Neck stiffness after transoral pharyngolaryngeal surgery for squamous cell carcinoma

IntroductionPyogenic spondylodiscitis is a rare, destructive intervertebral disc infection.Case summaryWe describe a case of C2-C3 pyogenic spondylodiscitis after transoral surgery of the posterior pharyngeal wall in a 64-year-old man with a history of oropharyngeal squamous cell carcinoma (SCC) treated by neck irradiation (45 Gy). Ten years after initial treatment, he underwent total laryngectomy for laryngeal SCC, together with transoral resection of carcinoma in situ (CIS) of the posterior pharyngeal wall followed by BioDesign® tissue repair graft. Five months later, C2-C3 spondylodiscitis was diagnosed with the formation of a fistula between the posterior pharyngeal wall and the intervertebral disc. Antibiotic therapy was administered for a total duration of 3 months (multi-susceptible Escherichia coli). Eight months after the diagnosis of spondylodiscitis, the patient died from carotid artery rupture following another course of radiotherapy for lymph node recurrence.DiscussionLarger-scale studies are necessary to evaluate the prevalence and risk factors of radiation-induced spondylodiscitis that currently remain poorly elucidated. The best treatment strategy (choice and duration of antibiotic therapy) and the optimal frequency of follow-up must be determined and the value of preventive measures (biomaterial, flap repair) needs to be evaluated.     

Spondylodiscitis after transoral robotic surgery: Retrospective 7-case series from the GETTEC group

BackgroundCervical spondylodiscitis is a rare but severe complication of pharyngeal surgery.Material and methodsThis multicenter retrospective study reported all patients in the database of the French head and neck tumor study group (GETTEC) affected by cervical spondylodiscitis after transoral robotic surgery (TORS) for malignant pharyngeal tumor from January 2010 to January 2017.ObjectivesTo describe cases of post-TORS cervical spondylodiscitis, identify alarm signs, and determine optimal management of these potentially lethal complications.ResultsSeven patients from 6 centers were included. Carcinomas were located in the posterior pharyngeal wall. Tumor stage was T1 or T2. All patients had risk factors for spondylodiscitis. Mean time to diagnosis was 12.6 days. The interval between surgery and spondylodiscitis diagnosis ranged from 20 days to 4.5 months, for a mean 2.1 months. The most common symptom was neck pain (87%). Infections were polymicrobial; micro-organisms were isolated in 5 cases and managed by intravenous antibiotics, associated to medullary decompression surgery in 3 cases. Follow-up found favorable progression in 4 cases, and 3 deaths (mortality, 43%).ConclusionThis French multicenter study found elevated mortality in post-TORS spondylodiscitis, even in case of limited resection. Surgeons must be aware of this complication and alerted by persistent neck pain, fever, asthenia, impaired or delayed posterior pharyngeal wall wound healing or elevation of inflammatory markers. MRI is the most effective diagnostic radiological examination.     

Cervical spondylodiscitis following cricopharyngeal botulinium toxin injection

BackgroundIatrogenic cervical spondylodiscitis is rare, but may occur after various medical interventions.MethodsWe report a case of a diabetic 70-years-old female with C5–C6 spondylodiscitis and symptomatic epidural abscess with neck pain and upper limb paresis after endoscopic botulinum toxin injection for the treatment of dysphagia. Treatment included antibiotic therapy with amoxicillin and later on benzylpenicillin for the next ten weeks and corporectomy with spondylodesis.ResultThe patient made an excellent recovery, with complete resolution of paresis and only minor residual hypoesthesia at one year after operation.ConclusionCervical spondylodiscitis should be considered early, in patients with neck pain after endoscopic cricopharyngeal injection, as timely diagnosis and treatment can prevent serious and irreversible neurological deficit.     

Transoral videolaryngoscopic surgery for papillary carcinoma arising in lingual thyroid

Carcinoma arising in lingual thyroid is an extremely rare entity accounting for only 1% of all reported ectopic thyroids. Here, we report a case of carcinoma arising in lingual thyroid, which has been successfully managed by transoral resection and bilateral neck dissections.A lingual mass 4-cm in diameter with calcification was incidentally detected by computed tomography at medical check-up. No thyroid tissue was observed in normal position. Ultrasound examination showed bilateral multiple lymphadenopathies. Fine needle aspiration biopsy from lymph node in his right neck was diagnosed as Class III and thyroglobulin level of the specimen was 459 ng/ml. Due to the difficulty in performing FNA of the lingual masses, right neck dissection was performed in advance for diagnostic purpose. Pathological examination showed existence of large and small follicular thyroid tissues in several lymph nodes, suggesting lymph node metastasis from thyroid carcinoma. Two months after the initial surgery, video-assisted transoral resection of lingual thyroid with simultaneous left neck dissection was performed. Postoperative course was uneventful. Papillary carcinoma was found in the lingual thyroid and thyroid tissues were also found in left cervical lymph nodes.Video-assisted transoral resection was useful for the treatment of thyroid cancer arising in lingual thyroid.     

Combined transoral–transhyoid endoscopic approach for hypopharyngeal cancer

Endoscopic transoral surgery for hypopharyngeal cancer is an effective treatment option to avoid invasive open surgery or chemoradiation. Here we describe the case of a 66-year-old patient with cT2N0M0 pyriform sinus cancer whom we treated using a transoral–transhyoid endoscopic approach. Using this approach, a transhyoid route was created in addition to the transoral route and used to extirpate the tumor. En bloc resection of the tumor was completed without difficulty. A combined transoral–transhyoid approach is a useful surgical option for treatment of selected patients with hypopharyngeal cancer. This technique is straightforward to perform and can be used as a backup technique in endoscopic transoral surgery. Also, more complicated lesions can be resected by this approach than by a single-route transoral approach.     

Endoscopic pharyngolaryngoplasty: A case report

IntroductionAny technique that allows decannulation of tracheostomy-dependent patients relieves their discomfort and reduces health costs.Case reportWe present the case of a 70-year-old tracheostomy-dependent patient with pharyngolaryngeal stenosis and a history of radiation therapy for laryngeal cancer in remission for 13 years and multiple decannulation failures. Endoscopic pharyngolaryngoplasty was performed using reconstructive transoral laser microsurgery techniques, allowing permanent decannulation. Endoscopic sutures secured by clips were performed to remodel the pharyngolarynx and prevent recurrence of synechiae.DiscussionEndoscopic surgery of the pharynx and larynx was initially developed for resection of small tumours. Reconstructive transoral laser microsurgery has been developed more recently. One of the objectives of this surgery is to reconstruct the pharyngolarynx to treat functional sequelae following surgery and/or radiation therapy for head and neck cancer. It allows reconstruction of the upper airways to restore mouth breathing in tracheostomy-dependent patients, thereby facilitating permanent decannulation.     

Minimally invasive techniques for head and neck malignancies: current indications, outcomes and future directions

The trend toward minimally invasive surgery, appropriately applied, has evolved over the past three decades to encompass all fields of surgery, including curative intent cancer surgery of the head and neck. Proper patient and tumor selection are fundamental to optimizing oncological and functional outcomes in such a personalized approach to cancer treatment. Training, experience, and appropriate technological equipment are prerequisites for any type of minimally invasive surgery. The aim of this review was to provide an overview of currently available techniques and the evidence justifying their use. Much evidence is in favor of routine use of transoral laser resection, transoral robot-assisted surgery, transnasal endoscopic resection, sentinel node biopsy, and endoscopic neck surgery for selected malignant tumors, by experienced surgical teams. Technological advances will enhance the scope of this type of surgery in the future and physicians need to be aware of the current applications and trends.     

Cirugía endoscópica transoral ultrasónica (TOUSS) en el diagnóstico del carcinoma de primario desconocido en cabeza y cuello

Metastatic carcinoma of unknown primary (CUP) to cervical lymph nodes represents less than 5% of all head and neck malignancies. Recent publications support the use of transoral surgery during the diagnosis work-up, and transoral endoscopic ultrasonic surgery represents a recently described alternative technique in transoral surgery. A pilot study to assess the feasibility of trans-oral ultrasonic base of tongue (BOT) mucosectomy and bilateral tonsillectomy approach in CUP diagnosis work-up was conducted. Ten patients were included consecutively. In two cases (20%) the primary was found, in one case in the right tonsil, and another one in the left BOT. According to our results, the use of trans-oral ultrasonic surgery to perform the base of tongue mucosectomy and bilateral tonsillectomy in CUP patient's during the diagnosis work-up represents an effective option in patients with good anatomical exposure.     

Synovial sarcoma of the pharynx: a case report

Synovial sarcoma is a malignancy not usually encountered in the head and neck region. We describe a case of synovial sarcoma of the posterior pharyngeal wall in a 14-year-old girl. The mass was completely excised via the transoral route. Postoperatively, the patient received irradiation to 60 Gy. At 40 months of follow-up, the patient remains disease-free.     

Simultaneous metastasized primary unknown signet ring cell carcinoma of the cervical lymph node and mucoepidermoid carcinoma of the parotid gland as double cancers

Lymph node metastasis from signet ring cellcarcinoma (SRCC) primary unknown is extremely rare. We here report a case of primary-unknown SRCC that metastasized to the cervical lymph nodes, co-existing with mucoepidermoid carcinoma (MEC) of the parotid gland as a simultaneous double cancer. A 68-year-old female patient with right swollen cervical lymph nodes consulted our medical center. A diagnosis of bilateral cervical lymph node metastasis and a right parotid tumor was made. After bilateral neck dissection and right parotidectomy, the pathological diagnosis was SRCC of primary unknown with metastasis to the cervical lymph node and MEC of the parotid gland. Examination of the CRTC1/3-MAML2 fusion gene showed no relation between SRCC of primary unknown with metastasis to the cervical lymph node and MEC of the parotid gland. Ten months after the first treatment, there was recurrence in the left neck lymph node, and left neck dissection was performed. Fourteen months after the first treatment, the patient is alive and cancer-free. This case is the fourth report of SRCC with lymph node metastasis, and highlights the value of fusion gene detection to determine relatedness between simultaneous cancers. Moreover, such cases should be closely monitored for the subsequent appearance of distant metastases.     

Pathomorphological aspects of transoral resection of hypopharyngeal carcinoma with preservation of the larynx. Patient selection, treatment results

BACKGROUND: In primary surgery of hypopharyngeal cancer, transcervical resection was chosen in order to preserve the larynx. This treatment produces good oncological results but also a high degree of morbidity so that in recent years transoral resection has been recommended. For wider application of this method it is very important to apply clearly defined criteria for selection of patients. MATERIAL AND METHODS: To define the criteria for selection for transoral microsurgical resection, we analyzed step serial sections of 33 whole organ specimens of hypopharyngeal squamous cell cancer (SCC) after primary radical surgery, mostly carcinoma of the piriform sinus. Criteria concerning the primary and the involvement of the neck nodes were differentiated. Twenty of 84 patients with hypopharyngeal cancer of different stages were treated by transoral resection and delayed neck dissection between 1994 and 1996. Most of the patients were irradiated postoperatively because of neck metastases. The therapeutic results after a minimum period of 24 months follow-up is listed according to Kaplan-Meyer. RESULTS: Three types were defined according to their site, growth, and spread into the larynx: Type I comprises limited exophytic, highly differentiated SCC with a minor tendency for metastasis originating in the upper half of the sinus. These tumors are well suitable for transoral resection. Type II includes tumors spreading superficially without deeper invasion of the larynx, especially of the laryngeal framework. These can be totally resected and the larynx preserved in spite of extended metastasis. Type III, the most frequent type, grows with ulceration and deeply infiltrates into the larynx and the neck. These tumors cannot be resected transorally. Primary radical resection is indicated. Up to 25% of all hypopharyngeal SCC could be treated by transoral resection, mostly with delayed neck dissection and postoperative irradiation. Functional results were excellent in all cases. Eating, voice, and air passage were normal. Oncological results with 80% disease free five-year survival rate were very good. Three patients died because of recurrences in the neck, only one because of a recurrence in the larynx. The rate of patients with a second primary, however, was extremely high (50%). CONCLUSIONS: By strictly following the pathological and clinical criteria for selection, about 25% of the SCC of the hypopharynx can be treated by transoral resection combined with neck dissection and postoperative irradiation with good oncological and excellent functional results, preserving the larynx without endangering the life of the patients.     

Transoral CO<Subscript>2</Subscript> laser management for selected supraglottic tumors and neck dissection

This study aimed to evaluate transoral laser resection as a method of choice for conservation surgery for supraglottic laryngeal carcinoma in carefully selected patients. Between 1987 and 2006, 55 patients with early supraglottic carcinoma were selected for transoral laser surgery. The outcome of the endoscopic CO₂ laser resection and larynx-sparing functional results without tracheotomy was evaluated. Fifty-five patients with T1, T2 supraglottic carcinomas underwent transoral CO₂ laser resection and seven patients with manifest neck metastasis required a neck dissection at one session with additional postoperative radiation therapy. There was no need for tracheotomy; deglutition was moderately disturbed. Forty of the 55 (73%) patients had no signs of recurrence to date. Fifteen patients with local recurrences underwent salvage therapies: six repeated laser excisions, three radiotherapies, four supraglottic laryngectomies and two total laryngectomies. Laser-specific survival is 84% and larynx preservation is 96%. The overall 5-year-survival after salvage treatment is 98%. Development of late metastasis required five radical neck dissections (RND) and radiation therapy. The results indicated that transoral laser resection can control early supraglottic cancer in selected patients and can be combined with simultaneous neck dissection with less morbidity than “open surgery”.     

Transoral approach to drain streptococcus pneumoniae spinal epidural abscess in an HIV-infected adult

Spinal epidural abscess due to Streptococcus pneumoniae is extremely rare in adults. It typically occurs in the thoracic, lumbar or lumbosacral epidural spaces, and less frequently in the cervical epidural space. The principal causative microbial agent is Staphylococcus aureus, representing 70% of cases, while 1.6% of cases are caused by S. pneumoniae. We report the first case of an HIV-infected patient with a cervical spinal epidural abscess. The patient was a 43-year-old male with pneumococcal bacteremia and a metatarsal abscess. He reported cervical pain with muscle spasm during cephalic flexion and extension, fever and a painful tumefaction on the second metatarsal of the left foot. MRI confirmed that the retropharyngeal abscess extended to the cervical spinal epidural space. Antibiotic therapy with cefotaxime plus vancomycin was initiated and a transoral surgical approach was used to achieve retropharyngeal and local debridement of the metatarsal abscess. Blood and pus cultures were positive for S. pneumoniae. After 4 months of follow-up the patient remained asymptomatic, without clinical or MRI evidence of recurrence.     

Transorale Resektion lokal fortgeschrittener Plattenepithelkarzinome der Oropharynxseitenwand

INTRODUCTION: Transoral laser microsurgery of locally advanced carcinomas of the lateral pharynx often results in exposure of major vessels of the neck and is accompanied by a substantial risk of intra- and postoperative bleeding. We therefore only perform these operations after external protection of neck vessels, if necessary combined with flap reconstruction. PATIENTS AND METHODS: Between October 2001 and December 2004, 11 locally advanced squamous cell carcinomas of the lateral oropharynx that reached the major vessels of the neck were treated as follows: after ipsilateral neck dissection with temporary protection of the jugular vein and carotid arteries, the neck remained open while transoral laser surgery of the primary tumor was performed. Pharyngeal defects were subsequently closed by either primary suture or a platysma myofascial flap. All patients underwent adjuvant radiotherapy. RESULTS: All primary tumors were completely resected. None of the patients required tracheotomy or placement of a percutaneous endoscopic gastrostomy tube. The mean duration of nasogastric feeding tubes was 12.7 days. In one case, the routine radiological contrast study revealed a blind cervical fistula 10 days after surgery. This healed spontaneously within 7 days. One mild postoperative hemorrhage had to be stopped by endoscopic coagulation under general anesthesia. During a mean follow-up of 19.4 months, none of the patients developed a local and/or regional recurrence. CONCLUSION: The surgical procedure described ensures sufficient protection of neck vessels during and after the transoral resection of advanced carcinomas of the pharynx. It successfully combines the advantages of minimally invasive laser microsurgery with those of flap reconstruction known from traditional surgery.     

Positron emission tomography scan to determine the need for neck dissection after chemoradiation for head and neck cancer: timing is everything

We present a case of a negative positron emission tomography (PET) scan in a patient with pathologic viable cancer at neck dissection. STUDY DESIGN: Case Report. METHODS: A 69-year-old man presented with clinical stage T2N2c squamous cell cancer of the left tonsil and was treated with definitive chemoradiation. Left-sided adenopathy decreased but remained palpable after therapy. RESULTS: PET scan performed 23 days after completion of treatment showed no suspicious uptake in the left neck. Neck dissection performed at 2 months post-therapy revealed viable tumor in left cervical nodes. CONCLUSIONS: Persistent adenopathy after chemoradiation for head and neck cancer remains a clinical dilemma. A negative PET scan is accurate but only if the scan is performed 3 to 4 months after therapy.     

Transoral laser resection with staged discontinuous neck dissection for oral cavity and oropharynx squamous cell carcinoma

Transoral laser resection of oral cavity and oropharynx squamous cell carcinoma (OOSCC) is a widely accepted approach in the absence of cervical lymph node metastases. This study investigated the results of transoral laser surgery and discontinuous neck dissection (ND) for OOSCC with clinically obvious or suspected cervical node metastases. One hundred seventeen patients with infiltrating oral carcinoma were treated for cure with transoral resection of the primary and staged ND. Twenty-nine primaries were classified as T1, 50 as T2, 35 as T3, and 3 as T4. Lymph node metastases were identified in the ND specimen of 36 patients. All patients were followed for a minimum of 3 years unless they died. Estimated tumor-related survival after 5 years is 81% for stage I and II disease of the oral cavity, 86% for stage I and II disease of the oropharynx, 73% for stage III disease of the oral cavity, 65% for stage III disease of the oropharynx, and 21% for stage IV disease of the oral cavity and the oropharynx. Local and regional control of cancer was achieved in 72 (62%) of the 117 patients. Forty-five local and regional recurrences were diagnosed during the follow-up period. Two patients died of distant metastases with no evidence of local or regional recurrence. The combination of transoral laser resection and staged ND for the treatment of OOSCC seems to offer satisfactory cure rates for a selected group of patients. These two minor surgical interventions cause less morbidity than commando-type surgery and lead to low perioperative mortality and morbidity.     

Transoral approach to drain streptococcus pneumoniae spinal epidural abscess in an HIV-infected adult

Spinal epidural abscess due to Streptococcus pneumoniae is extremely rare in adults. It typically occurs in the thoracic, lumbar or lumbosacral epidural spaces, and less frequently in the cervical epidural space. The principal causative microbial agent is Staphylococcus aureus, representing 70% of cases, while 1.6% of cases are caused by S. pneumoniae. We report the first case of an HIV-infected patient with a cervical spinal epidural abscess. The patient was a 43-year-old male with pneumococcal bacteremia and a metatarsal abscess. He reported cervical pain with muscle spasm during cephalic flexion and extension, fever and a painful tumefaction on the second metatarsal of the left foot. MRI confirmed that the retropharyngeal abscess extended to the cervical spinal epidural space. Antibiotic therapy with cefotaxime plus vancomycin was initiated and a transoral surgical approach was used to achieve retropharyngeal and local debridement of the metatarsal abscess. Blood and pus cultures were positive for S. pneumoniae. After 4 months of follow-up the patient remained asymptomatic, without clinical or MRI evidence of recurrence.     

A case of bilateral cervical lymph node metastasis of thyroglossal duct cancer

We reported a case of thyroglossal duct cancer, which metastasized to the bilateral cervical lymph nodes. The cervical lymph node metastases were detected in the upper portion of the neck. According to the results obtained in the preoperative fine needle aspiration cytology, the lymph node metastases were classified as group V and a diagnosis of papillary carcinoma was made. The preoperative studies with 123I revealed no concentration in the submittal tumor. In our surgical procedure, bilateral supraomohyoid neck dissection was added to excision of the tumor. CONCLUSION: In view of the fact that thyroglossal duct cancer metastasized bilaterally to cervical lymph nodes in the present case, we experienced an extremely rare case.     

Parapharyngeale Raumforderungen Differenzialdiagnostik anhand von Fallbeispielen

INTRODUCTION: Parapharyngeal tumors account for only 0.8% of all head and neck tumors which often presents the problem of preoperative diagnosis. Up to 80% of parapharyngeal tumors are benign. PATIENTS: Starting November 1995 to March 2001, 16 patients with parapharyngeal tumors and 1 retropharyngeal abscess were treated. The median age was 54 years. Only 2 patients demonstrated peripheral nerve lesions preoperatively. RESULTS: 17 tumors and the retropharyngeal abscess were excised via transcervical approach, with an extension by parotidectomy and temporary mandibular split in 1 case. Histological entities were pleomorphic adenomas in 5 cases, a ganglioneurinoma, neurinoma of the vagal nerve and metastasis of a squamous cell carcinoma in 2 patients each, furthermore neuroblastoma, extramedullary plasmocytoma, T-cell lymphoma, and hemangioma in 1 patient each. CONCLUSIONS: We demonstrate the differential diagnosis of parapharyngeal tumors as well as their diagnostic and therapeutic management. The tumors should be excised by a transcervical approach to protect cervical vessels and nerves, which is limited by a transoral approach.     

Advanced hypopharyngeal cancer with amyotrophic lateral sclerosis

We present a case of advanced hypopharyngeal cancer occurring in a patient with amyotrophic lateral sclerosis (ALS). A 58-year-old man diagnosed with ALS 2 years previously noticed a mass in his neck and dysphagia. We diagnosed him as having hypopharyngeal squamous cell carcinoma with the left cervical lymph node metastases (T3N2bM0) and treated with concurrent chemoradiotherapy. During and after the treatment, his neurological symptoms showed no worse signs. The patient has been cancer-free for 13 months after concurrent chemoradiotherapy. The influence of ALS on the patients’ quality of life (QOL) and/or prognosis had to be taken into consideration when determining an appropriate treatment for the hypopharyngeal cancer. To the best of our knowledge, this may be the first case with ALS who was treated for hypopharyngeal cancer.