Transoral robotic surgery (TORS) offers many technical advancements to existing endoscopic and transoral surgical approaches. This has faciliated a safer, less morbid and potentially more effective application of surgery to the management of both benign and malignant diseases in the head and neck. As this surgical approach gains widespread acceptance, it is important for all members of the treatment team to understand the strengths and current limitations especially when TORS is applied for malignant diseases. As of December 2009, Federal Drug Administration (FDA) has approved the use of the da Vinci® surgical system and TORS for selected malignancies of the oral cavity, pharynx and larynx and all benign disease. Of these sites, the greatest experience and longest duration of follow-up has been in the use of TORS for the management of oropharyngeal carcinomas where at least comparable oncologic outcomes and reduced long-term feeding tube dependency rates have been reported. Other anatomic sites where TORS has shown benefit based on preclinical studies and early human experiences include the larynx, hypopharynx, parapharyngeal space and infratemporal fossa for both benign and selected malignant tumors. Experience to date has demonstrated that the improved visualization with the robotic system offers the potential for improved oncologic resection with reduced morbidity. Based on present studies and outcomes data in conjunction with ongoing investigations, it is anticipated that TORS will make a major impact in the way we manage benign and malignant tumors within the head and neck and skull base.

Primary mucosal melanoma of the head and neck (MMHN) is a rare, aggressive tumor of neural-crest origin. Despite universal progress in cancer care, the prognosis of MMHN continues to remain dismal.

To analyze and report the outcomes of primary head and neck mucosal melanomas treated at Tata Memorial Hospital.

Retrospective chart review of all patients with a diagnosis of nonocular MMHN presenting to the institute between 1995 to 2003. Locoregional control and disease-free survival were used as outcome measures.

42 patients presenting within the study period with nonocular MMHN (oral-55%, sinonasal-40%, and pharyngeal-5%) at a median age of 53 years constituted the demographic cohort. 11 (26%) patients not amenable to any active anticancer treatment were treated with best supportive care alone and excluded from outcome analysis. 26 patients underwent surgery with complete resection of tumor. Seven (27%) also received adjuvant radiotherapy due to the adverse histopathologic features. Two patients were treated with radical radiotherapy due to unresectability, two patients received palliative chemotherapy, while one patient was treated with definitive chemoradiotherapy. With a mean follow-up of 11 months (range 1-58 months), the 3-year locoregional control and disease-free survival was 41% and 12% respectively. Age, sex, site of primary, tumor stage, surgical resection, margin status, depth of infiltration, and adjuvant radiotherapy did not affect outcome significantly.

Primary mucosal melanoma of the head and neck is a rare, but, aggressive tumor with a dismal prognosis. Surgical resection with clear margins offers the best chance of cure for early localized disease. The high incidence of locoregional as well as distant failures after surgical resection supports the use of adjuvant therapy. Deeper insights into the pathobiology of disease can help develop more specific and effective treatment strategies to improve long-term outcomes.

Khammam is the district of tribals in the Andhra Pradesh (India). Recently, we have conducted a study on oral cavity cancer in this tribal area and found that the incidence of oral cancer was 13.04%, male to female ratio was 1.03 : 1 and the incidence of oral cancer in youths (between 21 and 30 years) was 4.85%, which was too much compared with the global previous studies.

So, we decided to find the cause for the high incidences of oral cavity cancer among the youths, by conducting survey and by direct interviewing the youths at their villages and at their towns separately for the comparison between both locality youths. Also we undertook clinical examination of their oral cavity to find the presence of any pathological lesions. We prepared the proformas well in advance containing various parameters which cause oral cavity cancer and conducted mass interview of 3,000 youths both at rural and urban places separately. Master chart of both places was prepared and compared the differences between these two localities, to find the cause for increase in incidences oral cavity cancer. In rural area, out of 3,000 youths, 2,907 (96.9%) (including 1,605 male and 1,302 females) had various combination of habits whereas, in urban area, among 3,000 male youths, only 953 (31.76%) had various combination of habits. Illiteracy status in rural area was 77.56% and in the urban area, it is 13.23%. Among the youths having habits, various types of chewing habits in rural area were seen in 2,722 (93.69%) youths. In urban area, it was seen in 934 (98%). Among all 3,000 youths of each locality, oral cavity hygiene was unhygienic in 2,387 (79.56%) youths of the rural area whereas, in the urban area it is seen in 1109 (36.96%). Premalignant changes were seen 21 rural youths, but not in urban residents.

Education has vital role in rural area to control the chewing habits, for which media role and legislative act to ban the tobacco chewing should be mandatory to reduce the incidence of oral cavity cancer among the youths of tribal villages.

Despite the acceptance of concomitant chemoradiation (CRT) as an alternative to total laryngectomy (TL) in locally advanced laryngeal cancer (LALC), laryngeal preservation is sparingly recommended in developing countries. We report on prognostic factors and survival in T3/T4 laryngeal cancer treated with concomitant CRT at Shaukat Khanum Memorial Cancer Hospital and Research Center (SKMCH and RC) to provide comparison with other geographic locations.

During the period November 2003-April 2009, 101 patients with biopsy proven untreated LALC underwent concurrent CRT treatment at SKMCH and RC. According to AJCC staging system (6th edition) 41 had T3 and 60 patients had T4 disease. Radiation dose to the larynx was 70 Gy in 35 fractions with concomitant cisplatin. Induction chemotherapy was given to 42 patients. Thirty-one patients required tracheotomy either before or during concomitant CRT.

Actuarial overall survival and laryngectomy free survival (LFS) for the whole group at 5 years were 54% (95% CI; 48-60) and 47% (95% CI; 42-52) respectively. Median LFS was 4.17 years. On univariate analysis patients with T4 tumors (p = 0.04), positive neck nodal disease (p = 0.02), supraglottic site (p = 0.02) and tracheotomy (0.009) had a significantly inferior LFS. Multivariate analysis showed tracheotomy to be the only factor significantly (p = 0.03) related to a higher risk of failure for LFS.

Survival rates for LALC treated with concomitant CRT in our institution are acceptable. Our study supports the use of TL in patients with compromised airways that require tracheotomy as outcome with concomitant CRT is poor.

Influence of lymphatic metastases presence at immediate and follow-up results of pts surgical treatment is controversial especially for sporadic medullary thyroid carcinoma (SMTC).

3330 thyroid cancer pts were operated on (1973-2009), among them—226 (6.8%) medullary thyroid cancer (MTC) patients. In 11 observations MTC was appeared as a part of MEN syndrome. Sporadic character of disease was confirmed in 215 (95.1%) cases. There were 140 (80.8%) females and 33 (19.2%) males (4.2:1.0) with average age 48.6 ± 2.7. Long-term results (1-40 years) were investigated in 173 (94.2%) cases. All SMTC patients were divided into 3 groups. Group 1 made of 80 (46.2%) T1- 3N0M0, Group 2 made of 47 (27.3%) T1-3N1a-bM0, 3 Group made of 46 (26.6%) T4N1a-bM0 patients.

Organ-sparing operations were carried out in 59 (73.7%), thyroidectomies—in 21 (26.3%) patients. Multicentric tumor growth (MTG) was observed in 19.1%: in T1 cases—5.7%, T2—20.5%, T3—46.7%. All patients were undergone ipsilateral prophylactic central neck dissection (CND). Average period of postoperative observation (APPO) made 12.0 ± 1.7. 5 years survival rate made 98.4%, 10—91.7%. Local relapse of MTC was found in 1 patients (in contralateral thyroid lobe).

Organ-sparing operations were carried out in 20 (42.6%), thyroidectomies—27 (57.4%) with curative central or central and lateral lymphadenectomy (LAE). MTG took place in 47.2%. 6 group metastases only (T1a) were found in 38.9% and CND was performed. In other cases (61.1%) CND, lateral and mediastinal (8.3%) LAE were performed. APPO correspondent to 10.8 + 2.1 years. Repeated LAE because lymphatic metastases were carry out in 15 (31.9%) patients through 7.2 ± 2.4 years in average after initial operations. Tumor relapses were not found in thyroid remnant. 5 years survival rate made 89.2%, 10—67.8%.

MTG was observed in 64.3%. Central compartment group lymphatic metastases were revealed in 93.3%, in 2 to 5 groups — 86.7%, in mediastinum—38.5%, distant metastases—in 22.0%. Combined operations were performed in 58.9%, palliative—in 45 (26.6%) cases. Operations were completed by Tracheostomy in 38.4%. Adjuvant therapy (X-ray, chemotherapy) was applied in 28.9%. Postoperative lethality made 6.5%. APPO corresponded to 3.3 ± 0.8 (1-10 years). During first year, 8 patients have dead. 5 years survival rate made 32.4%.

Detection of regional metastases of SMTC during the first patients presentation significantly worsen survival rate. Early diagnose of SMTC by calcitonin level detection is the best way to improve results of treatment. Organ-sparing thyroidectomies with mandatory ipsilateral prophylactics CND are justified only at T1N0M0 sporadic MTC.

Cancrum oris is an orofacial gangrene, which during its fulminating course causes, progressive and mutilating destruction of the infected tissues with a consortium of microorganisms. This condition is considered to represent the “face of poverty” because factors connected with poverty, such as chronic malnutrition, poor oral hygiene and sanitation, faecal contamination, and exposure to viral and bacterial infections in an immunosupressed host contribute to disease progression. This condition is seen almost exclusively among the young children and carries a high mortality rate.

We present a case of cancrum oris in a 45 years old lady being treated for acute myeloid leukemia with chemotherapy, who in addition to a polymicrobial bacterial infection had superinfection with Mucormycosis.

Hypertrophic osteoarthropathy (HOA) is a condition characterized by periosteal reaction of tubular long bones and characteristic bulbous deformity of the digital tips with synovial effusion. It is usually encountered in conjunction with diseases involving the lungs, mediastinum, heart, pleura and gastrointestinal tract. The occurrence of HOA as a paraneoplastic manifestation in nasopharyngeal carcinoma is rare and only a handful of cases have been reported in literature and that too in the pediatric age group. An association with pulmonary metastasis was often described in these case reports. We present a case of HOA associated with nasopharyngeal carcinoma in a 20 years old gentleman in the absence of pulmonary metastasis.

Tumors arising from the minor salivary glands in the larynx are rare. The most common tumors occurring here are adenoid cystic carcinomas.1 Among the benign tumors, pleomorphic adenoma is the most common.1 We present a case of subglottic pleomorphic adenoma which was managed by endolaryngeal endoscopic CO₂ laser surgery. Laser as a primary treatment modality for the treatment of subglottic pleomorphic adenomas has not been well-described, as only one case has been reported in literature using this modality.

The scalp is a unique anatomical site that can be involved with a variety of malignant and premalignant conditions, although a majority of the lesions are benign. Adenoid cystic carcinoma is most commonly seen as a neoplasm of the salivary glands and seromucinous glands of the upper respiratory tract. Primary cutaneous adenoid cystic carcinoma (PCACC) is a rare appendageal tumor should only be considered if there is no history or evidence of extracutaneous adenoid cystic carcinoma. It usually has an indolent course but has a high tendency to recur locally. Lymph node and distant metastasis are exceedingly rare with only a handful of cases being reported. We report a case of a large scalp PCACC in a 61 years old gentleman with lymph node involvement at presentation.

Orbital metastasis of systemic cancer is rare and has fascinated the attention of both oncologist and ophthalmologists ever since the first description of a case report by Horner in 1864. The clinical characteristics of tumors metastatic to the orbit are related to primary tumor biology, and vary substantially among various primary types. The common known primary sites include breast, lung, prostate, and melanoma. Carcinoma thyroid metastasizing to the orbit has been reported mainly in isolated case reports, the histological variant in a majority of the cases being follicular carcinoma. We report a rare case of a follicular variant of papillary thyroid carcinoma (FVPTC) that presented with metastasis to the orbit with intracranial and extracranial subcutaneous tissues at the time of diagnosis.

A novel method for the primary reconstruction of the defect in the posterior oral cavity following excision of retromolar trigone (RMT) is described. It uses a combination of lateral pterygoid flap along with primary closure of the residual floor of mouth mucosa and buccal mucosa for primary repair of the defect.

This is a functionally satisfactory and simple reconstructive procedure with a shorter operation time and hence can be used for reconstruction in high-risk patients. To the best of our knowledge, this technique of primary repair of posterior oral cavity has not been described in literature.

Primary tracheoesophageal prosthetic speech is the gold standard for speech rehabilitation in patients undergoing total laryngectomy. However, despite a high success rate, the speech outcome can be suboptimal in 5-15% of these patients. The most frequent cause being hypertonicity of the pharyngoesophageal segment. We elaborate a simple clinical technique that can be performed in an outpatient clinic to identify the hypertonic pharyngoesophageal segment in patients with PES.

All these patients (13 males and 1 female) had undergone total laryngectomy and primary tracheoesophageal puncture followed by postoperative radiotherapy. Even after rigorous speech therapy, these patients had failed to develop fluent speech. The mean duration following surgery was 8 months (range 4-20 months). A simple clinical technique is elaborated utilizing the dermal ballooning effect observed in the cervical region to ascertain the site of pharyngo esophageal spasmodic segment.

Using this technique we have been able to identify the hypertonic segment successfully in 13 of the 14 patients with PES. In these patients the trial lignocaine block was injected specifically at these points medial to the carotid vessels. Improvement in speech following the block was observed, and was further confirming using a videofluroscopy.

This technique serves as a simple and useful clinical tool to map the spasmodic segment and to guide the injection site for trial lignocaine block and as well for botulinum a toxin. In addition, it also prevents inadvertent injection to the normal segments.