累及声门旁间隙的梨状窝癌喉功能保存手术

目的：探讨累及声门旁间隙的梨状窝癌喉功能保存手术的可行性和治疗效果。方法：回顾性分析14例累及声门旁间隙梨状窝癌患者的临床资料。手术切除病变组织后行喉成形,同时行双侧选择性颈清扫术。术后3例患者未接受放化疗,其余11例均行放化疗。术后随访6个月~5年,平均3年6个月。结果：12例患者切口一期愈合,2例咽瘘经换药后痊愈。患者均有术后吞咽呛咳,最迟术后2个月拔胃管经口进食。11例术后放化疗者中10例随访3年未见复发,1例复发未治疗后死亡。3例未接受放化疗者中,2例在6个月内复发,行放化疗后1例未见复发,1例失访;1例术后8个月复发,行全喉切除术,术后放化疗,首次术后1年6个月死亡。3年生存率为78.6%;患侧声带6例有轻微动度,8例无明显声带解剖标志。结论：选择适当病例,对累及声门旁间隙的梨状窝癌患者行喉功能保存手术,可取得较好的临床效果,使患者有更好的生存质量。     

The value of ultrasound examination in preoperative neck assessment and in early diagnosis of nodal recurrences in the follow-up of patients operated for laryngeal cancer

The purpose of this study was to prove the superiority of ultrasound (US) examination of the neck in comparison to palpation, to reveal unpalpable nodes (pN0) before surgery, and to allow for the early detection of nodal recurrences in patients with laryngeal cancers. In all, 1,120 patients with laryngeal cancers were operated on between 1990 and 1997. All underwent palpation and neck US before surgery. In the pN0 group US revealed enlarged lymph nodes in 261/505 cases, of which 63 (24.14%) were confirmed as metastatic by histology. All 1,120 patients underwent regular postoperative US follow-up. Nearly 5,000 US examinations were performed; 136 patients who developed nodal recurrences had surgical salvage procedures. In this group 61 patients had small, nonpalpable lesions, and 46 patients discrete and slight changes in scarred necks. In this latter group of 117 patients with nonpalpable lesions, 105 cases were histologically confirmed as metastatic. In postoperative check-ups, metastases were suspected in sonographically detected subclinical nodes, but the US scans obtained were difficult to interpret. In these cases, because of the dynamics of lesion changes, US was repeated two to three times at 10- to 14-day intervals. This reappraisal enabled us to exclude malignancy in regressing nodes, as well as to obtain the stable picture of scar, and support a diagnosis while the lesion grew larger or a central area of low attenuation or hypoechogenic echos appeared in the nodal capsule. Successful radical reoperation for tumor was done on110 patients; 78 patients underwent successful salvage surgery after an early US diagnosis. The sonographic-surgical correlation was nearly 95% and the sonographic-histological correlation was 90%. The follow-up period was 1–49 months. In all preoperative assessments US was found to be a valuable tool in the staging of laryngeal cancer and planning the extent of surgery. Close follow-up with US after radiotherapy and initial operation was essential for the early detection of tumor recurrences, making surgical salvage still feasible. Received: 26 September 1998 / Accepted: 13 April 1999     

Application of laser surgery to the treatment of laryngeal cancer

The authors utilized CO2 laser to treat laryngeal cancer in 28 patients. The operative methods were the following: Method I. Glottic T1 tumor was completely vaporized by laser irradiation alone. This method was employed in cases without involvement of the anterior commissure and cartilagenous portion. Method II. Radiotherapy was carried out after removal of major lesion by laser surgery. The purpose of this method was to improve the success rate of radiotherapy. Method III. After radiotherapy laser surgery was done to remove residual tumor as far as possible in patients who could not undergo radical surgery due to poor general condition. Method I, or complete tumor resection by laser surgery alone, seemed profitable because of short admission period. It is, however, indispensable to select patients suitable for this treatment. Method II permitted improving the success rate of radiotherapy. Even after vaporizing major lesion by laser irradiation, 60Gy irradiation was required. Method III, or laser surgery on postradiation residual tumor was often useful to treat the patients with poor general condition or who refused more radical surgery.     

Chondrosarcoma of the skull base: long-term follow-up.

OBJECTIVE: Chondrosarcoma of the skull base is an uncommon neoplasm comprising 0.15% of all intracranial tumors and 6% of skull base neoplasms. The outcome of treatment is difficult to assess because the slow growth rate means that there is a long interval before detecting the recurrence. We describe the use of lateral skull base techniques for these lesions and examine the long-term outcomes. The pathological features, radiological findings, and radiotherapy options are also discussed. STUDY DESIGN: Retrospective case review with current follow-up where possible. SETTING: Tertiary referral neurotologic private practice. PATIENTS: Eight patients with histologically confirmed skull base chondrosarcoma operated on since 1979. At the time of the surgery, the five women and three men ranged in age from 31 to 63 years, with a mean of 42.9 years. The follow-up ranged from 9 months to 25 years and 5 months. INTERVENTIONS: All patients underwent surgical removal; the earliest patient underwent surgical removal via transcochlear and retrosigmoid approaches, and seven via an infratemporal fossa approach, with or without exenteration of the otic capsule. MAIN OUTCOME MEASURES: Number of patients with residual and recurrent tumors. RESULTS: In the patient who underwent surgery via the transcochlear approach, recurrence was noted within 3 months, and new exploration using the retrosigmoid approach was performed for the removal of the recurrent lesion. This patient showed no signs of recurrence for 25 years since last surgery. Of the seven patients who underwent surgery via the infratemporal fossa approach, one had residual tumor found at 1 year, but remained alive and well for 21 years after the surgery. The other six had gross total resection and showed no signs of recurrence at the last known follow-up. One patient died as a result of an unrelated cause 18 years after surgery for the chondrosarcoma. CONCLUSION: The gross total resection of these lesions is possible because of the evolution of lateral skull base techniques and can be routinely accomplished with the infratemporal fossa approach. The improved exposure afforded by this approach seems to have resulted in more complete extirpation of the tumor and a decrease in the recurrence rate.     

Clinical Impact of Using Chemoradiotherapy as a Primary Treatment for Hypopharyngeal Cancer

Eighty-eight patients with hypopharyngeal cancer who received chemoradiotherapy as the primary treatment between 1979 and 1997 were investigated. Forty-six patients who received surgery as the primary treatment were analyzed as a control group. There were no statistically significant differences regarding TN classification, tumor stage, tumor site, age or sex between the radiation and surgery groups. The 5-year cumulative survival rate of primary chemoradiotherapy was 47% and this did not differ significantly from that for the primary surgery group. The larynx was preserved in 74% of cases in the primary chemoradiotherapy group, a far better preservation rate than that in the surgery group. After primary chemoradiotherapy, complete remission (CR) was observed in 59% of cases and the average period of CR was 38 months. Among patients with residual tumor, a salvage operation was employed in 31 cases, 13 patients refused to receive surgery and 8 were inoperable. A salvage operation was performed in 35% of all cases and the 5-year cumulative survival rate was 50%. Based on the 5-year survival, primary CR, salvage and laryngeal preservation rates, we conclude that chemoradiotherapy is a good primary treatment for hypopharyngeal cancer     

Clinical impact of using chemoradiotherapy as a primary treatment for hypopharyngeal cancer

Eighty-eight patients with hypopharyngeal cancer who received chemoradiotherapy as the primary treatment between 1979 and 1997 were investigated. Forty-six patients who received surgery as the primary treatment were analyzed as a control group. There were no statistically significant differences regarding TN classification, tumor stage, tumor site, age or sex between the radiation and surgery groups. The 5-year cumulative survival rate of primary chemoradiotherapy was 47% and this did not differ significantly from that for the primary surgery group. The larynx was preserved in 74% of cases in the primary chemoradiotherapy group, a far better preservation rate than that in the surgery group. After primary chemoradiotherapy, complete remission (CR) was observed in 59% of cases and the average period of CR was 38 months. Among patients with residual tumor, a salvage operation was employed in 31 cases, 13 patients refused to receive surgery and 8 were inoperable. A salvage operation was performed in 35% of all cases and the 5-year cumulative survival rate was 50%. Based on the 5-year survival, primary CR, salvage and laryngeal preservation rates, we conclude that chemoradiotherapy is a good primary treatment for hypopharyngeal cancer.     

鼻内窥镜下鼻腔蝶窦径路垂体肿瘤切除术

目的 探讨在鼻内窥下经鼻腔蝶窦垂体肿瘤切除术的术式改进方法及麻醉方法。方法 用鼻窦内窥镜经鼻腔蝶窦入路切除垂体肿瘤４２例,其中局部麻醉加基础麻醉３７例,并作了如下改进：剥离梨骨翼及后鼻孔上缘区域的粘骨膜瓣和切除梨骨翼及蝶嘴,避免了损伤鼻中隔后动脉的可能,也增加手术操作的空间。结果 术中出血少,手术顺利,４２例均无并发症发生。术后随访６～３５个月,均有不同程度的症状改善。结论 用局部麻醉在鼻内窥镜下     

Merkel cell carcinoma of the head and neck

Merkel cell carcinoma (MCC) is a skin cancer arising from neurosecretory cells which take part in APUD system. In most cases it is locally growing tumor with significant tendency to local recurrences after surgery. The authors have described four cases MCC localised on the skin of the middle angle of the eye, lower eyelid, auricle and cheek, without nodal metastases. All patients have been surgery treated, in two cases reconstructive surgery was performed. Radiotherapy followed surgery was used for two patients. The authors have reported 5-year survival rate in 2 cases, 2-year disease-free rate and 18 month in other cases.     

Invertierte Papillome der Nase und ihrer Nebenhöhlen Langzeitergebnisse nach endoskopischer endonasaler Resektion

There is still some skepticism about endoscopic endonasal resection of inverted papillomas. We conducted a long-term retrospective study and examined 104 patients (82 male, 22 female) with inverted papilloma who were operated at the ENT-Department of the University of Erlangen between 1974 and 1997. The endoscopic approach was chosen in each case, either alone or in combination with external approaches. In 64.4% (67 cases), tumors of all T-classes were resected by endoscopic approach alone (T1:17.9%, T2:23.9%, T3:41.8%, T4:16.4%). For the rest of the patients an additional transoral and transfacial approach was necessary due to difficult tumor localization (T2:24.3%, T3:29.7%, T4:45.9%). The mean age of the patients was 55 years. The recurrence rate after primary endoscopic endonasal sinus surgery was 22.4% (15/67) and after combined endoscopic and external surgery 16.2% (6/37). Second salvage surgery after endoscopic sinus surgery was performed again endonasally in 46% (7/15) and externally in 53.3% (8/15). The recurrence rate after the endonasal approach was now 57.1% (4/7) and 50% (4/8) after external surgery. Third salvage surgery was performed again endoscopically in four cases and externally in four cases. The recurrence rate in both groups was 50% each, so that up to six operations, either endoscopically or externally, were necessary for complete tumor resection. The longest period for a tumor recurrence was 3.4 years after endoscopic sinus surgery and 9 years after combined endoscopic and external surgery. A tumor recurrence after endoscopic endonasal sinus surgery that could not be managed endoscopically again occurred in 12%. Tumor localization is the limiting factor for endoscopic endonasal sinus surgery of inverted papilloma. However, in 64.4% of cases, endoscopic endonasal sinus surgery alone was performed successfully without any loss of one patient. Long-term follow-up is necessary since the recurrence of tumor can happen after a long time. Endoscopic endonasal sinus surgery of inverted papilloma is safe and should be preferred due to its minimal invasive character.     

The role of magnetic resonance angiography in head and neck surgery

Magnetic resonance angiography (MRA) is a recently developed, noninvasive vascular imaging technique. The authors of this investigation assessed the diagnostic value of MRA, along with its influence on therapeutic decisions, in 11 patients with a variety of head and neck disorders. In 5 patients, MRA diagnosed or ruled out an intrinsic vascular lesion. MRA was used to evaluate 5 of 8 patients with cancer for evidence of direct tumor involvement of vascular structures. Other uses of MRA included preoperative determination of tumor vascularity and delineation of anatomic relationships between normal vessels and head and neck pathology. Overall, MRA results guided management in 10 patients, and in some cases it determined the extent of surgical intervention. Because MRA is safer and more practical than traditional angiography, the authors recommend more frequent use of this imaging technique in the practice of head and neck surgery.     

External lateral osteotomy in rhinoplasty for the correction of nasal dorsal deviations

We present a revision of 45 patients with nasal deviation operated on between 1993 and 2001. Septorhinoplasties were done in all cases using the external lateral nasal osteotomies technique. 67% of our patients were male and 33% were female with a mean age of 25. In all cases a septoplasty was performed. To correct nasal deviation, medial osteotomies through an intercartilaginous approach and external lateral nasal osteotomies were done. We did a postoperative follow-up of 35 patients. In terms of patient satisfaction, 78% of them felt that their nasal appearance had improved after surgery, and 22% felt that they had a great improvement. One case had to be reoperated on because of a traumatic nasal fracture after surgery. We believe this technique offers important advantages, such as: an excellent control of the fracture line, fewer incidences of open roof and lateral step, without causing visible scars.     

中耳乳突炎性病变的人工耳蜗植入术

目的探索双侧重度感音神经性聋合并中耳乳突炎性病变人工耳蜗植入手术方法.方法 29例不同类型中耳乳突炎患者行人工耳蜗植入手术,根据炎症病变程度采用Ⅰ期手术26例,分期手术3例.非化脓性及慢性中耳炎静止期者,行完壁式乳突根治术,清除病灶,保留骨性外耳道,同期行人工耳蜗植入;化脓性中耳炎者,行完壁式或开放式乳突根治术,清除病灶保留骨性外耳道或重建外耳道后上壁,获得干耳后,Ⅱ期行人工耳蜗植入.结果 29例中耳乳突不同炎症病变患者经Ⅰ期或分期手术,人工耳蜗电极均顺利植入.随访2～8年,无炎症病变复发,开机后人工耳蜗工作正常,无电极裸露、脱出.结论中耳乳突炎性病变经正确的手术措施干预后,可行人工耳蜗植入.强调依据病变程度和范围个性化处理.     

Juvenile nasopharyngeal angiofibroma. A report of eighteen cases

Juvenile nasopharyngeal angiofibroma is a disease afflicting mainly adolescent males. The lesion is benign but characterized by local aggressive growth. In advanced cases the tumour may extend intracranially. In this study 18 cases of juvenile nasopharyngeal angiofibroma were investigated. Tumour extension was assessed with the use of angiograms and CT and the individual cases staged in four different categories on the basis of tumour extension. Two cases were staged as I (tumour confined to the nasopharynx), 7 cases as II (tumour extending into nasal cavity and/or sphenoid sinus), 8 as III (tumour extending into one or more of the following: antrum, ethmoid sinus, pterygomaxillary and infratemporal fossae, orbit and/or cheek) and one as IV (tumour extending into the cranial cavity). Preoperative arterial embolization was performed in 8 cases. All patients underwent surgery; none received irradiation. The follow-up period was 6 yrs 4 mo (6 months-17 years). In one case of intracranial extension, tumour recurrence occurred. It is concluded that with the aid of CT and arteriograms to evaluate the extension of the tumour and preoperative embolization, this lesion can be cured in the vast majority of cases, with surgery as the method of choice.     

Radiation following surgery for oral cancer: impact on local control

OBJECTIVES: The use of postoperative radiation therapy (RT) is commonly used in the treatment of patients with high-risk squamous cell carcinoma of the head and neck. However, few data exist that quantitate the incremental benefit of RT when administered following surgery. The retrospective study was designed to measure the incremental benefit of adjuvant RT after surgery on control of the primary lesion when compared with patients undergoing surgical therapy alone for squamous cell carcinoma of the oral cavity. STUDY DESIGN: Retrospective chart. METHODS: Previously untreated patients with squamous cell carcinoma of the floor of mouth or oral tongue who were treated between 1974 and 1998 were eligible for study. A minimum follow-up of 2 years was required. Tumor site, stage, and RT data were correlated with local control. RESULTS: Patients with missing or incomplete data and those lost to follow-up or dead as a result of intercurrent disease with follow-up of less than 2 years were censored. A group of 211 patients who could be evaluated was available for the study. Radiation therapy was administered postoperatively to 58 patients, and 153 patients were treated with surgery alone. In the group treated with combined therapy, the average irradiation dose was 5850 cGy; this group included 35 patients who received more than and 16 who received less than 5700 cGy. CONCLUSIONS: The incremental benefit in terms of control of tumor at the primary site for patients receiving postoperative RT was between 0% and 7%. Surgery alone controlled 80% to 85% of primary tumors. The dose of postoperative RT did not correlate with local control.     

Laryngotracheal reconstruction and the hidden airway lesion

OBJECTIVE: Single-stage laryngotracheal reconstruction (SSLTR) is an increasingly common technique to achieve decannulation of patients with laryngotracheal stenosis. In a proportion of cases airway distress on extubation may be attributed to a dynamic second airway lesion not diagnosed before surgery. Our aim is to describe our recent experience with these frustrating patients. METHODS: Between July 1997 and July 1999 we prospectively followed patients who underwent SSLTR and experienced difficulty after extubation owing to an unsuspected second airway lesion. RESULTS: During this 24-month period we performed 80 SSLTRs. In six surgeries performed on five patients, a second airway lesion complicated extubation. In five patients the second lesion was not diagnosed before surgery because there was significant airway stenosis and tracheotomy. The sixth patient was transferred to our care intubated. In all cases the airway surgery for the dominant lesion was technically successful, but revealed a second dynamic lesion. There were three cases of tracheomalacia, two cases of laryngomalacia, and one case of arytenoid prolapse. All patients required intervention. Tracheotomy was required in four patients. CONCLUSIONS: Failure to achieve extubation after SSLTR may be caused by a dynamic second airway lesion that was previously disguised by a more dominant airway lesion. Surgical repair of the dominant lesion will allow manifestation of the dynamic lesion due to the Bernoulli effect. The combination of a tracheotomy and a dominant airway lesion limits airflow and potentially disguises the situation.     

Diode laser surgery in the endoscopic treatment of laryngeal paralysis

Several surgical procedures have been proposed for the treatment of respiratory distress secondary to bilateral vocal cord paralysis. The aim of all surgical techniques used is to restore a glottic lumen sufficient to guarantee adequate breathing through the natural airway, without tracheotomy and preserving an acceptable phonatory quality. In this study we present our experience from 1998 to 2004 concerning the use of the diode contact laser for a modified Dennis-Kashima posterior endoscopic cordectomy (extended to the false homolateral chord in 3 cases and to the homolateral arytenoid vocal process in 6 cases). 18 patients (15 male, 3 female) were treated; the age range was 35-84 years. The etiology of paralysis varied: iatrogenic post-thyroidectomy and post-thoracic surgery in 5 cases (28%), post-traumatic in 2 cases (11%), secondary to a central lesion in 11 (61%). The operation was carried out with a diode contact laser (60W; 810 nm). Follow-up was 20 months. Dyspnea improved in all patients; the 9 tracheostomized patients were decannulated within 2 months after surgery. Final voice quality was subjectively good in 16 patients (88%). None of patients had any complications after surgery. In conclusion, the endoscopic posterior cordectomy performed by contact diode laser is an effective and reliable method for the treatment of dyspnea secondary to bilateral laryngeal paralysis, guaranteing a sufficient airway without impairing swallowing and maintaining acceptable voice quality.     

鼻内镜下低温等离子射频手术治疗鼻腔鼻窦良性肿瘤

目的 总结鼻内镜下低温等离子射频切除鼻腔良性肿瘤的疗效。方法 回顾性分析2012年1月至2013年5月诊治并完成1年随访的17例鼻腔鼻窦良性肿瘤患者的临床资料。患者均在鼻内镜下应用低温等离子射频实施手术, 其中内翻性乳头状瘤8例, 鼻咽纤维血管瘤1例, 鼻腔血管瘤3例, 上颌窦出血坏死性息肉5例。结果 术中出血量为5~150 mL, 中位数为30 mL。手术时间为20~55 min, 中位数为35 mim。术后2个月术腔上皮化良好, 无出血、鼻腔干燥等并发症。随访1年未见复发。结论 鼻内镜下低温等离子射频手术治疗鼻腔鼻窦良性肿瘤具有出血少、损伤小、手术时间短等优点。     

Surgical management of skull base chondroblastoma

OBJECTIVES: Chondroblastoma is a rare tumor accounting for 1% of primary bone tumors. Chondroblastoma involving the skull base is exceedingly rare with approximately 60 cases reported. We reviewed our experience with chondroblastoma of the skull base with an emphasis on current lateral skull base approaches and long-term tumor control. STUDY DESIGN AND SETTING: A retrospective case review at a tertiary neurotology private practice group was performed over a 20-year period. Five patients were identified with skull base chondroblastoma. All patients underwent surgical intervention, and success of surgery was determined by disease-free status at last follow-up. Mean follow-up time was 5.8 years. RESULTS: Two patients underwent gross tumor removal as primary therapy. One patient underwent partial tumor removal at an outside institution, and follow-up magnetic resonance imaging demonstrated rapid growth of residual tumor. This patient was successfully treated with gross total removal of residual tumor with an infratemporal craniotomy approach. Near total tumor removal was performed in two patients because of intimate involvement of vital structures. At last follow-up, no patient had radiographic evidence of tumor recurrence. There were no significant postoperative complications. CONCLUSIONS: Gross total or near total resection of skull base chondroblastomas through lateral skull base approaches results in long-term tumor control and low complication rates.     

Surgical treatment of temporomandibular joint: apropos of 94 cases

INTRODUCTION: The temporomandibular joint (TMJ) is a complex entity subjected to repeated stress with several symptoms. About one-third of people have at least one of those symptoms but only few (3 to 7%) need treatment. The aim of this retrospective study was to evaluate the results of temporomandibular joint surgery in 94 patients. PATIENTS AND METHODS: Several data were used for decision-making and the surgical technique was adapted to the etiology. The type of postoperative physiotherapy performed depended on the type of pathology. RESULTS: Most patients who underwent surgery between 1989 and 2004 were women (83%). The mean age was 30 years. We performed 179 surgical procedures and among them 151 Dautrey procedures. In 28 cases miniplates were used to avoid recurrences. In 57 cases postoperative physiotherapy was performed. The mean postoperative mouth opening increase was 4.7 mm (+ 23%). There was no infection or lost of plate. The mean of follow-up was about 14 months. DISCUSSION: With a long follow-up and an acceptable number of patients and operations, this retrospective study demonstrated the effectiveness of the Dautrey procedure in TMJ subluxations.     

Cricotracheal resection for pediatric subglottic stenosis

Until recently, cricotracheal resection (CTR) has not been commonly accepted as a treatment modality for severe subglottic stenosis in the pediatric age group. The reasons have included the risk of a possible dehiscence at the site of the anastomosis, the likelihood of injury to the recurrent laryngeal nerves, and the interference with normal growth of the larynx. Thirty-eight infants and children with a severe subglottic stenosis underwent a partial cricoid resection with primary thyrotracheal anastomosis. Thirty-three patients were tracheotomy-dependent at the time of surgery and 34 were referred cases; 27 were classified as grade III, and 10 as grade IV stenoses according to new Cotton's classification. Nineteen patients were younger than 3 years of age at the time of surgery. The tracheotomy was resected during the surgical procedure in 21 cases. Decannulation was achieved in 36/38 cases after an open procedure. There is one complete restenosis and one good result awaiting decannulation after further surgery for a Pierre Robin syndrome. The authors experienced no lesion of the recurrent laryngeal nerves and no fatality. Thirty-one patients show no exertional dyspnea, three a slight stridor while exercising, and two patients are not decannulated. The postoperative follow-up in longer than 10 years in eight cases. All patients show a normal growth of the larynx and trachea. Compared to laryngotracheoplasties, CTR gives better results for severe subglottic stenosis. This operation should become the treatment of choice for severe (grade III and IV) subglottic stenosis in infants and children.