mouth (p=0.03). Fatigue, numbness/tingling, and constipation were rated more severe for those who had received systemic therapy (p0.05 for each), but absolute differences were small. Overall, 51% had no more than mild symptom ratings across all 22 symptoms assessed.The long-term patient reported symptom profile in this cohort of tonsil cancer survivors treated with definitive IMRT-based treatment showed a majority of patients with no more than mild symptoms, low symptom interference, and provides an opportunity for future comparison studies with other treatment approaches.

Background An analysis of the value and limits of non-robotic transoral oropharyngectomy for local control of T1-2 squamous cell carcinoma of the tonsillar fossa. Methods A retrospective series of 111 T1 and 133 T2 (N0: 129; N1: 52; N2: 53; N3: 10). Induction chemotherapy and postoperative radiation therapy were used in 63.5% and 29.5% of cases, respectively. Actuarial analysis of local failure, impact of various variables upon local failure and consequences of local failure upon other oncological events and survival are documented. Results The 5-year actuarial local failure estimate was 10.4% and 14.2% for T1 and T2 tumors, respectively. The 5-year actuarial local failure estimate was significantly reduced when resection margins were safe or yielded dysplasia (P = 0.008) and when induction chemotherapy achieved complete histologic regression (P = 0.013). Salvage treatment achieved a 97.2% and 93.2% overall local control rate in T1 and T2 tumors, respectively. The 5-year actuarial nodal failure estimate was 35.1% in patients with local failure versus 10.8% without (P = 0.0001). The 5-year actuarial metachronous second primary estimate was 7% in patients with local failure versus 33.2% without (P = 0.016). The impact of local failure on survival (5-year actuarial survival estimate: 67.3% without and 46.4% with local failure) was not significant. Conclusion In T1-2 squamous cell carcinoma of the tonsillar fossa, non-robotic transoral oropharyngectomy appeared to be highly effective in terms of local control. The high incidence of head and neck metachronous second primaries further advocates the use of this treatment option in order to reserve radiation therapy to such cases.

Given the frequency with which operative intervention is undertaken in the pediatric oral cavity and oropharynx, knowledge of the anatomy is critical for all otolaryngologists. There are subtle, yet significant differences from adult oral anatomy that can affect the approach to operative intervention. Here, we present pediatric oral anatomy as it pertains to operative approach and technique.

The main postoperative complications after tonsillectomy are due to bleeding, and effective hemostasis may lead to a reduction of overall postoperative morbidity. This study was undertaken to determine the efficacy and safety of a novel kaolin-based hemostatic dressing in tonsillectomy.A pilot, single-blind, open label study was performed in patients aged 3-20 y with history of chronic or hypertrophic tonsillitis. Cold dissection tonsillectomy (CDT) + ligature was performed by the same surgeon. Hemostasis on each tonsillar fossa was achieved using kaolin-impregnated gauze (KG; study group) or standard surgical cotton gauze (CG; control). Time to complete hemostasis, operative time, intraoperative blood loss, pain score, analgesic use, and return to normal diet and activity were recorded for all children.A total of 230 patients with a mean age of 8.0 y (138 in the study group and 92 in the control group) were included in the study. Both operative time and intraoperative blood loss were significantly reduced in the KG group (P 0.0001) versus the CG group. At 5 min, 84.8% patients using the KG successfully achieved complete hemostasis versus 34.8% in the CG group where standard gauze controlled bleeding only partially. Results show significantly less pain for the KG group at 6- and 12-h postoperative when compared with the CG group (P 0.0001). Also, the KG group required less analgesic medications, returned to normal diet and normal activities faster than the CG group (P 0.01).Preliminary findings show that the KG is effective and safe in managing surgical bleeding after tonsillectomy. In addition to rapid bleeding control, the dressing causes minimal inflammation and pain and allows patients to quickly return to normal activities. This novel dressing is a promising tool for ear, nose and throat surgical hemostasis.

Surgical robotic techniques are quickly being developed and adapted for using the robot for head and neck surgery. Given the altered perspective and approach to transoral neoplasms using the robot as compared to the traditional open approach, it is necessary for the head and neck surgeon to be familiar with this different viewpoint. We present the embryology and anatomy of the oropharynx including the tonsillar fossa and base of tongue as pertains to transoral robotic surgery.

Background and purpose To investigate the impact of unilateral neck irradiation (UNI) of well-lateralized oropharyngeal cancer (OPC) on outcome and toxicity. Materials and methods Unilateral neck IMRT was applied to 185 consecutive patients with well-lateralized OPC (restricted to tonsillar fossa, soft palate with at least 1cm from midline or lateral pharyngeal wall). Endpoints were regional control (RC), local control (LC), disease-free survival (DFS), overall survival (OS), and toxicity. Results Six regional failures were reported (3.2%); 2 were contralateral (1.1%). The 5-year Kaplan–Meier estimates of RC, LC, DFS, and OS were 96%, 91%, 84%, and 70%, respectively. Feeding tube was given to 11.3%. Chemotherapy was significantly predictive for toxicity. However, no patient was still feeding tube dependent 6weeks after treatment. Overall grade 3 late toxicity was 2.2%. Grade 3 xerostomia was reported in only 1 patient while no patient developed grade 3 dysphagia. Conclusion This largest study on unilateral neck IMRT for well-lateralized OPC showed excellent outcome and favorable toxicity profile. Given the increasing incidence of OPC, especially among younger patients, and the favorable results reported in the current study and by other investigators, expanding the indications for UNI still needs to be further investigated in prospective, preferably, randomized trials.

Purpose To assess, through a retrospective review, clinical outcomes of patients with squamous cell carcinoma of the tonsil treated at the M. D. Anderson Cancer Center with unilateral radiotherapy techniques that irradiate the involved tonsil region and ipsilateral neck only. Methods and Materials Of 901 patients with newly diagnosed squamous cell carcinoma of the tonsil treated with radiotherapy at our institution, we identified 102 that were treated using unilateral radiotherapy techniques. All patients had their primary site of disease restricted to the tonsillar fossa or anterior pillar, with n = 17 patients), T1 ( n = 52), or T2 ( n = 33) disease, with Nx ( n = 3), N0 ( n = 33), N1 ( n = 23), N2a ( n = 21), or N2b ( n = 22) neck disease. Results Sixty-one patients (60%) underwent diagnostic tonsillectomy before radiotherapy. Twenty-seven patients (26%) underwent excision of a cervical lymph node or neck dissection before radiotherapy. Median follow-up for surviving patients was 38 months. Locoregional control at the primary site and ipsilateral neck was 100%. Two patients experienced contralateral nodal recurrence (2%). The 5-year overall survival and disease-free survival rates were 95% and 96%, respectively. The 5-year freedom from contralateral nodal recurrence rate was 96%. Nine patients required feeding tubes during therapy. Of the 2 patients with contralateral recurrence, 1 experienced an isolated neck recurrence and was salvaged with contralateral neck dissection only and remains alive and free of disease. The other patient presented with a contralateral base of tongue tumor and involved cervical lymph node, which may have represented a second primary tumor, and died of disease. Conclusions Unilateral radiotherapy for patients with TX–T2, N0–N2b primary tonsil carcinoma results in high rates of disease control, with low rates of contralateral nodal failure and a low incidence of acute toxicity requiring gastrostomy.

The palatine tonsils play a key role in initiating immune responses against antigens entering the body through the mouth. They are also replication sites of some pathogens. There is no data available about the structure of the palatine tonsils of the Egyptian water buffalo. Therefore, palatine tonsils of 14 clinically healthy buffalo bulls (2–3 years old) were examined macroscopically and microscopically using light, and transmission electron microscopes. The tonsils had an elongated kidney shape with a central invagination (tonsillar fossa) containing a single macroscopic opening leading to a small central cavity (tonsillar sinus). A number of macroscopic crypts originated from this sinus (internal crypts). Besides the tonsillar fossa, also small macroscopic crypts (external crypts) were present. The tonsils were enclosed by a thin connective tissue capsule and septa divided the tonsils into incomplete lobes. Within these encapsulated organs mucous glands were very obvious. Each crypt was highly branched and lined with stratified squamous non-keratinized epithelium. Several lymphoid cells infiltrated between the epithelial cells forming patches of lymphoepithelium. The crypt lumen contained lymphocytes, neutrophils and erythrocytes. Lymph nodules with clear germinal centers extended under the epithelial surface. Diffusely distributed lymphocytes were found in the narrow interfollicular region. High endothelial venules, interdigitating dendritic cells, macrophages and plasma cells were observed among the diffuse lymphocytes. Lymphatics filled with lymphocytes drained the tonsils.

Summary Conventional surgical approaches for tonsillar carcinomas have a great risk for developing treatment-related morbidity. To minimize this morbidity, transoral lateral oropharyngectomy (TLO) using the robotic surgical system was performed, and the efficacy and feasibility of this procedure was evaluated. TLO was performed using the da Vinci surgical robot (Intuitive Surgical, Inc., Sunnyvale, CA). It consists of a surgeon’s console and a manipulator cart equipped with three robotic arms. The surgeon is provided with three-dimensional magnified images from the endoscopic arm and can control two instrument arms for delicate operations from the console. Safe resection of tonsillar carcinoma was possible with the three-dimensional magnified images. When proceeding with resection of the buccopharyngeal fascia, we could prevent damage to the carotid artery, which is located posterolateral to the tonsillar fossa, since the joint at the distal part of the robotic arm can be bent freely from side to side. By using the 30° endoscope, we can achieve a better surgical view of the base of the tongue area. TLO was performed successfully in all five patients without surgical complications. The mean operating time was 44 min, and an average of 19 min was required for setting up the robotic system. TLO using the robotic system will be a good option for organ preservation therapy in the treatment of carcinomas of the tonsil and the tonsillar fossa in the future.

A 13-year-old boy was transferred to our trauma center after sustaining a shotgun wound to his neck and head. Workup revealed an injury to his tonsillar fossa, a pseudoaneurysm less than 4 mm in his internal carotid artery, and diffuse cerebral edema. After management of his intracranial hypertension, follow-up angiogram revealed 4 pseudoaneurysms in his internal carotid artery. In the operating room, the affected segment was resected, and a transposition of the external carotid artery to the internal carotid artery was performed. Workup of penetrating neck trauma and management options for internal carotid artery pseudoaneurysms in a pediatric patient are discussed.

INTRODUCTION: Radiotherapy for oropharyngeal cancer often causes severe side effects. If the primary tumour is localized to the tonsillar region, elective irradiation may be limited to the ipsilateral neck, sparring the contralateral normal tissues. We wanted to study the consequences of volume sparring on all prospectively registered morbidity endpoints. METHODS AND PATIENTS: Medical records, treatment charts and database information were collected for all 158 oropharynx cancer patients treated from 1998 to 2002 at Aarhus University Hospital. Of the 139 patients treated with curative intent 40 were treated with an ipsilateral technique. RESULTS: Primary tumour extension outside the tonsillar fossa and T-stage were the only patient-, disease- and treatment related factors that differed between ipsilaterally and bilaterally treated patients. Loco-regional control and survival were not negatively influenced by the volume sparring technique. Side effects were reduced, in the ipsilaterally treated group, for all endpoints: xerostomia, dysphagia, hoarseness, atrophy, fibrosis and oedema. The number of patients experiencing moderate to severe toxicity was more than halved with ipsilateral treatment for all endpoints except fibrosis. CONCLUSION: For selected patients with tonsillar cancer without involvement of midline structures, ipsilateral treatment is safe and reduces morbidity compared with bilateral treatment. Udgivelsesdato: 2007-Oct

The lateral pharyngeal wall has been well documented to be the cause of collapse in many patients with obstructive sleep apnea (OSA). The inability to correct this disorder is a cause of uvulopalatopharyngoplasty failure using traditional techniques. A technique termed lateral pharyngoplasty is a procedure to address the lateral pharyngeal wall collapse in patients with OSA. The technique consists of microdissection of the superior pharyngeal constrictor muscle within the tonsillar fossa, sectioning of this muscle, and suturing of the created laterally based flap of that muscle to the same-side palatoglossus muscle. The preliminary results are promising and side effects minimal. This procedure can be performed alone or as part of the multilevel surgical algorithm in the treatment of OSA.

Objectives To evaluate the usefulness of fusioning positron emission tomography withcomputed tomography (PET/CT) for the detection of head and neck carcinomas of unknown primary. Methods This prospective study included 20 patients with cervical lymph node of squamous.cell carcinoma of unknown primary after standard initial workup (nasofibroscopy and CT scan of the chest and head and neck). Patients underwent PET/CT and panendoscopy ofthe upper airways and upper digestive tract with PET/CT directed biopsies. The follow-up was 6 months minimum in all patients. Results A potential primary tumor was found in 10 of the 20 cases and confirmed by histology.in 7 cases (3 bases of tongue, 1 tonsillar pillar, 1 vallecula, 1 tonsillar fossa, 1 piriformsinus). Four of these seven patients presented a normal endoscopy (diagnosis was made with submucosal PET/CT directed biopsies). PET/CT was normal in 10 of 20 cases with 3 false negatives. The sensitivity of PET/CT was 70%, the specificity was 70% and the accuracy was 70%. Conclusion PET/CT seems to be of interest in the detection of head and neck carcinoma of unknown primary. PET/CT detected 15% of unknown primary tumors with treatmentrelated implications.

Tonsillectomy has been associated with complications such as bleeding, pain, dehydration, edema, airway obstruction, atlantoaxial subluxation and infection. However, fungal infection is a very rare complication of tonsillectomy. We describe the case of a 12-year-old girl who developed oral Candida infection as a complication of tonsillectomy. She had pain and difficulty in swallowing on the third postoperative day, and a local examination revealed an easily grazing, white plate on the tonsillar fossa. A culture of the lesion tissue identified Candida albicans . Local nystatin therapy was administered, and the lesion healed completely by postoperative day 12. We conclude that fungal infection, though rare, can occur as a complication of tonsillectomy.

To compare the administration of bupivacaine hydrochloride, dexamethasone and lidocaine hydrochloride in decreasing post-tonsillectomy pain.Eighty patients were enrolled in the study in ENT Clinic, Firat University, and in ENT Clinic Elaziğ SSK Hospital, Elaziğ (Turkey). Children between 6 and 14 years of age referred to our department for bilateral tonsillectomy for either recurrent tonsillitis or tonsillar hypertrophy. Data from 80 patients were analyzed. The first group had bupivacaine hydrochloride. The second group had dexamethasone infiltrated around each tonsil. The third group was given equal doses of 10% lidocain hydrochloride sprayed on the tonsillectomy fossa four times a day, and a placebo group received 9% NaCl applied to the tonsillar fossa four times a day. Pain scores, determined by visual analog scale, were obtained in the first, third and seventh postoperative days.Pain scores in the postoperative period were identical in the first, third and seventh postoperative days. According to VAS results the groups were compared on the basis of postoperative pain. In the first postoperative day, the difference between bupivacaine-placebo, dexamethasone-placebo and lidocaine-placebo groups was found to be statistically significant (P0.05). Nevertheless the difference between bupivacaine-dexamethasone, bupivacaine-lidocaine and dexamethasone-lidocaine were not significant (P0.05). In the third postoperative day, the difference between bupivacaine and lidocaine group found to be statistically significant (P0.05). In the seventh post-operative day the results of bupivacaine, dexamethasone, lidocaine and placebo groups were similar (P0.05).Bupivacaine, Dexamethasone and Lidocaine nasal aerosol decreased the pain significantly in the first postoperative day when it was compared with the placebo group. These three medicines can be used to reduce pain for children during the postoperative period applied tonsillectomy during the post-operative period. But lidocaine was more preferable, reducing pain in the third postop day better than bupivacaine.

Purpose: Elongated styloid process can be a source of craniofacial and cervical pain and remains a diagnostic challenge to many. The aim of the study was to determine the symptomatology and various criteria for the diagnosis of an elongated styloid process and its management. Patients and Methods: Our clinical study consisted of 58 patients with elongated styloid process who had symptoms of vague cervicofacial pain and presented to our department during a period of 10 years. Special emphasis is given to palpation of the tonsillar fossa, lidocaine infiltration test, and orthopantomography. Results: Minimal complications and zero incidence of deep neck infection were noted. Conclusions: All of the patients were managed surgically through the intraoral approach, which was found to be a safe procedure. © 2002 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 60:171-175, 2002

Resumen Se ha llevado a cabo un estudio retrospectivode 34 pacientes con carcinoma epidermoide de la region amigdalina tratados con dos modalidades terapeuticas, entre 1989 y 1996. Veintitres lo fueron mediante cirugia (reseccion transoral o bucofaringectomia transmaxilar con reconstruccion miocutanea y vaciamiento cervical ipsilateral). Once lo fueron con quimioterapia y radioterapia. La supervivencia global a los 5 anos fue del 41,2%. La supervivencia en los estadios I-II fue del 71,4% y en los estadios III-IV fue del 33,3%. En el analisis multivariante la edad (p=0,28) y la modalidad de tratamiento (p=0,80) no influyeron en la supervivencia. Pero los pacientes en estadios avanzados (III-IV) mostraron un riesgo de muerte 3,4 veces mayor que los que estaban en estadios precoces (I-II) (p=0,11). Abstract It has been carried out a retrospective analysis of 34 patients suffering from carcinoma epidermoid of the tonsillar fossa being treated with two different therapies from 1989 to 1996. Twenty three of them were treated with surgery (transoral resection or bloc radical tonsillectomy with myocutaneous flap reconstruction and ipsilateral lymph node dissection). Eleven of them were treated with chemotherapy and radiotherapy. The rate of overall survival at 5 years were 41,2%. Actuarial survival rates were (71,4%) in stages I-II and 33,3% in stages III-IV (p = 0,08). On multivariate analysis, age (p=0,28) and modality of treatment (p=0,80) were not significant effect on survival. Advanced stages (III-IV) showed 3,4 times much more risk of death than early stages (I-II) (p=0,11).

Introduction: The treatment of midline tumors in the head and neck by conventional radiotherapy almost invariably results in xerostomia. This study analyzes whether a simple three-dimensional conformal radiotherapy (3D-CRT) technique with beam intensity modulation (BIM) (using a 10-MV beam of the MM50 Racetrack Microtron) can spare parotid and submandibular glands without compromising the dose distribution in the planning target volume (PTV). Methods: For 15 T2 tumors of the tonsillar fossa with extension into the soft palate (To) and 15 T3 tumors of the supraglottic larynx (SgL), conventional treatment plans, consisting of lateral parallel opposed beams, were used for irradiation of both the primary tumor (70 Gy) and the elective neck regions (46 Gy). Separately, for each tumor a 3-D conformal treatment plan was developed using the 3-D computer planning system, CadPlan, and Optimize, a noncommercial program to compute optimal beam profiles. Beam angles were selected with the intention of optimal sparing of the salivary glands. The intensity of the beams was then modulated to achieve a homogeneous dose distribution in the target for the given 3D-CRT techniques. The dose distributions, dose–volume histograms (DVHs) of target and salivary glands, tumor control probabilities (TCPs), salivary gland volumes absorbing a biologically equivalent dose of greater than 40 or 50 Gy, and normal tissue complication probabilities (NTCPs) of each treatment plan were computed. The parameters of the 3D-CRT plans were compared with those of the conventional plans. Results: In comparison with the conventional technique, the dose homogeneity in the target volume was improved by the conformal technique for both tumor sites. In addition, for the SgL conformal technique, the average volumes of the parotid glands absorbing a BED of greater than 40 Gy (V40) decreased by 23%, and of the submandibular glands by 7% (V40) and 6% (V50). Consequently, the average NTCPs for the parotid and submandibular glands were reduced by 7% and 6%, respectively. For the To conformal techniques, the V40 of the parotid glands was decreased on average by 31%, resulting in an average reduction of the NTCP by 49%. Both the average V50 and the NTCP of the submandibular glands were decreased by 7%. Conclusion: For primary tumors of the oropharynx, the parotid glands could be spared to a considerable degree with the 3D-CRT technique. However, particularly the ipsilateral submandibular gland could not be spared. For primary tumors of the larynx, the 3D-CRT technique allows sparing of all salivary glands to a considerable and probably clinically relevant degree. Moreover, the conformal techniques resulted in an increased dose homogeneity in the PTV of both tumor sites.

Tonsillar actinomycosis manifested as expectorated debris Abstract Actinomycosis is a festering bacterial infection frequently affecting the cervicofacial area, for which the germs responsible are Gram-positive bacilli of Actinomyces sp. We present a case of atypical presentation of actinomycosis, in the shape of repetitive mass in the tonsillar fossa with complex therapeutic management. & 2009 Elsevier Espana, S.L. All rights reserved.

Actinomycosis is a festering bacterial infection frequently affecting the cervicofacial area, for which the germs responsible are Gram-positive bacilli of Actinomyces sp. We present a case of atypical presentation of actinomycosis, in the shape of repetitive mass in the tonsillar fossa with complex therapeutic management.

Second branchial cleft cysts and sinuses rarely present diagnostic problems to the pediatric otolaryngologist as their course is usually predictable based on consistent embryologic development. However, we evaluated two fistula tracts that did not fit the classic description of second branchial tract fistulas. Upon radiographic and intraoperative evaluation, their eventual course ending in the tonsillar fossa was identified. Realizing the potential for aberrancy and using preoperative radiographic evaluation will assist the surgeon in the excision of these developmental anomalies with little risk to underlying neurovascular structures.

Purpose : To assess the efficacy of a concomitant boost fractionation schedule of radiotherapy for treating patients with squamous carcinoma of the tonsillar fossa. Patients and Methods : Between December 1983 and November 1992, 83 patients with squamous carcinoma of the tonsil were treated with concomitant boost fractionation. The distribution of American Joint Committee on Cancer T stages was TX-4, T1-5, T2-29, T3-41, T4-4; N stages were NX-1, N0-26, N1-13, N2-31, N3-12. Patients were treated with standard large fields to 54 Gy in 6 weeks. The boost treatment consisted of a second daily 1.5 Gy fraction for 10–12 fractions, usually delivered during the final phase of treatment. The tumor dose was 69–72 Gy, given over 6 weeks. Twenty-one patients, who all had N2 or N3 regional disease, underwent neck dissections, either before (13 patients) or 6 weeks after radiotherapy (8 patients); the other patients were treated with radiotherapy alone. Results : The 5-year actuarial disease-specific survival and overall survival rates were 71 and 60%, respectively. Patients with T2 and T3 primary tumors had 5-year actuarial local control rates of 96 and 78%, respectively. Patients with T3 disease who received the final-phase boost had a 5-year actuarial local control rate of 82%. Actuarial 5-year regional disease control rates were N0, 92%; N1, 76%; N2, 89%; and N3, 89%. The 21 patients who had neck dissections all had their disease regionally controlled. Patients presenting with nodal disease or after a node excision who were treated with radiation alone had a 5-year actuarial regional disease control rate of 79%. All but five patients had confluent Grade 4 mucositis during treatment. Severe late complications attributable to radiation included mandibular necrosis [1], in-field osteosarcoma [1], and chronic dysphagia for solid foods [5]. Conclusions : High rages of local and regional disease control were achieved with the concomitant boost fractionation schedule, with few cases of severe late morbidity. Patients with N2 and N3 neck disease were effectively treated with radiation and the selective use of neck dissections. The concomitant boost schedule is our preferred fractionation approach for treating patients with intermediate stage tonsil cancer who are not participating in our current research protocols.

Penetrating injuries of the soft palate are not uncommon in the pediatric population. The majority are minor, requiring only conservative treatment. Despite the close proximity of the carotid artery to lateral soft palate and tonsillar fossa, the incidence of carotid injury is low. When carotid injury does occur, it is usually secondary to blunt trauma to the carotid with a resultant thrombosis. A concomitant neurologic deterioration often follows occurring from 3 h to 3 days after the initial injury ( Hengerer et al. (1984) . Laryngoscope 94, 1571–1575 ). The potential neurologic sequelae of such an injury make these seemingly innocuous wounds a diagnostic and management dilemma for the clinician. We present an unusual case of an internal carotid artery pseudoaneurysm in a neurologically intact child following soft palate impalement. We review the diagnostic evaluation including angiography and magnetic resonance angiography, the surgical approach, and postoperative issues including anticoagulation. The literature is reviewed and a discussion regarding the approach to penetrating injuries of the soft palate is presented.

(OPSCC) undergoing definitive concurrent chemoradiation (CCRT) remains unclear. The purpose of this review was to examine these effects on survival outcomes among a single institute population. Materials/Methods: This retrospective review of OPSCC patients treated with CCRT between 2008 and 2015 was conducted. All tumors were examined for HPV 16/18 status (+/). Smoking status and other clinical characteristics were abstracted from the electronic medical record. Former smokers are patients who quit within a month of diagnosis or treatment. Descriptive summaries, overall survival (OS), and multivariate cox proportional hazard ratios (HR) were completed. Results: Out of 134 patients, 94 patients (71%) had HPV-positive (HPV+) tumors. Age, gender, and overall stage were not statistically different between patients with HPV+ or HPV-negative (HPV-) tumors. HPV+ patients had higher tumor grade (P

secutive patients who underwent transoral robotic surgery for head and neck pathology between March 2010 and March 2012 were retrospectively reviewed. Results: A total of 37transoral robotic surgery for head and neck pathology cases among 34 patients were identified. Among the 37 cases, 25 cases were for malignant tumor and 12 cases were for benign pathology.Malignant tumor sites were tonsillar fossa (n 11), base of the tongue (n 12), posterior pharyngeal wall (n 1), and retromolar trigone (n 1). Ten patients (40%) had simultaneous neck dissection with TORS. Three patients underwent re-resection of positive margins by TORS yielding negative final margins. 10 of 22 patients had concurrent neck dissection with TORS. Primary Tumor staging (T) include ten T1 stage (40%), twelve T2 stage (48%), and two T3 stage (12%). Final surgical margins found to be negative for cancer in 9 of 10 patient with T1 (90%), 9 of 12 with T2 (75%), and 1 of 3 with T3 tumor (33%). Subtotal resection performed on 2 of 5 T2 tumors due to significant growth of tumor noted at the time of surgery. 13 of 22 patients who underwent malignant tumor resection, treated with adjuvant therapy. 10 patients treated with postoperative radiation therapy (RT), 3 patients with concurrent chemoradiation therapy. 5 of 13 (38%) patients received deescalated postoperative RT. Benign pathology cases include seven tonsillectomies, two submandibular sialoadnectomies, two lateral pharyngeal space pleomorphic adenoma, and one periglottic branchial cleft cyst, one lingual tonsil hypertrophy with obstructive sleep apnea. No major intraoperative or postoperative complications encountered in all cases. One case with periglottic mass was aborted due to severe retrognathic mandible limiting adequate retraction for TORS Conclusions: Transoral robotic surgery demonstrated alternative surgical options for effective resection of selected head and neck cancer by offering unobstructed access for oropharyngeal cancer. In our experiences, for T1 and T2 oropharyngeal cancer, it is feasible to obtain excellent surgical outcome with TORS while the patients benefit from low morbidity and improved postoperative recovery. With concurrent neck dissection, patient may avoid delayed operative treatment and necessary adjuvant therapy. Role of TORS combined with deescalated adjuvant therapy will be investigated in future. TORS has limited role in benign pathology cases.

Metastatic cancer to the palatine tonsil is extremely rare. We describe a 66-year-old man who was diagnosed with hepatocellular carcinoma 2 years previously and who had the sensation of having a lump in his throat for 1 month before presentation. One reddish-blue, ulcerated, granular tumor was found at his right tonsillar fossa. After tonsillectomy, pathology showed metastatic hepatocellular carcinoma. The patient died from sepsis and hepatic failure 9 months later.

Introduction The trapezius myocutaneous flap is an effective alternative to microsurgical techniques for reconstruction of surgical defects after oncological resection in oral cavity. The extraction technique is simple, being a predictively viable flap. It may be harvested as an osteomyocutaneous flap and can even be used to reconstruct the mandible. As a main drawback, highlights the need for change in posture of the patient during surgery, which stretches, although not overly, the operative time. We present a series of patients operated in our Department, in which we used the trapezius flap for the reconstruction of surgical defects in the head and neck. Materials and methods Nine cases are included in our study. In eight of them the flap was designed as a myocutaneous flap, while in the last patient it was an osteomyocutaneous flap, incorporating the spine of the scapula to reconstruct a segmental mandibular defect created after a tumor excision. Seven cases were oncologic surgical defects (squamous cell carcinomas of the tongue, jaw, retromolar trigone, tonsillar fossa and soft palate). The other two cases were used to temporal fossa reconstruction after a titanium mesh that were used in a previous reconstructive attempt, were removed because of its exposure with a soft tissue defect. The mean time to harvest of the flap was 65 min. Results One patient died of locoregional recurrence of the tumor at 6 months after surgery and another two patients had a flap necrosis by compression of the pedicle. MMSS mobility was recovered in all cases after rehabilitation and physiotherapy. In two cases, surgical wound dehiscence occurred at the back, resolved without the need for skin grafting. Conclusions While at present microsurgical flaps are the first choice for the reconstruction of head and neck cancer defects, regional flaps as the trapezius or pectoralis remain a valid and effective weapon when free flaps can not be considered for some reasons, attributable to the patient or to structural problems in the Surgery Departments. The myocutaneous or osteomyocutaneous trapezius flap is easy to manage, with a constant vascular pedicle. No major complications have been found postoperatively.

Purpose The Buccinator and Facial Artery Musculo-Mucosal (FAMM) flaps can be used to reconstruct a wide range of intra-oral defects including floor of mouth, tonsillar fossa and lateral tongue. We describe our experience with the Buccinator and FAMM flaps in the aforementioned areas and a novel use for the reconstruction of oropharyngeal tumours at the tongue base and lateral pharyngeal wall. Materials and methods We retrospectively reviewed all patients who underwent Buccinator and FAMM flap reconstruction examining indication, operative details, and post-operative outcomes. We describe our technique for its novel use in lateral pharynx/tongue base reconstruction through neck dissection access. Results There were no flap failures with all patients achieving primary healing with minimal complications. All donor sites closed directly with mouth opening at pre-operative status by 21 days post-op. Deeper flaps were adequately visualised and monitored using flexible nasoendoscopy. Conclusion In our experience Buccinator and FAMM musculo-mucosal flaps are an extremely versatile ‘like for like’ local flap option due to their long arc of rotation that we have used for the first time to successfully reconstruct the tongue base and lateral pharynx. As inset can be achieved via neck dissection access this avoids lip/jaw split as per conventional oropharyngeal surgical management further minimising morbidity.

The response of two human tumour xenografts to single dose and fractionated X-rays has been tested using regrowth delay as the assay. The tumours were line transplanted cells from a moderately well-differentiated squamous carcinoma of the tonsillar fossa (XJ) and an undifferentiated carcinoma of the floor of the mouth (XR). Comparison of the dose response curves for single doses in air, clamped, or after misonidazole administration, led to estimates of the hypoxic fraction (approximately 15%) and the sensitizer enhancement ratio (less than or equal to 1.6). When 5 daily fractions were used, the effect of misonidazole (miso) was lost and reoxygenation appeared to be effective in both tumours. Comparison of single doses and 5 fractions in clamped tumours, and in those sensitized by miso, allowed the sparing effect of fractionation to be estimated. When analysed by the linear quadratic model the alpha/beta ratios were found to be in the range of 6.4-9.2 Gy and 6.8-16.0 Gy for the two tumours. These values are in good agreement with murine tumours (assayed in vivo or in vitro), with human tumour cells assayed in vitro, and with analyses of fractionated clinical data for skin cancer.

From 1960 through 1976, 353 consecutive patients with carcinoma of the tonsillar region were primarily treated with radiation therapy. The mean age of patients was 58 years with males predominating (78%). Patients were classified according to a TNM and stage classification. Most of the tumors were large, and the specific site of origin could not be determined in 33% of the patients. The predominant identifiable sites were the soft palate and uvula, 18%, the anterior tonsillar pillar, 18%, and the tonsillar fossa, 13%. Patients were treated with radiation to doses of 6700 rad given in 48 days and 33 fractions using Cobalt 60 radiation. We found a 91.7% control rate for patients with T1 disease and 76.9%, 49.5%, and 25% for T2, T3, and T4 patients, respectively. The overall local control rate was 62.3%. Surgery was used most often in recurrences for Stage III patients. Salvage surgery was carried out in 93 patients. Surgery was more successful in controlling the disease in patients in whom the primary was controlled by irradiation. Overall, the tumors in 43% of the patients who had surgery were subsequently controlled as a result of this treatment. Metastasis occurred rapidly, with 75 of the patients exhibiting metastases by 18 months. Complications were not related to dose but were slightly higher in patients who had surgery (5%). We conclude that radiation therapy is the preferred treatment for Stage I and II squamous cell carcinoma of the tonsillar region. No satisfactory results were obtained in Stage IV; other approaches should be tried.

Between July 1968 and December 1983, 150 patients with previously untreated squamous cell carcinomas of the tonsillar fossa received megavoltage external beam irradiation with curative intent at U.T.M.D. Anderson Cancer Center. These patients were treated following a series of patients who had received radiotherapy between 1954 and May 1968. One hundred and thirty-seven patients were treated with conventional fractionation, the mean doses to the primary being 64.3 Gy, 67.8 Gy, 70.2 Gy, and 72.6 Gy for T1, T2, T3, and T4 lesions respectively. Thirteen patients were treated by altered fractionation schedules, 7 by hyperfractionation, and 6 by a concomitant boost to the primary. Elective bilateral neck irradiation was routine in all patients. A planned neck dissection was performed in 26 patients. The 5-year actuarial overall and disease-specific survival rates were 47% and 70%, respectively. Absolute local control rates with a minimum of 2 years follow-up after irradiation were 94%, 79%, 58%, and 50% for patients with T1, T2, T3, and T4 disease respectively. A total of 37 patients had local treatment failure; in 5 of 18 surgical salvage was successful. Only 4 patients with primary disease control developed failure in the neck and none of those with N0 or N1 disease did so when the primary was controlled. Twelve patients developed transient self-limited bone exposure, 7 developed osteoradionecrosis of the mandible, all requiring surgical resection. Most severe late complications occurred in patients with T3 and T4 lesions whose dose to the primary exceeded 67.5 Gy.

A new operation based on the concept of the pullthrough resection for mouth cancers and utilizing a posterior pharyngotomy approach for exposure has been developed for the surgical treatment of carcinomas of the oropharynx and nasopharynx. The operation has been used on six patients with a variety of extensive carcinomas of the pharynx. Three patients had lesions involving primarily the lateral pharyngeal wall, tonsillar fossa, and base of tongue; one patient had an extensive tumor involving the base of tongue bilaterally; one patient had a large carcinoma of the soft palate, tonsillar fossa, and nasopharynx; and the last patient had three primary carcinomas, one in the posterolateral pharyngeal wall, one in the tonsillar fossa, and one in the midline of the base of the tongue. All tumors were large T 3 or T 4 lesions ordinarily considered inoperable, and all patients had previously been treated by radiotherapy or surgery. The procedure developed makes it possible to carry out an effective en bloc resection of carcinomas of the lateral pharyngeal wall, tonsillar fossa, soft palate, nasopharynx, and base of tongue, together with their lymphatic drainage, in a one-stage operation. No mandibular resection is necessary and primary closure is possible in most instances. The morbidity of the operation is negligible, and the cosmetic and functional results are extremely satisfactory.

In patients treated for carcinoma of the tonsillar fossa by irradiation alone or preoperative irradiation and surgery a close correlation was observed between the doses of irradiation and adequacy of the portals, with control of the tumor in the primary and the neck lymph nodes. Radiation alone, at doses in the range of 5500 to 6000 rad will adequately control T 1 lesions; for T 2 tumors, 6000–6500 rad are necessary; and for T 3 − T 4 tumors, 7000–7500 rad. The neck nodes tumor is controlled with doses of 5000 rad when there is only subclinical disease ( N 0 ), 6000 rad for N 1 nodes, 6000–6500 rad for N 2 , and 6500–7500 rad for N 3 nodes, depending on the number of fractions. Approximately 50% ofthe patients failing in stages T 3 and T 4 had inadequate coverage of the entire areas of potential marginal tumor spread by the irradiation portals. In patients who were treated with preoperative irradiation, usually 3000 rad in 3 weeks, a greater proportion of pathological specimens with no evidence of tumor were seen in the patients with T 1 − T 2 or N 0 − N 1 lymph nodes. There were almost no failures in the patients with no pathological evidence of residual tumor, in contrast to over 50% of the patients with persistent tumor showing primary recurrences, and 45% of the patients with persistent tumor in the neck nodes developing neck failures. This suggests that higher doses oC preoperative irradiation, which produce a high number of negative specimens, may result in greater tumor control. This study emphasizes the significance of the dose of radiation delivered and the volume treated in patients with carcinoma of the tonsil managed by irradiation alone or combined with a surgical procedure.

A case of branchial cyst of the oropharynx in a 46-year-old man is reported. There was no recurrence following its excision, and no contralateral cyst developed during a period of 10 years. It is postulated that a branchial cyst in the oropharynx (tonsillar fossa) is derived from sequestrated remnants of the lateral portion of the second pharyngeal pouch.