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Objectives: To determine if the coblation tonsillectomy (subcapsular dissection) results in less postoperative pain, equivalent intraoperative blood loss, equivalent postoperative hemorrhage rates, and faster healing compared with tonsillectomy was performed using unipolar electrocautery in adult patients. Study Design: The authors conducted a prospective clinical trial. Methods: Forty-eight patients underwent tonsillectomy and were randomly assigned to have one tonsil removed with coblation and the other with unipolar electrocautery. Outcome measures included time to remove each tonsil, intraoperative blood loss, patient-reported pain, postoperative hemorrhage, and amount of healing 2 weeks after surgery. Results: Mean time to remove a single tonsil with coblation and electrocautery was 8.22 minutes and 6.33 minutes, respectively (P = .011). Mean intraoperative blood loss for each technique was less than 10 mL. Postoperative pain was significantly less with coblation as compared with electrocautery: 18.6% less painful during the first week of recovery. Seventy percent of blinded patients identified the coblation side as less painful during the overall 14-day convalescent period. Postoperative hemorrhage rates (2.1% for coblation and 6.2% for electrocautery) were not significantly different. No difference in tonsillar fossa healing was observed between the two techniques 2 weeks after surgery. During nine of the 48 surgeries, wires on the tip of the coblation handpiece experienced thinning to the point of discontinuity while removing a single tonsil. Conclusions: Coblation subcapsular tonsillectomy was less painful than electrocautery tonsillectomy in this 48-patient group. On average, intraoperative blood loss was less than 10 mL for both techniques. Postoperative hemorrhage rates and the degree of tonsillar fossa healing were similar between the two techniques. The coblation handpiece experienced degradation of vital wires in 18% of cases necessitating the use of a second, new handpiece.

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.

Plasmacytoma is a malignant disease that present either in bone marrow (medullary plasmacytoma), within the bone (solitary plasmacytoma of bone), or outside of bone, as the extramedullary plasmacytoma. Extramedullary plasmacytoma accounts for 3% of all plasma cell tumours and approximately 90% of extramedullary plasmacytomas affect the head and neck region commonly affecting the nasal cavity, paranasal sinuses, tonsillar fossa and oral cavity. Multiple extramedullary plasmacytoma is defined when there is more than one extramedullary tumour of clonal plasma cells and such presentations are extremely rare. We report such a rare case of multiple extramedullary plasmacytoma involving gingiva and neck. Here is a case report of a 65-year-old female patient presenting with extramedullary plasmacytoma of the gingiva and soft tissue in neck.

Objectives: This consecutive case series is presented to describe inside-out complete tonsillectomy and to assess its effects on postoperative pain and bleeding and its initial effectiveness in controlling recurrent sore throat and peritonsillar abscess formation. Methods: Bipolar electrosurgical scissors are used for bloodless resection of 90% of the tonsillar mass. During controlled resection, tonsil tissue is intentionally left at the superior and inferior poles and at the deepest part of the tonsillar fossa to provide coverage for nutrient arteries and the tonsillar plexus of veins. This tissue is then electrodesiccated and removed under direct vision and indirect mirror guidance to achieve complete tonsillectomy. Results: One hundred eighty-three consecutive tonsillectomies were performed by a single surgeon in a 16-month period, 47 of which were for the indication of recurrent sore throat (44) or recurrent peritonsillar abscess (3). Among these 47 children, there were 2 readmissions for dehydration. There were no immediate or delayed bleeding episodes. The average child required 4 days of narcotic pain medication. The mean annualized number of severe sore throats decreased from 5.24 before operation to 0.36 after operation (p Conclusions: Inside-out complete tonsillectomy achieves the surgical goal of complete tonsillectomy with the smallest possible wound and minimal injury to the surrounding tissue. The perioperative morbidity is markedly decreased compared to that of historical controls. The initial results suggest effectiveness similar to that of extracapsular tonsillectomy.

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.

Wide excision of cancer arising from the tonsillar fossa and soft palate has several functional sequelae (e.g., speech, swallowing, chewing, and breathing) that require surgical restoration of the pharyngeo-palatal structure and optimal velopharyngeal function. For this purpose, several kinds of surgical procedures have been introduced. Our method to reconstruct the tonsillar fossa and soft palate entails folding the flaps and reconstructions at the same time as the oral and nasal planes, with some modifications.Patient 1 was a 64-year-old man with left soft palate cancer. After wide excision of the tumor, the defect size of the nasal floor was 3 × 3 cm, and that of soft palate and tonsillar fossa was 8 × 5 cm. Patient 2 was a 49-year-old man with left tonsil cancer. The defect size of the nasal floor was 3 × 3 cm, and that of left lateral wall of the tonsillar fossa was 8 × 3 cm. For reconstruction of oral, nasal, and tonsillar plane, we designed the flap fit to the defect site, especially cutting of the edge of the square plane of the flap to a round shape.Both patients achieved good functional recovery without surgical complications. The average speech intelligibility score in the 2 patients was 10. Swallowing functional score was 4 in both patients. Creative reconstruction with modified radial forearm free flap for tonsillar and soft palate area makes it possible to restore velopharyngeal function to levels close to the preoperative condition.

Objective: To present a case report and to propose an anatomic explanation for a rare complication of tonsillectomy, severe dysphagia caused by bilateral paralysis of the glossopharyngeal nerve. Study Design: Retrospective case review and prospective cadaveric dissection. Methods: The medical record and radiologic data were reviewed from a patient who had severe dysphagia after tonsillectomy. In addition, 10 formalin-preserved cadaver head and neck specimens were dissected to identify the anatomic course of 20 glossopharyngeal nerves. The distance between the nerve and tonsillar fossa was measured at two sites. Results: The patient was diagnosed with bilateral paralysis of the glossopharyngeal nerve and required use of gastrotomy tube for years postoperatively. The mean distance from the posterosuperior tonsillar fossa and the main trunk of the glossopharyngeal nerve was 10.7 mm, and the mean distance from the posteroinferior tonsillar fossa and the closest lingual branch of the glossopharyngeal nerve was 6.5 mm. Conclusions: Direct nerve injury seems the most plausible explanation for this rare complication of tonsillectomy. The proximity of the glossopharyngeal nerve to the tonsillar fossa emphasizes the importance of maintaining the correct surgical plane during surgery.

Purpose To report on the tumor control, adverse late normal tissue sequelae, and functional performance in patients with tonsillar fossa and/or soft palate (SP) tumors. The aim of the study is to validate the use of a more selective clinical target volume in conjunction with highly conformal radiotherapy (RT) techniques to better spare the surrounding normal tissues. Methods and materials Between 1986 and 2001, T1-T3 tonsillar fossa/SP tumors were treated in the Erasmus Medical Center using external beam radiotherapy (EBRT) to 46 Gy in 2-Gy fractions to the primary tumor and neck, followed by brachytherapy (BT) to the primary. Neck dissection was performed for node-positive disease (BT group; 104 patients). If BT was not feasible, patients underwent surgery and postoperative RT (PORT) to a dose of 50–70 Gy in 2-Gy fractions (surgery group; 86 patients). Local control, regional control, disease-free survival, and overall survival were determined. Late side effects were scored using the Radiation Therapy Oncology Group criteria. Univariate and multivariate Cox regression analyses were performed for regional failure (RF), with the parameters gender, age, site, TN stage, modality, dose, and overall treatment time. Recurrences in the contralateral neck were also related to significant ipsilateral involvement of the base of tongue and/or involvement of the SP crossing the midline. To determine the performance status scale scores and degree of xerostomia, a survey was conducted among patients living with no evidence of disease and a minimum of 2 years of follow-up. For that purpose, a research nurse interviewed patients regarding eating in public, normalcy of diet, normalcy of speech, and xerostomia. Results The tumor control rates after BT vs. surgery at 5 years were 88% vs. 88% for local control; 93% vs. 85% for regional control; 57% vs. 52% for disease-free survival; 67% vs. 57% for overall survival; and 5% vs. 6% for RF. No patient had RF in the contralateral untreated N0 neck (0 of 14 vs. 0 of 15). Multivariate Cox regression analysis for RF was statistically significant for Stage T2 vs. T3 (hazard ratio 0.09) and for the dose to the neck >46 Gy (hazard ratio, 8.7; 95% confidence interval, 1.3–57.1). The significant late side effects in the BT group vs. surgery group were ulcer in 39% vs. 7% (p = 0.001) and trismus in 1% vs. 21% (p = 0.005). The performance status scale scores and response to questions regarding xerostomia for BT vs. surgery revealed no statistically significant differences for eating in public, normalcy of diet, normalcy of speech, and xerostomia. The mean visual analog score for xerostomia was 5.5 in the BT group vs. 6 in the surgery group. conclusion Excellent locoregional control was obtained in T1-T3 tonsillar fossa and/or SP tumors. The rate at 10 years was 84% (BT group) vs. 78% (surgery group). However, adverse late side effects were not negligible. In addition to modality-specific side effects (ulcer/trismus), both treatment groups were significantly affected by xerostomia. Only 6 recurrences (4%) were observed in the 149 electively treated contralateral necks, and no relapses were seen in the 29 untreated contralateral necks. We, therefore, suggest that it is not necessary to treat the contralateral neck, unless the tumor extends beyond the midline of the soft palate (uvula) or beyond the lateral one-third of the ipsilateral base of the tongue. Moreover, with the currently available CT-based neck level definitions, more conformal contours (i.e., tighter boundaries) around the clinical target volume can be designed. In this way, critical structures such as the temporomandibular joint and part of the pterygoid muscles can be avoided more easily. Also, when using highly conformal treatment techniques (e.g., intensity-modulated RT), one can further reduce the dose to the major salivary glands and oral mucosa. We believe these measures will lead to less trismus and less xerostomia.

Purpose Locoregional control rates, late normal tissue sequelae, and functional outcome scores have not been different for tonsillar fossa and/or soft palate tumors treated by either brachytherapy (BT) or surgery in an organ function preservation protocol. For additional prioritizing in clinical decision-making, we focused on a comparison of the full hospital costs of the different treatment options. Methods and materials Between 1986 and 2001, tonsillar fossa and/or soft palate tumors were treated by external beam radiotherapy (EBRT) to the primary tumor and neck, followed by fractionated BT to the primary. Neck dissection (ND) was performed for node-positive disease (BT group; 104 patients). If BT was not feasible, resection combined with postoperative EBRT was executed (surgery group; 86 patients). Locoregional control, disease-free survival, and overall survival were calculated according to the Kaplan-Meier method. The performance status scales, late side effects, and degree of xerostomia have been previously reported. This paper focused on the hospital and follow-up costs for the treatment groups EBRT and BT with or without ND compared with surgery followed by postoperative RT (PORT). Finally, these costs were also computed for future treatment strategies (e.g., better sparing of normal tissues by intensity-modulated RT [IMRT]). Results Locoregional control, disease-free survival, and overall survival rate at 5 years for patients treated with EBRT and BT with or without ND vs. surgery plus PORT was 80% vs. 78%, 58% vs. 55%, and 67% vs. 57%, respectively. The major late side effect was xerostomia. Dry mouth syndrome affected the BT group and surgery group equally. The total costs for all treatment groups were €14,262 (BT group), €16,628 (BT plus ND group), €18,782 (surgery plus PORT group), €14,532 (IMRT group), and €16,897 (IMRT plus ND group). Conclusion Excellent locoregional tumor control was observed with either modality, with no statistically significant differences in the incidence of the most noted side effect xerostomia. The total costs for BT were less than for surgery: €16,628 ($19,452) for EBRT plus BT plus ND vs. €18,782 ($22,074) for surgery plus PORT. To reduce the morbidity of xerostomia, we propose further optimizing our organ function preservation protocol by implementing IMRT as a more conformal, tissue-sparing, RT technique. This is of particular interest because the costs of IMRT plus ND (€16,897; $19,767) were not very different from those for BT plus ND (€16,628; $19,452) and were far less than the costs for surgery.

Objective To review a single institution's experience with posterior marginal (ramus) mandibulectomy for mandibular preservation in the management of patients with squamous cell carcinoma of the retromolar trigone or oropharynx. To review the history and surgical technique with emphasis on functional as well as oncologic outcomes. Study design and setting Retrospective review at a tertiary care academic referral center from 1996 to 2002. Results Between 1996 and 2002, 382 patients with squamous cell carcinoma of the oral cavity and oropharynx were surgically treated at the Loyola University Medical Center. Medical records were reviewed and 152 patients were identified who had some form of mandibular procedure (segmental resection, marginal resection, or mandibulotomy) performed in conjunction with their tumor resection. Eighteen posterior marginal mandibulectomies were performed for primary cancers of the retromolar trigone, tonsillar fossa, and/or base of the tongue. All patients received adjuvant radiotherapy. Bone invasion of the marginal mandibulectomy specimens by squamous cell carcinoma was observed in 2 cases, neither of which developed a local recurrence. Mean and median overall survivals were 41.4 and 37.5 months, respectively. Functional outcomes were determined by administering the University of Washington Quality of Life instrument administered at 12 months. Patients reported significant alterations in chewing, but all were able to maintain satisfactory oral intake and no patient required a gastrosotomy tube. Conclusions A posterior osteotomy of the mandibular ramus is a useful adjunct in the surgical treatment of cancer of the retromolar trigone or oropharynx. Negative surgical margins can be obtained even with focal invasion of mandibular bone. The loss of bone in this area does not significantly affect patients' appearance. Patients report deterioration in chewing following this procedure but are able to maintain a diet of solid food.

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.

BACKGROUND Postoperative period after tonsillectomy is characterized by inevitable discomfort for the patient. The aim of the study was to estimate whether fusafungine in spray has an effect on healing process after the operation, especially on pain and consumption of analgesics. PATIENTS A prospective open, randomized study was performed on 68 patients (age 15 - 55) undergoing tonsillectomy for chronic tonsillitis. Except of standard postoperative therapy 34 patients received fusafungine in spray 4 times daily and 34 patients served as a control. Pain score in the morning and in the evening, consumption of analgesics and visual estimation of wound healing in the tonsillar fossa was evaluated. RESULTS Fusafungine in spray significantly reduces pain in the early days (2 - 4 day) after the operation and offers almost 16 % decrease in total consumption of analgesics (p < 0.04). Despite of that, total evaluation of pain score shows no significant differences in the both groups. The observation of wound healing suggests better cleanliness in 25 % of patients after fusafungine. CONCLUSION Fusafungine in spray improves quality of life after the tonsillectomy and so completes the spectrum of adjuvant postoperative local treatment possibilities.

Objective: The study goal was to determine whether the combination of dexamethasone with preemptive analgesia has an additive effect in further improving recovery. Study Design: We conducted a prospective, randomized, double-blinded trial of 50 children undergoing tonsillectomy at a university ambulatory surgery center. One study group received 1 intravenous dose of dexamethasone, and another group received 1 dose of saline solution. All patients received tonsillar fossa injections of ropivacaine plus clonidine before tonsil excision. Results: The 2 study groups were similar in main outcome measurements. Pain intensity and quality of life were not statistically different between the groups. There was a small trend to less trismus and less cumulative codeine use in the steroid group. Overall, there was a very low incidence of nausea and vomiting in both groups, which may have been due to the preemptive analgesia. Conclusion: Dexamethasone does not significantly improve the morbidity of pediatric tonsillectomy when preemptive analgesia with ropivacaine and clonidine is used concurrently. (Otolaryngol Head Neck Surg 2002;126:307-15.)

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

Background: The aim of the study is to correlate the clinical palpability of the styloid process with its length which is determined by CT scan. Methods: A prospective study of 50 patients who presented to ENT OPD from January 2011 to January 2016 with cervicofacial pain and features of Eagle’s syndrome were clinically evaluated for elongated styloid process by palpating the tonsillar fossa. These patients were subjected to a detailed CT scan with coronal, axial and 3D cuts. The length of the styloid process in the CT scan was correlated with the clinical palpability of the styloid process. Results: It was noticed that only styloid process of length greater than 28 mm was clinically palpable. Correlation between the clinical palpability and the minimum length required was established in this study. Conclusions: Patients with cervicofacial pain should be evaluated for styalgia by imaging and clinically by palpating the tonsillar fossa.

Tonsilloliths are rare dystrophic calcifications caused by chronic inflammation of the tonsils. They are usually small and occur on one side. Herein, we report a case involving a 75-year-old man presenting odynophagia and progressive dyspnea for days who was found by computed tomography image to have bilateral giant tonsilloliths. Hyperdensity lesions were found over the tonsillar fossa on both sides. Tonsillectomy was performed leading to immediate relief of symptoms. A review of relevant literature revealed that most patients with tonsilloliths are asymptomatic and need only conservative treatment. Severe symptoms such as dyspnea are extremely rare. Although tonsillolith can be easily diagnosed by computed tomography, otolaryngologists should be careful to differentiate this entity.

Glossopharyngeal neuralgia (GPN) is one of several microvascular compression syndromes. The neuralgia is characterized by unilateral, paroxysmal, lancinating pain in the oropharynx or tonsillar fossa, spreading to the external auditory canal through the eustachian tube. It is often caused by activities such as talking, eating, swallowing, and coughing. “Typical” GPN is easily diagnosed when a patient presents the aforementioned symptoms in combination with radiological features, ascertained by magnetic resonance imaging (MRI)/magnetic resonance angiography (MRA), such as posterior inferior cerebellar artery (PICA) with a high origin that forms an upward loop (Fig. 13.1). However, unless these typical features of PICA are evident on MRI/MRA, the diagnosis and efficacy of microvascular decompression (MVD) remain uncertain. In such cases, the characteristics of the pain, e.g., location within the distribution of cranial nerve (CN) IX, paroxysmal, and association with swallowing, aid diagnosis. Carbamazepine therapy is effective and can be used for a diagnostic trial. Furthermore, the application of 10 % cocaine or lidocaine to the pharynx, a test block, relieves the pain of GPN. With the confirmation of these characteristics, the diagnosis of GPN becomes more reliable and successful outcomes of MVD can be expected.

Objectives:(1) Describe 3-dimensional (3D) computed tomography (CT) anatomic features of the stylohyoid chain in Eagle’s syndrome patients (ES), glossopharyngeal neuralgia patients (GPN), and normal asymptomatic controls (NC). (2) Understand 3D-CT features findings associated with Eagle’s syndrome.Methods:Retrospective chart review from November 2000 to November 2013. 3D shaded surface display CT reconstructions of the stylohyoid chain were generated for 10 ES patients, 16 GPN, and 15 NC patients. Demographic and clinical symptom data were recorded. Anatomic data collected from CT scans included: length of ossified styloid process, anterior-posterior (APA) and medial-lateral (MLA) styloid process angulation, ossification pattern of the stylohyoid chain, and minimum distances between the styloid process and the internal carotid artery, C1 transverse process, and tonsillar fossa.Results:The average distance from the styloid process tip to the tonsillar fossa was found to be significantly shorter in ES patie...

Objectives:(1) Describe key anatomic structures in lateral oropharyngeal wall and tongue base transorally. (2) Determine surgical landmarks to increase intraoperative safety in transoral robotic surgery.Methods:Transoral dissections were performed endoscopically in 5 vascular silicone-injected fresh human cadavers. Anatomic structures were also confirmed with lateral neck dissections.Results:Tonsillar bed is largely made by superior pharyngeal constrictor muscle and overlying pharyngobasilar fascia. Palatoglossus and palatopharyngeus muscles limit this tonsillar bed anteriorly and posteriorly, forming tonsillar pillars. Stylopharyngeus and styloglossus muscles and stylohyoid ligament run between superior and middle pharyngeal constrictor muscles contributing to inferior tonsillar fossa. These structures are located just medial to facial, lingual, and internal maxillary arteries in parapharyngeal space. Internal carotid artery lies posterolateral to the branches of external carotid artery. Lingual artery i...

To evaluate the preemptive analgesic effect of submucosal infiltration of ropivacaine for uvulopalatopharyngoplasty.Randomized controlled trial.Comprehensive clinical center and academic hospital.Fifty consecutive male patients scheduled for uvulopalatopharyngoplasty were divided randomly into group A and group B. In group A, 4 mL of 0.33% ropivacaine and normal saline with epinephrine was preincisionally injected under the mucosa on both sides of the tonsillar fossa, soft palate, and the lower part of palatoglossal arch, whereas the upper and middle parts of the palatoglossal arch and the upper part of the palatopharyngeal arch were infiltrated with 2 mL of the same mixture. In group B, an identical volume of normal saline with epinephrine was administered. In both groups, postoperative pain was initially controlled by intravenous morphine titration until patient-controlled analgesia with morphine could be used. Cumulative patient-controlled analgesic morphine consumption; visual analog scale scores at 4, 8, 12, 24, and 48 hours postoperatively at rest and during swallowing; and opioid-related adverse effects were recorded.The visual analog score was lower at rest during the 48-hour postoperative period and during swallowing within the first 12 hours for group A versus group B (P.05). Patients in group A required 44.1%, 38.2%, and 41.1% less morphine during the first 24 hours, 24 hours to 48 hours, and 48 hours postoperatively, respectively, and fewer patients experienced nausea, vomiting, and pruritus (P.05).Preemptive submucosal infiltration with 0.33% ropivacaine effectively controlled pain after uvulopalato-pharyngoplasty.

Background Eagle’s syndrome (Elongated styloid process) is often misdiagnosed due to its vague symptomatology. The diagnosis relies on detail history taking, palpation of styloid process in tonsillar fossa and imaging modalities.Objective To assess the length and medial angulation of elongated styloid process with the help of three dimensional computed tomography (3D CT) scan and to describe our clinical and surgical experience with patients suffering from Eagle’s syndrome.Method Prospective, analytical study conducted from August 2011 to August 2012 among 39 patients with Eagle’s syndrome. Detailed history taking, clinical examination and 3D CT scan was performed. Length and medial angulation was calculated. Patients with styloid process length longer than 2.50 cm underwent surgical excision via intraoral approach. Medial angulation of styloid process on both sides was correlated with each other using rank correlation coefficient. Wilcoxon Signed Rank test was applied to test significant difference between pre-operative and post-operative symptoms scores.Result Significant positive correlation was found between the medial angulation of styloid process on right side and left side (? =0.81, p

Background:Adenoidectomy is often carried out in children for conditions such as nasal obstruction, otitis media with effusion, and obstructive sleep apnoea. Traditionally, it is performed as a blind procedure with a St Clair Thomson curette. An acceptable alternative technique is suction diathermy adenoidectomy. This study aimed to ensure that the complication rate of this latter technique was within published rates and national guidelines.Method:A retrospective case note review was conducted, and information regarding surgery, indications and complications was collected.Results:Post-operative haemorrhage was recorded for 2 of 121 patients (at days 10 and 11 post-operatively): 1 returned to the operating theatre and the other was managed conservatively. Two patients were diagnosed with infection post-operatively and managed with oral antibiotics. A further four patients re-presented with pain; in all cases, this was recorded as secondary to tonsillar fossa infection, rather than being pain related to adenoidectomy.Conclusion:Given the rare but serious potential complications, the authors support National Institute for Health and Clinical Excellence guidance, which recommends that only surgeons with specific training perform this technique. By using the standard procedures for clinical governance, it is possible to ensure safe practice of even little-used techniques.

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).

We report a case of complete congenital branchial fistula with an internal opening near the tonsillar fossa. Cysts, fistulas, and sinuses of the second branchial cleft are the most common developmental anomalies arising from the branchial apparatus. In our case, a 43-year-old man presented with a several-year history of a discharging sinus from the right side of his neck, consistent with a branchial fistula. He underwent various investigations and finally was treated with a one-stage complete surgical excision of the fistula tract. We describe the general clinical presentation, investigations, and surgical outcome of this case.

Purpose Post-tonsillectomy pain is a notable concern and thermal injury produced by electric surgical devices is considered a main cause. Intraoperative cooling of the tonsillar fossa and pharyngeal mucosa with cold water has effectively reduced postoperative pain, but no studies have fully evaluated the effects of this technique with a proper study design. We assessed mucosal cooling in two groups of patients undergoing the same surgical technique by a single surgeon, with one group receiving cold-water cooling and the other group as a control. Methods Forty patients who underwent monopolar electrocautery tonsillectomy were randomly assigned to two groups (n = 20 for each group). Group 1 received cooling of the tonsillar fossa and pharyngeal mucosa with 4 °C saline just after removal of each tonsil whereas Group 2 did not receive cooling. Postoperative pain was recorded on operation day and 1, 2, 4, 7, and 10 days postoperatively. Post-tonsillectomy pain, return to normal diet, and incidence of postoperative bleeding were compared between the groups. Results Post-tonsillectomy pain on 6 selected days and overall pain during the 10-day follow-up period were significantly lower in Group 1. However, return to normal diet and incidence of postoperative bleeding did not differ significantly between the groups. Conclusions Intraoperative application of cold water after tonsillectomy significantly reduced postoperative pain. We recommend cooling the tonsillar fossa and pharyngeal mucosa with cold water during tonsillectomy to easily and effectively reduce post-tonsillectomy pain.

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.

PURPOSE: There are no definitive randomized studies that compare radiotherapy (RT) with surgery for tonsillar cancer. The purpose of this study was to evaluate the results of RT alone and RT combined with a planned neck dissection for carcinoma of the tonsillar area and to compare these data with the results of treatment with primary surgery. PATIENTS AND METHODS: Four hundred patients were treated between October 1964 and December 1997 and observed for at least 2 years. One hundred forty-one patients underwent planned neck dissection, and 18 patients received induction (17 patients) or concomitant (one patient) chemotherapy. RESULTS: Five-year local control rates, by tumor stage, were as follows: T1, 83%; T2, 81%; T3, 74%; and T4, 60%. Multivariate analysis revealed that local control was significantly influenced by tumor stage (P = .0001), fractionation schedule (P = .0038), and external beam dose (P = .0227). Local control after RT for early-stage cancers was higher for tonsillar fossa/posterior pillar cancers than for those arising from the anterior tonsillar pillar. Five-year cause-specific survival rates, by disease stage, were as follows: I, 100%; II, 86%; III, 82%; IVa, 63%; and IVb, 22%. Multivariate analysis revealed that cause-specific survival was significantly influenced by overall stage (P = .0001), planned neck dissection (P = .0074), and histologic differentiation (P = .0307). The incidence of severe late complications after treatment was 5%. CONCLUSION: RT alone or combined with a planned neck dissection provides cure rates that are as good as those after surgery and is associated with a lower rate of severe complications.

Objective/Hypothesis To evaluate the use of cryoanalgesia in reducing post-tonsillectomy pain. Study Design A prospective, randomized double-blind study of 59 consecutive patients (age range, 8–40 y) undergoing tonsillectomy for recurrent tonsillitis. Methods All patients underwent bipolar tonsillectomy. At the completion of the tonsillectomy patients were randomly assigned to a control or a cryotherapy group. The cryotherapy patients had both their tonsillar fossa “supercooled” to between −20°C and −32°C for 1 minute. Patients recorded their pain using a visual analogue scale over the next 10 days. Patients were also monitored for postoperative complications, time until resumption of a normal diet, time back to work or school, and analgesic consumption. Results The two groups were similar for age and sex. There was a 28.3% reduction in mean pain scores over the 10 days in the cryotherapy compared to the control group. This difference did not significantly depend on the day after operation or time of the day. Cryotherapy patients also returned to work or school, on average, 4 days earlier than controls. There was no significant difference in postoperative complications between the two groups. Conclusion Cryotherapy is a new technique that significantly reduces post-tonsillectomy pain without evidence of causing additional complications.

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.

Extracardiac rhabdomyomas are very uncommon tumors comprising approximately 2% of the neoplasms of striated muscle origin. The adult extracardiac rhabdomyoma is generally characterized as a slowly growing, usually solitary lesion, which is nearly always found in the head and neck area of elderly persons. The most common reported head and neck subsites are the floor of the mouth, tongue, palate, lips, and cheeks. We report an unusual presentation of rhabdomyoma that should be included in the differential diagnosis of tumors presenting as a large tonsillar fossa mass. In our review of the almost 160 clinical notes reported in the literature, only 2 instances of tonsillar rhabdomyomas were found. The cytologic and immunohistochemical differential diagnoses of this tumor are also discussed.

A 43-year old man is examined for evaluation of a persistent, right-sided sore throat for 4 months, and a painless, slowly enlarging right neck mass for 3 months. On further questioning, he has right otalgia, but denies dysphagia, odynophagia, hemoptysis, hoarseness, or weight loss. He has a 40 pack/year smoking history, but is otherwise in good health. Physical examination reveals a 3 cm × 3 cm exophytic mass involving the right tonsillar fossa and posterior tonsillar pillar. There is no trismus, the tongue base and soft palate are not involved, and his teeth are in good repair. The remainder of the head and neck examination is remarkable only for a firm, freely mobile 4 cm × 4 cm right level II lymph node. A chest radiograph is normal, and a neck CT is shown in Figure 1. Examination under anesthesia confirmed the above findings, and no synchronous primaries are seen in the upper aerodigestive tract and esophagus. The biopsy is positive for invasive moderately well-differentiated squamous cell cancer, therefore staged as T2 N2a M0.

Background The purpose of this study was to evaluate the efficacy of the modern diagnostic evaluation for squamous cell carcinoma metastatic to cervical lymph nodes from an unknown head and neck primary site. Methods One hundred thirty patients were evaluated between June 1983 and June 1997. All underwent head and neck examinations, head and neck computed tomography (CT), and/or magnetic resonance imaging (MRI) scans, panendoscopies, and biopsies of head and neck mucosal sites. Twenty-four patients underwent 2-[fluorine-18]-2-deoxy-D-glucose (FDG) single photon emission computed tomography (SPECT); 34 patients underwent tonsillectomy. Results The primary site was identified in 56 patients (43%); the likelihood was increased in patients with suggestive findings on physical examination and/or radiographic evaluation. Eighty-three percent of the lesions were located in the tonsillar fossa and base of tongue. Results of FDG-SPECT scans were positive in 20 patients (83%); the primary tumor was detected in 7 patients (35%). Twelve (35%) of 34 patients who underwent tonsillectomy had a primary tumor discovered in the tonsillar fossa. Multivariate analysis of successful primary site detection revealed that suggestive findings on physical examination (p = .0225) and suggestive findings on CT and/or MRI (p = .0013) were significantly related to this end point. Conclusion The primary lesion will be detected in over 40% of patients with physical examination of the head and neck and CT and/or MRI followed by panendoscopy and biopsies. Limited data pertaining to FDG-SPECT suggest that this provides additional useful information in a small subset of patients. Tonsillectomy is useful for those with suggestive findings on physical examination and/or radiographic evaluation. © 1998 John Wiley & Sons, Inc. Head Neck 20: 739–744, 1998.

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.

Objective: To compare the efficacy and treatment outcomes in patients with tonsillar fossa cancer using surgery or radiation as a single modality therapy. Methods: From 1971 to 1991 239 patients with oral pharyngeal cancer were treated at Roswell Park Cancer Institute. Of these patients 90 had tonsillar carcinoma. Seventy-six of these patients received either surgery (SA) (n = 56) or radiation therapy (RA) (n = 20) as single-modality therapy and are the subject of this review. All patients in the radiation arm of this review were surgical candidates who declined primary surgical therapy. Results: Sixty-three percent of the SA and 80% of the RA treatment groups presented with either stage m or stage IV disease (P ≤.05). Forty-seven percent of the SA group and 52% of the RA patients had clinically positive regional disease at initial presentation. There was a predictable pattern of nodal presentation, with level II the most frequently involved region. The rate of occult metastasis was 27% and was evenly distributed between T1 and T4 disease. The overall local control rate in the SA group was 75%, compared with 60% in the RA group (P value was not significant). The disease-specific survival (all stages) was 61% in the SA group and 37% in the RA group (P ≤.05). The disease-free survival for stage m and stage IV disease in the SA group was 47% and in the RA group 27% (P ≤.05). Survival measured against clinical response to radiation therapy, in complete responders (all stages) was 83%; by contrast there were no survivors past 24 months in the partial response group (P ≤.001). Conclusion: The results from this study suggest that for early disease (stage I/II), surgery or radiation therapy as single-modality treatment is equally effective. For advanced disease radiation therapy is inferior to surgery as a single-modality treatment, as measured by ultimate survival and the local control of disease. There is, however, a subset of patients with advanced disease who respond to radiation therapy and whose survival is equivalent to our surgical cohort of patients.

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.

Clinical symptoms and radiographical findings in four cases of elongation of the styloid process are presented. The chief complaint in all four cases was a sore throat. Case 1: 60-year-old female. No obvious inflammation was found in the pharynx, but induration in the tonsillar fossa was detected by palpation. Case 2: 32-year-old male. Inflammation was slight and no process was detected by repeated palpation of the pharynx. Case 3: 72-year-old female. A slight projection was found on the palatoglossal arch, and a hard process was palpated in that region. Case 4: 35-year-old male. A hard process was palpated on the palatoglossal arch. Both orthopantomography and simple occipitofrontal radiography with open mouth were performed. Although orthopantomography can always image the Styloid process, findings from simple occipitofrontal radiography were sometimes in better agreement with clinical symptoms. Simple occipitofrontal radiography of the Styloid process sometimes showed an overlap of the upper jaw, but this problem can be solved by head rotation toward the healthy side during imaging. Case 2 underwent surgery and the symptoms improved.

Reconstruction of the tonsillar fossa and soft palate is sometimes troublesome, because of postoperative deglutition and speech disorder. In this study, we reviewed 84 patients who underwent reconstruction surgery of this area at our hospital during the period from 1977 to 1995. As a result, (1) wide resection causes poor postoperative quality, (2) patients after 1990 shows better function of eating and speaking than patients before 1990, (3) free flap reconstruction has more benefit than pedicled flap because trimming of the free flap is quite easy and it can fit any defect of the lesion. One of the most important things during surgery are not to injure the function of nasophayngeal closure and tongue mobility. In these couple of years, we routinely use rectus abdominis M - C flap after wide resection of the oropharyngeal cancer.

Objectives:The current study is a follow-up to a previous study determining the efficacy of a truly novel material for use during tonsillectomy to improve post-operative pain. The goal of the current study is to further evaluate its use and analyze possible post-operative pain reduction using the material.Methods:This is a prospective single blinded evaluation of Biodesign tissue grafts (COOK Medical) with patients serving as self-controls. This study involved adult patients undergoing tonsillectomy for chronic tonsillitis or as part of Uvulopalato-pharyngoplasty (UPPP) for sleep apnea surgery. Biodesign was fashioned and then sutured into the right tonsillar fossa using a combination of 2.0 polysorb (Covidien) and 2.0 chromic suture. The left tonsil was closed without Biodesign. If a palatoplasty was performed, it was left to granulate with secondary intention. Post-operatively, the patients filled out a diet and narcotic log for 14 days and a visual analog pain scale for 10 days. A total of 25 patients ...

The buccinator musculo-mucosal island or Zhao flap 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 inferiorly based facial artery buccinator musculo-mucosal flap for a novel use in the reconstruction of oropharyngeal tumours at the tongue base and lateral pharyngeal wall. We prospectively reviewed all patients who underwent buccinator musculo-mucosal island 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. Deeper flaps were adequately visualised and monitored using flexible nasoendoscopy. There were no flap failures with all patients achieving primary healing with minimal complications. All donor sites closed directly with minimal scarring. Two patients reported mild tightness on mouth opening and two patients reported transient weakness of the mandibular branch of the facial nerve. In our experience the buccinator musculo-mucosal island flap is an extremely versatile 'like for like' local flap option due to its long arc of rotation. As inset can be achieved via neck dissection access, this avoids lip/jaw split as per conventional oropharyngeal surgical management further minimising morbidity. We present the first series of its effective use in oropharyngeal reconstruction.

Trigeminal neuralgia is the most common and best known of the cranial neuralgias; glossopharyngeal neuralgia (GPN) is much rarer and less well-recognised. First described by Weisenberg1 in 1920, GPN is characterised by severe paroxysms of pain affecting the ear, beneath the angle of the jaw, base of tongue and tonsillar fossa. The pain lasts seconds to minutes and typically worsens with swallowing, talking and coughing. The stereotyped nature of the attacks, lack of alternative explanation and normal neurological examination, fulfil the International Headache Society Diagnostic criteria for GPN.2 Like trigeminal neuralgia it can result from microvascular or other causes of compression of …

Cutaneous metastases from head and neck cancer are an unusual problem. We review risk factors, management strategies, and clinical outcome in patients with cutaneous metastases from epidermoid cancer of the head and neck. From 1980 to 1994 a total of 12 patients with pathologically documented cutaneous metastases from epidermoid cancer of the head and neck were identified at Yale University School of Medicine. Patient records were reviewed and cases were evaluated for risk factors, therapeutic techniques, and clinical outcome as it relates to local control and survival. Median follow-up was 6 months. There were 11 males and 1 female in this series. Primary tumor sites included tonsillar fossa, anterior tonsillar pillar, base of tongue, pyriform sinus, buccal mucosa (2 patients), auricle, larynx, and unknown primary (4 patients). Predominant tumor histology was squamous cell carcinoma, seen in 10 of 12 patients. Treatment modalities for primary and recurrent disease prior to development of cutaneous metastases included surgery, external beam radiotherapy (EBRT), intraoperative brachytherapy (IOBT), and/or chemotherapy. Management of cutaneous metastases included observation, chemotherapy, electron beam radiotherapy (EB), wide excision of involved skin (WE) with IOBT and reconstruction, and definitive brachytherapy implantation of cutaneous nodules. Local control of cutaneous metastases was achieved in 6 patients, all treated with WE and IOBT or WE and EB. Median survival after cutaneous metastases was 6 months. Three patients remain alive, 2 with progressive disease and 1 without evidence of disease. Since patients in this series were clinically heterogeneous and treated with one or more modalities for primary and recurrent disease, it is difficult to draw conclusions as to which modality or clinical presentation may put patients at highest risk for cutaneous metastases. Those patients requiring extensive neck surgery, high dose EBRT, and/or IOBT, all of which may interrupt both deep and dermal lymphatics, may put patients at greatest risk rather than any single modality alone. Those patients that do develop dermal metastases may be effectively managed with a combined modality approach including WE and IOBT with or without EB. This approach appears to offer the best chance of local control, palliation, and perhaps even curative potential. Dermal metastases, however, are a harbinger of progressive disease with most patients ultimately succumbing to their disease. Radiat Oncol Invest 1996;4:176–184. © 1996 Wiley-Liss, Inc.

In a retrospective study carried out at Nangia ENT Hospital Gurgaon, 210 operated cases on Tonsillectomy. Adenotonsillectomy and Tonsillo-styloidectomy for period of 4 years and 3 months w.e.f. Janurary 96 to April 2000 were analysed.

The incomplete branchial fistula is not an uncommon congenital anomaly of branchial apparatus but a complete one is rare. Here we report a case of complete congenital branchial fistula with an internal opening near the tonsillar fossa.

Branchial fistulae are of congenital origin(6) and consists of skin lined tract opening internally at junction of cartilaginous and bony meatus in case of 1(st) arch anomaly, tonsillar fossa in case of 2(nd) arch, while 3(rd) and 4(th) arch sinuses have internal opening at level of pyriform sinus or below. A complete tract of 3(rd) or 4(th) arch fistulae is yet to be described. Fourth arch fistulae(1) have a distinct clinical pattern of internal opening at pyriform apex, are left sided and associated with suppurative thyroiditis(3), they manifest at a younger age and treatment involves excision of tract with ipsilateral thyroid lobectomy.

(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