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PubMed2006

Quality of life after neck dissection.

OBJECTIVE: To assess the impact of modifications to radical neck dissection on postoperative quality of life. DESIGN: Cross-sectional study using a self-administered neck dissection questionnaire and an arm abduction test. SETTING: Department of Otolaryngology-Head and Neck Surgery, Kobe University Hospital. PATIENTS: Seventy-four patients who had undergone neck dissection for the treatment of head and neck cancer. MAIN OUTCOME MEASURES: Arm abduction test results and responses to questions on quality of life related to neck dissection. RESULTS: Forty-one patients underwent bilateral neck dissections, and 33 patients underwent unilateral neck dissection. Level V nodes were dissected in 74 necks. Among them, the spinal accessory nerve (SAN) was resected in 29 necks. Patients who had neck dissections that spared the SAN had better shoulder function. When the SAN was preserved, patients without dissection of level IV and V nodes had better scores on measures of pain and constriction of the neck. Sacrifice of the sternocleidomastoid muscle and/or the SAN had a significant effect on daily activities, work, and leisure. The arm abduction test scores and answers to questions regarding shoulder function were significantly correlated. CONCLUSIONS: Modifications to radical neck dissection contribute to improvements in the postoperative quality of life after neck dissection. A multicenter study using the arm abduction test and questionnaire used in this study is currently in progress to further evaluate the impact of modifications to radical neck dissection on quality of life after surgery.

Accessory Nerve↗
PubMed2004

Neck pain and disability following motor vehicle accidents--a cohort study.

The primary aim of the study was to compare the prevalence of neck pain and disability in a group exposed to motor vehicle accidents (MVAs) with those in the general population. The secondary aim was to assess the prevalence of a past history of exposure to an MVA with sequelae of neck pain in the general population. The exposed group consisted of 121 patients with neck complaints following an MVA in 1983. The control group, consisting of 1,491 subjects, was randomly selected, with attention to the distribution of age and gender in the exposed group. A neck-pain questionnaire was mailed to the subjects. In the control group, it included enquiry about a history of exposure to an MVA with sequelae of neck pain. The Neck Disability Index (NDI) was used to assess neck-related disability. In the exposed group 108 subjects (89%) responded, and in the control group 931 (62%) did. Seventeen years after the MVA, 59 subjects (55%) reported neck pain in the exposed group, with no gender differences. In the control group 270 (29%) reported neck pain with a higher frequency among women (34%) than men (19%) (p<0.01). There was a significant difference between the exposed group and the control group regarding the occurrence of neck pain (p<0.001). In the control group 34% recalled a history of an MVA, among whom one-third reported neck pain in connection with the accident and 28% had persistent neck pain referable to the accident. The exposed group scored significantly higher on the NDI (p<0.001) and reported significantly higher neck pain intensity than did the control group (p<0.001). In conclusion, a past history of exposure to an MVA with sequelae of neck pain appears to have a substantial impact on future persistent neck pain and associated disability.

Accidents, Traffic↗
PubMed2000

Pain, quality of life, and spinal accessory nerve status after neck dissection.

OBJECTIVE: To assess quality of life (QOL) in patients with head and neck cancer who underwent neck dissection and to compare QOL scores for patients in whom the spinal accessory nerve (CN XI) was resected or preserved. SETTING AND DESIGN AND OUTCOMES MEASURES: Three hundred ninety-seven patients who had undergone treatment for head and neck cancer completed the University of Michigan Head and Neck Quality of Life (HNQOL) instrument, the Medical Outcomes Study SF-12 General Health Survey, and questions on "pain despite pain medications" and headaches. RESULTS: Of the 397 patients, 222 had no neck dissection, 46 had neck dissections resecting CN XI, and 129 had dissection sparing CN XI. Of the latter group, 68 patients had dissections sparing level V and 61 dissections included level V. Age, sex, primary site distribution, and T stage were not different between the groups. Patients who had neck dissections sparing CN XI had better scores on the HNQOL pain domain (P = .002), had less shoulder or neck pain (P = .003), and took pain medications less frequently (P = .0004) compared with patients who had neck dissections sacrificing CN XI. When CN XI was preserved, patients who had no level V dissection had better pain domain scores (P = .03) and eating domain scores (P = .007) on the HNQOL, had less shoulder or neck pain (P = .006), and had less physical problems (P = .03) than patients who had level V dissected. On multivariate analysis, pain-related QOL scores after neck dissection were significantly better (P < .01) if patients had dissections with preservation of CN XI and if level V was not dissected. CONCLUSION: Neck dissections sparing CN XI are associated with better pain scores on the HNQOL, less shoulder and neck pain, and less need for medications. When CN XI is spared, not dissecting level V of the neck is associated with better HNQOL pain scores, less shoulder or neck pain, and fewer physical problems.

Accessory Nerve↗
PubMed2002

[Effect of ultrasonography on postoperative changes in treatment of neck lymph nodes and improvement of long term results in patients with laryngeal neoplasms].

Ultrasonography (US) is a well-known and valuable method of detecting lymph nodes in the neck. It is widely used in the preoperative neck assessment and in follow-up patients treated for head and neck cancer. The aim of the study was to compare the larynx cancer patients in two decades: the 80-ies and the 90-ies and the influence of a single diagnostic tool, i.e. ultrasonography, on therapeutic decisions and final results. Two groups of patients were selected: 737 patients treated between 1981-1985 (before the introduction of US) and 840 patients treated between 1991-1995 (routinely examined with the help of US) in ENT Dept. of Karol Marcinkowski University of Medical Sciences in Poznań. We aimed at analysing the percentages of neck metastases at the moment of diagnosis, the frequency of particular types of primary neck treatment, the percentages of neck recurrences, their advancement at the diagnosis and the methods of secondary treatment. Particular attention to feasibility of salvage was paid. Mean survival time in the group of patients with recurrence and the overall 5-year-long survival rates were analysed. No marked differences were stated between both groups as to epidemiological data, primary tumor advancement and types of the performed larynx surgery. Neck metastases occurred in both groups, 34% and 42%, respectively. Relapse rates were 12.9% and 12.6%, respectively. It was found that the number of elective neck dissections over the period given above became smaller, the number of radical neck dissections was stable, while the number of patients referred to wait and see policy increased. The number of successful neck salvage surgeries markedly increased while the number of patients not qualified for salvage decreased. For the both studied data, the curves on diagrams cross around the year 1992. The turning point situated in this time shows that ultrasound, introduced in 1991, gradually changed the types of primary treatment and possibilities of salvage neck treatment. The statistically significant differences in both groups were shown as to: types of the initial i.e. first neck treatment, relapse rate and the possibility of performing surgical salvage, while the only change was the introduction of a new diagnostic tool, i.e. neck ultrasonography. Survival rate was markedly better in the second group of patients. The methods of qualifying patients for the primary neck treatment and follow-up schedule have been changed since ultrasonography diagnostics was introduced in 1991 for routine assessment of the neck lymphatics in the larynx cancer patients. Strict follow-up schedule allow for early detection and successful treatment in high percentage of relapses.

Carcinoma↗
PubMed1979

Responses of Purkinje cells of the cerebellar vermis to neck and macular vestibular inputs.

1. The dynamic analysis of the control exerted by neck and macular vestibular receptors on the cerebellar cortex has been investigated in precollicular decerebrate cats submitted to sinusoidal rotation along the longitudinal axis of the animal at the frequency of 0.026 Hz and at peak amplitudes up to 10 degrees for the neck input and 15 degrees for the macular input. 2. Purkinje (P) cells located in the vermal cortex of the cerebellar anterior lobe, particularly in the longitudinal parasagittal zone which projects to the ipsilateral lateral vestibular nucleus (LVN), showed a sinusoidal modulation of the firing rate in response to sinusoidal stimulation of the neck receptors or the vestibular receptors, the phase of the responses being in most units related to the extreme neck or head position. Mossy fiber (MF) and/or climbing fiber (CF) responses of the same or different P-cells to the two inputs were observed. 3. The sensitivity of the MF-response of the P-cells to the neck input, elicited by sinusoidal rotation of the neck and expressed in per cent of the average firing rate per degree of neck rotation, corresponded on the average to 2.71 +/- 1.67, S.D. This value was significantly higher than that of the MF-response of the P-cells to the macular input elicited by sinusoidal tilt along the longitudinal axis of the whole animal, which correspond to 1.71 +/- 1.01, S.D. 4. Most of the MF-responses of the P-cells to the neck input were characterized by an excitation during side-down rotation of the neck and by an inhibition during side-up rotation, whereas most of the MF-responses of the P-cells to the macular input showed just the opposite behavior, being inhibited by side-down tilt of the animal and excited by side-up tilt. 5. Units which received a convergent input from both neck and macular receptors and showed an antagonistic pattern of response to the two inputs were tested during rotation of the head alone, in order to excite simultaneously the two kinds of receptors. Due to the higher sensitivity of the neck over the macular response, the magnitude of the combined response tended to be similar to the difference between the individual ones. Moreover, the phase of the resulting response was always modified with respect to that of the response to the neck input alone, and became in some instances related to velocity of neck rotation rather than to neck position. 6. These findings indicate that opposite responses to neck and macular inputs occur at corticocerebellar level. However, a final integration of the two inputs, leading to suppression of the conflicting responses, may occur either at medullary (LVN) or at spinal cord level.

Acoustic Maculae↗
PubMed1997

Is prophylactic neck irradiation indicated in patients with squamous cell carcinoma of the maxillary sinus?

PURPOSE: To determine the proportion of patients with squamous cell carcinoma of the maxillary sinus who will fail in regional nodes without elective neck treatment and to identify any prognostic factors that may influence neck control. METHODS AND MATERIALS: From 1971-1995, 42 consecutive patients with squamous cell carcinoma of the maxillary sinus were seen at our department for curative treatment. There were 35 males and 7 females, with a median age at diagnosis of 63.5 years (range, 42-77 years). One tumor was classified as T1, 5 had T2, 15 had T3, and 21 had T4 disease. Four of 42 patients (9.5%) had cervical lymphadenopathy at initial presentation. Thirty-three patients had surgical resection and radiotherapy and nine had radiotherapy alone. None of the 38 patients with clinical N0 necks received elective treatment to the cervical nodes. RESULTS: Median overall survival was 30 months for all patients. Of the 38 patients with N0 disease, 11 (28.9%) had neck recurrence. Of the 11 neck failures, 9 were ipsilateral only, 1 was contralateral, and 1 had bilateral neck recurrence. The most common site of neck failure was in the upper neck (submandibular and jugulodigastric lymph nodes). Four of the 38 patients (10.5%) had isolated neck failure. Only tumor stage was found to be significant for neck relapse, with T1 and T2 doing worse compared to T3 and T4 tumors. Location of tumor (infrastructure vs. suprastructure), involvement of the oral cavity/oropharynx, nasal cavity, nasopharynx or orbit did not predict for cervical node relapse. Local control at the primary site was likewise not prognostic. The median overall survival for patients who remained N0 was 80 months and for those with initial cervical involvement or recurred in the neck without elective neck irradiation was 25 months (p = 0.05). CONCLUSION: Based on the 28.9% rate of neck recurrence and the poor median survival of patients who recur in the neck, we recommend prophylactic ipsilateral neck irradiation in patients with T1-T4 squamous cell carcinoma of the maxillary sinus.

Adult↗
PubMed2005

Proprioception and rotation range sensitization associated with subclinical neck pain.

STUDY DESIGN: Cross-sectional study. OBJECTIVE: To investigate neck proprioception, range of motion, muscle endurance, and self report of pain and disability in patients with subclinical neck pain. SUMMARY OF BACKGROUND DATA: Untreated (i.e., subclinical) neck pain represents a category intermediate between "no pain" and "treated (i.e., clinical) pain." Therefore, the features that characterize it may be targeted for early management to prevent progression. METHODS: Eighty-one healthy Korean university student volunteers, aged between 18 and 30 years (mean age, 23.2 years), were measured for proprioceptive sensitivity to differences in the extent of midrange neck retraction and rotation movements using a device that was not attached to the head; neck range of motion (twice) using the cervical range of motion device; and neck muscle endurance using a modified Biering-Sorensen test. Finally, patients were asked about any recurrent neck pain and completed Korean translations of four commonly used neck pain and disability questionnaires. RESULTS: Patients were categorized into three frequency of neck pain groups: never/infrequent, monthly, or weekly. There were significant differences between these groups on the four self-report questionnaires. Neck muscle endurance was significantly lower for the groups reporting monthly and weekly pain compared with the never/infrequent group. At the second range of motion test, increased range was obtained for patients with infrequent or no neck pain, but left rotation range of motion was less on the second test (sensitization) for patients reporting monthly and weekly pain. Movement extent discrimination was best for the group with the greatest pain frequency. CONCLUSIONS: A history of subclinical neck pain is associated with lower neck muscle endurance capacity and with less rotation range of motion on second testing but when frequent (occurring weekly or more often) is associated with greater sensitivity in judging neck movement extent. Improving strength and rotation range should therefore be investigated as targets of treatment for subclinical neck pain.

Adolescent↗
PubMed2006

Neck management in patients undergoing postradiotherapy salvage laryngeal surgery for recurrent/persistent laryngeal cancer.

OBJECTIVE: To determine a plan for the management of cervical lymph nodes in patients undergoing salvage laryngeal surgery (SLS) for recurrent/persistent laryngeal cancer after primary radiotherapy (RT). STUDY DESIGN: : Retrospective chart review. METHODS: Charts of 51 consecutive patients who had salvage total or supracricoid laryngectomy with or without neck dissection for recurrent/persistent laryngeal squamous cell carcinoma after primary RT from 1988 to 2005 in our institution were reviewed. No patients received concomitant or neo-adjuvant chemotherapy. Thirty-four patients underwent SLS along with unilateral or bilateral neck dissection, whereas 17 patients underwent the SLS without neck dissection. Reports of preRT and preSLS staging of the primary tumor and the neck, recorded using the TNM system, were reviewed. Reports of the final histopathologic examination for the excised laryngeal cancer and cervical lymph nodes were reviewed. RESULTS: Thirty-four patients underwent SLS with unilateral or bilateral neck dissection. The preRT staging of the primary tumor for those 34 patients showed that 32 (94%) were staged T-1 (14) and T-2 (18), whereas the preSLS staging of the primary tumor for those 34 patients showed that 29 (85%) were staged T-3 and T-4. The postSLS final histopathologic examination of the excised lymph nodes in those 34 patients demonstrated that 30 (88%) did not have any evidence of nodal metastasis. On comparing patients with and without nodal metastasis (on their postSLS final histopathology), we found that the preSLS neck staging, based on computed tomographic (CT) scanning of the neck, was significantly associated with the negative/positive postSLS status of nodal metastasis (P = .006). Of 29 patients staged preSLS as N-0, 28 (97%) patients did not have nodal metastasis on their postSLS final pathology (negative predictive value = 97%, confidence interval, 82.2-99.9). PreRT neck staging, preRT and preSLS staging of the primary tumor, along with laryngeal subsite involvement (supraglottis, glottis, subglottis) did not significantly correlate with the status of neck metastasis on final postSLS histopathology (P = .68, 0.78, 0.49, and 0.42, respectively). None of the 34 patients had any neck tumor recurrence in the postSLS follow-up period (median, 3 yr). In addition, all 17 patients who underwent SLS without neck dissection were staged N-0 both before RT as well as preSLS, and none developed neck disease in the postSLS follow-up period (median, 2.5 yr). CONCLUSION: Management of the neck in patients undergoing salvage total or supracricoid laryngectomy for laryngeal cancer recurrence/persistence after primary RT should be based on the preSLS CT staging of the neck. Patients staged N-0 preSLS are not likely to harbor occult nodal metastasis and therefore may not require elective neck dissection.

Adult↗
PubMed2003

[Prophylactic neck dissection for submandibular gland cancer].

The indication and preferred dissection field for prophylactic neck dissection for submandibular gland cancer are controversial and have not been standardized. We reviewed 27 patients who underwent a definitive operation for previously untreated submandibular gland cancer. The 27 patients consisted of 13 patients with adenoid cystic carcinoma, 6 patients with mucoepidermoid carcinoma, 6 patients with adenocarcinoma, and 2 patients with squamous cell carcinoma. The diagnostic accuracies of malignancy and histology with fine needle aspiration cytology were 86% and 56%, respectively. In sixteen out of 21 cases without neck lymph node metastasis, a prophylactic neck dissection was performed and pathological neck lymph node metastases were detected in five cases. On the other hand, in five cases that did not receive a prophylactic neck dissection, latent neck lymph node metastasis was observed in 2 cases. In both cases of neck lymph node metastasis, pathological positive lymph nodes were observed in only level 2 or level 3. The rates of occult neck lymph node metastasis according to the T stage were 0% in T1, 33.3% in T2, 57.1% in T3 and 100% in T4. The rates of occult neck lymph node metastasis according to the histopathology were 46.2% in adenoid cystic carcinoma, 50% in mucoepidermoid carcinoma, 50% in adenocarcinoma, and 50% in squamous cell carcinoma. In conclusion, we believe that supraomyohoid neck dissection is suitable for N0 cases of submandibular gland cancer because of four reasons: 1) rate of occult neck lymph node metastasis in submandibular gland cancer is high, 2) pathological neck lymph node metastasis in N0 cases and latent neck lymph node metastasis were observed in level 2 and level 3, 3) the prognosis of cases with neck lymph node metastasis was poor, and 4) same skin incision can be used not only for the primary resection but also for the neck dissection.

Adult↗
PubMed2006

Neck recurrence in early carcinoma tongue.

OBJECTIVE: To study the efficacy of different locoregional treatment options for tongue cancer in determining the prognosis, with reference to recurrence of disease in neck. METHODS: This is a retrospective analysis of 80 patients with early (T1/T2) carcinoma tongue who had hemiglossectomy with or without neck surgery and radiotherapy for 14 years. RESULTS: Eighty patients were included in this study, 49 (61.3%) men and 31 (38.8%) women; 36 (45%) patients with T1 lesion and 44 (55%) with T2 lesion. Sixty two patients (77.5%) were staged cN0 and 18 patients had a clinically palpable neck nodes (cN+). Thirty seven patients were pathologically negative (pN0), whereas 22 were pathologically positive (pN+) and 21 were not operated so they were staged pathologically (pNx) (undissected necks). Thirty patients received postoperative adjuvant radiotherapy. The median follow-up was 16.5 months with a range of 10-120 months. The over-all rate of recurrence in neck was 32.5% (27 patients). The rate of recurrence was 23% in T1 and 45.8% in T2 lesion (P-value 0.09) without radiotherapy. The recurrence rates with T1 lesion patients who were given adjuvant radiotherapy did not change significantly whereas with T2 lesions the recurrence rate decreased from 45% to 25% in the group without radiotherapy. Recurrence rate was higher in undissected neck as compared to patients who underwent elective neck dissection having radiotherapy and staged pN0 (P-value 0.009) or pN+ (P-value 0.005). Patients having therapeutic neck dissection, on comparison of final pathological node staging (i.e. pN0 or pN+) the rate of recurrence in patients pN+ was 56% and in group with pN0 it was 11%, with (P-value 0.046). CONCLUSION: We did not find any effect of age, gender and surgically resected margins of primary early tongue tumor on recurrence of disease in neck. There was no significant difference between primary tumor stage T1 and T2 lesions on neck recurrence when treated with surgery alone, but adjuvant radiotherapy further reduced the neck recurrence in T2 groups. Adjuvant radiotherapy also showed a significant reduction in recurrence rates in both pN0 and pN+. Undissected necks have higher incidence of neck recurrence than dissected neck irrespective of pathological status of neck metastasis.

Adult↗
PubMed2006

Long-term followup of patients after redo bladder neck reconstruction for bladder exstrophy complex.

PURPOSE: The aim of this study was to determine whether redo bladder neck reconstruction is effective in achieving continence after a failed bladder neck reconstruction procedure. MATERIALS AND METHODS: We retrospectively reviewed the hospital records of patients with bladder exstrophy who had undergone redo bladder neck reconstruction. There were 30 patients in the study, including 20 boys and 10 girls. Mean patient age at redo bladder neck reconstruction was 9.3 years (range 3.2 to 15.5). The patients were divided into 3 groups on the basis of the preoperative pattern of incontinence--incomplete wetters, complete wetters and those on continuous suprapubic drainage. Of the patients 15 already had undergone bladder augmentation, 12 had undergone a Mitrofanoff procedure and 12 had been treated with bulking agents injected in the bladder neck in an attempt to achieve continence. Four patients had undergone more than 1 bladder neck procedure. The patients were investigated with a combination of noninvasive urodynamics, cystoscopy, cystogram and ultrasound. All patients underwent Mitchell's modification of Young-Dees-Leadbetter bladder neck reconstruction. Additional procedures performed included augmentation cystoplasty and Mitrofanoff formation. RESULTS: Mean followup was 6.9 years (range 1.2 to 15.5). Postoperatively 28 patients were using clean intermittent catheterization to empty the bladder (5 per urethra, 23 via Mitrofanoff). Two patients remained on continuous suprapubic catheter drainage. A total of 18 patients (60%) were dry postoperatively (80% of girls and 50% of boys). Among dry patients only 3 were performing clean intermittent catheterization per urethra and 15 via a Mitrofanoff channel. No patient was able to void per urethra without the need for clean intermittent catheterization. The 2 patients on continuous suprapubic catheter drainage continued to remain so. At night only 50% of the patients were dry (5 on free drainage, 4 on clean intermittent catheterization, 6 not on any drainage). Those patients who did not respond satisfactorily to redo bladder neck reconstruction underwent subsequent additional procedures, which included injection of bulking agents (3 patients), insertion of an artificial urinary sphincter (1), Mitrofanoff formation (2) and bladder augmentation plus Mitrofanoff channel (1). Postoperative complications included difficulty with clean intermittent catheterization (8 patients), perivesical leak (1), recurrent epididymo-orchitis (1), upper urinary tract dilatation (2) and incisional hernia (1). Bladder neck closure was being considered in 5 patients. CONCLUSIONS: In our experience redo bladder neck reconstruction cannot achieve continence with volitional voiding per urethra. Although redo bladder neck reconstruction can render a significant number of patients dry, it is only effective if performed in conjunction with augmentation. Failure of the initial bladder neck reconstruction may be a reflection of a bladder that is of inadequate capacity and/or compliance. Therefore, bladder augmentation should be considered in all patients requiring redo bladder neck reconstruction. Bladder neck closure may be a better alternative to redo bladder neck reconstruction.

Adolescent↗
PubMed1988

Critical assessment of supraomohyoid neck dissection.

During a recent 5-year period, 115 patients had 131 supraomohyoid neck dissections. Eighty-one percent of these procedures were performed for squamous carcinoma. Seventy-nine percent of the primary tumors were located in the oral cavity and 16 percent arose in the oropharynx. Almost 80 percent of the necks dissected for primary squamous carcinoma were clinically N0, and occult nodal disease was discovered in 31 percent of these neck specimens. When the supraomohyoid neck dissection specimen showed no involvement, the overall incidence of treatment failure in the neck at 2-year follow-up was 5 percent. Almost all patients with occult squamous carcinoma in the supraomohyoid neck dissection specimen received postoperative radiotherapy, and the failure rate in the neck was 15 percent. When neck nodes were both clinically and pathologically involved, neck recurrence developed in 29 percent of the patients despite the addition of adequate postoperative radiotherapy. Among those patients with nonsquamous primary tumors and a pathologically negative supraomohyoid neck dissection specimen, there was only one subsequent treatment failure in the neck. Supraomohyoid neck dissection appears to be a valid staging procedure for clinically N0 patients with primary squamous carcinomas located in the oral cavity or oropharynx, with an appropriate yield of occult nodal disease, and infrequent treatment failure in the dissected neck when the supraomohyoid neck dissection specimen is pathologically uninvolved. When nodal disease is clinically obvious, treatment failure is more frequent, even with the addition of postoperative radiotherapy. The role of supraomohyoid neck dissection in this setting deserves further study.

Carcinoma, Squamous Cell↗
PubMed1997

[Intraoperative aneurysmal rupture at the neck].

Intraoperative rupture of an aneurysm can lead to disastrous results when the rupture occurs at the neck. The authors have encountered eight cases (5%) of intraoperative rupture in a series of 155 patients. All patients were operated on in the acute stage by one of the authors of this paper (T.Y.). In six cases, the aneurysm ruptured at the dome and in two, at the neck. We report these two patients with intraoperative rupture at the neck. The first case, a 50-year-old female, developed SAH, but a 4-vessel study failed to show an aneurysm. The second series of angiograms obtained ten days later showed a broad-based, left proximal A1 aneurysm. It was decided to employ a right pterional approach. The aneurysm was arising from the right A1 segment just proximal to the anterior communicating artery. The neck was wide, with thin walls. Thus, it seemed better to apply a clip parallel to the A1 segment axis than to apply it from a direction perpendicular to the A1 segment axis. However, the right pterional approach precluded a parallel clipping, so the blades of a clip were applied perpendicularly. The clip seemed not to be completely across the neck of the aneurysm. After applying a temporary clip to the A1 segment proximal to the aneurysm, the clip blades were opened and advanced just when bursting of the sac at the base occurred and microvascular suture repair was required to control the bleeding. The second case, a 57-year-old female, underwent clipping of a right IC-PC aneurysm. However, two years postoperatively, the patient again suffered SAH. Cerebral angiography at this time revealed a relatively large recurrent IC-PC aneurysm in which the old clip was situated on the dome of the aneurysm. Aneurysmal clipping was performed on the day of rupture. Tough granular tissue was removed from the ICA, PcomA, aneurysmal neck, and the old clip. After the true neck was identified, a straight clip was applied to the neck parallel to the ICA. Soon after the clipping, arterial bleeding occurred near the neck. The ruptured aneurysm was trapped using two temporary clips. A curved clip was applied to the ruptured neck, including the wall of the ICA, to control the bleeding. This clipping caused a substantial stenosis of the ICA. Both patients demonstrated postoperative neurological deficits due to ischemia caused by temporary clipping. These encounters dramatically demonstrated that a very thin-walled aneurysm or a recurrent aneurysm has a fragile neck. In surgical treatment of these unusual aneurysms, a clip should be placed on the neck parallel to the parent artery. Furthermore, temporary clipping is advisable when dissecting the neck or applying the clip to the neck to reduce the damage to the neck.

Aneurysm, Ruptured↗
PubMed2004

Decreased neck muscle strength is highly associated with pain in cervical dystonia patients treated with botulinum toxin injections.

OBJECTIVES: To compare the isometric neck muscle strength of cervical dystonia patients treated with botulinum toxin injections with that of healthy control subjects and to evaluate the association between neck strength, neck pain, and disability in these patients. DESIGN: Clinical cross-sectional study. SETTING: Outpatient rehabilitation and neurology clinics in a Finnish hospital. PARTICIPANTS: Twenty-three patients with cervical dystonia with botulinum toxin-treated neck muscles and 23 healthy control subjects. INTERVENTIONS: Not applicable. Main outcome measures Isometric neck strength was measured by a special neck strength measurement system. Disability was measured by the Neck Disability Index, and pain and symptoms of cervical dystonia by a visual analog scale. RESULTS: Isometric neck strength in all directions measured was significantly lower (25%-44%) in the cervical dystonia patients than in the healthy controls. Neck pain levels reported during the strength tests (r range, -.36 to -.70) and neck pain experienced during the preceding week (r range, -.52 to -.63) were inversely associated with isometric strength results. The difference between sides in rotation strength was 35% in the patient group (P<.001), whereas no significant difference between sides was found in the healthy controls. Fifty-one percent of the patients reported moderate or severe disability. Pain, stiffness, and incorrect position of the head were the most prominent symptoms. CONCLUSIONS: Cervical dystonia patients with botulinum toxin-treated neck muscles showed significantly lower maximal neck strength than healthy controls. The patients also had a statistically significant difference between sides in neck rotation strength. Thus, strength measures may be useful to detect disturbance in the function of the neck muscles.

Botulinum Toxins, Type A↗
PubMed2004

[Selective neck dissection in patients presenting clinical node metastases].

OBJECTIVE: To evaluate the results obtained with selective neck dissection in patients with clinically positive neck nodes at diagnosis (N+). PATIENTS AND METHODS: Retrospective study of N+ patients treated with a lateral or supromohyoid selective neck dissection with prophylactic purpose (sides of the neck N0) or therapeutic purpose (sides of the neck N+). RESULTS: Forty nine selective neck dissections were carried out in 42 N+ patients. In 18 cases the neck dissection had a prophylactic purpose (sides of the neck N0), and in 31 of them a therapeutic purpose (sides of the neck N+). In 39 patients summary was followed by postoperative radiotherapy. There was no regional relapse in either side of the neck treated with a selective neck dissection. CONCLUSIONS: Selective neck dissections in selected N+ patients are an adequate surgical technique. The main advantages of selective neck dissections are to shorten the surgical time, and to avoid the morbility associated with the dissection of the neck zones not included.

Head and Neck Neoplasms↗
PubMed2000

Cervical lymph node metastases from unknown primary tumours. Results from a national survey by the Danish Society for Head and Neck Oncology.

BACKGROUND AND PURPOSE: The management of patients with cervical lymph node metastases from unknown primary tumours is a major challenge in oncology. This study presents data collected from all five oncology centres in Denmark. MATERIAL AND METHODS: Of the 352 consecutive patients with squamous cell or undifferentiated tumours seen from 1975 to 1995, a total of 277 (79%) were treated with radical intent. The general treatment policy at all centres during the entire study period has been to treat all suitable candidates with radiotherapy to both sides of the neck and include elective irradiation of the mucosal sites in nasopharynx, and larynx, hypopharynx and larynx (81%). Irradiation of the ipsilateral neck only was done in 26 patients (10%). Radical surgery was the only treatment in 23 N1-N2 patients (9%). RESULTS: The 5-year estimates of neck control, disease-specific survival and overall survival for radically treated patients were 51, 48 and 36%, respectively. The emergence of the occult primary was observed in 66 patients (19%). About half of the emerging primaries were within the head and neck region with oropharynx, hypopharynx and oral cavity being the most common sites. Emerging primaries outside the head and neck region were primarily located in the lung (19 patients) and oesophagus (five patients). The frequency of emerging primary in the head and neck was significantly higher in patients treated with surgery alone, the actuarial risks at 5-year being 54+/-1% (no RT) vs. 15+/-3% (with RT), P<0.0001. The most important factor for neck control was nodal stage (5-year estimates 69% (N1), 58% (N2) and 30% (N3)). Other important parameters for neck control and disease-specific survival included haemoglobin, gender and overall treatment time. Patients treated with ipsilateral radiotherapy had a relative risk of recurrence in the head and neck region of 1.9 compared with patients treated to both neck and mucosa. At 5 years, the estimated control rates were 27% (ipsilateral) and 51% (bilateral; P=0.05). The 5-year disease-specific survival estimates were 28 and 45%, respectively (P=0.10). CONCLUSIONS: This study has confirmed that patients with neck node metastases from occult head and neck cancer have clinical features and prognosis similar to other head and neck malignancies. Extensive irradiation to both sides of the neck and the mucosa in the entire pharyngeal axis and larynx resulted in significantly less loco-regional failures compared with patients treated with ipsilateral techniques, but only a trend towards better survival. A prospective randomized trial is required to determine the optimal strategy in terms of locoregional control, survival and morbidity.

Adolescent↗
PubMed2004

Neck muscle strength and endurance in fighter pilots: effects of a supervised training program.

INTRODUCTION: Cervical discomfort is common among pilots of high performance aircraft. An exercise program was introduced to increase the strength and endurance of the neck muscles. The purpose of this study was to analyze whether coaching or reinforcement strategies by a physical therapist was associated with improvement in neck muscle strength, endurance, and neck complaints in two cohorts of fighter pilots performing regular neck muscle exercises. METHODS: A reinforced group (RG) of 20 pilots (24-40 yr) at an Air Force base received weekly encouragement to perform their standardized exercise program three times per week. A non-reinforced reference group (NRG) of 20 pilots (23-37 yr) from another Air Force base carried out the same program without any supervision. Both groups performed the training program for 6-8 mo. Before and after the training period, isometric measurements of the neck flexors and neck extensors were performed in both groups. RESULTS: After the completion of the 6-8 mo training period, the RG pilots significantly increased their neck muscle strength (flexors: M = 3.9 nm, p = 0.000 and extensors: M = 5.0 nm, p = 0.001) as well as endurance in their neck extensors (M = 53 s, p = 0.000). The NRG pilots significantly decreased both strength (M = 11.5 nm, p = 0.0001) and endurance (M = 33 s, p = 0.003) of their neck extensors. Furthermore, the NRG pilots did not show any significant change of their neck flexor strength. No significant changes in the frequency of neck complaints were reported in either group throughout the entire study period. CONCLUSION: The reinforced training program increased the strength and endurance of the appropriate muscle groups. In order to draw any further conclusions concerning reducing neck complaints, a longer observation period with a larger group of pilots might be needed. However, it is likely that there is an individual correlation between strength and endurance of the neck muscles and neck pain, which means that any rehabilitation program should be tailored for each individual.

Accidents, Occupational↗
PubMed2002

Development and validation of the neck dissection impairment index: a quality of life measure.

OBJECTIVES: To validate a health-related quality-of-life (QOL) instrument for patients following neck dissection and to identify the factors that affect QOL following neck dissection. DESIGN: Cross-sectional validation study. SETTING: The outpatient clinic of a tertiary care cancer center. PATIENTS: Convenience sample of 54 patients previously treated for head and neck cancer who underwent a selective neck dissection or modified radical neck dissection (64 total neck dissections). Patients had a minimum postoperative convalescence of 11 months. Thirty-two underwent accessory nerve-sparing modified radical neck dissection, and 32 underwent selective neck dissection. MAIN OUTCOME MEASURE: A 10-item, self-report instrument, the Neck Dissection Impairment Index (NDII), was developed and validated. Reliability was evaluated with test-retest correlation and internal consistency using the Cronbach alpha coefficient. Convergent validity was assessed using the 36-Item Short-Form Health Survey (SF-36) and the Constant Shoulder Scale, a shoulder function test. Multiple variable regression was used to determine variables that most affected QOL following neck dissection RESULTS: The 10-item NDII test-retest correlation was 0.91 (P<.001) with an internal consistency Cronbach alpha coefficient of.95. The NDII correlated with the Constant Shoulder Scale (r = 0.85, P<.001) and with the SF-36 physical functioning (r = 0.50, P<.001) and role-physical functioning (r = 0.60, P<.001) domains. Using multiple variable regression, the variables that contributed most to QOL score were patient's age and weight, radiation treatment, and neck dissection type. CONCLUSIONS: The NDII is a valid, reliable instrument for assessing neck dissection impairment. Patient's age, weight, radiation treatment, and neck dissection type were important factors that affect QOL following neck dissection.

Aged↗