Dental impression silicone putty in transoral laser laryngeal surgery: prevention of oral complications

Objective

To describe a new method to improve the exposure of the surgical field and to protect the oral cavity during transoral laser micro-surgery (TOLMS) of the larynx.

Methods

Dental Impression Silicone Putty (DISP) was employed as an alternative to traditional mouthguards.

Results

DISP mouthguards perfectly fit to each patient, reduce encumbrance in the mouth, and reduce pressure on the teeth; disadvantages are minimal.

Conclusions

Although clinical studies are necessary to demonstrate the efficacy of the method in reducing the incidence of oral complications, DISP mouthguards represent a significant aid for laryngeal exposure.

Open partial horizontal laryngectomy and adjuvant (chemo)radiotherapy for laryngeal squamous cell carcinoma: results from a multicenter Italian experience

PURPOSE

To evaluate the functional and oncologic outcomes of adjuvant (chemo)radiation [(C)RT] after open partial horizontal laryngectomies (OPHLs).

METHODS

Multicenter retrospective evaluation of 130 patients (116 males, 14 females) submitted between 1995 and 2017 to OPHL Types II and III for laryngeal cancer and receiving adjuvant (C)RT for one or more of the following risk factors at histopathologic examination of the surgical specimen: pT4a and/or > pN2a categories, close/positive resection margins, or presence of both perineural (PNI) and lympho-vascular invasion (LVI). The primary study endpoints were evaluation of the presence of tracheostomy and/or gastrostomy at last follow-up, and calculation of laryngo-esophageal dysfunction-free survival (LEDFS).

RESULTS

Mean age of the study cohort was 60.8 ± 8.9 years (median, 62; interquartile range [IQR], 13). Mean follow-up was 50.7 ± 39.4 months (range 24-188; median, 38; IQR, 51). Adjuvant therapy consisted of CRT in 53 (41%) patients, and RT alone in 77 (59%). Five-year LEDFS was 85%. Overall survival was 71.5%, while 13% of patients remained tracheostomy- and 3% gastrostomy-dependent at the last follow-up. The only significant variable in predicting survival (p = 0.020) was tracheostomy dependence: it was maintained in 7.5% of subjects after OPHL Type II and in 34% of those submitted to OHPL Type III (p < 0.001).

CONCLUSIONS

In selected patients affected by advanced laryngeal cancer, OPHLs Type II and III have a relatively good laryngeal safety profile and provide favorable oncologic outcomes even in case of need for adjuvant (C)RT.

Endoscopic transoral approach to accessory parotid gland

Objective; Neoplasm of accessory parotid glands are very rare, accounting for only 1% to 7.7% of all parotid gland tumors. External appproaches including parotidectomy or facelift incision are the recommended treatment, allowing a good control over the anterior facial nerve's branches and Stensen's duct, but they require a large flap elevation and leave an external scar.

METHODS

We report the case of a 76-year-old woman presented with a chief complaint of swelling in the right cheek. The patient underwent ultrasonography, FNAC and MRI which identified a subcutaneous mass over the anterior border of the masseter muscle.

RESULTS

An endoscopic-assisted transoral resection was performed, no postoperative complications were recorded. Final histology was consistent with pleomorphic adenoma.

CONCLUSION

In selected cases, the endoscope-assisted transoral approach allow accessory parotid mass excision with better cosmetic results if compared to the transcutaneous approach. Although not negligible, the risk of facial nerve injury is minimized under endoscopic magnification.

A case of cervical fasciitis complicated by mediastinitis and pre-peritoneal abscess: the role of video-assisted thoracoscopic surgery

Cervical necrotizing fasciitis (CNF) is the name for a group of bacterial infections characterized by necrosis of the fascia and subcutaneous cellular tissue of the neck. Descending necrotizing mediastinitis (DNM) is a well-known and feared complication of CNF that severely affects the prognosis. Abdominal involvement is rare. The mainstay of treatment is prompt and aggressive medical therapy and surgical debridement of all involved sites. The role of video-assisted thoracoscopic surgery (VATS) in this setting, even if already reported in the literature, is not universally adopted. We present a case of CNF complicated by DNM and pre-peritoneal involvement, treated with open surgical drainage of the neck and video-assisted thoracoscopic debridement of the mediastinal space.

Development of the international orbital Cavernous Hemangioma Exclusively Endonasal Resection (CHEER) staging system

BACKGROUND

Orbital cavernous hemangiomas (OCH) are the most common adult orbital tumor and represent an ideal index lesion for endonasal orbital tumor surgery. In order to standardize outcomes reporting, an anatomic-based staging system was developed.

METHODS

An international, multidisciplinary panel of 23 experts in orbital tumor surgery was formed. A modified Delphi method was used to develop the cavernous hemangioma exclusively endonasal resection (CHEER) staging system with a total of 2 rounds being completed.

RESULTS

Tumors medial to a plane along the long axis of the optic nerve may be considered amenable for an exclusively endonasal resection. In select cases, tumors may extend inferolaterally if the tumor remains below a plane from the contralateral naris through the long axis of the optic nerve (ie, plane of resectability [POR]). This definition reached consensus with 91.3% of panelists in agreement. Five stages were designed based on increasing technical resection difficulty and potential for morbidity. Stages were based on the relationship of the tumor to the extraocular muscles, the inferomedial muscular trunk of the ophthalmic artery (IMT), and orbital foramina. Staging by anatomic location also reached consensus with 87.0% of panelists in agreement. Size was not included in the staging system due to the lack of agreement on the contribution of size to resection difficulty.

CONCLUSION

Endoscopic orbital tumor surgery is a nascent field with a growing, yet heterogeneous, body of literature. The CHEER staging system is designed to facilitate international, high-quality, standardized studies establishing the safety, efficacy, and outcomes of endonasal resection of OCH.

The controversial role of electrochemotherapy in head and neck cancer: a systematic review of the literature

Electroporation, also known as electrochemotherapy, combines an antineoplastic agent with electroporation, causing localized progressive necrosis in the treated area. Today it is primarily used in the palliative treatment of cutaneous and subcutaneous metastases and has been found to be safe and efficacious in head and neck cancer recurrences. Despite the steady increase in the number of published studies this treatment is not universally available and used systematically in head and neck carcinomas. To shed light on its limitations and analyze treatment outcome we have, therefore, reviewed all available literature regarding this topic. This systematic review includes 16 studies on head and neck squamous cell carcinoma and reports the data of 200 treated patients. The combined results show a very heterogeneous overall response rate, ranging from 0 to 100%, while the complete response rate ranges between 0 and 83.3%. No major side effects have been described in those who used electrochemotherapy as a mono modality palliative treatment. This systematic review shows how standardization of treatment is still pivotal to achieve a more homogeneous response rate in the approach to head and neck tumors. In conclusion, due to the scarcity of alternatives of treatment in advanced stage cancer in this anatomical region and the good tolerability and mostly high success rates of electrochemotherapy, this palliative approach should be taken into consideration in these patients.

The implications of orbital invasion in sinonasal tract malignancies

In recent decades, the management of sinonasal tumors abutting the orbit has been widely discussed. A real guideline has yet to be proposed, as prospective randomized studies on this topic are very difficult to organize, given the relative rarity of this pathology, the wide spectrum of histologic patterns, and the different clinical behavior of tumors. Nevertheless, in recent years, a better assessment of tumor extension has been obtained thanks to the refinement of preoperative imaging tools and, therefore, more conservative approaches could be adopted, with no worsening of the oncological outcomes and, at the same time, with more attention given to the post-surgical quality of life. Currently, tumors that extend to the bony orbital walls with or without focal infiltration of the periorbit are amenable to orbital preservation. On the other hand, infiltration of extraocular muscles and neurovascular structures are an indication to orbital exenteration. The ideal surgical treatment in cases of limited involvement of orbital fat still remains a matter of debate. We report and discuss the recent English literature on this interesting topic.

Endoscopic endonasal orbital cavernous hemangioma resection: global experience in techniques and outcomes

BACKGROUND

Endoscopic orbital surgery represents the next frontier in endonasal surgery. The current literature is largely composed of small, heterogeneous, case series with little consensus regarding optimal techniques. The purpose of this study was to combine the experience of multiple international centers to create a composite of the global experience on the endoscopic management of a single type of tumor, the orbital cavernous hemangioma (OCH).

METHODS

This was a retrospective study of techniques for endoscopic OCH resection from 6 centers on 3 continents. Only primary data from strictly endoscopic resection of OCHs were included. Responses were analyzed to qualitatively identify points of both consensus and variability among the different groups.

RESULTS

Data for a total of 23 patients, 10 (43.5%) male and 13 (56.5%) female were collected. The majority of lesions were intraconal (60.9%). The mean ± standard deviation (SD) surgical time was 150.7 ± 75.0 minutes with a mean blood loss of 82.7 ± 49.6 mL. Binarial approaches (26.1%) were used exclusively in the setting of intraconal lesions, which were associated with a higher rate of incomplete resection (31.3%), postoperative diplopia (25.0%), and the need for reconstruction (37.5%) than extraconal lesions. Orthotropia and symmetric orbital appearance were achieved in 60.9% and 78.3% of cases, respectively.

CONCLUSION

Extraconal lesions were managed similarly; however, greater variability was evident for intraconal lesions. These included the laterality and number of hands in the approach, methods of medial rectus retraction, and the need for reconstruction. The increased technical complexity and disparity of techniques in addressing intraconal OCHs suggests that continued research into the optimal management of this subclass of lesions is of significant priority.

Purely endoscopic trans-nasal management of orbital intraconal cavernous haemangiomas: a systematic review of the literature

The surgical management of medial and inferior orbital lesions is demanding via traditional external approach, since the conic-shaped surgical field is narrow and damage to neural, muscular or vascular structures of the orbit can have serious consequences. In recent years, the evolution of endoscopic endonasal approaches for lesions that goes beyond the nose brought the orbit to the attention of rhinosurgeons. If procedures such as transnasal orbital decompression and lacrimal pathways surgery have been described some decades ago, the last frontier of transnasal orbital surgery, namely intraconal tumor surgery, is a new and rapidly expanding field. Papers describing endoscopic endonasal approaches to the orbit appeared in the international literature, but most of them contain a small number of cases, also because the relatively rarity of intraorbital lesions. We herein report the results of a systematic review of the literature regarding the endoscopic endonasal approach to intraconal cavernous haemangiomas, the most common benign orbital lesion. The endoscopic management of intraconal cavernous haemangiomas results feasible and safe. A critical step of this kind of surgery is the management of the medial rectus muscle, mandatory to expose the intraconal space.

Electrochemotherapy and its controversial results in patients with head and neck cancer

BACKGROUND

Electrochemotherapy (ECT) is proposed as an innovative treatment for cutaneous and subcutaneous primary and secondary malignancies. Its actual application is limited to palliative treatment but recent experience predisposes for its utilization as neoadjuvant and first-line treatment. We explored the clinical application of ECT in a population of patients with head and neck cancer and we critically analyzed our results.

PATIENTS AND METHODS

Nine patients (four females; mean age=62.7 years) with recurrent or persistent squamous cell cancer in the head and neck area were treated with electrochemotherapy (ECT), with the aim of controlling local neoplastic growth and diminish local symptoms (pain, bleeding).

RESULTS

Our results in terms of local control and impact on quality of life were evaluated: among 14 lesions assessable for the study, 6/14 lesions exhibited a partial response, 4/14 a complete response, and in four cases we observed progression of the disease.

CONCLUSION

Our personal experience in a heterogeneous, small group of patients with head and neck cancer gave controversial results, with disputable advantages in terms of quality of life improvement. We believe that the critical aspects of ECT in patients with head and neck cancer need to be further analyzed in order to better focus on the role of ECT for head and neck cancer.

Patient-related and ENT-related predictive factors based on the pain experienced during flexible nasendoscopy

OBJECTIVES/HYPOTHESIS

The objective was to explore the role of specific patient-related and operator-related factors in pain perception during flexible laryngoscopy, which is one of the most common ENT procedures.

STUDY DESIGN

Monocentric, randomized, individual prospective study.

METHODS

A total of 532 patients (145 men and 387 women), without any relevant ENT diseases, underwent laryngoscopy performed by otolaryngologists with various degrees of experience. Patient discomfort was reported using visual analog scores, and willingness to repeat the experience was also recorded.

RESULTS

Statistical analysis showed that greater pain was significantly associated with female patients and female otolaryngologists, whereas the pain was less severe in the cases of experienced laryngologists and older patients. Pain plays an important role in determining the willingness to repeat the examination; in fact, patients who experienced lower levels of pain during laryngoscopy were more prone to repeat the experience.

CONCLUSION

This article explores the importance of the extrinsic factors that are related to the patient and the otolaryngologist in determining the level of pain associated with laryngoscopy. Our study indicated that laryngoscopy is generally a well-tolerated procedure, causing little overall discomfort, but that a subgroup of patients may experience more pain than others, which may affect the patient's perspective toward undergoing a similar future experience. Our analysis may be helpful for clinicians in understanding pain perception during a routine procedure, enabling them to focus more on that subgroup of patients who are more prone to pain.

LEVEL OF EVIDENCE

1b.

Transnasal endoscopic surgery for selected orbital cavernous hemangiomas: our preliminary experience

BACKGROUND

Endoscopic transnasal approaches to the orbit have been recently described and they have been proposed as an option in the surgical management of medial and inferior orbital lesions.

METHODS

Retrospective evaluation of 3 patients operated on in our department during 2011 to remove a cavernous hemangioma of the inferior-medial orbit. Two patients were operated on via an endoscopic transnasal approach and 1 patient was operated on via an external anterior approach.

RESULTS

A complete surgical resection was obtained in all patients. A transient postoperative diplopia was recorded in the patient operated on via the external approach. No other significant complications were recorded.

CONCLUSION

Extraconal lesions adjacent to the paranasal sinuses can be safely removed through an endoscopic transnasal route. Intraconal lesions located inferiorly and medially to the optic nerve are amenable of transnasal endoscopic resection in selected cases.

Clear cell adenocarcinoma of the base of the tongue: a case report and review of the literature

Clear cell adenocarcinoma is an extremely rare tumor of the head and neck region. We report a case of a 75-year-old Caucasian woman with a 10-day history of hemoptysis but with no pain or other significant symptoms. A head and neck computed tomography scan with contrast medium showed an irregular, soft-tissue-like, irregularly enhanced lesion of the base of the tongue extending to its posterolateral portion. The tumor reached the lateral wall of the oropharynx, which showed a nonhomogeneous aspect. The patient underwent resection of the tumor via a conservative transmandibular approach. A clear cell adenocarcinoma of the base of the tongue is rarely a primary malignant lesion; it is more frequently a secondary lesion from a metastatic renal tumor. Because of this neoplasm's relatively slow growth rate and low incidence of metastasis or local recurrence, the gold standard of treatment is complete excision of the tumor with a sufficient tumor-free margin.

Reasons for revision surgery after orbital decompression for Graves' orbitopathy

Objectives

An analysis of complications and causes of failure in orbital decompression necessitating a second operation.

Methods

Between December 1992 and April 2007, 375 patients (719 orbits) were operated on using various techniques. Fourteen patients were initially operated on in our unit: 8 (group A1) were re-operated on after a short time due to complications connected with the decompression operation, 7 (group A2) were operated on after some time due to recurrence of the illness or unsatisfactory decompression (one patient is in both group A1 and A2). Five patients (group B) underwent a first operation elsewhere.

Results

For group A1 the most serious complications were connected to the nasal approach. For group A2 the operations were performed either because of a neuropathy recurrence or for further proptosis reduction due to recurrence or patient dissatisfaction. Lack of preoperative data hinders conclusions about group B, apart from one patient where the operation had not resolved a serious optic neuropathy after decompression based on Olivari technique combined with three-wall operation according to Mourits and colleagues (1990).

Conclusions

We can deduce from group A1 that extreme attention is necessary during endonasal access, from group A2 that balancing the eyes is advisable, sacrificing maximum proptosis reduction to gain greater patient satisfaction, and from group B that decompression of the orbital apex is fundamental in the case of neuropathy.

Endoscopic transnasal anatomy of the infratemporal fossa and upper parapharyngeal regions: correlations with traditional perspectives and surgical implications

BACKGROUND

The aim of this study was to illustrate the endoscopic surgical anatomy of the infratemporal fossa (ITF) and upper parapharyngeal space and to provide useful landmarks by comparing transnasal perspectives with external ones.

MATERIALS AND METHODS

6 fresh double injected heads were dissected. External lateral dissection was performed through a pre-auricular skin incision while external anterior dissection started with a modified Weber-Ferguson incision. External medial to lateral dissection was performed starting from the rhinopharyngeal and pterygoid regions, after cutting the specimen in 2 halves passing through the nose. Endoscopic dissection was performed through an endonasal approach (0° and 45° scopes).

RESULTS

Among all the structures identified during the dissection, the most useful landmark when dissecting the ITF in a lateral to medial direction is the lateral pterygoid muscle. In anterior approaches (mostly endoscopic) the role of the lateral pterygoid muscle is less important and the Eustachian tube (ET) represents the most important landmark to point out the upper portion of the parapharyngeal internal carotid artery (ICA). The role of the ET, in lateral dissection is, on the contrary, by far less important given the fact that it is very deep in the surgical field and that the ICA is encountered earlier during surgical approaches. Another crucial landmark during anterior endoscopic surgery is the vidian nerve because it points to the anterior genu of the internal carotid artery.

CONCLUSION

The complex 3-dimensionality of the ITF and the upper parapharyngeal space needs a sound knowledge of the surgical anatomy. The role of the same landmarks changed in different approaches. The ability to orientate oneself in this complex area is related to an accurate knowledge of its anatomy through comparison of endoscopic and external perspectives.

Transnasal approach to the medial intraconal space: anatomic study and clinical considerations

BACKGROUND

The aim of this study was to illustrate the anatomy of the medial compartment of the orbit by comparing the endoscopic transnasal perspective with the external ones.

METHODS

8 orbits from 5 double-injected heads were carefully dissected. An endoscopic anterior transconjunctival dissection was performed in one orbit while an endoscopic transnasal intraconal dissection was conducted in 3 orbits. External dissections (from medial, superior and anterior perspective) were also performed.

RESULTS

The role of the medial rectus muscle is emphasised. It represents the first important landmark encountered, covering all the other structures during transnasal approaches. By displacing it, the medial intraconal space with its contents becomes visible: the ophthalmic artery and related branches, the superior ophthalmic vein, the nasociliary nerve and, in the deepest part of the medial compartment, the optic nerve.

CONCLUSION

The medial compartment of the orbit can be addressed transnasally. By displacing the medial rectus muscle, it is possible to gain adequate space for the instruments and to control all of the medial compartment, including the medial aspect of the optic nerve.

A rare case of primary systemic amyloidosis of the neck with massive cervical lymph node involvement: a case report and review of the literature

Amyloidosis is a term applied to a diverse group of disorders that share the deposition of amyloid protein in various extracellular tissues. Systemic amyloidosis may involve almost any organ system in the body including regions in the head and neck; however, neck lymph node involvement is rare, with only five previous cases reported. We present the case of a primary systemic AL amyloidosis with hepatic, cervical, retroperitoneal, axillary and inguinal lymphnode localizations, unresponsive to medical therapy and treated with a surgical approach followed by autologous bone marrow transplantation. We review the pertinent literature with exclusive attention to the otorhinolaryngologic aspect.

Lateral wall orbital decompression in Graves' orbitopathy

Orbital decompression can be carried out, for rehabilitative reasons, using various techniques, but a general consensus on the ideal surgical approach has not been reached. Postoperative diplopia is the most common side effect of decompression surgery. The authors report 39 patients (72 orbits) who underwent lateral wall orbital decompression. Mean preoperative and postoperative Hertel exophthalmometry were 22.8+/-2.2mm (mean+/-SD; range 16-26 mm) and 18.2+/-2.1mm (range 15-22 mm), respectively. Mean proptosis reduction was 4.5+/-1.9 mm. A new appearance of diplopia postoperatively in the extreme gaze direction was observed in three patients (8%). The complication rate in this series was low, making the procedure safe and well tolerated. In the authors' opinion, when a single-wall approach is feasible, lateral wall decompression should be the first choice because of its effectiveness in terms of proptosis reduction and safeness in terms of postoperative diplopia.

Endoscopic transnasal management of cerebrospinal fluid leaks of the sphenoid sinus

The authors reviewed the medical records of patients who had undergone endoscopic management of sphenoid sinus (SS) cerebrospinal fluid (CSF) leaks in our department between 2005 and 2007. Eight patients were included in this study: 4 males and 4 females. CSF fistulae were due to trauma, surgery, and some were idiopathic. In all the patients, a multilayer skull base closure was performed. No SS obliteration was carried out. One patient required revision surgery for persistent CSF leak. Multilayer skull base closure is confirmed as the preferred option in sphenoid CSF leaks. The limited morbidity and high success rate fit well with the data in the literature and make this treatment option advisable.

Marginal mandibulectomy in oral cancer surgery: a 13-year experience

The management of the mandible when dealing with oral cavity cancer is still controversial. In this article, we present our experience with marginal mandibulectomy over a 13-year period. We retrospectively evaluated 56 patients who underwent marginal mandibulectomy between 1990 and 2002. Mean age at surgery was 60.3 + or - 9.5 SD years. Neither intraoperative nor perioperative deaths were observed. Infiltration of the resected bone was detected in only one patient (1.8%). Fracture of the mandible was a complication in only one patient (1.8%). Eight patients (14.3%) presented a local and/or regional recurrence. Distant metastases were diagnosed in two patients (3.6%). The 5-year overall and disease-specific survival rates were 60.7 and 77.3%, respectively. Marginal mandibulectomy allows to conduct the resection in a safe tissue or to excise tumors of the floor of the mouth with a limited involvement of the alveolar periosteum. Whenever the tumor is close to the mandible or when it adheres to the alveolar periosteum, marginal mandibulectomy offers the possibility to perform an oncologically sound procedure.

Frontal mucocoele communicating with an arachnoid cyst of the anterior cranial fossa

Mucocoeles usually involve the frontal sinus and can extend to the orbit or intracranially. In this case symptoms and radiological findings were typical of a left frontal mucocoele with intracranial extension. Intraoperative findings were compatible with a left frontal mucocoele communicating with an arachnoid cyst of the anterior cranial fossa.

Extensive solitary fibrous tumor of the retropharyngeal space

BACKGROUND

Solitary fibrous tumor (SFT) is a rare neoplasm whose histologic diagnosis poses significant problems in differential diagnosis. Although most of these neoplasms arise at the level of the pleura, there have also been reports of extrapleural origins. The most frequent localization in the head and neck region is in the nasal cavity.

METHODS

We describe the case of an 81-year-old patient with an SFT that arose in the retropharyngeal space. Symptoms were solid food dysphagia associated with modest dyspnea.

RESULTS

Physical examination revealed the presence on the posterior pharyngeal wall of an apparently circumscribed, multilobed mass, which was compact in consistency and partially obstructed the upper aerodigestive tract. After radiologic assessment to carefully evaluate its size and relationship to surrounding structures, the tumor was surgically removed.

CONCLUSIONS

The importance of immunohistochemical findings in the histologic differential diagnosis are discussed. Follow-up plays a crucial role in evaluating the possible recurrence of such tumors, because parameters for determining their aggressiveness are still controversial.

Endoscopic dacryocystorhinostomy: personal experience

Data are reported on a series of 52 endoscopic procedures of dacryocystorhinostomy, performed in the Department of Otorhinolaryngology of the Hospital of Varese, between May 1999 and February 2003. The study population comprised 42 patients (32 female, 10 male. mean age 57 and 51 years, respectively) with naso-lacrimal obstruction. In all cases, pre-operative diagnosis consisted in irrigation of the lacrimal pathways, confirmed on dacryocystography; in selected cases, an additional computed tomography examination was carried out. All procedures were performed under general anaesthesia and surgical times were recorded; mean time for primary dacryocystorhinostomy was 30 minutes. A silicone tube was inserted in all patients for a period of 3 months. The procedure was successful in 81% of primary dacryocystorhinostomy cases and in 75% of revision dacryocystorhinostomy cases. Personal clinical and surgical experience, focusing on surgical techniques used in dacryocystorhinostomy, is described.

Malignant cervical teratoma: report of a case in a newborn

Malignant cervical teratoma (MCT) usually appears in newborns as an enlarging mass of the neck that causes respiratory distress, requiring prompt airway control. We report a case of MCT in an infant electively delivered at 32 weeks to prevent airway impairment. At first, the preoperative diagnosis was hygroma of the neck, and a surgical excision was performed when the newborn was 9 days old. Diagnosis was benign extragonadic immature teratoma, but it was changed in MCT when cervical metastases appeared and the alpha-fetoprotein (AFP) level increased. Subsequent surgical procedures and chemotherapy were necessary. The child has been free from disease and healthy for 7 years since the last surgery. The preoperative diagnosis of MCT is difficult because of its rarity and non-specific clinical findings. Surgical excision is required for an adequate cure and airway repair; a long-term follow-up is mandatory to promptly treat any recurrence.

Mandibular reconstruction with frozen autologous mandibular bone and radial periosteal fasciocutaneous free flap: preliminary report

The authors present a new method of mandibular reconstruction with frozen autologous mandibular bone. Vascular supply to the neomandible is ensured by the periosteal layer of a microvascular radial periosteal fasciocutaneous free flap, placed so as to envelop the bone and cover the surgical defect. The use of the periosteal layer of the radius to provide new blood vessels to the frozen mandible is an original technical feature that we describe. We describe 2 cases of oral carcinoma involving the mandible, treated with mandibular resection and reconstruction. This technique allows good functional and aesthetic results, avoiding more serious complications related to the use of composite free flaps harvested from distant anatomic donor sites.

Elective treatment of the neck in squamous cell carcinoma of the larynx: clinical experience

BACKGROUND

In head and neck cancer, the best prophylactic treatment for the N0 neck is a subject of debate. Some authors propose lateral selective lymph node dissection (levels II-IV) on the basis of the probability of finding occult metastases in those lymph nodes. A more extensive procedure including Vth level is considered unnecessary because of the low incidence of metastases in the posterior triangle.

METHODS

We retrospectively evaluated 346 N0 patients affected by laryngeal carcinoma and consecutively treated at the Department of Otorhinolaryngology of the Ospedale di Circolo, Varese, Italy. The patients underwent elective selective neck dissection (levels II-V) for a total of 602 dissected heminecks.

RESULT

Seventy heminecks (11.6%) were pN+, and in 10 of 70 cases (14.3%) level V was involved; in 5 of 10 metastases were isolated.

CONCLUSION

Our retrospective study confirms the probabilistic criteria of the incidence of occult metastasis by level in laryngeal cancer. On the basis of our data Vth level nodes, although very rarely, 10 of 604 (1.6%), are involved with laryngeal cancer. Our approach to routinely dissect Vth level nodes is discussed.

Supracricoid partial laryngectomy as salvage surgery after radiation failure

BACKGROUND

Radiotherapy is often chosen as the definitive treatment for early stage laryngeal carcinoma. Total laryngectomy is the main procedure for failures. Endoscopic treatment of recurrences by CO(2) laser has found limited application. Partial laryngectomy through an external approach has been proposed as salvage surgery, and the vertical partial laryngectomy (VPL) is the most mentioned surgical technique in the literature, although there are, to date, very few reports regarding the use of the supracricoid partial laryngectomy (SCPL) as salvage surgery after radiation failure.

OBJECTIVES

The aim of the study is to check the feasibility of SCPL with cricohyoidoepiglottopexy (CHEP) or cricohyoidopexy (CHP) in patients with laryngeal recurrence after radiation failure and to evaluate the oncologic results, morbidity, and functional outcome.

METHODS

Fifteen consecutive patients were treated with salvage intent by SCPL from January 1992 to December 1998. CHEP and CHP were performed in 11 and 4 patients, respectively. Five patients underwent homolateral surgical neck dissection, and one underwent bilateral neck dissection. All patients had a temporary tracheostomy, and two patients required percutaneous endoscopic gastrostomy (PEG) to ensure feeding. Functional rehabilitation started 2 weeks after the operation.

RESULTS

The results have been evaluated in terms of oncologic outcome and functional preservation. Twelve patients are alive with a minimum follow-up of 36 months and 3 patients died after 36 days, 6 and 14 months after surgery, the first and second patient from heart failure and the third from lung metastasis. Respiratory function was recovered in all cases. Oral intake began 12 days after surgery, and in 14 cases satisfactory swallowing was recovered 30 days after surgery. An acceptable quality of the voice was achieved by most patients, and a high rate of local immediate complications was solved in all cases.

CONCLUSIONS

SCPL represents an effective technique as salvage treatment of laryngeal cancer after exclusive radiotherapy; there is a good functional recovery with acceptable morbidity and good oncologic long-term control.

[Severe Frey syndrome after parotidectomy: treatment with botulinum neurotoxin type A]

Based upon an inception cohort of 30 patients with severe Frey's syndrome, after conservative parotidectomy, the technique and the results of intracutaneous injection of botulinum toxin type A are presented. The skin surface involved with Frey's syndrome was managed with intracutaneous injection of 2.5 international units of botulinum toxin type A per square centimeter. A minimum follow-up of 16 months was achieved. The only adverse side effect encountered was a temporary paresis of the upper lid noted in 2 patients. Frey's syndrome vanished within 2-5 days from the intracutaneous injection of botulinum toxin type A. Frey's syndrome was controlled in 53.2% of cases (17/30) after the initial injection of botulinum toxin type A. Five of the 13 patients with recurrence of Frey's syndrome elicited to undergo a watch and wait policy due to the lack of discomfort induced by the recurrence. The remaining eight patients with recurrence of Frey's syndrome were successfully managed with a secondary intracutaneous injection of botulinum toxin type A. Such preliminary data, together with the review of the literature suggests, that the intracutaneous injection of botulinum toxin type A should now be the first line treatment option in patients with severe Frey syndrome.

Carbon dioxide laser debulking for obstructing endolaryngeal carcinoma: a 10-year experience

The results of the carbon dioxide (CO2) laser debulking procedure for obstructing endolaryngeal carcinoma were analyzed in terms of efficiency, complications, secondary tracheotomy rate, and peristomal recurrence rate in a series of 50 patients consecutively managed at our department. The CO2 laser was used to reestablish a safe airway without resorting to tracheotomy and without performing a transoral resection. Our series included 42 patients in a pre-definitive treatment group (group 1) and 8 patients in a palliation group (group 2). Complications included death, pneumonia from inhalation, and cutaneous burns in 2 patients, 1 patient, and 1 patient, respectively. Thirty-two percent of patients required a repeat laser treatment to maintain the airway. Overall success rates of 92.8% and 87.5% were achieved in group 1 and group 2 patients, respectively. None of the variables under analysis could predict the success of the CO2 laser debulking procedure. The overall incidences for secondary tracheotomy were 4.7% and 0% in group 1 and group 2 patients, respectively. Peristomal recurrence was not encountered in patients managed with definitive therapy with curative intent.

A multimodal strategy for the treatment of patients with T2 invasive squamous cell carcinoma of the glottis

BACKGROUND

The current conservative standard of care for T2 squamous cell carcinoma of the glottis is either partial laryngectomy or radiation therapy.

METHODS

Based on an inception cohort of 100 patients with T2 squamous cell carcinoma of the glottis and a minimum of 3 years of follow-up, the present study documented the results achieved with a multimodal strategy using platinum-based induction chemotherapy and partial laryngeal surgery. Statistical analysis of survival and local control was based on the Kaplan-Meier actuarial life table method. Univariate analysis was performed to determine whether there was a correlation among various factors and toxicity, clinical response, histologic regression, local control, and survival.

RESULTS

A complete clinical response and a partial response after induction chemotherapy was achieved in 24% and 58% of patients, respectively. Complete histologic regression was noted in 31%. A significant statistical relation (P < 0.0001) was noted between a complete clinical response after induction chemotherapy and a complete histologic regression. The 5-year actuarial survival estimate was 85.8%. The 5-year actuarial local control estimate was 95.7% (97.7% if the vocal cord was mobile and 93.8% if the motion of the vocal cord was impaired). Salvage treatment resulted in an overall 99% rate of local control and a 95% rate of laryngeal preservation.

CONCLUSIONS

Because this represents a nonrandomized retrospective study, no definitive conclusions can be derived. However, when compared with the data reported in a large series using radiation therapy or partial laryngectomy alone, this 10-year experience suggests that, in patients with "early" invasive squamous cell carcinoma of the glottis, the use of platinum-based induction chemotherapy prior to a conventional conservative treatment modality should be investigated further.

Speech and voice characteristics after near-total laryngectomy. A preliminary prospective study

Selected characteristics were prospectively compared in the speech and voice of 10 patients managed with near-total laryngectomy. Tape-recorded speech samples were measured for durational features with a stopwatch. Acoustic features were analyzed with the Computerized Speech Lab and the Multidimensional Voice Program from Kay Elemetrics. Speech and voice parameters recorded preoperatively were compared with the parameters recorded postoperatively. Our data corroborate the prior reported good quality of the voice and speech after near-total laryngectomy.

Local failure after supracricoid partial laryngectomy: symptoms, management, and outcome

The medical files of 15 patients with local recurrence after supracricoid partial laryngectomy consecutively managed at Laënnec Hospital were reviewed. The clinical symptoms and the laryngeal computed tomography appearance of local recurrence, as well as the salvage treatment performed, are presented. The main presenting symptom was dyspnea. None of the local recurrences was considered to be unresectable. One patient refused any form of salvage treatment. Radiation therapy and salvage total laryngectomy were the options retained for local salvage. A minimum 5-year follow-up was always achieved. In patients who underwent salvage total laryngectomy, perioperative or postoperative death and postoperative pharyngocutaneous fistula were not encountered. The 5-year survival was 33.3%. The local control rate was 66.6%. The percentage of patients who experienced nodal recurrence was 26.6%, and the distant metastasis estimate was 53.3%. The cause of death was distant metastasis in eight patients, local recurrence in two, and intercurrent disease in one. Peristomal recurrence was not encountered. Overall, 80% local control and 6.6% laryngeal preservation rates were achieved.

Supracricoid partial laryngectomies in the elderly: mortality, complications, and functional outcome

A review of the postoperative course, complications, and functional outcome of 69 elderly patients (older than 65 years of age) consecutively managed with a supracricoid partial laryngectomy between 1977 and 1993 is presented. The tumors were glottic and supraglottic in origin in 53 and 16 patients, respectively. A cricohyoidoepiglottopexy, a tracheo-cricohyoidoepiglottopexy, and a cricohyoidopexy were performed in 48, five, and 16 patients, respectively. Immediate laryngeal, cervical, and medical complications were noted in 5.8%, 10.2%, and 10.2% of patients, respectively. Supracricoid partial laryngectomies never resulted in perioperative or postoperative death. The 5-year actuarial survival and local control estimates were 68%, and 93.9%, respectively. Late surgical complications included laryngocele, laryngeal stenosis, and pneumonia from aspiration-related death in 4.3%, 4.3%, and 1.4% of patients, respectively. Completion total laryngectomy, permanent gastrostomy, and permanent tracheostomy were requested in 1.4%, 1.4%, and 2.91% of patients, respectively. Overall a 92.8% laryngeal preservation rate was achieved. Univariate analysis of the potential correlation of different factors with the mortality incidence and causes, the incidence and type of the various complications, and the incidence for postoperative aspiration is presented.

Supracricoid partial laryngectomy with cricohyoidoepiglottopexy for "early" glottic carcinoma classified as T1-T2N0 invading the anterior commissure

PURPOSE

"Early" glottic squamous cell carcinoma classified as T1-T2N0 with anterior commissure invasion is conventionnaly managed with vertical partial laryngectomy (VPL) or radiation therapy (RT). At our insitution, in the early 1980s, vertical partial laryngectomy was progressively replaced by supracricoid partial laryngectomy with cricohyoidoepiglottopexy (SCPL-CHEP). The medical files and operative charts of 62 patients with "early" glottic carcinoma classified as T1-T2N0 invading the anterior commissure, consecutively managed with cricohyoidoepiglottopexy, were retrospectively reviewed to ascertain whether any conclusions could be drawn regarding this treatment modality.

MATERIALS AND METHODS

Survival, local control, nodal recurrence, distant metastasis, and metachronous second primary tumor estimate was analyzed using the Kaplan-Meier life table method.

RESULTS

The 3- and 5-year actuarial survival estimate was 93.3% and 86.5%, respectively. The 3- and 5-year actuarial local control estimate was 98.2%. The only patient with local recurrence was successfully salvaged with RT resulting in an overall 100% local control rate and laryngeal preservation rate. The 3- and 5-year actuarial nodal recurrence estimate was 1.8%. The 3- and 5-year actuarial distant metastasis estimate was 0% and 2%, respectively. Aspiration related completion total laryngectomy and permanent tracheostomy never occurred.

CONCLUSION

The present retrospective study suggests that cricohyoidoepiglottopexy for glottic carcinoma classified as T1-T2 invading the anterior commissure resulted in higher local control rates and overall laryngeal preservation rate when compared with historical series using either VPL or RT. Further series are warranted to confirm our results.

Laryngofissure and cordectomy for glottic carcinoma limited to the mid third of the mobile true vocal cord

The objective of this study was to analyze the long-term results of laryngofissure with cordectomy for invasive glottic squamous cell carcinoma limited to the mid third of the mobile true vocal cord. The authors conducted a retrospective review of the medical charts and operative files of 33 patients with invasive glottic carcinoma limited to the mid third of the mobile true vocal cord managed with laryngofissure and cordectomy. A 10-year follow-up was achieved in 30 patients (90.9%). Kaplan-Meier actuarial analysis of survival, local control, nodal recurrence, distant metastasis, and second primary metachronous tumor was performed. The 5-year actuarial survival, local control, nodal recurrence, and distant metastasis estimates were 97%, 100%, 0%, and 0%, respectively. Tracheotomy was never performed. The overall laryngeal preservation rate was 100%. The 5- and 10-year actuarial metachronous second primary tumor estimates were 3% and 11.5%, respectively. The authors' experience suggested that laryngofissure and cordectomy should still be considered a valuable oncologic option for the management of invasive glottic carcinoma limited to the mid third of the mobile true vocal cord.