[Unilateral laryngeal paralysis after intra capsular loboisthmectomy without laryngeal nerve dissection]

OBJECTIVES

To document the incidence, outcome and variables that increase the risk for unilateral laryngeal paralysis after loboisthmectomy performed according to the intracapsular dissection technique.

MATERIALS AND METHODS

A retrospective analysis of an inception cohort of 317 loboisthmectomies consecutively performed at a single institution by the same surgeon during the years 2002-2007 using the intra capsular dissection without laryngeal nerve dissection, neuromonitoring and modern hemostasis techniques (Ligasure, Ultracision). The immediate and definite rate for unilateral laryngeal nerve paralysis is documented. A statistical analysis is performed for potential relation between these events and the following variables: age, gender, comorbidity, tracheal compression and intrathoracic characteristics of the thyroid lesion, side of the loboisthmectomy, etiology of the thyroid lesion (benign, malignant, hyperthyroidy), associated thyroiditis, size of the largest resected nodule and weight of the resected lobe.

RESULTS

The immediate unilateral laryngeal nerve paralysis incidence was 1,2%. Recovery of motion occurred by the 1st, 3rd, 5th or 9th post operative month resulting in a 0% incidence for definitive unilateral laryngeal nerve paralysis. No significant statistical relation was noted between immediate unilateral laryngeal nerve paralysis and the variables under analysis.

CONCLUSION

Based on the current series and the review of the medical literature, it appears that the loboisthmectomy according to the intra capsular technique without inferior laryngeal nerve identification, in patients not previously operated, performed according to is a surgical technique whose goal is to ascent the thyroid lobe and dissect the region of the nerve penetration within the larynx by the end of the resection, does not increase the risk for transient or permanent unilateral laryngeal nerve paralysis.

[Facial anatomy and botulinum toxin: the muscular balances]

The muscular topographic anatomy of the face has long been known. The functional anatomy of the face has been studied by many neurologists, with Duchenne of Boulogne one of the first. The possibility of correcting not only wrinkles, but also certain regional balances gives botulinum toxin a certain number of advantages as well as limitations that should be well known by future injectors as well as the more experienced of practitioners who seek to treat the most difficult zones.

Fermeture cutanée par colle à base d'octylcyanoacrylate (Dermabond®) en chirurgie cervicofaciale programmée : étude longitudinale prospective

OBJECTIVES

A prospective non-randomised evaluation of the octyl-2-cyanoacrylate (Dermabond) for skin closure in head and neck surgery.

MATERIALS AND METHODS

An inception cohort of 52 patients managed by six otorhinolaryngologists head and neck surgeons at a single institution (university teaching and tertiary referral center) during the months of May-July 2004. The length of the skin incision varied from 3 to 30 cm (mean: 7 cm). Morbidity evaluation, longitudinal analysis of the evolution of the scar, and analysis of the degree of satisfaction.

RESULTS

Postoperative death was not encountered. The overall morbidity rate was 3.8% (2/52). There was no instances of wound dehiscence's. A subcutaneous abscess was noted in one patient. From an aesthetic point of view, the scar appearance was considered to be slightly retracted during the first postoperative month and to be very good 2 to 4 months from initial surgery. Only one patient developed a minimal cheloid scar. Among the 47 patients who expressed an opinion postoperatively regarding the use of the octyl-2-cyanoacrylate (Dermabond) for skin closure, the degree of satisfaction was very high due to the ability to take an early shower (40 patients) followed by the lack of skin sutures (5 patients) and the lack of any allergic skin reaction (2 patients).

CONCLUSION

At our department, the octyl-2-cyanoacrylate (Dermabond) for skin closure at the time of head and neck surgery is becoming more and more utilized due to the completion of a solid and aesthetic suture, the ability to take an early shower and the high degree of satisfaction expressed by the patients.

Information orale et chirurgie programmée pour pathologie tumorale bénigne de la glande thyroïde :le point de vue du chirurgien, du médecin, de l'avocat, et du magistrat

OBJECTIVE

Analysis of the consequence of the preoperative information delivered orally to patients requiring surgery for benign pathology of the thyroid gland from various perspective (head and neck surgeon, physician, judge, lawyer).

METHODS

Prospective study conducted in an academic tertiary care referral center. Inception cohort of 123 patients with benign pathology of the thyroid gland consecutively informed orally and by the same surgeon during the years 2003-2004. Analysis of the consequences of the preoperative information, degree of memorization regarding the surgical related risks as well as the patient's opinion regarding this information.

RESULTS

Due to the information regarding the risks related to surgery 14.6% of patients refused to undergo surgery. None of the patients remembered more than 4 out of the 6 main surgical risks. 68.8% of patients remembered only one or two surgical related risks. 12.2% of patients did not remember a single surgical related risk, 85.5% of patients remembered the risk of a unilateral laryngeal nerve paralysis, 41.1% the risk of death related to the completion of a general anesthesia and 21.1% the risk of a bilateral laryngeal nerve paralysis. Less than 11% of patients remembered the other risks (general risks related to any open field surgical approach, hypocalcemia and loss of breast feeding) Among the patients who had an opinion postoperatively, 87.6% had a positive opinion and 41.9% a negative opinion regarding the preoperative information related to the surgical related risks. Also, 28.4% of patients expressed simultaneously a positive and a negative opinion.

CONCLUSION

Oral information of the patient regarding the surgical risks resulted in an important stress for the patient and modified the relation patient-surgeon. Due to the information, a non-neglectable group of patients elicited not to follow the advice of the surgeon. Various measures are discussed since the information on the surgical related risks is a must from a legal point of view but is also highly appreciated and requested by most of the patients.

Tracheal resection with end-to-end anastomosis for isolated postintubation cervical trachea stenosis: long-term results

A 20-year experience with end-to-end tracheal resection and anastomosis for isolated postintubation stenosis of the cervical trachea, in a consecutive series of 32 adult patients, has been reviewed. Surgical death was never encountered. The overall incidences for superficial wound infection, pneumonia, and inferior left laryngeal nerve paralysis were 6.2%, 3.1%, and 3.1%, respectively. One-, 3- and 5-year actuarial anastomosis success rates were 96.7%, 93.3%, and 93.3%, respectively. Successful revision tracheal end-to-end anastomosis was performed once, resulting in an overall 96.9% success rate in our series. None of the following variables-sex, age, cause for intubation, intubation type (laryngotracheal and/or tracheotomy) and duration, delay from initial injury, presence of an open stoma, number of tracheal rings resected, and type of sutures used-were statistically related to the anastomosis success rate or the incidence of complications.

Supracricoid partial laryngectomy after failed laryngeal radiation therapy

Twelve patients managed with supracricoid partial laryngectomies (SCPLs) after failed laryngeal radiation therapy (RT) were evaluated. None of the recurrent tumors were amenable to vertical or horizontal partial laryngectomy. Results were analyzed for tracheostomy decannulation, oral alimentation, morbidity, local control, and survival. Major complications included perichondritis (2 patients), laryngeal stenosis (2 patients), and pneumonia from aspiration (1 patient). Mucocutaneous fistula and cricoarytenoid joint ankylosis were not encountered. Margins of resection were uninvolved in all cases. The Kaplan-Meier 3-year actuarial survival and local control estimate was 83.3%. Salvage total laryngectomy allowed for an overall 100% local control rate and a 75% laryngeal preservation rate. This preliminary report suggests that, in patients with failed laryngeal RT not amenable to vertical or horizontal partial laryngectomy, the SCPL procedures should be discussed before advocating salvage total laryngectomy. Further series analyzing the role and limitations of the various SCPL procedures after failed laryngeal RT are warranted.

[Surgery of primary malignant melanomas of the mucosa of the nasal fossa and facial sinuses]

A retrospective analysis of 22 patients with primary malignant melanoma of the nasal fossa and/or paranasal sinuses consecutively managed with surgery at our department from 1975 to 1993 was conducted. Fifteen patients had negative margins of resection. Neoadjuvant chemotherapy and post-operative radiation therapy was associated in 4 and 5 of these 15 patients, respectively. Four patients had positive margins. Adjunctive treatment was chemotherapy and postoperative radiation therapy in 2 and 3 of these 4 patients, respectively. The remaining 3 patients were managed with palliative treatment (debulking surgery and chemotherapy). No patients were lost to follow up. A 3-year follow-up was always achieved. In patients in whom surgical resection achieved negative margins, the 5-year actuarial survival, and local control estimate was 17.9%, and 26.9%, respectively. None of the variables under analysis were statistically related to local recurrence or survival. Death always occurred within 24 months from initial diagnosis in all 7 patients but one in whom surgical resection with negative margins was not achieved or debulking surgery was performed.

Total conservative parotidectomy for primary benign pleomorphic adenoma of the parotid gland: a 25-year experience with 229 patients

A 25-year experience with total conservative parotidectomy for primary benign pleomorphic adenoma (PBPA) of the parotid gland in a consecutive series of 229 patients has been reviewed. This study focuses on survival, morbidity, PBPA recurrence, postoperative facial nerve dysfunction, and Frey's syndrome. Surgical death was never encountered in this study. The overall incidence for postoperative hemorrhage, hematoma, seroma, skin necrosis, great auricular nerve schwannoma, and keloid scar was 1.7%, 6.1%, 4.8%, 0.9%, 15.7%, and 8.3%, respectively. Five-, 10-, 15-, and 20-year PBPA control actuarial rate was 99.6%. The overall incidence for temporary facial paresis and paralysis was 64.6% and 5.6%, respectively. Kaplan-Meier actuarial analysis demonstrated that paresis recovery was noted until the eighteenth postoperative month. The overall incidence for permanent facial paresis and paralysis was 3.9% and 0%, respectively. None of the following variables--sex, age, PBPA size, PBPA location, PBPA contact with the facial nerve, inadvertent PBPA spillage, or surgeon's experience--was statistically related to PBPA recurrence and facial nerve dysfunction. The overall incidence for Frey's syndrome was 65.9%. Kaplan-Meier actuarial analysis demonstrated the need for a minimal 5-year follow-up to assess Frey's syndrome incidence. The mean age was statistically lower in patients presenting with Frey's syndrome.

A clinical trial of continuous cisplatin-fluorouracil induction chemotherapy and supracricoid partial laryngectomy for glottic carcinoma classified as T2

BACKGROUND

Vertical partial laryngectomy (VPL) and radiation therapy (RT) are the recommended conventional conservative options for glottic carcinoma classified as T2. In series presenting more than 100 patients with a minimum 3-year follow-up, however, local recurrence rates were reported as 22-43.5%. The authors' experience with a new strategy based on continuous cisplatin-fluorouracil induction chemotherapy (IC) and supracricoid partial laryngectomy with cricohyoepiglottopexy (CHEP) is presented.

METHODS

A retrospective analysis of 67 patients who presented with untreated moderately to well differentiated invasive glottic carcinoma classified as T2, managed from 1983 to 1991 with IC and CHEP, was conducted. Statistical analysis of survival, local control, nodal control, distant metastasis, and metachronous second primary tumor incidence was based on the Kaplan-Meier actuarial method. Univariate analysis was performed to analyze the relationships between various factors and survival, local recurrence, and nodal recurrence. Clinical response, histologic response, IC toxicity and postoperative course were reported.

RESULTS

The Kaplan-Meier 5-year survival, local recurrence, nodal recurrence, distant metastasis, and metachronous second primary tumor estimate were 92.3%, 5.6%, 1.5%, 1.8%, and 5.6%, respectively. Overall laryngeal preservation was achieved in 65 patients (97%). Ultimate local control was achieved in all patients but one. Nodal recurrence was statistically more likely in patients presenting with a local recurrence. Analysis of the specimens demonstrated complete histologic response to IC in 25 (37.3%) patients. A strong statistical relation (P < 0.0001) was noted between complete clinical response after IC and complete histologic response.

CONCLUSIONS

The change from the prevailing treatment modalities of RT and VPL to a new multimodal strategy (IC+CHEP) did not decrease survival and allowed for an increase in laryngeal preservation rate. The high rate (37.3%) of complete histologic response suggests that IC deserves further consideration in the management of patients with glottic carcinoma classified as T2. The favorable results achieved in this series, when compared with historic controls, should stimulate prospective clinical trials comparing the two surgical procedures (CHEP vs. VPL with or without IC) for resection of Stage II glottic carcinoma.

Nasal dermoid sinus cyst

Nasal dermoid sinus cyst is one of the diagnoses of midline nasal masses in children. This retrospective study analyzes the various theories regarding the origin of this congenital abnormality, the differential diagnosis, and the value of magnetic resonance imaging, as well as the various surgical options available.

Supracricoid hemilaryngopharyngectomy in selected pyriform sinus carcinoma staged as T2

From 1964 to 1985 supracricoid hemilaryngopharyngectomy (SCHLP) was performed at the authors' institution for 34 selected pyriform sinus carcinomas staged as T2. Tumors involved the anterior part of the pyriform sinus, the lateral wall, the medial wall, and the whole aryepiglottic fold in all cases. Tumors with invasion of the apex of the pyriform sinus, of the retrocricoid region, of the posterior pharyngeal wall, or with fixation of the true vocal cord were excluded from the study. Such a technique was aimed at preserving physiologic phonation, respiration, and swallowing while achieving the same local control rate as pharyngolaryngectomy. Patients were monitored for at least 6 years or until death. No patients were lost to follow-up. The 5-year cause-specific survival rate was 55.8%. The main cause of death was second primary tumor. The 5-year actuarial local recurrence rate was 3.4%. The authors' experience with the SCHLP technique challenges the traditional teaching of pharyngolaryngectomy and establishes this technique as a safe method of voice preservation in selected cases of pyriform sinus carcinomas.

Cricohyoidopexy in selected infrahyoid epiglottic carcinomas presenting with pathological preepiglottic space invasion

Nineteen patients who presented with infrahyoid epiglottic squamous cell carcinoma with gross pathological preepiglottic space invasion, not amenable to a partial horizontal supraglottic laryngectomy, were offered a supracricoid partial laryngectomy with a cricohyoidopexy technique; this was an attempt to preserve physiological phonation, respiration, and deglutition while achieving the same local control rate as with a total laryngectomy. Preoperative chemotherapy and bilateral jugulocarotid lymph node dissection were performed in all cases. Patients were monitored for at least 5 years or until death. No patients were unavailable for follow-up. The 5-year actuarial survival (Kaplan-Meier method) was 84.2%. Local recurrence, nodal recurrence, and distant metastasis occurred once in our series, while six patients presented with a second primary tumor. We present, analyze, and compare functional results with those of the previously reported series. Our experience with the supracricoid partial laryngectomy with a cricohyoidopexy, in the face of selected infrahyoid epiglottic squamous cell carcinoma invading the preepiglottic space, not amenable to a partial horizontal supraglottic laryngectomy, suggested that a total laryngectomy might be avoided without decreasing the cure rate.