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Background: Trigeminal neuralgia (TN) is an excruciating unilateral facial pain, which negatively affects patient's quality of life. Historically, it has been difficult to compare treatment efficacy due to the lack of standardized outcomes. In addition, patients' perspective has seldomly been acknowledged. The aim of this study was to reach consensus on what outcomes of treatment are important to different TN stakeholders (patients, clinicians and researchers), to identify the TN Core Outcome Set (TRINCOS)., Methods: A list of outcomes identified through a systematic review and focus group work was used to develop the survey questionnaire. A three-round Delphi was conducted. Participants were asked to score the outcomes on scale from 1 to 9 (1-3 not important;4-6 important but not critical;7-9 critical). Outcomes scored as critical by ≥70% and not important by <15% were retained, and those for which no consensus was reached were discussed at a consensus meeting., Results: Of the 70 participants who completed the Delphi, 26 were patients, 38 were clinicians and six were researchers. Of the 40 outcomes presented, 17 were scored as critical and no consensus was met for 23 outcomes. Agreement was reached during a consensus meeting on 10 outcomes across six domains (pain, side effects, social impact, quality of life, global improvement, and satisfaction with treatment)., Conclusion: Implementation of TRINCOS in future clinical trials will improve homogeneity of studies' results, reduce the redundancy in the outcome assessment and effectively allow comparison of different treatments to better inform researchers, clinicians and most importantly patients, about the efficacy of the different treatments., Significance: Implementation of a 10-item core outcome set in trigeminal neuralgia will improve comparability between studies allowing patients to have faster access to better treatments., (© 2022 The Authors. European Journal of Pain published by John Wiley & Sons Ltd on behalf of European Pain Federation - EFIC ®.)

The purpose of this study was to determine the frequency and outcomes of breast malpractice suits among all enrollees in One Call Medical Inc.'s panel of interpreting radiologists nationally and to evaluate state-by-state variations. The 8401 radiologists enrolled had 4764 suits, of which 826 were related to breast disease. In New York and New Jersey, the ratio of breast suits to One Call Radiologists was 0.28 and 0.27, twice as much as in any other state. Breast suits in radiology have a wide variation in frequency across the country with New York and New Jersey far exceeding all others in relative frequency and number of radiologists with multiple breast suits., (© 2017 Wiley Periodicals, Inc.)

Objective: To create a clinical consensus statement to address ambiguities and disparities in the diagnosis and management of nasal valve compromise (NVC)., Subjects and Methods: An updated systematic review of the literature was conducted. In addition, a Modified Delphi Method was used to refine expert opinion and facilitate a consensus position., Results: After two rounds of surveys and conference calls, 36 items reached consensus, six items reached near consensus, and 10 items reached no consensus. The categories that had the greatest percentage of consensus or near consensus items were as follows: definition, history and physical examination, outcome measures, and management. Conversely, the categories with greater percentage of no consensus items were adjunctive tests and coding., Conclusion: The consensus panel agreed that NVC is a distinct clinical entity that is best evaluated with history and physical examination findings. Endoscopy and photography are useful but not routinely indicated, whereas radiographic studies are not useful in evaluating NVC. Other objective nasal outcome measures may not be useful or accepted for NVC. Nasal steroid medication is not useful for treatment of NVC in the absence of rhinitis, and mechanical treatments may be useful in selected patients. Surgical treatment is the primary mode of treatment of NVC, but bill coding remains ambiguous and confusing., (2010 American Academy of Otolaryngology-Head and Neck Surgery Foundation. Published by Mosby, Inc. All rights reserved.)

Problem: This study aimed to examine if the experience of peer relational aggression victimization (PRAV) can be linked to feelings of depression in the African American adolescent female population., Methods: The sample included 241 college-age African American adolescent females assessed for PRAV and depression. Statistical analysis was carried out to determine the relationship between the variables., Findings: PRAV in this study population does exist as a detrimental phenomenon, whereby PRAV significantly correlates with depression, r (214) = 0.29, p < .01., Conclusion: Nurses can assist the adolescent clients experiencing relational aggression by becoming knowledgeable on the presentation and manifestations of this experience.

Secretory carcinoma of the breast is a rare but histologically distinct neoplasm that generally demonstrates an indolent growth pattern and a favorable prognosis. We present the mammographic, sonographic, and pathologic findings of a case of this tumor which initially presented as a palpable mass. Its appearance on breast ultrasound as a solid, well-circumscribed mass is not specific for this entity and, in fact, mimics benign entities such as fibradenoma, as well as other well-differentiated breast carcinomas. Thus, biopsy is needed for definitive diagnosis of this entity. Since this may initially be performed under imaging guidance, radiologists and clinicians alike need to be aware of this most unusual tumor and its therapeutic and prognostic implications.

Fast inversion recovery for myelin suppression is a new magnetic resonance sequence with the ability to increase gray-white matter contrast. This can improve the definition of normal anatomical structures.

Twenty-five squamous cell carcinoma (SCC) cell lines from 20 patients with head and neck cancer were assessed for radiosensitivity in vitro using a 96-well plate assay. Four non-SCC lines were also tested. Radiation sensitivity of individual cell lines was compared using the area under the survival curve (AUC) as a measure of the mean inactivation dose. Tumor lines were tested with either a cobalt-60 (60Co) gamma-irradiator having a dose rate of 100 cGy/minute or with a 4-meV photon beam having a dose rate of 200 cGy/minute. The mean AUC of the 25 SCC cell lines was 188 +/- 7 (SEM) cGy (range, 100 to 250 cGy) whereas the four non-SCC lines had a mean AUC of 225 +/- 9 cGy. The SCC cell lines with mean inactivation dose values greater than 188 cGy were classified as relatively radioresistant whereas those with values less than 188 cGy were considered relatively radiosensitive. In seven cases SCC cell lines were derived from patients who had already received radiation therapy. In four of these cases the tumor cell lines were radioresistant (AUC, 210 to 250) but in the other three cases the tumor lines were radiosensitive (AUC, 160 to 180). Thus, failure of a tumor to respond to radiation did not always select for radioresistant cells. The mean of the AUC for cell lines from previously irradiated patients (197 +/- 11 cGy) did not differ significantly from that of the cell lines from patients who received no prior radiation therapy (182 +/- 9 cGy). However, among radiation-resistant lines those from the four previously irradiated patients were significantly more resistant (mean AUC = 235 +/- 9) than seven other radioresistant lines from nonirradiated patients (mean AUC, 208 +/- 4) (P = 0.0194). In four cases more than one cell line was derived from different tumor specimens in the same patient. In each of these cases the lines from the same patients were similar to one another in their degree of radioresistance. Based on these observations the authors conclude that the degree of in vitro radiation resistance is an inherent property of some squamous cell tumors.

Ninety-nine patients with carcinoma of the nasopharynx were reviewed. No significant relationship was found between T classification and survival or between tumor cell type and survival. The presence of regional metastases, however, did influence the outcome of therapy. A 5-year survival of 34.4% was recorded for patients without nodal disease in contrast to 14% for patients with massive lymphadenopathy or bilateral cervical metastases. The significance of regional metastases is supported by the relationship between survival and disease stage. The 5-year survival for stage I was 67%, while the average survival for stages III and IV was 21%. The average 3- and 5-year survivals for the entire series of patients were 36.2% and 23.9%, respectively. Early lesions confined to the primary site have the greatest chance of cure, but even advanced disease with bone destruction or cranial nerve involvement may be controlled with radiotherapy in some cases. Patients who develop cervical metastases following successful control of nasopharyngeal tumor may be cured by radical neck dissection. Two (28.6%) of seven patients undergoing surgical treatment survived for 10 years following neck dissection.

The principal objective of regional chemotherapy is tumor cell kill. The rationale for regional delivery is based on the steep dose/response curve exhibited by most antineoplastic agents. Intraarterial (IA) chemotherapy has the potential advantage of increased drug concentration at the tumor site, decreased systemic drug levels, and continuous tumor cell exposure to an antineoplastic agent. Despite these advantages, the use of IA chemotherapy has not been universally accepted. This is in part due to the difficulties associated with establishing and maintaining arterial access. Considerable improvement in the techniques and efficacy of regional therapy for head and neck cancer will be necessary before there is widespread clinical acceptance. These improvements must be based on anatomic and pharmacologic factors that ensure success of regional therapy. In addition, the development of safe, reliable delivery systems will be necessary. Part 1 of this two-part article will review these factors and discuss delivery systems.

The high tumor response rates associated with intensive chemotherapy in previously untreated patients with advanced head and neck squamous cell carcinoma (HNSCC) led to the initiation of a multi-institutional National Cancer Institute trial. This trial used preoperative chemotherapy in patients with resectable Stage III and IV squamous cell carcinoma of the oral cavity or larynx/hypopharynx. Response rates, toxicity, and a variety of patient and tumor characteristics were analyzed to determine which factors might be useful in predicting tumor response to preoperative chemotherapy. Two hundred eighty-two patients received one course of preoperative cisplatin and bleomycin chemotherapy and were evaluable. There were 22 complete responses (CR) and 114 partial responses (PR) at the primary site (48% response rate). Of 197 patients with clinically positive regional adenopathy, 29 CRs and 73 PRs were observed (52%). Toxicity associated with the chemotherapy regimen was minimal. Primary tumor and regional node responses to chemotherapy were strongly correlated. No significant differences were found in primary or nodal response rates with respect to differing tumor site, stage, histologic differentiation, patient performance status, nutritional status, leukocyte count, hemoglobin level, age, sex, or alcohol use. Primary tumor response, however, was significantly related to T classification (P = 0.048). Nodal response was strongly associated with N classification and nodal size (P = 0.02 and P = 0.075, respectively). These findings suggest that, of the patient and tumor characteristics analyzed, none were more useful in predicting tumor response than clinical tumor staging parameters.

Periorbital cellulitis is a commonly occurring infectious process limited to the eyelids in the preseptal region. It occurs with greater frequency in the pediatric age group. It is important to distinguish this disease from orbital cellulitis, a potentially lethal infectious process involving the contents of the orbit. A retrospective study of clinical and laboratory data from 137 cases with orbital and periorbital cellulitis was performed. Periorbital cellulitis was documented in 98 cases (71%) in contrast to orbital cellulitis, which was noted in 39 (28%) patients. Sinusitis was the most frequently encountered predisposing factor for the development of periorbital cellulitis occurring in 29 patients. All patients with a diagnosis of periorbital cellulitis were hospitalized and received antibiotics, the majority (95%) receiving intravenous therapy. Hemophilus influenzae was the most frequently isolated pathogenic organism. It was necessary to operate on eight patients. Six patients underwent incision and drainage of an eyelid or periorbital abscess. A distinction between periorbital and orbital cellulitis is clarified. The separation of these entities on the basis of physical examination and radiographic studies is stressed.

A retrospective review was performed of 66 patients with squamous cell carcinoma of the maxillary sinus. The majority of patients presented with tumors classified as T3 (31.8%) and T4 (54.5%). Seven (10.6%) patients presented initially with neck metastases and 13 (19.7%) patients subsequently developed regional disease. For the 66 patients studied, the observed 5 and 10 year actuarial survival rate was 27.3% and 20.7% respectively. The presence of cervical metastases, particularly when they developed subsequent to initial therapy, was associated with a poorer survival rate. Five year survival rate for patients without cervical metastases was 32.6% in contrast to 28.6% for patients initially presenting with nodal disease and 7.7% for patients who subsequently developed regional metastases. Overall, 5-year survival rate for all patients with cervical metastases was 15.0%. A combined treatment regimen (surgery and radiation therapy) appeared to be superior to single modality therapy. A 58.0% observed 5-year actuarial survival rate was achieved with combined therapy. Surgery or radiation therapy when used alone as a single modality resulted in a 5-year survival rate of 20.0% and 15.7% respectively.

Mohs surgery, as it has evolved since its inception by Dr. Mohs, is a technique for removal of certain cancers using careful, precise microscopic marginal control. The contemporary technique using fresh tissue is detailed, illustrating advantages that include maximal conservation of normal surrounding tissue and structures, an extremely high cure rate, and a tumor-free defect which can be reconstructed immediately. The indications and applications for Mohs surgery, once limited to large recurrent basal cell carcinomas, have expanded to include several cutaneous and paracutaneous neoplasms. These, with an emphasis on certain basal cell carcinomas, are discussed in detail. With better understanding of the Mohs technique, its indications, applications, and advantages, an interdisciplinary approach to certain cutaneous and paracutaneous neoplasms is proposed.

Data collected from review of 99 patients with carcinoma of the nasopharynx was submitted for statistical analysis. The purpose of the analysis was to determine patient, tumor and treatment factors that influence survival. The only patient factor observed to influence survival was patient age (P = 0.05). Greatest survival was noted for patients in the age group 0 to 20 years (44%), while poorest survival rates were in patients over 60 years of age (14%). Tumor factors influencing survival included the location of regional metastases (P = 0.05). Homolateral cervical metastases was associated with survival rates approximating 30% compared with 10% when bilateral metastases were present. Survival decreased markedly as cervical metastases progressed from the upper third of the neck to involvement of the middle and lower thirds. Survival was 20% when nodal involvement was confined to the upper neck compared with 8% when metastases extended to lower cervical regions. The only treatment factor apparently influencing survival was duration of therapy (P = 0.08). Longer treatment periods offered better five-year control rates. Higher dosage levels of radiotherapy were associated with improved survival, but not significantly so.

Six cases of laryngocele are reported including 2 bilateral, external laryngoceles, 1 internal laryngocele associated with amyloidosis, and 3 combined laryngoceles. Laryngoceles occur predominantly in males. Cervical mass and hoarseness were the most common signs and symptoms. Bilateral, external laryngoceles that decompress spontaneously when intralaryngeal air pressure returns to normal were managed conservatively. Combined and internal laryngoceles should be removed surgically through an external, lateral neck approach. This approach is preferable to anterior laryngofissure because it avoids trauma to the anterior commissure and the true vocal cords. In addition, blunting of the anterior commissure and the risk of subglottic stenosis are avoided.

We are studying membrane antigens of human squamous cell cancer with the use of naturally occurring autologous antibodies from patients' sera, along with a set of other serologic reagents and monoclonal antibodies raised against cultured squamous cell lines. Twenty-eight squamous cell carcinoma cell lines have been established in our laboratory from tissues obtained from 23 patients. Antibody reactivity has been found against the autologous tumor cell line in 13 of 23 patients. One of these is of sufficient titer for detailed analysis. Four cell lines are available from this patient. UM-SCC-17A is derived from the primary laryngeal carcinoma, and UM-SCC-17B is derived from a lymph node metastasis removed during the same surgical procedure. Fibroblasts have been cultured from normal mucosa, and a B-lymphoblastoid line has been developed by Epstein-Barr virus transformation of the patient's peripheral blood lymphocytes. Antibody from this patient reacts with the UM-SCC-17A and -17B tumor cell lines but does not react with the normal fibroblasts (UM-NF-17).

Malignant salivary gland neoplasms in children are rare. Such tumors usually occur in the parotid gland of older children. Sixteen cases of major salivary gland malignancy are reviewed, 14 occurring in the parotid gland and two in the submandibular gland. Adenoid cystic carcinoma was the most common malignancy encountered, occurring in five patients; four have died of disease. Low-grade mucoepidermoid carcinoma occurred in three patients and all remain alive and free of disease. An assorted variety of other cancers occurred in eight patients. One child died of reticulum cell sarcoma of the parotid gland, and two children have died of adenocarcinoma. The remaining five patients remain alive and free of disease. Salivary gland malignancies in children appear to have similar biological activity as those occurring in adults. Such tumors must be treated according to the same principles generally accepted for management of salivary gland malignancies in adults.

Intraarterial infusion chemotherapy has not been widely accepted for the treatment of head and neck cancer due to the high rate of complications it involves. To avoid these complications, a totally implantable infusion pump has been developed to achieve continuous low-level drug delivery for long periods of time. The pump is implanted in a subcutaneous pocket and connected to a permanent, indwelling, arterial catheter. It can be repeatedly refilled with chemotherapeutic agents by hypodermic needle injection through the skin and through a self-sealing septum located at the entry to the pump. Refilling the pump recharges an inexhaustible power source for the next delivery cycle. Preliminary results suggest that long term intraarterial infusion chemotherapy for the treatment of head and neck cancer is practical for outpatients.

Chemotherapy delivered through angiographically placed catheters requires patient hospitalization, and is usually limited to short-term infusions. Treatment given through surgically placed catheters with external portable infusion pumps permits greater patient freedom and longer infusion durations. However, some patient restrictions remain, and thrombotic or infectious complications are common with long-term therapy. A totally implantable pump has allowed long-term intraarterial therapy in an outpatient population. Patient activity was unrestricted, and the complication rate has been low. This system has been used to deliver single-agent therapy with FUdR, dichloromethotrexate or bleomycin, and combination-drug treatment with cisplatin + FUdR or bleomycin + mitomycin C + dichloromethotrexate. The majority of patients have responded to at least one drug program. Seven of 14 patients who had pumps implanted over 1 year ago have received therapy for at least 1 year, and four patients have had functioning system for over 2 years. Systemic toxicity (except for nausea and vomiting with cisplatin) has been uncommon. Further clinical experience with these programs will be necessary to fully establish the objective response rate. However, the Infusaid Pump has proven safe, reliable and has high patient acceptance.

Mohs surgery, as it has evolved since its inception by Mohs, is a technique for removing certain cancers using careful, precise microscopic marginal control. The contemporary technique using fresh tissue has enabled the application of Mohs surgery to the treatment of malignancies of the upper aerodigestive tract. Mohs surgery, once limited to large recurrent basal cell carcinomas, has expanded to include several cutaneous and noncutaneous neoplasms. With better understanding of the Mohs technique, its indications, applications, and advantages, an interdisciplinary approach to manage certain head and neck neoplasms is proposed.

Magnetic resonance imaging (MR) has already gained wide acceptance in the evaluation of intracranial and spinal canal abnormalities. MR also provides excellent resolution of certain tumors of the head and neck and is particularly useful for the evaluation of neoplasms in the vicinity of the skull base. The absence of a bone signal prevents the streaking artifact so troublesome with computerized axial tomography (CT) and allows better definition of tumor. MR does not use ionizing radiation and appears to be an innocuous imaging mode--thus multiple examinations in young patients are not objectionable with MR. The ability to obtain images in multiple planes by control of the magnetic gradients allows for axial, sagittal, and coronal imaging, without changing the supine position of the patient. Multiple projections are helpful in providing better preoperative assessment of the extent and size of certain neoplasms of the neck.

Despite almost 3 decades of experience, the use of intraarterial (IA) chemotherapy for the treatment of head and neck cancer is not universally accepted. The overall reported response rates are not substantially different from the therapeutic results obtained with systemic therapy. The additional complications associated with establishing and maintaining arterial access have further dampened enthusiasm for this approach. It is clear that considerable improvement in the techniques and efficacy of IA chemotherapy is necessary. This second and last part of this article considers the past and present clinical experience with IA therapy in the treatment of head and neck cancer and explores future developments.

The treatment of advanced cancer of the maxillary sinus often requires extensive ablation and orbital exenteration that results in large full-thickness defects of the upper cheek and orbital regions. Reconstruction of such defects with local flaps is usually difficult because of the need for a large flap. Several regional flaps such as the deltopectoral flap, the temporal flap, and the shoulder flap may be used, but these techniques frequently require surgery in stages and result in severe deformity of the donor site. The island pedicled, pectoralis major myocutaneous flap may be rotated up to the orbital region; however, the uncertain blood supply to the skin in the distal area of the pectoralis may cause unexpected marginal necrosis of the flap. Reconstruction of large orbital-maxillary defects can readily be accomplished in one stage using microsurgical free transfer of latissimus dorsi myocutaneous flaps. The thoracodorsal artery and vein that form the nutrient pedicle of the flap approaches 2 mm in external diameter and up to 10 cm in length, allowing greater versatility in head and neck reconstruction. The muscle may be used to fill the orbital and maxillary cavities and will accept a skin graft on its deep surface. The donor defect is closed primarily and the resulting scar is well concealed beneath the arm. If necessary, extremely large flaps may be transferred by harvesting the entire latissimus dorsi muscle and the overlying skin based on the thoracodorsal system.

We have evaluated the use of the completely implantable infusaid pump in 22 patients with advanced cancer confined to the head and neck. Unilateral head lesions are treated with a single-catheter pump infusing the external carotid artery. A dual-catheter pump is used for midline or bilateral head lesions (both external carotid arteries infused) or unilateral head and neck disease (the second catheter positioned in the thyrocervical trunk). The infused volume of each catheter is determined by nuclear tomography after slow intra-arterial injection of 99mTc-labeled macroaggregated albumin through the pump's auxiliary port. The injection port/infusion chamber configuration of the pump permits long-term, multiple-course, combination-drug intra-arterial therapy on an outpatient basis. To date, 15 patients have been treated longer than 6 months and five longer than 1 year with no bleeding or neurologic complications. Eight of 10 patients treated with cisplatin and fluorodeoxyuridine (FUdR) have responded. The Infusaid pump permits long-term, practical, cost-effective, intra-arterial therapy to the entire tumor volume of ambulatory head and neck cancer patients with a high rate of tumor response.

Squamous cell carcinoma of the nasopharynx is an uncommon disease in childhood. Ten patients under the age of 18 years with nasopharyngeal carcinoma are reviewed. The average patient age was 13 years and the average duration of symptoms was 18 weeks. Cervical mass (8/10) and hearing loss (4/10) were the most frequently encountered complaints. Three- and five-year determinate survival was 50% and 44% respectively. Bilateral cervical metastases or cranial nerve impairment from neoplasm offered a poor prognosis.