CURRENT LITERATURE

J Oral Maxillofac Surg60:475-477, 2002

Annotated AbstractsHead and Neck Cancer. Forastiere A, Koch W, Triotti A, etal. N Engl J Med 345:1890, 2002

In a review article of therapy for head and neck cancer,the authors highlight advances in diagnosis and treatment.Emphasis is placed on using molecular biology to enhancediagnosis and therapy. The molecular progression of headand neck cancer is outlined and illustrated, beginning withthe loss of p16 function. Molecular changes are significantlygreater in patients who abuse tobacco and alcohol. Secondprimary tumors appear more often in those who smokeand/or drink. It seems that more than half of cancers arisingin the oropharynx contain human papilloma virus. A shiftfrom the traditional staging methods that have not provenhelpful to individual patients, to a molecular staging ap-proach is proposed. New chemotherapy methods such asusing monoclonal antibodies directed against epidermalgrowth factor, overexpressed often in squamous-cell head

and neck cancers, are advocated. Perhaps newer ap-proaches will improve the outcome for patients with thisdisfiguring and usually fatal disease.

Reviewer’s Comment: This article is recommendedreading for anyone involved in the detection and diagno-sis of head and neck cancer. Perhaps most interesting isthe detection of molecular changes though the mucosaappears relatively normal clinically. Certainly, molecularmarkers show better promise for predicting outcomes inindividual patients than traditional methods. Perhaps wecan finally believe that progress will be made in treatingthis disease.—R. WHITE

Reprint requests to Dr Sidransky: Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins School of Medicine, 818Ross Research Bldg, 720 Rutland Ave, Baltimore, MD 21205-2196;e-mail: dsidrans@jhmi.edu

AbstractsGrowth Factors, Extracellular Matrix Componentsand Cell Adhesion Molecules in Warthin’s Tumor. Na-kamura Y, Yamamoto M, Sakamoto K, et al. J Oral PatholMed 30:290, 2001

Warthin’s tumor is a benign neoplasm that occurs almostexclusively in the parotid gland, representing the secondmost common benign parotid tumor. Although the pathol-ogy of this tumor is uncertain, 2 theories have been dis-cussed most frequently in the literature. The first is that thetumor develops from heterotopic salivary ducts presentwithin pre-existing lymphoid tissue within or around theparotid gland. The second theory contends that the tumor isan epithelial neoplasm inciting a lymphocytic response. Theauthors of this study hypothesized that the epithelial andlymphoid components of Warthin’s tumor interact and pro-liferate through various growth factors and their receptors,extracellular matrix components and their receptors, andcell adhesion molecules. The study consisted of sectioning7 surgical specimens of Warthin’s tumors and 5 normalsalivary glands. All samples were from the parotid gland.Fifty-one antibodies were used to detect various growthfactors, extracellular matrix components and cell adhesionmolecules of the Warthin’s tumors and normal parotidglands. Additionally, RNA was extracted from the samplesand reverse-transcriptase (RT) and polymerase chain reac-tion (PCR) amplification was performed to further confirmthe presence of proteins detected by various antibodies.Results showed only Warthin’s tumor samples to have trans-forming growth factor (TGF)-�. These tumors also displayedTGF-�2, TGF-�3, and the receptor TGF-�RII. RT-PCR resultsconfirmed this finding. In the literature, TGF-� has beenshown to both stimulate and inhibit epithelial proliferation.The authors suggest that TGF proteins and their receptorsmay regulate the epithelial component of the tumor. Theseresults support the theory of an epithelial neoplasm inciting

a lymphocytic response in the pathogenesis of Warthin’stumor.—D.L. SQUIRE

Reprint requests to Dr Nakamura: Department of Pathology, StMary’s Hospital, 422, Tsubukuhon-machi, Kurume-shi, Japan 830-8543.

Preserved Costal Cartilage Homograft Application forthe Treatment of Temporomandibular Joint Anky-losis. Demir Z, Velidedeoglu H, Shani U, et al. Plast Recon-str Surg 108:44, 2001

The authors of this article present a series of 7 patientswith bony ankylosis of the temporomandibular joint (TMJ)(3 bilateral cases and 4 unilateral). Each patient was treatedwith preserved costal cartilage as an interpositional materialafter a gap arthroplasty on the affected TMJ. Maximal incisalopening (MIO) was less than 5 mm in all the patientspreoperatively. The solvent preservation of cartilage in-volves cellular destruction by osmotic exchange baths. Thefirst step of the preparation includes the cartilage treatmentwith an aqueous solution of hydrogen peroxide followed bya 1-hour sodium hydroxide wash at room temperature.After the last wash, the cartilage is dried and finally steril-ized with gamma irradiation. According to the article, thisprocess assures a sterile product free of enzymes and anti-gens. The surgical procedure was carried out in the usualmanner for a TMJ gap arthroplasty via a preauricular ap-proach. After a gap bigger than 5 mm was achieved in theTMJ, the cartilage was carved and positioned between the 2bony surfaces. The authors did not use any form of fixationfor the cartilage. The approach was closed in a layeredfashion. Active physical therapy started 2 days after surgeryand continued until 6 months postoperatively. The postop-erative follow-up ranged from 6 months to 4 years. Theresults showed a significant improvement on MIO. A mean

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measurement of 15.2 mm was recorded initially after sur-gery, and a mean measurement of 32 mm was recordedafter completion of physical therapy. The authors suggestthat benefits of this technique include no donor site mor-bidity, a shorter surgical time, and good biocompatibilityprofile.—A.F. HERRERA

Reprints to Dr Demir: Onep Plastic Surgery, Ugur Mumcu cad.97/11, G.O.P./Ankara 06700, Turkey; e-mail: zuhtudemir@hotmail.com

Multidisciplinary Care in Head and Neck Cancer.Miller MJ, Evans GRD. Clin Plast Surg 28:253, 2001

Modern cancer treatment is a carefully designed combi-nation of surgery, radiation, and chemotherapy. Subspecial-ties have emerged in each of these major disciplines, andthe allied health professions have developed importantroles. Fostering multidisciplinary cooperation represents asignificant conceptual advance that is promoted actively inNorth America and in Europe. Multidisciplinary cooperationis particularly important in head and neck oncology. Theanatomic structures are complicated and compact, and theyhave interrelated functions. There is significant overlapamong different medical and surgical specialties that treathead and neck disorders. Each practitioner develops a par-ticular skill in his or her specialized area but also has someexpertise in closely related areas that ordinarily are thedomain of other specialties. Recent outcomes of studies inhead and neck cancer emphasize the importance of multi-disciplinary care, especially for advanced lesions. Althoughcurrent literature tends to focus on the integration of sur-gery, radiation therapy, and medical oncology, the principleof multidisciplinary care is properly applied more broadlyto each subspecialty that has emerged within the disci-plines. A comprehensive multidisciplinary head and neckcancer team consists of health care personnel with specialexpertise and techniques in diagnosis, treatment, rehabili-tation, and patient support. Some important members ofthis comprehensive multidisciplinary team are the follow-ing: the head and neck oncologic surgeon, head and neckmedical oncologist, radiation oncologist, neurosurgeon,medical specialists, reconstructive surgeon, speech andswallowing therapist, otologist, maxillofacial prosthetist,otolaryngologist, ophthalmologist, diagnostic imaging radi-ologist, interventional radiologist, Moh’s dermatologist, gen-eral surgeon, thoracic surgeon, anesthesiologist, dentist,oral surgeon, nutritionist, social worker, psychiatrist, spe-cialized nurse, dental hygienist, pathologist, and chaplain.Because surgery remains the primary modality for treatingmost head and neck cancers, the responsibility for coordi-nating the activities of the multidisciplinary team usuallyresides with the head and neck surgical oncologist. Thealternative modality for local tumor control in early stagetumors is radiation therapy. Most head and neck cancersremain a locoregional disease for which surgery and radia-tion therapy provide the greatest chance for control. Nev-ertheless, advances have been made in chemotherapy,particularly with preoperative neoadjuvant or inductiontherapeutic regimens. Physicians and technicians on thepathology service play diagnostic and therapeutic roles onthe multidisciplinary team. Patients with head and neckcancer are often elderly, poorly nourished, or have historiesof substance abuse and associated medical illnesses. Assuch, they frequently are at risk for medical problems in thecourse of cancer treatment, and a multidisciplinary teamthat includes various other medical specialists provides op-

timal care. The critical role of specialists in diagnostic im-aging and interventional radiology hardly needs to be em-phasized for the head and neck patient. When tumorablation requires loss of dentition, exposure of the oralcavity to therapeutic irradiation, or destruction of visiblefeatures of the midface, then the multidisciplinary teammust include not only the plastic surgeon but also the dentaloncologist and specialist in maxillofacial prosthetics. Theconcept of multidisciplinary care, pioneered at the nation’scomprehensive cancer centers, should be adopted univer-sally by clinicians seeking to offer the patient with head andneck cancer the best care.—R.H. HAUG

Reprint requests to Dr Miller: Department of Plastic Surgery, Uni-versity of Texas M.D. Anderson Cancer Center, 1515 HolcombeBlvd, Houston, TX 77030.

Injuries Associated With Mandible Fractures Sus-tained in Motor Vehicle Collisions. Fischer K, Zhang F,Angel MF, et al. Plast Reconstr Surg 108:328, 2001

The incidence of mandible fracture and associated inju-ries in patients involved in motor vehicle collisions wereretrospectively studied. This group of patients consisted of148 patients with mandible fractures listed in the Universityof Mississippi’s trauma registry during the past 5 years. Onehundred (67.6%) patients were male and 48 (32.4%) werefemale. The age range was 3 to 77 years, with the peakincidence occurring in the second and third decades of life.Only 1 patient had no recorded injuries other than a man-dible fracture (0.7%). The incidence of associated injurieswith mandible fractures from a motor vehicle collision was99.3%. In this group of patients, there were 12 deaths, for amortality rate of 8.1%. The major causes of death wereclosed head injury in 8 cases, intra-abdominal and thoracicinjuries in 6 cases, cervical spine fracture in 4 cases, andbasilar skull fracture or depressed skull fracture in 2 cases.Facial and head lacerations and facial fractures were themost common associated injuries, followed closely byclosed head injuries, then lower extremity fractures. Ninety-six patients (64.8%) had associated life-threatening injuries.Closed head injuries and skull fractures were the mostcommon of these injuries. The data suggest that mandiblefractures sustained from motor vehicle collisions should notbe viewed as an isolated injury, but rather as part of aspectrum of potentially disabling and sometimes life-threat-ening injuries that require thorough trauma evaluation.—A.J. LIBUNAO

Reprint requests to Dr Lineweaver: Division of Plastic Surgery,University of Mississippi Medical Center, 2500 N State St, Jackson,MI 39216.

Sensory Impairment of the Lingual and Inferior Alve-olar Nerves Following Removal of Impacted Mandib-ular Third Molars. Gulicher D, Gerlach KL. Int J OralMaxillofac Surg 30:306, 2001

Altered sensation in the areas innervated by the inferioralveolar and lingual nerves are distinctive complicationsafter mandibular third molar extractions. These nerve inju-ries result from direct or indirect trauma to the nerve duringsurgical manipulation. The study consisted of 687 consec-utive patients, for a total of 1,106 impacted lower thirdmolars. Clinical, radiographic, and surgical factors of theteeth were recorded. Incidence and degree of sensory im-pairment were assessed during follow-up appointments.

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Patients were followed up until complete recovery or untilpostoperative week 27, if altered sensation remained. Thepatient population consisted of 516 males and 590 females.The ages ranged from 12 to 97 years, the average being 27.3years. Of the 1,093 teeth reviewed within the first postop-erative week, 39 showed hypesthesia or paresthesia of theinferior alveolar nerve (3.6%). Ninety-one percent had di-minished light touch sensation, 60% had diminished tactilediscrimination, and 51% had diminished perception of pain.In 25 of these cases, impairment of sensation completelyresolved within 27 weeks, leaving 0.9% with some remain-ing degree of deficit after the last follow-up. Twenty-onepatients (2.1%) complained of altered sensation lingually.Eighty-five percent had reduced light touch, 40% had dimin-ished tactile discrimination, and 55% had altered perceptionof pain. Sixty-five percent reported hypogeusia. Eighteen ofthese cases were transient and resolved completely within33 weeks. Inferior alveolar nerve damage was significantlyrelated to the age of the patient, the incidence being greaterin patients over the age of 35 years. Higher probability ofimpairment was also correlated with completely developedroots, deep impactions, and radiographic superimpositionof roots over the mandibular canal. In addition, surgicalinstrumentation deep into the socket increased the proba-bility of nerve damage. Conversely, osteotomy and section-ing merely between the crown and roots were not signifi-cantly related to complications. Lingual nerve damage wasfound to occur more often with the use of general anesthe-sia. The most likely explanation for this is the use of atongue retractor and the selection of the most difficultimpactions for this type of pain control. The authors’ sta-tistics were in agreement with figures for the overall inci-dence of inferior alveolar and lingual nerve damage assessedin previous studies. It was concluded that sensory impair-ment remaining after 6 months may be regarded as perma-nent and that the risk of permanent alteration was greater inthe lingual nerve. It is recommended that all patients beevaluated for the necessity of third molar extraction duringadolescence. It is also the authors’ recommendation thatgreat care be taken in retracting the lingual flap and deeplingual insertion of instruments be avoided at all costs.—ADAM HERSHKIN

Reprint requests to Dr Gulicher: Klinic fur Mund-, Kiefer- undGesichtschirurgie, Klinic der Otto-von-Guericke-Universitat, Leip-ziger StraBe 44, D-39120 Magdeburg, Germany.

Of Principles and Pens: Attitudes and Practices ofMedicine Housestaff Toward Pharmaceutical IndustryPromotions. Steinman MA, Shlipak MG, McPhee SJ. AmJ Med 110:551, 2001

Pharmaceutical promotions are big business. In recentyears, the pharmaceutical industry has spent more than $5billion per year on visits to hospitals and doctors, averagingalmost $9,000 per practicing physician. A substantial com-ponent of this total is directed toward housestaff, whoseevolving prescribing behavior makes an attractive target forindustry promotions. To investigate these issues, a question-naire was developed to measure physician attitudes andpractices toward a wide range of pharmaceutical industrypromotions. Using this instrument, a survey of medicinehousestaff was conducted to identify their attitudes toward

industry gifts, examine how perceptions of appropriatenesscorrelate with characteristics of these gifts, and assess theassociation between residents’ attitudes and their gift-takingbehaviors. Of 117 eligible residents, 105 responded. Themean age was 29 years; 44% were women, 56% were first-year residents, and 45% were affiliated with a primary careprogram. The promotions were categorized on the basis oftheir cost (inexpensive vs expensive) and educational value(noneducational vs educational). Six residents were elimi-nated from the study because of incomplete responses.Among the 99 eligible residents, 79 considered inexpensivegifts more appropriate than expensive ones, 19 rates themequally appropriate, and 1 found expensive gifts more ap-propriate. Similarly, educational items were rated appropri-ate more often than noneducational ones. Sixty-three resi-dents considered educational gifts more appropriate thannoneducational ones, 19 rated them equally appropriate,and 17 found noneducational gifts more appropriate. Mostphysicians in this study believed themselves free from in-fluence, although substantially fewer of the residents sur-veyed considered their physician colleagues equally im-mune.—R.H. HAUG

Reprint requests to Dr Steinman: VA Box 111G, San FranciscoVeterans Affairs Medical Center, 4150 Clement St, San Francisco,CA 94121.

Detection of Human Papilloma Virus DNA in BenignOral Squamous Epithelial Lesions in Venezuela. Jime-nez C, Correnti M, Salma N, et al. J Oral Pathol Med 30:385,2001

This study examines the incidence of human papillomavirus (HPV) in biopsy specimens taken from both healthymucosa and mucosa with benign epithelial lesions. Twentysamples were taken from healthy subjects with no indica-tion of oral pathology and 40 samples were taken fromsubjects showing squamous cell papilloma, oral condyloma,oral verruca vulgaris, or focal epithelial hyperplasia as indi-cated by light microscopy. DNA samples were extractedfrom frozen portions of the biopsied tissues and amplifiedvia the polymerase chain reaction method. The sampleswere separated by agarose gel electrophoresis and identi-fied as positive and separate strains of the HPV DNA. Squa-mous cell papilloma specimens showed a 40.74% presenceof HPV DNA with HPV subtype 6 being the most prevalentstrain at 54.54%. Oral verruca vulgaris specimens showed a50% presence of HPV DNA also with a high prevalence ofsubtype 6. Condyloma specimens showed a 100% occur-rence of HPV DNA, composed exclusively of subtype 6.Focal epithelial hyperplasia specimens also showed a 100%occurrence of HPV DNA with 88% subtype 13 and 12.5%subtype 32. Surprisingly, healthy mucosal samples showeda 10% incidence of HPV DNA. The data confirm the suppo-sition that these benign lesion may be caused by or act asreservoirs for HPV. Furthermore, the authors point out thepossibility of latent or subclinical infection with HPV asevidenced by the 10% incidence of HPV DNA in normalmucosal specimens.—S. BRANDON

Reprint requests to Dr Cavazza: Laboratorio de Histoquimica, Piso4, Instituto de Biomedicina, UCV, Apartado, 4043, Caracas 1080,Venezuela.

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