To present the clinicopathological profile, surgical management, and the outcome of parapharyngeal space (PPS) neoplasms in 14 patients.

This is a retrospective review of the clinical records of 14 patients treated for PPS tumors. The age of patients ranged from 24 to 54 years, with female to male ratio of 1.3:1. The commonest clinical presentation was a slowgrowing, painless neck swelling. The preoperative protocol was based on: (1) imaging study to establish site, size, and anatomical relationships. (2) Fine-needle aspiration cytology (FNAC) was performed to determine the nature of the mass. Details of the management, morbidity, and outcome of these patients are presented.

A total of 85.7% of the PPS neoplasms were benign and 14.2% were malignant. Majority of the benign tumors were of neurogenic origin. The histocytopathology confirmed 12 (85.7%) of these diagnoses (2 patients were with “nondiagnostic” result). The positive predictive value of the FNAC was 83.3% for benign tumors and 100% for malignant tumors. In 6 patients (60%), a transcervical surgery was performed. Three patients (30%) underwent transparotid–transcervical surgery for a pleomorphic adenoma of the deep lobe of the parotid gland in the prestyloid space and transcervical–transmandibular approach was taken in 1 case (10%). Postoperative complications occurred in 3 out of 10 patients (33.3%).

The results of our study are in agreement with other studies reported in the literature and confirm the need to follow a careful preoperative diagnostic protocol that must take advantage of imaging studies (computed tomography, magnetic resonance imaging) and of cytology FNAC, in order to plan surgical treatment with a safe approach and that reduces complications, esthetic and functional damage, and the risk of recurrence.

Shivanandappa PD, Doddamane VP, Munish KS, Yogeesha BS, Shivakumar AM. A Clinical Approach to the Parapharyngeal Space. Int J Head Neck Surg 2017;8(1):1-4.

The aim of this study is to study the clinical profile and outcome of primary and secondary intracerebral hemorrhage (ICH) and to study the different parameters that affect the outcome.

A total of 40 patients who were diagnosed to have ICH, both primary and secondary, by computed tomography scan were included in the study. Among the selected patients, the clinical profile, radiological profile, and the modality of treatment undertaken and the outcome were noted. Outcome variables included survived [improvement in the Glasgow Coma Scale (GCS)], death, and vegetative state. The outcome variable was compared with respect to age, sex, GCS, etiology, location of the hematoma, and the modality of treatment to find out any statistically significant difference in the rate of outcomes.

The mean age of the patients was 36.78 ± 18.5 years; mean GCS at the time of presentation was 9.05 ± 1.82. Common causes of ICH were trauma (57.5%) and hypertension (25%). Significant association was found between outcome and age group, GCS, etiology of ICH, and location of the bleed. Poor outcome was associated with GCS ≤ 8 (40%), >50 years of age (45.5%), hypertension (50%), and basal ganglia bleed (50%). Best outcome was seen in patients with GCS ≥9, a lobar bleed, and trauma as the cause of ICH where the patient survival was 90%.

In case of ICH depending upon the clinical and radiological profile, the treatment should be individualized. The rates of survival and favorable outcome are better in patients with GCS ≥ 9, a lobar bleed, and trauma as the cause of ICH.

Sidram V, Kumar PCC, Raghavendra B. A Study of Clinical Profile of Intracerebral Hemorrhage and ENT Manifestations and its Surgical Outcome. Int J Head Neck Surg 2017;8(1):5-10.

To review the current protocols and assess their efficacy in the emergency management of cases presenting with Ludwig's angina.

A retrospective study of patients diagnosed with Ludwig's angina, admitted and treated in our institution between November 2007 and December 2012.

There were 40 cases with 24 males (60%) and 16 females (40%), ages ranged between 16 and 80 years. Duration of symptoms was between 3 days and 2 weeks. The most common cause was dental infections seen in 23 cases (57.5%), one of them was a pregnant lady. Six were due to habitual tooth pricking with a broom stick (15%). In 3 patients it was due to submandibular duct stenosis secondary to calculi (7.5%). Five patients had diabetes as underlying disease (12.5%). Facial trauma contributed in 2 patients (5%) and in 1 patient it was due to carcinoma buccal mucosa (2.5%). All the patients were treated with systemic broad spectrum antibiotics, intravenous fluids, and analgesics. Twenty patients (50%) underwent tracheostomy with surgical decompression through small incisions under local/ general anesthesia. Ten patients (25%) were subjected to incision and drainage with subsequent removal of the diseased teeth. Ten patients (25%) were managed conservatively with antibiotics, analgesics, and under close supervision for airway compromise. There were no complications recorded and no mortality.

Ludwig's angina is a life-threatening surgical emergency. Early diagnosis and immediate surgical intervention can save lives. The appropriate use of parenteral antibiotics complemented with airway protection and surgical decompression remains the standard treatment protocol in advanced cases of Ludwig's angina.

Ambikavathy M, Kumar S. Ludwig's Angina: Report of 40 Cases and Review of Current Concepts in Emergency Management in a Rural Tertiary Facility Teaching Hospital. Int J Head Neck Surg 2017;8(1):11-14.

To compare laryngeal preservation rates, survival rates, and voice outcomes after treatment of early glottic cancer between transoral laser microsurgery (TLM) and radiotherapy (RT).

A review of oncologic results was performed on a consecutive series of individuals with early-stage glottic carcinoma (T1 and T2) who were treated between 2011 and 2014 at Kidwai Memorial Institute of Oncology and had received either RT or TLM. Data were collected with a view to assess overall survival, disease-specific survival, laryngectomyfree survival, and laryngeal preservation rates. The Voice Handicap Index-30 (VHI-30) was used as the measure of voice quality after treatment.

Two-year overall survival for TLM group was 93.8% and for RT group was 90.5%, p = 0.643. Disease-free survival (TLM = 90.6% vs RT = 76.2%) was not found to be significant (p-value = 0.104). Laryngeal preservation rate was 79.5% in TLM and 71.4% in RT group (p-value = 0.003). Laryngectomy- free survival was better in TLM (TLM = 96.9% vs RT = 76.2%, p = 0.003). Substage analysis showed equivalent voice for TLM (VHI = 6–12) and RT (VHI = 6–14) in T1a patients (p = 0.94), whereas voice outcome was better for RT in T1b (VHI = 10–16 for TLM vs VHI = 11–18 for RT, p = 0.044) and T2 (VHI = 21–29 for TLM vs VHI = 16–23 for RT, p = 0.002) stages.

Transoral laser microsurgery can be considered the treatment of choice for early glottic cancer in view of better laryngeal preservation rate and laryngectomy-free survival with added advantage of low treatment cost and shorter hospital stay compared with RT.

Laryngeal cancers represent the most common malignancy of head and neck, with estimated worldwide incidence of 120,000 cases annually. Optimal treatment modality has generated significant controversy in literature. External beam RT, open partial laryngectomy, and TLM are various treatment options available. This study depicts TLM as a preferred modality for early glottic cancer.

Shenoy AM, Sharma V, Chavan P, Halkud R, Ranganath N, Pasha T, Shenoy P, Ravikumar B, Narayana SM, Sharif MI, Vijay CR. Transoral Laser Microsurgery vs Radiotherapy for Early Glottic Cancer: Study at Tertiary Care Center in India. Int J Head Neck Surg 2017;8(1):15-20.

To prove the validity of an invasive pattern grade score (IPGS) as an independent prognostic factor in oral squamous cell carcinomas.

Oral squamous cell carcinomas are the most common type of cancers in Indian males and their treatment is associated with morbidity and socioeconomic losses to the individual and society. In spite of advances in diagnosis and therapy, prognosis and survival remain dismal: One, due to late clinical presentation and two, due to the unpredictable biological behavior of these cancers. Validation of IPGS as an independent prognostic factor may reduce the uncertainty involved in treatment.

A retrospective analysis of the records of all patients with oral cavity squamous cell carcinomas treated with surgery between July 2010 and June 2012 was done. A total of 54 patients were analyzed with respect to various clinicopathological parameters including IPGS.

Statistically significant associations were established between IPGS and tumor recurrence (p < 0.004) and death due to cancer (p < 0.02). Invasive pattern grade score was not influenced by age, tumor size, gender, site, clinical stage, or histologic grade.

Our study indicates the validity of IPGS as an independent prognostic factor that can be used to predict disease behavior in oral cavity squamous cell carcinomas. Further studies are required to establish this score as a routine part of the histopathological examination and to help us in choosing treatment modalities.

Ranganath R, Sethi S, Madur B. Validation of the Invasive Pattern Grade Score as an Independent Prognostic Factor in Oral Squamous Cell Cancers. Int J Head Neck Surg 2017;8(1):21-24.

To highlight a rare case of a congenital midline cervical cleft (CMCC) in context with embryological theories/hypothesis, presentation, and management along with review of literature.

Congenital midline cervical cleft is a rare but interesting anterior neck anomaly with controversial theories/ hypothesis regarding its embryogenesis.

We describe here a classical case of midline cervical cleft that presented at birth with a cephalocaudal orientation, extending from the level below the hyoid bone to the suprasternal notch with a length of 3 cm and width of 0.5 cm. At 6 months of age, the lesion was excised and closure was done by multiple Z-plasty, with satisfactory results.

Although the diagnosis is clinical, it is frequently misdiagnosed. The associated clinical features could include thyroglossal duct cysts, cleft lip/mandible/sternum, cervical contractures, mandibular spurs, microgenia, and/or bronchogenic cysts. If it is not treated at an early age, it can result in complications like webbing of the neck, dental malocclusion, and restricted neck movements.

Earliest recognition of CMCC and proper intervention can provide better esthetic and functional prognosis.

A correct earlier recognition of the lesion and appropriate surgical management are key to avoid longterm complications.

Jaiswal AA, Behera BK, Membally R, Mohanty MK. Congenital Midline Cervical Cleft: A Case Report with Review of Literature. Int J Head Neck Surg 2017;8(1):25-30.

The present case describes a rare and large size of giant keratoacanthoma (KA) of pinna.

Keratoacanthoma is a fast growing benign cutaneous tumor resembling closely to well-differentiated squamous cell carcinoma (SCC) on clinical and histopathological examination (HPE).

A 70-year-old male presented with a rapidly growing mass on the left ear for 9 months. Tumor was excised and sent for HPE, which revealed well-differentiated SCC with focal features of a KA.

Differentiation of KA from SCC has been a major challenge for dermatosurgeons, especially at setups with unavailability of molecular studies. So, if the tumor is giant, nonregressing in size especially on sun-exposed sites in an elderly patient, always think of SCC and treat it by surgical excision rather than watching for a spontaneous resolution.

Chauhan S, Thakur K, Garg A, Tegta GR, Chauhan P. Giant Keratoacanthoma of Pinna: A Rare Presentation. Int J Head Neck Surg 2017;8(1):31-33.

Gupta R, Mohindroo NK, Azad R. Nasopharyngeal Carcinoma with an uncommon Presentation. Int J Head Neck Surg 2017;8(1):34-36.