[Lymph node metastasis in head-neck tumors]

BACKGROUND

One of the most important criteria of malignancy of head and neck cancer are the cervical lymph metastases. Being significant for the therapeutical plan is how tumor depending parameters like T-stage, degree of differentiation and tumor localisation will influence the N-stage and therefore the extension of neck dissection.

METHOD

To evaluate the pattern of formations of metastases and the success of therapy a retrospective study was performed on 405 patients with carcinoma of the oral cavity (n = 47), the oropharynx (n = 117), the hypopharynx (n = 47) and the larynx (n = 193).

RESULTS

By the time of surgery carcinoma of the hypopharynx were most frequently accompanied by cervical metastases (80%), followed by carcinoma of the oropharynx (70%), the oral cavity (52%) and the larynx (26%). Occurrence and extension of regional lymph node metastases correlated well with T-stages and degree of differentiation. After surgical therapy locoregional recurrence could be observed in 5.2% of the patients. Five-year-survival rate was reduced to 50% on patients with positive lymph nodes. The different tumour sites showed preferred patterns of metastatic spread, without complete avoidance of certain levels.

CONCLUSION

For the decision on indication and extent of neck dissection the preoperative diagnostic (ultrasound, CT-scan, MRI), localisation of tumour, T-stage, degree of differentiation and the knowledge of typical metastatic spread must be considered.

[Main symptom: "pulse-synchronous tinnitus"]

BACKGROUND

In comparison to cochlear or nerval generated ear noises, pulsatile tinnitus is a rare condition. Due to its own etiology, specific diagnostic steps are necessary.

PATIENTS

We present 6 patients with pulsating tinnitus as the leading symptom. By means of these cases the various etiologies, rational diagnosis and therapy will be discussed.

RESULTS

Pulsatile tinnitus is frequently caused by an increased blood flow in the cranial vessels through various pathologies. Besides those diseases going along with a general increase of blood circulation, regional alterations can be classified as hypervascular/hyperemic, arterial or venous conditioned.

CONCLUSIONS

Physical examination and modern imaging can detect the underlying reasons in a quick and reliable way.

Electromyography of the infrahyoid muscles: pathological and normal findings

In recent years, the infrahyoid muscles (IHM) have been used by plastic reconstructive surgeons as a neurovascular muscle flap in the neck and mouth region.

METHODS

A preoperative electromyographic examination (EMG) of the IHM was performed in 10 patients, of whom 9 suffered from tongue cancer, in order to detect neurogenic lesions caused by possible metastases or lymph nodes. The results were compared to those of 10 healthy controls.

RESULTS

The EMG at rest showed no pathological spontaneous activity in any patient. During light voluntary innervation, the motor unit potentials (MUPs) were normal in controls and in patients with normal sonographic images, computertomographic scans, and histologic findings after surgery in the neck region. When metastatic lymph nodes were found on one side of the neck, the number of polyphasic MUPs in the IHM of that side was increased in some cases (n = 6), and normal in others (n = 5). Traumatic or radiogenic lesions clearly resulted in pathological EMG findings (n = 6). A maximal innervation of the IHM was achieved during head bending and jaw opening, there was no activation of the IHM with tongue movements and vice versa.

CONCLUSIONS

If the presence of lymph node pathology was demonstrated using imaging techniques, a resulting lesion of the ansa cervicalis can functionally be demonstrated by EMG. In patients without lymph node metastases and without concurrent other lesions in the cervical region, EMG of the IHM seems to give no further clinical information. A clear postoperative functional differentiation of the transplanted IHM and the indigenous tongue muscles is possible.

[Microsurgical reanastomosis of the parotid duct]

Deep injuries to the parotid region may result in trauma to vital structures: i.e., the parotid gland and duct and the facial nerve and its branches. While there is no doubt concerning primary microsurgical reconstruction of injuries to the facial nerve clinical approaches for treating disruptions of the parotid duct have been controversial. A case report is presented of a secondarily reanastomosed parotid duct following complete transection. The microsurgical technique and its indications are discussed.

[Topographic and anatomic study of lateral upper arm transplants]

An anatomic and topographic study of the lateral upper arm free flap for the clinical use in reconstruction. Defects of the laryngopharynx and the oral cavity after cancer ablation are increasingly reconstructed by free microvascular anastomosed tissue transfer. Besides the jejunum transplant we use the free radial forearm flap frequently. This flap is suitable for restoring intraoral and pharyngeal integrity. Major disadvantages are the requirement of a skin graft to obtain wound closure and the cosmetic deformity. The lateral upper arm free flap is intended as alternative method for the fasciocutaneus tissue transfer. Based on our dissection of ten cadavers we demonstrate the anatomy of the flap, the harvesting technique, and present data of vascular pedicle length, vessel calibers, and flap size. The vessel calibers of the profound brachial artery (X = 2.5 mm) and its terminal branch, the posterior radial collateral artery (X = 1.8 mm), are comparable to the radial artery. The pedicle length can be extended up to 13 cm by using a lateral approach. The subcutaneous tissue volume was 1.3 cm in average, and compared to the radial flap rather thick. Because of his bulky and strong fascia the lateral arm flap seems to be useful as a fascia-fat flap in facial augmentation or as a fascia flap in soft tissue reconstruction. Disadvantageous are the difficult dissection technique and the loss of sensitivity on the lateral aspect of the forearm. Where a fasciocutaneous flap is indicated, we prefer the radial forearm flap.

[Neurovascular infrahyoidal myofascial flap. Anatomic and topographic study of the innervation and blood supply]

The neurovascular infrahyoidal myofascial flap: An anatomical and topographical study of the innervation and blood supply. 15 cadavers had bilaterally been examined for the topography of the upper thyroid artery and vein and of the lower cervical ansa, as an axial bundle of vessels and nerves for the infrahyoidal myofascial flap. With the injection of methylene blue the vascular territories of the upper thyroid artery had been demonstrated. The upper thyroid artery and vein could be found in all cases. This artery was deriving in 47% from the external carotid artery, in 30% from the bifurcation and in 23% from the common carotid artery. The vein flowed in 43% into the facial vein and in 37% into the internal jugular vein. In the remaining 20% several segmental veins were found, which flowed into the jugular vein separately. In case of a far caudally situated vascular bundle the radius of rotation can be limited in cranial direction. The voluntary innervation of the muscles of this flap is derived from the lower cervical ansa. The upper radix of the ansa can be found 1 cm in latero-cranial direction of the greater horn of the hyoid bone, where it is separating from the hypoglossal nerve. The upper thyroid artery is supplying the infrahyoidal musculature in the whole extension from the hyoid bone to the sternum. Therefore it is possible to develop a myofascial flap of 3.5 cm x 11.5 cm in size, which is pedicled at an upper vascular and nerval bundle. Depending on the radius of rotation defects of the floor of mouth, of the tongue and of the oro- and hypopharynx can well be covered with this new neurovascular myofascial flap.

[Topographic anatomic study of cells transplanted from the groin region]

We performed 25 fresh cadaver dissections to describe the anatomy of the superficial and deep circumflex iliac artery and the superficial inferior epigastric artery how they can be used as donor vessels for the free transfer of groin flaps and for living iliac bone. With the injection of ink the capillary region of these vessels in the bone (iliac crest), the muscle (internal oblique muscle) and skin (groin and thigh) was stained. The superficial and deep circumflex iliac artery are the main supply vessels of the groin and thigh, they can be found in 96% and 100% of the cases. The venous drainage of this region follows from a superficial (superficial circumflex iliac vein) and a deep venous system (Vv. comitantes accompanying the arterial branches). Both venous systems can always be found. The superficial circumflex iliac artery only supplies the skin and is the main donor vessel for skin and soft tissue transplants. The deep circumflex iliac artery supplies the pelvic bone, the internal oblique muscle and a small constant area of skin above the iliac crest. Bone, bone-muscle and bone-muscle and skin transplants can be obtained with this donor vessels. To enlarge the skin area the two arterial branches can be combined in one transplant. With an average vessel diameter of 1.5 mm (superficial circumflex iliac artery) and 3 mm (deep circumflex iliac artery) both vessels can very well be used for microvascular transplantation. These different tissues (muscle, bone, skin) can be obtained in adequate size and form struct composite defects in the upper aerodigestive tract.

[Topographic-anatomic study of tissue transplants of the inguinal region]

We performed 25 fresh cadaver dissections to describe the anatomy of the superficial and deep circumflex iliac artery and the superficial inferior epigastric artery to determine how they could least to used as donor vessels for the free transfer of groin flaps and living iliac bone. With injection of ink the capillary region of these vessels was stained in (iliac crest) bone, the internal oblique muscle and skin of the groin and thigh. The superficial and deep circumflex iliac artery were shown to be the main supply vessels of the groin and thigh and could be found in 96%-100% of cases. The venous drainage of this region followed from a superficial system (superficial circumflex iliac veins) and a deep venous system (Vv. comitantes accompanying arterial branches). Both venous systems could always be found. The superficial circumflex iliac artery was shown to only supply the skin and was the main donor vessel to the skin and soft tissue transplants. The deep circumflex iliac artery supplied the pelvic bone, the internal oblique muscle and a small constant area of skin above the iliac crest. Bone, muscle and bone, muscle and skin transplants could be obtained with this donor vessel, with enlargement of the skin area possible by combining two arterial branches combined in one transplant. With an average vessel diameter of 1.5 mm (superficial circumflex iliac artery) and 3 mm (deep circumflex iliac artery) both vessels could be used satisfactorily for microvascular transplantation. Different tissues including muscle, bone and skin could be obtained in adequate amounts to replace composite defects in the upper aerodigestive tract.

[Cinematographic functional diagnosis of swallowing after plastic reconstruction of large tumor defects of the mouth cavity and pharynx]

BACKGROUND

Reestablishing good swallowing function after resection and reconstruction of head and neck tumors is very important for our patients' well-being. Today many different surgical concepts for reconstruction after tumor surgery are in common use. It is necessary to establish a good diagnostic procedure for postoperative assessment of the swallowing function. High-speed cineradiography at a minimum of 50 frames per second is well established for evaluating swallowing problems in head and neck patients.

METHODS

Thirty-six patients divided into three groups were examined using high speed cineradiography after surgical treatment of pharyngeal and oral cavity cancer. Group 1 (n = 12) included patients with a subtotal or total tongue resection and reconstruction with infrahyoid myofascial flap and jejunal flap; Group II (n = 8), patients with total resection of the oropharynx soft palate and velum and reconstruction with a free radial forearm flap; Group III (n = 15), patients with total laryngopharyngektomy and reconstruction with jejunal flap and siphon and with or without repair of the digastric muscle.

RESULTS

Group I: All patients with tongue reconstruction were able to swallow normally from the oral cavity into the pharynx. All patients had normal bolus propulsion because of a good tongue volume and tongue motility. There was only one case of aspiration after total glossectomy with the larynx left in place. All patients could swallow with the head and neck in a normal position. Group II: All patients with reconstruction of the soft palate and velum were able to initiate proper bolus propulsion without nasal regurgitation or rhinolalia aperta. Only one patients suffered from chronic aspiration after hemiresection of the oropharynx and hypopharynx. Group III: All patients with pharynx reconstruction had no problems with bolus transfer through the reconstructed pharynx. Aspiration into the reconstructed pharynx was a major problem for those patients without repair of the digastric muscle (5/8 = 63%). Better results were observed in the patients who underwent repair of the digastric muscle. There was only one case (13%) of aspiration.

CONCLUSIONS

By using high-speed cineradiography it is possible to make a detailed description of the swallowing function after extensive surgical treatment of pharyngeal and oral cavity cancer. We think that high-speed cineradiography is a very sensitive diagnostic procedure capable of detecting all functional aspects of swallowing. High-speed cineradiography should be one of the standard diagnostic studies performed surgery of the oral cavity and pharynx.

[Plastic reconstructive surgery of soft palate defects--functional and oncological aspects]

BACKGROUND

Resection of the soft palate in tumor surgery can lead to significant swallowing disorders. Therefore rehabilitation needs a functional reconstruction of the remaining defects.

MATERIALS AND METHODS

In four years, nine patients received a partial removal, and six patients a total removal of the soft palate including adjacent parts of the oropharynx in six cases due to oropharyngeal carcinoma. Partial defects were reconstructed with a neurovascularized infrahyoidal muscle flap, total defects with fasciocutaneous flaps of the lateral arm, radial forearm or scapula region. The function of the new palate was evaluated by interview, cinematography, and pressure measurements of the pharynx.

RESULTS

These investigations demonstrated proper swallowing without aspiration or regurgitation in all cases. Values of 60% of normal pressure behind the palate have been achieved after palate reconstruction with a pressure slope directed into the hypopharynx. Decannulation was possible on average 34 days postoperatively, removal of the feeding tube on average 29 days postoperatively. Now 87% of our patients are free of tumor after a mean observation time of 24 months. In light of the fact that two-thirds of all patients suffered from advanced carcinoma, results can be considered as good. This study shows good functional and oncologic results after tissue reconstruction of the soft palate.

[Perfusion manometry in the evaluation of postoperative swallowing function following various reconstructive procedures of the upper aero-digestive tract]

BACKGROUND

The swallowing function can be restored after large oncologic resections in the upper aerodigestive tract with microvascular anastomosed transplants.

PATIENTS AND METHODS

With the help of the perfusion manometry we would like to demonstrate the functional advantages of this reconstruction method. We examined three reconstructed regions: tongue with 15 patients, soft palate with 11 patients, and the laryngeal and pharyngeal complex after total laryngopharyngectomy with 17 patients.

RESULTS

Patients with reconstructed tongue or soft palate reached 69% or 74% of their pressure compared to normal values.

CONCLUSIONS

We demonstrated that although normal pressure values were not reached after reconstruction of large defects with microvascular anastomosed transplants; these reconstruction methods restored the pressure gradient essential for swallowing, with a higher pressure of the soft palate and a lower pressure of the base of tongue.

[Clinical comparison between radial and lateral forearm flap]

BACKGROUND

Free fasciocutaneous flap transplantation is a versatile method for soft tissue reconstruction. This clinical study points out differences between the radial forearm flap and the lateral arm flap.

METHODS

We used the radial forearm flap in 36 patients following tumor ablation and in 11 patients we used the lateral arm flap for soft tissue reconstruction. We studied the arterial and venous vessel calibers of the flaps, the vessel pedicle length, and the size of the skin paddle. Motor and sensory function tests of the upper/ lower arm and hand were performed after surgery. Recipient and donor site morbidity was noted.

RESULTS

Compared to the forearm flap the lateral arm flap is bulky (1-5 cm vs. 0.5-1.5 cm), its vessel calibers are smaller (Art.: 1.4 vs. 1.8 mm, Ven.: 1.8 vs. 2.0 mm), flap size and maximum vessel pedicle length (10 vs. 12 cm) are equal. Raising the lateral arm flap is more demanding and needs more time due to the deep location of the vessel pedicle and the accompanying radial nerve within the intermuscular septum. On the other hand the lateral arm flap is advantageous because of primary wound closure of the donor site. The donor site of the forearm flap had to be covered with skin graft in all cases. We found sensory deficits of the proximal lower arm in 50% after dissection of the lateral arm flap and in 14% on the distal lower arm and thumb joint after dissection of the radial forearm flap.

CONCLUSIONS

Both transplants are fasciocutaneous and optional innervated, they offer a constant anatomy and can be harvested simultaneously without interference to the head and neck team. Because of the specific characteristics of these flaps we prefer the radial forearm flap for soft tissue reconstruction. We use the lateral upper arm flap, if a forearm flap cannot be harvested, for head or neck augmentation and for reconstruction of large and deep defects.

Experimental and clinical evaluation of laryngeal chondrosynthesis

The aim of this study was to investigate and develop techniques for stabilization and reconstruction of laryngeal defects with a method similar to osteosynthesis. In an anatomical study, 400 extrusion forces of sutures and various screws (Howmedica) were measured in the thyroid cartilage of fresh cadavers. A new screw was then especially designed for cartilage and a new technique was developed for stabilizing cartilage, using a screw-nut made out of bone. To date, 30 patients have undergone chondrosynthetic reconstruction of the larynx. Measurements of extrusion forces were found to depend on the degree of calcification present in the area of the laryngeal skeleton examined and the type of fixation device used. Good clinical results were achieved in all 30 patients studied and depended on stabilization of the two sides of the thyroid cartilage after thyrotomies, bridging of laryngeal defects and splinting of laryngeal fractures. Besides the increased extrusion forces the advantages of chondrosynthesis lay within the possibilities of axial stabilization and exact bridging of defects with or without implants.

[Neurovascular infrahyoid muscle fascia flap for tongue and pharynx reconstruction. Postoperative histologic long-term follow-up]

After surgical treatment of cancer, reconstruction of large defects in the oral cavity or pharynx with myocutaneous island flaps will often lead to cicatrical shrinkage of the transplant. To avoid further loss of function we used a neurovascular infrahyoid muscle flap for reconstruction of large muscular defects in the mouth or pharynx. The advantages of this neurovascular flap were voluntary muscular contractions and reduced shrinkage of the flap's volume compared with myocutaneous island flaps alone. In this study we examined the characteristics of the transplanted muscles at 6 weeks, 7 months and 11 months after surgery. Biopsies were taken from the transplanted infrahyoid muscles and examined with light and electron microscopy. To identify nerves an immunofluorescence method was used. In the specimens taken several months postoperatively no atrophy or degeneration of the musculature could be seen. As a possible consequence of tenectomy an irregular arrangement of the myofibrils was noted. Nerves were found in all biopsies that served as further evidence for a functioning musculature.

[Lateral upper arm flap: topographic-anatomic study for clinical use as vascular pedicled transplant]

Defects of the laryngopharynx and the oral cavity after cancer ablation are increasingly reconstructed by free microvascular anastomosed tissue transfer. Besides the jejunum transplant, we use the free radial forearm flap frequently. This flap is suitable for restoring intraoral and pharyngeal integrity. Major disadvantages are the requirement of a skin graft to obtain wound closure and the cosmetic deformity. The lateral upper arm free flap is intended as alternative method for the fasciocutaneous tissue transfer. Based on our dissection of ten cadavers we demonstrate the anatomy of the flap, the harvesting technique, and present data of vascular pedicle length, vessel calibers, and flap size. The vessel calibers of the profund brachial artery (mean = 2.5 mm) and its terminal branch, the posterior radial collateral artery (mean = 1.8 mm), are comparable to the radial artery. The pedicle length can be extended up to 13 cm by using a lateral approach. The subcutaneous tissue volume was 1.3 cm in average, and compared to the radial flap rather thick. Because of its bulky and strong fascia, the lateral arm flap seems to be useful as a fasciafat flap in facial augmentation and as a fascia flap in soft tissue reconstruction. Disadvantageous are the difficult dissection technique and the loss of sensitivity on the lateral aspect of the forearm. Where a fasciocutaneous flap is indicated, we prefer the radial forearm flap.

[Microvascular anastomoses in reconstructive head and neck surgery]

At the ENT Department of the University of Lübeck, 57 microvascular tissue transplants with 129 anastomoses (61 arterial and 68 venous) have been performed in the last three years. Arteries have always been anastomosed end to end. The venous anastomoses have primarily been performed as end-to-side unions with the jugular vein. In nine patients, great distances between the donor and recipient vessel had to be connected with venous interponates. In two cases in which veins were lacking in the neck after radical neck dissection or radiation fibrosis, we used the cephalic vein or veins of the capsule of the thyroid gland as recipient vessels. The jejunal or osteomyocutaneous transplants were first fitted into the defect before performing the anastomosis. The jejunal peristalsis and the required freedom of movement in shaping the bone necessitated this technique. Microvascular anastomosis was first performed on the transplant of the radialis flap and the neurovascular infrahyoid muscular flap, and then they were integrated into the defect. We lost two transplants postoperatively because of venous thrombosis. In this article wie describe our anastomosis technique, the frequency distribution of recipient vessels, and the rules and characteristics of microvascular anastomosis after radiation and neck dissection.

[Neurovascular infrahyoid myofascial flap. Anatomic-topographic study of innervation and vascular supply]

Fifteen cadavers were examined bilaterally for the topography of the superior thyroid artery and vein an lower cervical ansa as an axial bundle of vessels and nerves for the infrahyoid myofascial flap. Using injections of methylene blue, the vascular territories of the superior thyroid artery were demonstrated. The superior thyroid artery and vein could be found in all cases. This artery was derived in 47% of cases from the external carotid artery, in 30% from the bifurcation and in 23% from the common carotid artery. In 43% of cases the vein flowed to the facial vein and in 37% to the internal jugular vein. In the remaining 20%, several segmental veins were found that flowed separately to the jugular vein. In case of a far caudally situated vascular bundle the radius of rotation was limited in a cranial direction. The voluntary innervation of the muscles of the infrahyoid myofascial flap was derived from the lower cervical ansa. The upper radix of the ansa was found 1 cm in latero-cranial direction to the greater horn of the hyoid bone, where it separated from the hypoglossal nerve. Present findings show that the superior thyroid artery supplies the infrahyoid musculature in its whole extension from the hyoid bone to the sternum. It is therefore possible to develop a myofascial flap of 3.5 cm x 11.5 cm in size, which can be predicted at an upper vascular and neural bundle. Depending on the radius of rotation, defects of the floor of mouth, tongue and oro- and hypopharynx can be covered sufficiently with this neurovascular myofascial flap.

[A new method of tongue reconstruction with neurovascular infrahyoid muscle-fascia flaps]

Surgical treatment of tongue cancer can lead to extended defunctionalization, depending upon the size and localisation of the defect. Great problems of swallowing arise after total glossectomy or extensive resections of the base of the tongue even after reconstruction with myocutaneous island flaps or free flaps. We developed a neuromuscular island flap derived from the infrahyoidal musculature to reconstruct a total tongue or large defects of the tongue base. This fasciomuscular flap is formed by the M. sternothyroideus, M. sternohyoideus and the upper part of the M. omohyoideus. The axial blood supply arises from the A. thyroidea sup. The innervation is derived from the Ansa cervicalis N. hypoglossi. In case of total glossectomy we took this flap from both sides of the neck. With this new method we reconstructed total tongues after glossectomy in two patients and large defects of the tongue base in six patients. In the present paper the new surgical method and the functional results are described.

[Voice rehabilitation with the jejunum speech siphon: the biventer rein, a modification for prevention of aspiration]

The principle of operative voice rehabilitation after laryngectomy consists in forming a shunt between trachea and hypopharynx. The results of voice rehabilitation are generally good. Aspiration is the main disadvantage of this method, which negatively affects the quality of life. We modified the jejunum siphon of Ehrenberger and used this shunt operation mostly in total pharyngolaryngectomies. To avoid aspirations we formed a rein from both sides of the neck using the m. biventer. This rein hold the knee of the siphon and acts as a sphincter when the patient swallows, because the contractility of this muscle is preserved. We present this new method and compare the results of the first seven patients with those of the patients who were operated on without a rein from the m. biventer.