Faucial Arch Research Articles

Lateral advancement flaps in obstructive sleep apnea

Objectives: Palatal and pharyngeal soft tissue laxity and redundancy contribute to upper airway obstruction and obstructive sleep apnea. Hypertrophic tonsils exacerbate the condition. Uvulopalatopharyngoplasty with-or-without tonsillectomy is the procedure of choice to correct the disorder. In some instances, however, excision of the excess lateral soft tissues creates a faucial arch defect that cannot be closed primarily. We present our technique using laterally-advanced full-thickness pharyngeal muscular-mucosal flaps to achieve tension-free closure of the tonsillar fossae. Methods: Open lateral wall defects in the oropharynx heal by secondary intention. Drawbacks with this approach include excess scar tissue deposition, contracture of the fauces, and decreased mobility of the pharyngeal arch, which contribute to a poor surgical result. Coincidentally, too tight a closure causes the same result. To avoid these complications, we undermine the lateral free edge of the posterolateral pharyngeal wall to include a thick cuff of muscle and overlying mucosa. The thickest flaps expose the prevertebral fascia. The flaps can be elevated unilaterally or bilaterally. The blood supply is random, primarily based on terminal branches of the ascending pharyngeal arteries, arising inferiorly. The venous plexus is sufficiently dense to provide adequate vascular drainage. Results: The vascular integrity and elasticity of the pharyngeal musculature permits medially based lateral soft tissue advancement sufficient to allow reapproximation to the palatoglossus. Defects approaching 50% of the flap’s length have been closed. Conclusion: In complex cases, primary, tension-free closure of the faucial arch using soft tissue advancement flaps from the posterior pharynx reduces the likelihood of infection and scar contracture, facilitates healing, and improves surgical results.

MCM2: Test of utility as a molecular marker in advanced-stage oropharyngeal carcinoma

5590 Background: MCM2 is a member of the family of minichromosome maintenance (MCM) proteins that play an important role in the regulation of DNA replication. MCM2 has been shown to be a proliferation marker in several types of tissue. In this study we examined the utility of the proliferation marker MCM2 as a molecular prognostic marker in 30 oropharyngeal squamous cell carcinomas. Methods: Parallel sections of 30 oropharyngeal tumors were stained with antibodies against MCM2. The tumor sub-sites were: base of tongue in 11 patients, tonsillar fossa in 13 patients, pharyngeal wall in 5 patients, and faucial arch in 1 patient. The percentage of positively stained nuclei was scored for each antibody. Clinicopathologic patient data were retrospectively collected from medical charts. Results: The average age at presentation was 52 years and 2 months (range 43 - 80 years) in the overall patient population. Twenty-four patients were men and six patients were women. Twenty-eight patients (93%) presented with advanced stage (Stage III and IV) disease. There was no significant difference in the proportion of cells stained by anti-MCM2 between patients who died of the disease and those who remained alive (67.6% versus 62.9%, respectively, p=.74). Similarly, employing a multivariate Cox regression analysis, risk of death was not found to be associated with elevated MCM2 expression. These findings did not vary by disease subsite. Conclusions: Our data suggest that the cellular proliferation marker MCM2 is of limited clinical utility as a disease prognosticator in individuals diagnosed with advanced stage oropharyngeal carcinoma. The role of MCM2 as a molecular prognosticator in patients with early stage disease requires further investigation. No significant financial relationships to disclose.

MCM2: Test of utility as a molecular marker in advanced-stage oropharyngeal carcinoma

5590 Background: MCM2 is a member of the family of minichromosome maintenance (MCM) proteins that play an important role in the regulation of DNA replication. MCM2 has been shown to be a proliferation marker in several types of tissue. In this study we examined the utility of the proliferation marker MCM2 as a molecular prognostic marker in 30 oropharyngeal squamous cell carcinomas. Methods: Parallel sections of 30 oropharyngeal tumors were stained with antibodies against MCM2. The tumor sub-sites were: base of tongue in 11 patients, tonsillar fossa in 13 patients, pharyngeal wall in 5 patients, and faucial arch in 1 patient. The percentage of positively stained nuclei was scored for each antibody. Clinicopathologic patient data were retrospectively collected from medical charts. Results: The average age at presentation was 52 years and 2 months (range 43 - 80 years) in the overall patient population. Twenty-four patients were men and six patients were women. Twenty-eight patients (93%) presented with adv...

Oncologic Rationale For Bilateral Tonsillectomy In Head And Neck Squamous Cell Carcinoma Of Unknown Primary Source

OBJECTIVE: To demonstrate on oncologic basis for the recommendation to perform bilateral tonsillectomy as a routine measure in the search for a primary mucosal lesion in patients presenting with cervical nodal metastasis of squamous cell carcinoma (SCC). STUDY DESIGN: A case series of individuals selected from a 3-year period is reported. SETTING: Masina Hospital, Bombay -Academic medical center. RESULTS: Each individual presented with metastatic squamous cell carcinoma in a cervical lymph node from an unknown primary source. In each case, the primary, either located contralateral to the node, or in both tonsils. CONCLUSIONS: The rate of contralateral spread of metastatic cancer from occult tonsil lesions appears to approach 10%. For this reason, bilateral tonsillectomy is recommended as a routine step in the search for the occult primary in patients presenting with cervical metastasis of SCC and palatine tonsils intact. The presentation of cervical metastatic head and neck squamous cell carcinoma (HNSCC) from a clinically occult primary is an unusual event, classically estimated as accounting for less than 5% of all HNSCC.1 The actual rate of “unknown primary” cancer in any series of HNSCC depends on the definition applied when a case is assigned that designation. The recommended work-up for individuals presenting with metastatic SCC without an obvious mucosal primary site currently includes computerized radiographic evaluation and examination under anesthesia with biopsies taken from specified sites that may commonly harbor occult mucosal lesions. There is growing support for the practice of tonsillectomy as a part of the screening directed biopsies used in the work-up of these patients. Several clinical series including our own have been published in the last decade indicating that an occult primary mucosal lesion can be identified in a tonsillectomy specimen in upwards of 30% of cases.2,3,4,5,6 Our rationale for bilateral tonsillectomy was to create a symmetric faucial arch to avoid confusion during the clinical post treatment surveillance for recurrence and second primary cancer and to capture the rare case of bilateral disease. Subsequently, we have identified 3 individuals who present with unilateral metastatic SCC in a cervical node and were found to have a primary lesion only in the contralateral tonsil. Finally, there were 2 individuals with bilateral nodal metastases & found to have an invasive carcinoma in one tonsil and an in situ lesion in the other. These cases prompted a renewed evaluation and repeated emphasis of the oncologic value of bilateral tonsillectomy.

Place de l'endocuriethérapie par iridium 192 dans l'irradiation exclusive des carcinomes épidermoïdes T1–T2 de l'arche véloamygdalienne

We have reviewed the results of 165 T1 and T2 squamous cell carcinomas of the faucial arch treated by definitive irradiation including or not iridium 192 brachytherapy to ascertain whether a significant relationship exists between iridium implantation, local control, complications and survival. From March 1971 to November 1990, 58 T1 and 107 T2 (NO: 107/165; N1: 30/165; N2: 9/165; N3: 19/165) biopsy proven squamous cell carcinomas of the tonsillar region (104/165) and the soft palate and uvula (61/165) were treated in the Henri Mondor Hospital by definitive irradiation with curative intent. From 1971 to 1981 (period 1), only guide gutter technique was available, so that implants were reserved for small tumors: patients were either managed by definitive telecobaltherapy to tumor site and neck node areas (group I; n = 48; mean dose: 70 Gy; confidence interval: +/- 5.5, 5 fractions of 1.8 Gy per week) or by exclusive iridium implant (group 2; n = 11; all T1NO; 64 Gy +/- 4.8) or by a combination of external beam radiation therapy to tumor site and neck nodes areas and iridium implant (group 3; n = 40). In 1981 (period 2), a new plastic tube technique, which enables implantation of larger areas, was introduced and all patients (group 4; n = 66) were then managed by external radiation therapy (group 3 + 4: 47 Gy +/- 4.3) followed by an iridium implant (31 Gy +/- 10.5). Clinically positive neck nodes either received additional external dose with electrons or were excised. Overall 5-year survival (Kaplan Meier) was 23%, 50.5%, and 60% in groups 1, 2 and 3 + 4, respectively (p < 0.001, log rank). Five-year local control was 58%, 100%, and 91%, respectively (p < 0.001). Five-year necrosis rate was 10%, 25% and 30%, respectively (NS). Comparison of results between the two periods of the study (group 1 + 2 + 3 vs group 4) shows that these two groups are statistically comparable according to site and size of tumor and N status and that both local control (77% vs 94% at 5 years; p < 0.01) and disease free survival (56% vs 71%; p = 0.03) were improved after 1980, while there was a trend to an increase in overall survival (42% vs 53% at 5 years; p = 0.08); nodal control (86% vs 95% at 5 years) and necrosis rate (11% vs 20% at 5 years) were not modified. Multivariate analysis showed that both local control (p < 0.0001) and overall survival (p < 0.0001) were improved when tumor was implanted. We recommend then to treat T1 and T2 squamous cell carcinomas of the faucial arch by external radiation therapy to tumor site and neck areas (45 Gy/25 fractions/5 weeks) followed by a 30 Gy iridium implant and, for patients with clinically positive nodes, either a further 25-30 Gy electron beam irradiation to the nodes or neck node dissection.

Speech and Swallow Function After Tonsil/Base of Tongue Resection With Primary Closure

Speech and swallowing function was examined in 11 patients who underwent surgical resection of greater than 1 cm of tongue base, tonsil, and faucial arch with mandible resected on the side of the tumor and reconstruction by primary closure. Preoperatively and 1 and 3 months post-healing, high fidelity audio recordings were made of a 6- to 7-minute conversational speech sample, the sentence version of The Fisher Logemann Test of Articulation Competence was administered, and videofluoroscopic assessment of oropharyngeal swallow was conducted. All subjects exhibited changes in speech and swallowing function postoperatively, with little improvement during the study. Patients exhibited greatest difficulty on stop and fricative consonants and bolus propulsion. Comparison with patients who received anterior tongue and floor of mouth resections and distal flap reconstruction revealed consistently better speech performance by the tonsil/base of tongue patients, although the same phonemes were affected. Swallow function was equally affected in the two groups. Results are discussed in terms of locus of surgical resection, nature of reconstruction, and need for swallowing therapy.

Place of iridium 192 implantation in definitive irradiation of faucial arch squamous cell carcinomas

Purpose : We have reviewed the results of 165 T1 and T2 squamous cell carcinomas of the faucial arch treated by definitive irradiation including or not Iridium 192 brachytherapy to ascertain whether a significant relationship existed between Iridium implantation, local control, complications, and survival. Methods and Materials: From March 1971 to November 1990, 58 T1 and 107 T2 (NO: 107 165 ; N1: 30 165 ; N2: 9 165 ; N3: 19 165 ) biopsy proven squamous cell carcinomas of the tonsillar region ( 104 165 ) and the soft palate and uvula ( 61 165 ) were treated in Henri Mondor Hospital by definitive irradiation with curative intent. From 1971 to 1981 (period 1), only guide gutter technique was available, so that implants were reserved for small tumors: patients were either managed by definitive telecobaltherapy to tumor site and neck node areas (Group 1; n = 48; mean dose: 70 Gy; confidence interval: ±5.5; 5 fractions of 1.8 Gy per week) or by exclusive Iridium implant (Group 2; n = 11; all T1 NO; 64 Gy ± 4.8) or by a combination of external beam radiation therapy to tumor site and neck nodes areas and Iridium implant (Group 3; n = 40). In 1981 (Period 2), a new plastic tube technique, which enables implantation of larger areas, was introduced in the department and all patients (Group 4; n = 66) were then managed by external radiation therapy (Group 3 + 4 : 47 Gy ± 4.3) followed by an Iridium implant (31 Gy ± 10.5). Clinically positive neck nodes either received additional external dose with electrons or were excised. Results : Overall 5-year survival (Kaplan Meier) was 21%, 50.5%, and 60% in groups 1, 2, and 3 + 4, respectively ( p < 0.001, log rank). Five-year local control was 58%, 100%, and 91%, respectively ( p < 0.001). Five-year necrosis rate was 4.5%, 20.5% and 18%, respectively (N.S.). Comparison of results between the two periods of the study (Group 1 + 2 + 3 vs. group 4) show that these two groups are statistically comparable according to site and size of tumor and N status and that both local control (77% vs. 94% at 5 years; p < 0.01) and disease-free survival (56% vs. 71%; p = 0.03) were improved after 1980, while there was a trend to an increase in overall survival (42% vs. 53% at 5 years; p = 0.08); nodal control (86% vs. 95% at 5 years), and necrosis rate (11% vs. 20% at 5 years) were not modified. Multivariate analysis showed that both local control ( p < 0.0001) and overall survival ( p < 0.0001) were improved when tumor was implanted. Conclusion : We recommend then to treat T1 and T2 squamous cell carcinomas of the faucial arch by external radiation therapy to tumor site and neck areas (45 Gy/25 fractions/5 weeks) followed by a 30 Gy Iridium implant and, for patients with clinically positive nodes, either a further 25–30 Gy electron beam irradiation to the nodes or neck node dissection.

Place of iridium 192 implantation in definitive irradiation of faucial arch squamous cell carcinomas

Place of iridium 192 implantation in definitive irradiation of faucial arch squamous cell carcinomas

Usefulness of 198Au grain implants in the treatment of oral and oropharyngeal cancer

A series of 177 patients with squamous cell carcinoma of the oral cavity and oropharynx were treated with 198Au grain (gold grain) implants. Sites of the lesion included the tongue, mouth floor, buccal mucosa and oropharynx, especially the soft palate and faucial arch. Three-fourths of the patients were treated in combination with prior external beam irradiation. A permanent implant dose (total decay) of 80–90 Gy was given in the form of gold grains alone and in combination with an external dose of no more than 30 Gy, and 60–70 Gy, total decay, was given after an external dose greater than 30 Gy. The 2-year recurrence-free rate was 86.2% in the case of T 1N 0, 72.6% in T 2N 0 and 72.2% in T 3N 0. The difference in the results of implant therapy alone and combined therapy was not significant. Late complications were minimal after grain implantation alone, and when used in combination, less than 70 mCi of grain activity after a 40 Gy external dose did not seem to be a serious hazard with respect to bone damage except in the case of cancer of the mouth floor. Gold grain implants were useful and easily applied under local anesthesia to early or superficial lesions at sites where a rigid linear source could not be used. Exposure of the radiology staff was only 5–10 mrad in the case of the usual 10–15 (50–75 mCi) implant grains.

Salvage irradiation of oropharyngeal cancers using iridium 192 wire implants: 5-year results of 70 cases.

Between May 1971 and November 1980, 70 patients with recurrent or new oropharyngeal cancers arising in previously irradiated tissues were treated using iridium 192 afterloading techniques. The actuarial local control was 72% at 2 years and 69% at 5 years. Although local control of the tumor was achieved in the majority of these patients, only 10 patients remained alive at 5 years (14%). Patients with lesions of the faucial arch and posterior pharyngeal wall had the best results; local control was achieved in 100% of these patients. Patients with lesions of the base of tongue and of the glosso-tonsillar sulcus had poorer results; local control was achieved in 61%. Because these results compare favorably with the results of previously published series, we recommend re-irradiation with brachytherapy for recurrent or new malignancies arising in a previously irradiated oropharynx. When the lesion is located in the faucial arch, brachytherapy is the treatment of choice. When the lesion is located in the base of tongue, brachytherapy is a reasonable option.

Management of cervical nodes, either fixed or bilateral, from squamous cell carcinoma of the oral cavity and faucial arch.

Of 75 patients with advanced cervical lymph node metastases from primary squamous cell carcinoma of the oral cavity, 75% had T3–4 lesions. Control of the primary lesion arrested spread in 20 of 35 cases (57%) followed for twenty-four months or more. The inability to control primary disease (chiefly in lesions of the oral tongue and soft-palate uvula) was responsible for 30 of 45 failures. Many patients were saved by radiotherapy alone or in combination with limited surgery. Irradiation to the whole neck is necessary, even when nodes are present only in the upper portion.

Evolution of neck disease in patients with primary squamous cell carcinoma of the oral tongue, floor of mouth, and palatine arch, and clinically positive neck nodes neither fixed nor bilateral.

The evolution of neck disease in 180 patients with controlled squamous cell carcinomas of the oral tongue, floor of the mouth, and faucial arch having initially clinically positive nodes neither fixed nor bilateral has been analyzed by modality of treatment of the neck disease, i.e., radical neck dissection, combined radical neck dissection and irradiation, and irradiation. There is a shift to earlier primary lesions and less extensive neck disease in the patients having had a radical neck dissection only. In addition to less recurrences in the radically dissected neck, there was diminution in the development of contralateral nodes from 34% in the patients with radical neck dissection only to 4%in the patients having had the combined treatment or irradiation only. Contralateral metastases almost always appear in the opposite subdigastric area. Doses from 3,000 rads in 3 weeks to 5,000 rads in 5 weeks were given to the opposite subdigastric area in the patients having had the combined treatment or irradiation.

Evolution of clinically negative neck. Squamous cell carcinoma of oral cavity and faucial arch.

The question of whether to electively treat the neck which is clinically negative in patients with squamous cell carcinoma of the oral cavity and faucial arch long has been debated among surgeons and radiotherapists. Some surgeons have found a high incidence of subclinical cancer in the cervical nodes of patients having elective neck dissection, and therefore suggest that radical neck dissection should be done routinely. 5,6 Berger and his co-workers 7 showed that cancer will rarely develop in the electively radiated neck of patients with oropharyngeal and nasopharyngeal cancer, if the tumor dose is 5,000 rads in five weeks or more. Radical neck dissection and radical radiation are not without their complications, and are warranted as an elective treatment only if it can be demonstrated that cervical metastases cannot be successfully managed if they subsequently develop. The policy at the University of Texas MD Anderson Hospital and Tumor Institute, Houston,

Evolution of Clinically Negative Neck

The question of whether to electively treat the neck which is clinically negative in patients with squamous cell carcinoma of the oral cavity and faucial arch long has been debated among surgeons and radiotherapists. Some surgeons have found a high incidence of subclinical cancer in the cervical nodes of patients having elective neck dissection, and therefore suggest that radical neck dissection should be done routinely. 5,6 Berger and his co-workers 7 showed that cancer will rarely develop in the electively radiated neck of patients with oropharyngeal and nasopharyngeal cancer, if the tumor dose is 5,000 rads in five weeks or more. Radical neck dissection and radical radiation are not without their complications, and are warranted as an elective treatment only if it can be demonstrated that cervical metastases cannot be successfully managed if they subsequently develop. The policy at the University of Texas MD Anderson Hospital and Tumor Institute, Houston,

Evolution of the clinically negative neck in patients with squamous cell carcinoma of the faucial arch.

EVOLUTION OF THE CLINICALLY NEGATIVE NECK IN PATIENTS WITH SQUAMOUS CELL CARCINOMA OF THE FAUCIAL ARCHROBERT D. LINDBERG, M.D., HOWARD T. BARKLEY, JR., M.D., RICHARD H. JESSE, M.D. and GILBERT H. FLETCHER, M.D.Audio Available | Share

A clinicopathologic study of oral carcinoma in situ

From reviewing the literature and from studying a group of patients, one gains an impression about oral carcinoma in situ. The alteration in oral mucous membrane known as carcinoma in situ is primarily a disease of people in the fifty to eighty years age group. Its distribution is chiefly along the floor of the mouth and the faucial arch. In addition to the intra-epithelial carcinomatous changes, there is seen microinvasion and involvement of salivary gland ducts, alterations suggesting intermediary changes between a preinvasive and an invasive process. These findings plus the coincidence of in situ and invasive lesions in the same patients corroborate the impression that carcinoma in situ is a stage in the evolution of oral cancer.

TREATMENT OF DISEASED TONSILS BY MEANS OF RADIUM

In making this report concerning a series of patients treated with radium and now under observation for a period of three years, I feel that enthusiasm for this method of treatment is fully warranted by the results obtained in the nose and throat department of Beth Israel Hospital. I do not, however, advocate radium as a substitute for tonsillectomy. It should be used only in those cases in which tonsillectomy is indicated, but in which surgery is inapplicable. In performing a tonsillectomy the majority of surgeons remove the tonsil still enclosed in its capsule, so that immediately after the operation the faucial pillars appear intact and the faucial arch perfectly symmetrical; yet several months later, the throat presents a very different appearance. By this time granulations will have appeared and covered the exposed muscles, resulting in cicatricial tissue and contraction of pillars and arches. Such a result