Interdisciplinary plastic and reconstructive surgery of head and neck squamous cell carcinomas

Squamous cell carcinomas are the most common malignancies in the oral cavity, pharynx, and larynx. Even in the age of the most modern drug treatment methods, radical resection of these tumors is and currently remains the therapeutic gold standard. The loss of anatomical structures associated with surgery inevitably increases the functional deficits caused by the tumor itself. In this context, the extent of functional deficits is largely determined by the extent of resection. Complete organ resections, such as glossectomy, complete palate resection, laryngectomy, or transverse pharyngo-laryngectomy, lead to severe functional deficits, such as swallowing disturbances with life-threatening aspiration and articulation disorders up to the inability to speak. With the help of plastic reconstructive surgery, the lost tissue can be replaced and the specific functions of the upper aerodigestive tract can be preserved or restored.In recent decades, reconstructive surgical procedures have developed enormously in the treatment of malignant tumors of the head and neck. In order to make optimal use of them, a comprehensive, interdisciplinary therapy concept is a prerequisite for positive oncological and functional outcome. In addition to general medical and social parameters, surgical parameters play a crucial role in the choice of the reconstruction method. The extent to which the surgical measures must be interdisciplinary depends on the localization of the defects in the head and neck region and on the type of replacement tissue required. Here, the expertise of plastic surgery, oral and maxillofacial surgery, and abdominal surgery comes into play in particular. The use of different tissues, the combination of different grafts and flaps, or the preforming of donor regions allow reconstructions far beyond the level of simply restoring surface integrity. The functional results and thus the quality of life of patients after surgical therapy of extensive tumors of the mentioned localizations depend decisively on the type of reconstruction. Therefore, in the following review, special emphasis 1 be placed on the choice of reconstruction method and reconstruction technique for tissue loss after resections of HNSCC.

[Plastic reconstructive surgery in patients with oropharyngeal tumors]

Oropharyngeal tumors can cause severe dysfunctions, which are often worsened by surgical and/or radiotherapy. The severity and type of dysfunction depends on the extent and localization of the resection. In general, entire organ resections lead to greater impairment than partial resections, whereas extended partial resection often equates to total resection. Plastic reconstructive surgery can help to preserve and reconstruct specific functions. Herein, the various surgical techniques with different flaps and tissue grafts are described, and the indications are presented depending on the dysfunctions, the defect location, and the extent of resection (partial versus total).

Induction chemotherapy (IC) followed by radiotherapy (RT) versus cetuximab plus IC and RT in advanced laryngeal/hypopharyngeal cancer resectable only by total laryngectomy-final results of the larynx organ preservation trial DeLOS-II

Background

The German multicenter randomized phase II larynx organ preservation (LOP) trial DeLOS-II was carried out to prove the hypothesis that cetuximab (E) added to induction chemotherapy (IC) and radiotherapy improves laryngectomy-free survival (LFS; survival with preserved larynx) in locally advanced laryngeal/hypopharyngeal cancer (LHSCC).

Patients and methods

Treatment-naïve patients with stage III/IV LHSCC amenable to total laryngectomy (TL) were randomized to three cycles IC with TPF [docetaxel (T) and cisplatin (P) 75 mg/m2/day 1, 5-FU (F) 750 mg/m2/day days 1-5] followed by radiotherapy (69.6 Gy) without (A) or with (B) standard dose cetuximab for 16 weeks throughout IC and radiotherapy (TPFE). Response to first IC-cycle (IC-1) with ≥30% endoscopically estimated tumor surface shrinkage (ETSS) was used to define early responders; early salvage TL was recommended to non-responders. The primary objective was 24 months LFS above 35% in arm B.

Results

Of 180 patients randomized (July 2007 to September 2012), 173 fulfilled eligibility criteria (A/B: larynx 44/42, hypopharynx 41/46). Because of 4 therapy-related deaths among the first 64 randomized patients, 5-FU was omitted from IC in the subsequent 112 patients reducing further fatal toxicities. Thus, IC was TPF in 61 patients and TP in 112 patients, respectively. The primary objective (24 months LFS above 35%) was equally met by arms A (40/85, 47.1%) as well as B (41/88, 46.6%). One hundred and twenty-three early responders completed IC+RT; their overall response rates (TPF/TP) were 94.7%/87.2% in A versus 80%/86.0% in B. The 24 months overall survival (OS) rates were 68.2% and 69.3%.

Conclusions

Despite being accompanied by an elevated frequency in adverse events, the IC with TPF/TP plus cetuximab was feasible but showed no superiority to IC with TPF/TP regarding LFS and OS at 24 months. Both early response and 24 months LFS compare very well to previous LOP trials and recommend effective treatment selection and stratification by ETSS.

Clinical trial information

NCT00508664.

Superselective microcoil embolization in severe intractable epistaxis: an analysis of 12 consecutive cases from an otorhinolaryngologic and an interventional neuroradiologic point of view

From 2006 to 2013, 12 patients with severe epistaxis refractory to prior conservative and surgical therapy were treated by superselective embolization of nasal arteries. Supersoft platinum microcoils with smallest diameters were used as the sole embolic agent in all cases. Coils were applied far distally in a stretched position for obtaining ideal target vessel superselectivity. The objective of this study is to evaluate efficacy and complications of superselective coil embolization for treatment of severe intractable epistaxis and to discuss results from an otorhinolaryngologic and an interventional neuroradiologic point of view. Retrospectively, all epistaxis inpatients between 2006 and 2013 were identified and subdivided by form of treatment: conservative, surgical and interventional therapy. Medical records of interventionally treated patients were reviewed for demographics, medical history, risk factors, clinical data, complications and short-term success, and patients were followed up for long-term success. Mean follow-up was 37 months. In 12 patients, 14 embolizations were carried out, with short-term success in 9 patients (75%), while early post-interventional rebleeding occurred in 3 patients (25%). Of 9 patients with short-term success, 1 died during stay, 1 was lost to follow-up and 1 had minor re-bleeding after 30 months. Six patients had short-term and long-term success. Before the first embolization, 3 ± 1 conservative and/or surgical procedures had been undertaken. Length of stay was 12.8 ± 3.6 days. 8 patients (67%) received red cell concentrates. Most frequent complications were mucosal damage and nasal pain, but these were related to repeated packing and surgery. Typical embolic complications as neurological or visual impairment or soft tissue necrosis were not observed in any patient. From the otorhinolaryngologic point of view, surgery is the treatment of choice in severe refractory epistaxis, but in case of repeated failure, superselective microcoil embolization is a valuable addition to the therapeutic spectrum. From the interventional neuroradiologic point of view, superselective microcoil embolization is an effective, well tolerable and safe procedure and complications may be reduced in comparison to microparticle embolization. Modern supersoft microcoils with smallest diameters enable ideal superselectivity of the target vessels.

[Total laryngopharyngectomy and reconstruction with a jejunum speech siphon : A case report]

Advanced laryngeal and hypopharyngeal carcinomas are associated with a poor prognosis and a pronounced loss of quality of life due to impairment of the swallowing and voice function. The fundamental therapeutic challenge is successful tumor control with concomitant rehabilitation of swallowing and voice functions. Further objectives are a low complications rate (fistula, aspiration) and prompt transfer to the adjuvant radio-oncologic therapy. With these factors in mind, the microvascular anastomosed jejunum speech siphon with a biventer rein has proven to be an effective method of reconstruction following extensive circular laryngopharyngeal resections. In this case report, a typical operative and postoperative course is presented, as are the functional results.

[Coblation tonsillectomy. Results of a pilot study]

BACKGROUND

The introduction of coblation tonsillectomy (CTE) may contribute to reduce the postoperative morbidity in terms of pain, delayed oral intake and bleeding.

METHODS

A prospective pilot study was undertaken to evaluate the clinical course by inpatient observation (5 days) and telephone contact 6 months after CTE. The data from 61 patients (aged 44 months-69 years) were analyzed. The patients were grouped into those with surgical care of bleeding (A), non-surgical care of bleeding (B), and no bleeding event (C).

RESULTS

The study was terminated early due to major bleeding complications in seven patients (A). Fifteen patients experienced minor (B) and 41 no (C) bleeding episodes. In the interview, 29 patients identified pain, lasting 16.7 (A), 11.6 (B) and 11 (C) days, as the most significant complication of surgery.

CONCLUSIONS

The introduction of CTE was followed by a dramatic increase in major bleeding complications, including late bleeding episodes. Pain following tonsillectomy remains a problem to be solved by further techniques. We will continue to perform the cold dissection technique.

Hemorrhage following tonsillectomy and adenoidectomy in 15,218 patients

OBJECTIVE

To evaluate potential risk factors and the incidence of bleeding following adenoidectomy or tonsillectomy, with or without adenoidectomy requiring surgical treatment under general anesthesia.

STUDY DESIGN AND SETTING

Retrospective chart review of 15,218 patients who underwent surgery between January 1, 1988, and September 30, 2001, at our institution (St. Anna Hospital, Duisburg).

RESULTS

A total of 229 patients experienced postoperative bleeding (1.5%). Patients of male gender and 70 years of age or older were significantly at risk for post-tonsillectomy hemorrhage. The incidence of bleeding increased with age. Of the bleeding episodes, 76% occurred on the day of surgery; immediate abscess-tonsillectomy was not associated with an increased risk of bleeding.

CONCLUSIONS

Hemorrhage following tonsillectomy and adenoidectomy is rare and predominantly occurs early after surgery. Male patients, 70 years of age or older, infectious mononucleosis, and a history of recurrent tonsillitis were identified as risk factors for post-tonsillectomy hemorrhage. Delayed hemorrhage has the potential to be life-threatening.

Intubation laryngeal mask: atraumatic diagnostic tool in suspension laryngoscopy

CONCLUSION

The new technique of ILM-guided vocal cord biopsy and APC is safe, cost-effective and non-invasive. It provides excellent airway control, adequate exposure of the vocal cords and effective treatment of laryngeal bleeding.

OBJECTIVE

Suspension microlaryngoscopy is a standard diagnostic procedure for vocal cord biopsy. In experienced hands failure of the procedure is extremely rare and may indicate a need for more invasive techniques. The aim of this study was to present a new technique of laryngoscopy/vocal cord biopsy and to review the relevant literature.

MATERIAL AND METHODS

After induction of general anesthesia and preoxygenation an intubation laryngeal mask (ILM) was inserted. A flexible bronchoscope was passed through the ILM and an anterior lesion was identified at the vocal cord. Biopsies were taken with forceps inserted through the instrument's working channel. The procedure was performed using video-endoscopic guidance. Bleeding from the wound surface was adequately treated with argon-plasma coagulation (APC).

RESULTS

Identification of the vocal cords was readily accomplished using the ILM. Only four literature reports matched our search criteria; all used the standard laryngeal mask or other instruments such as a laser or did not use the procedure for definitive therapy.

Peritonsillarabszess

BACKGROUND

Peritonsillar abscess (PTA) is the most common deep neck space infection treated by otolaryngologists affecting predominantly young adults. Children present a challenge owing to the difficulty in obtaining an exact history and adequate physical examination. Particularly for the pediatric age group controversy surrounds the question of optimal treatment. This study was undertaken to evaluate bleeding complications following immediate tonsillectomy (TAC) in a pediatric population (<16 years) of age and to compare our management protocol with the current status in the literature.

MATERIAL AND METHODS

The data of 218 children who had undergone TAC between January 1988 and January 2003 in our clinic were enrolled in a retrospective study. The youngest patient was 18 months, the oldest 15.9 years of age (mean: 14.53; median: 14; STD: 12.11 years). 95 patients were male (43.6%), 123 female (56.4%). Various treatment protocols of the current literature are addressed.

RESULTS

Postoperative hemorrhage (all from the opposite side) requiring surgical treatment under general anesthesia occurred in 4 children (1.8%). Repeated hemorrhage did not occur, blood transfusions were not required, there was no case with lethal outcome. Several reports indicate that needle aspiration (NP) or incision and drainage (ID) may suffice for the majority of cases but do not distinguish between different treatments for children and adults. More recently, conscious sedation has become a great support for pediatric treatment protocols.

CONCLUSIONS

The initial success rates of NP or ID are both very high (>90%) and the overall recurrence rate is low, particularly in children. Only for selected subgroups, patients may profit from TAC, which was clearly not associated with an increased risk of bleeding in our pediatric population.

Dysphagie durch Aneurysma der A. subclavia

BACKGROUND

Dysphagia may be due to oral, pharyngeal or esophageal dysfunction and poses a frequent problem for the otolaryngologist. Motor disturbances, structural disorders, functional problems, congenital lesions and malignancies have to be excluded in an interdisciplinary diagnostic approach. Currently, vascular diseases play a minor role in the diagnosis of dysphagia.

CASE REPORT

A 70-year-old female presented with constant dysphagia and a foreign body feeling in the throat of about 2 months duration. Palpation and ultrasound revealed a tumor situated in the right supraclavicular region. The lesion was identified as a true aneurysm of the subclavian artery by digital subtraction angiography. Successful resection and reconstruction was accomplished using a PTFE graft.

DISCUSSION

Aneurysms of the subclavian artery are rare and in most cases related to thoracic outlet syndrome (TOS) or arteriosclerosis. It can be assumed that an increasingly aged population will present with an increasing incidence of diseases related to atherosclerosis. Moreover, the increasing incidence of specific infections may contribute to this phenomenon. This neglected disease should be included in the differential diagnosis when dealing with supraclavicular lesions, foreign body feeling or dysphagia.

Extranasopharyngeal angiofibroma: etiology, incidence and management

OBJECTIVE

Angiofibromas in the head and neck area usually arise in the nasopharynx (NA) in adolescent males. They may also occur outside the nasopharynx (ENA) and can therefore be misdiagnosed. An ill-advised biopsy may result in brisk bleeding. This study was undertaken to evaluate the incidence and clinical features of ENA.

MATERIAL AND METHODS

A review of the international literature was performed.

RESULTS

A total of 65 patients with ENAs from 16 different countries were reported in the literature. Two patients had a congenital lesion, the oldest being 78 years old. A total of 48 patients were male (73%). The maxilla was the most commonly affected site (24.6%), with the ethmoid, nasal cavity or septum and other sites being involved less frequently. Symptoms arose in 40 patients within 6 months. Among a wide variety of symptoms, epistaxis with or without nasal obstruction was reported for 18 patients. Brisk bleeding resulting from a total of 23 biopsies occurred in 13 patients, and required blood transfusion in 11. Death was reported for two patients as a result of acute respiratory compromise and endocranial extension.

CONCLUSION

ENAs are extremely rare compared to NAs and have to be acknowledged as a different entity. In comparison to patients with NAs, as female adults are affected, the lesion is diagnosed earlier and is less vascularized and the patients are older. Surgical resection is sufficient treatment due to a tendency for local and less aggressive growth.

[Extranasopharyngeal angiofibroma of the nasal cavity and paranasal sinuses]

BACKGROUND

Angiofibromas commonly arise in the nasopharynx in young male patients. Diagnosis is widely based on radiographic imaging to avoid ill-advised biopsy which may result in brisk bleeding. This study was undertaken to evaluate the incidence, clinical features and complications that may occur during the process of diagnosis and surgical therapy of angiofibromas outside the nasopharynx.

METHODS AND PATIENTS

Case report of a 13-year-old female patient and review of the literature.

RESULTS

Our patient received multi-agent chemotherapy elsewhere due to a misdiagnosed angiofibroma. Computed Tomography (CT) revealed a maxillary tumor which was repeatedly biopsied. Hypervascularity was excluded by arteriography and the lesion removed after lateral rhinotomy. The data of 42 patients were analyzed including our own case. 32 patients were male, 10 female. The majority became symptomatic aged 19 years or younger (71.4 %). The maxilla was most commonly affected (38 %), less frequently the ethmoid, nasal cavity or septum, beside others. In 38 patients, symptoms developed within 12 months or less (average: 8.5 months). Epistaxis, nasal obstruction and facial swelling were reported for most patients. Brisk bleeding occurred in 10 patients during tumor removal and resulted from biopsies in 11 of 20 patients. Angiography detected hypervascularity in 3 of 4 patients. There was no case with lethal outcome.

CONCLUSION

Extranasopharyngeal angiofibromas of the nasal cavity or paranasal sinuses should be included in the differential diagnosis of nasal tumors. Compared to nasopharyngeal angiofibromas, more female patients are involved, symptoms develop more quickly but hypervascularity is less common. Signs of questionable hypervascularity in Computed Tomography and Magnetic Resonance Imaging (MRI) should indicate arteriography prior to surgical procedures. Preoperative embolization of hypervascular lesions during arteriography will reduce the risk of brisk bleeding during biopsy or surgical tumor removal.

[Reconstruction after extended partial laryngeal and hypopharyngeal resections. A new method with rib cartilage, chondrosynthesis and free radial transplants]

Partial pharyngectomy combined with subtotal laryngectomy results in permanent tracheostomy and long lasting swallowing difficulties in many cases. Based on our prior experimental and clinical studies on laryngeal chondrosynthesis the objectives of this project were to develop a method for reconstruction of up to two thirds of the larynx and one pyriform sinus.

METHOD

The resected laryngeal framework is reconstructed with autogenous rib cartilage and stabilized with plates and screws. In addition a piece of cartilage is used as a buttress for apposition by the remaining mobile vocal cord. A free radial forearm flap covers the reconstructed framework and forms the sulcus of the pyriform sinus.

RESULTS

Up to now 7 patients have been operated with this technique. The follow up was 35 months on average. None of the patients has a clinically relevant aspiration. All patients have a well understandable voice and one of them--a teacher--could even resume his speech profession.

CONCLUSION

In selected patients these techniques enable functional rehabilitation of swallowing, breathing and speech even after extended partial pharyngolaryngectomy.

[Electromyography of the infrahyoid muscles - part 2: pathological findings]

BACKGROUND

The infrahyoid muscles (IHM) can easily be used as a neurovascular myofascial flap for reconstructive surgery in the oral cavity and pharynx and especially for functional tongue reconstruction following tumor ablation.

METHODS

In order to detect neurogenic lesions caused by neck pathologies, in particular lymph node metastasis, we studied ten patients (nine patients suffering from tongue carcinoma and one patient after traumatic tongue ablation) by preoperative electromyography of the IHM. These results were compared to ten healthy controls.

RESULTS

We found no pathological spontaneous activity with the EMG at rest in any patient. During light voluntary innervation, the motor unit potentials (MUP) were normal in controls and in patients with normal ultrasound, CT scans and histologic examination after neck surgery. When pathologic lymph nodes were found in the neck, the number of polyphasic MUP in the ipsilateral IHM 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). Maximal innervation of the IHM was obtained during head bending and jaw opening. We found no difference in the discharge pattern of both groups.

CONCLUSIONS

Due to their extent lymph node metastasis can lead to neurogenic lesions of the cervical ansa of the IHM. Neurogenic damages are most clearly present after traumatic lesions of the neck (prior operations, radiotherapy). EMG at maximal voluntary contraction instead revealed no lesions. The clinical impact of these demonstrated neurogenic lesions need to be studied by measuring the muscle strength of the IHM.

[Electromyography of the infrahyoid muscles - part 1: normal findings]

BACKGROUND

The infrahyoid muscles (IHM) are very useful as a neurovascular myofascial flap in plastic reconstructive surgery of the upper aerodigestive tract, especially for restoration of the muscular component in larger tongue defects. As a base for further postoperative investigations on the function of transferred IHM this first part of the study describes the physiological function and the electromyographical features of the IHM.

METHODS

In 17 patients with cancer of the upper aerodigestive tract the sternohyoid and sternothyroid muscles and in additionally eight patients the upper part of the omohyoid muscle were studied electromyographically. Muscular activity was recorded at various movements and maximal voluntary innervation. In ten healthy volunteers the motor unit potentials (MUP) during light voluntary innervation of these muscles were studied.

RESULTS

In both muscles we found the steadist and strongest muscular activity at isometric head bending and yaw opening, in the omohyoid muscle also at head rotation. At swallowing and breathing in (2/3) of the cases muscular activity could be recorded. Amplitudes and electromyographic charge pattern in comparison were diminished. Phonation und tongue movements showed no noticable muscular activity. Analysis of the MUP in 10 healthy volunteers showed a mean amplitude of 274 +/- 59 microV and a mean duration of 8.5 +/- 0.6 ms.

CONCLUSIONS

The presented study demonstrates that EMG of the IHM are recorded best while head bending, yaw opening and head rotation. Since there is no interchange of nerve fibres between the hypoglossal nerve and the cervical ansa it should be possible to differentiate between original tongue muscles and transferred muscles in electromyographic studies of myofascial flaps after tongue reconstruction.

Single photon emission tomography: scintigraphy in the assessment of mandibular invasion by head and neck cancer

BACKGROUND

This study was performed to determine the effectiveness of single photon emission tomography (SPET) in contributing to the initial staging of patients with cancers of the head and neck because information about osseous infiltration of head and neck cancer is of major importance for staging and planning of treatment.

METHODS

A retrospective analysis of 89 cases with probable tumor infiltration of the mandible by oral/pharyngeal cancer was undertaken by comparing the preoperative SPET as well as CT-scans, if available, with clinical and postoperative histological examinations.

RESULTS

For SPET examinations, a sensitivity of 95% and a specificity of 48% were calculated. The positive predictive value was 65%, and the negative predictive value was 93%. CT scans showed a sensitivity of 75% and a specificity of 78%. The positive predictive value was 65%, and the negative predictive value was 93%.

CONCLUSIONS

SPET is a powerful method to detect infiltration of carcinomas into the head and neck skeleton. Its sensitivity is high and superior to CT scans, although the specificity is small due to a high number of false positive results.

[Electromyography of the infrahyoid muscles - part 3: findings after transposition as a myofascial flap in tongue reconstruction]

BACKGROUND

Due to the preservation of its nerval supply the neurovascular infrahyoid muscle flap in tongue reconstruction enables to prevent atrophy of the musculature. In this study the integrity of the infrahyoid muscles (IHM) after transposition into the oral cavity was examined by means of electromyography.

METHODS

17 patients after partial or complete reconstruction of the tongue with IHM were studied at varied times after surgery. The IHM in the oral cavity was inserted by a concentric needle electrode and activity at rest as well as the discharge pattern at maximal voluntary innervation was evaluated. During light voluntary activity a motor unit potential (MUP) analysis were performed.

RESULTS

13 of 17 patients (76,5 %) in total revealed electromyographic activity in the transfered IHM flaps. Within the first 6 months after surgery 71,5 % of the patients or 77,8 % of the IHM flaps showed activity. After 6 months in 61,5 % of the patients or 64,7 % of the IHM flaps muscular activity was demonstrated. In 84,6 % of the patients or 88,2 % of the flaps we could detect neurogenic lesions at least once. Maximal voluntary contraction showed a discrete activity pattern in 63 %. In 26 % of all cases we found a discrete to reduced interference pattern and in 10 % a reduced interference pattern.

CONCLUSIONS

Functioning muscle tissue could be demonstrated in the most IHM flaps, but almost all of the studied muscles showed neurogenic lesions with a loss of motor units due to the traumatic surgery. Maybe bioelectrical stimulation of the Ansa cervicalis with implantable amplifiers will lead to better flap contractility in the future.

[Transplants from the shoulder-back region]

BACKGROUND

In spacious or multilayered tissue losses and cases of multiple locations of defects, a large amount of tissue with different components such as skin, fatty tissue, and muscle is required for proper reconstruction. A donor area which can meet these demands is the shoulder-back region with the subscapular vessel, which arises from the axillary artery.

PATIENTS AND METHODS

We report our clinical experience with 12 patients in whom we reconstructed defects with transplants from this region.

RESULTS

Our anatomic investigation and measurements provided proof of a constant anatomy of the vessels with a length of the vascular pedicle and a vascular diameter suitable for microvascular anastomosis. Based on our clinical experience, the scapular, parascapular, and latissmus dorsi muscle transplants are very suitable for the reconstruction of very large superficial defects or for the augmentation of multilayered defects of the upper aerodigestive tract.

CONCLUSIONS

A main advantage of the transplants from the shoulder and back region is the possibility of combining several transplants with a wide variety of tissue combinations with one vascular pedicle for a single-step reconstruction of multiple defects of the oral cavity and the pharynx.

A preclinical model for experimental chemotherapy of human head and neck cancer

We developed a mouse model in a representative human derived head and neck cancer cell line for preclinical studies to evaluate antitumor response, tumor-free survival and host toxicity of alkylating agents, antimetabolites, platinum analogs and taxanes alone or in combination. Ninety athymic NMRI mice were inoculated with human derived oral squamous cell carcinoma cells growing on the hind paw to an average volume of 180 +/- 80 mm3. Animals were stratified according to tumor volume into 10 groups (n=6-10) and treated with ifosfamide (65 mg/kg b.w.), docetaxel (24 mg/kg b.w.), cisplatin (2 mg/kg b.w.), carboplatin (6 or 10 mg/kg b.w.), methotrexate (1 mg/kg b.w.), and fluorouracil (15 mg/kg b.w.) intravenously in single agent or combination (ifosfamide plus docetaxel or ifosfamide plus carboplatin) treatment schedules or controls. Tumor volume was measured 3 times per week for 60 days. The average tumor volume, the overall survival time and the response rates (CR, PR) of the treated animals were compared with the data obtained from untreated controls and statistically evaluated. Untreated tumors showed rapid and exponential tumor growth. Single agent therapies with ifosfamide, cisplatinum, and docetaxel lead to significant tumor regression and improved overall survival. Low dose carboplatin monotherapy induced significant tumor growth delay, but not significant tumor regression. Most impressive tumor-free survival was achieved by combination treatment with ifosfamide and docetaxel. This preclinical study demonstrates an animal model capable of differentiating various chemotherapy regimens.

[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.