Surgical treatment of the neck in cancer of the larynx

Current concepts in management of the clinically negative and clinically positive neck in laryngeal cancer are reviewed. Occult disease in the neck not detected by physical and radiographic examination may also be difficult to identify on routine histologic examination. Immunohistochemistry or molecular analysis may detect metastatic involvement not apparent by light microscopy. The surgeon should be aware of the relatively high incidence of micrometastases in patients with laryngeal cancer to establish optimal treatment approaches. Elective treatment of the neck is recommended for supraglottic tumors staged T2 or higher, and glottic or subglottic tumors staged T3 or higher. The neck may be treated electively by either surgery or irradiation, but irradiation is best reserved for cases where that modality is employed for the primary tumor. Elective neck dissection provides important information for prognostic purposes and therapeutic decisions, by establishing the presence, number, location and nature of occult lymph node metastases. The selective lateral neck dissection (levels II, III and IV), unilateral or bilateral, is the procedure of choice for elective treatment. Paratracheal nodes (level VI) should be dissected in cases of advanced glottic and subglottic cancer. Complete radical or functional neck dissections are excessive in extent, as levels I and V are almost never involved. Sentinel lymph node biopsy may fail to detect tumor on frozen section examination or may not reveal 'skip' metastases. The clinically involved neck is usually treated by complete radical or functional neck dissection of levels I through V. Selective neck dissection has been employed successfully in selected cases, particularly for N1 or occasionally N2 nodal involvement. The selective neck dissection can be extended to include structures at risk. More advanced disease has been treated in this manner often in association with adjuvant chemotherapy and/or irradiation. While the benefit of adjuvant treatment is difficult to assess, it appears most useful in cases with extranodal spread of disease, a factor associated with the worst prognosis.     

An alternate method for determining functional gain of hearing aids

The functional gain of a hearing aid typically is determined by comparing aided and unaided behavioral thresholds. With this method, however, true gain may be underestimated in frequency regions of normal or near-normal hearing sensitivity (i.e., in cases of sloping, rising, or trough-shaped audiograms). Internal hearing-aid noise and/or amplified room noise imposes a lower limit on obtainable aided thresholds. In these cases, comparing aided and unaided acoustic-reflex thresholds may be a valuable clinical alternative to traditional means of determining real-ear gain. This study compared sound-field behavioral threshold and acoustic-reflex threshold estimates of functional gain for individuals with a variety of audiometric configurations. The sound-field behavioral threshold measurements were found to underestimate functional gain if unaided thresholds approached the normal hearing range. In regions of greater hearing loss, behavioral and acoustic-reflex estimates of functional gain were in good agreement.     

Plasma cell tumors of the head and neck

This communication discusses seven cases of plasma cell tumors isolated to the head and neck and reviews the pertinent literature. Five of the cases presented were located in the nasal passages and the paranasal sinuses, one in the temporal bone and one in the mandible. Because these neoplasms may signal the presence of multiple myeloma, full evaluation is required to exclude disseminated disease. Thereafter, the treatment of choice is high-dose radiotherapy with life-long follow-up. Radiographs and paraprotein levels may be used to assess tumor control or dissemination. Should new lytic lesions occur, or an elevation in paraprotein levels be noted, consideration should be given to further irradiation or systemic chemotherapy. Surgery is reserved exclusively for diagnostic purposes or when severe functional disability intervenes.     

Neural plasticity and neurorehabilitation: teaching the new brain old tricks

Following brain injury or disease there are widespread biochemical, anatomical and physiological changes that result in what might be considered a new, very different brain. This adapted brain is forced to reacquire behaviors lost as a result of the injury or disease and relies on neural plasticity within the residual neural circuits. The same fundamental neural and behavioral signals driving plasticity during learning in the intact brain are engaged during relearning in the damaged/diseased brain. The field of neurorehabilitation is now beginning to capitalize on this body of work to develop neurobiologically informed therapies focused on key behavioral and neural signals driving neural plasticity. Further, how neural plasticity may act to drive different neural strategies underlying functional improvement after brain injury is being revealed. The understanding of the relationship between these different neural strategies, mechanisms of neural plasticity, and changes in behavior may facilitate the development of novel, more effective rehabilitation interventions for treating brain injury and disease. LEARNING OUTCOMES: Readers will be able to: (a) define neural plasticity, (b) understand how learning in the intact and damaged brain can drive neural plasticity, (c) identify the three basic neural strategies mediating functional improvement, and (d) understand how adjuvant therapies have the potential to upregulate plasticity and enhance functional recovery.     

Survival,functional, and quality of life outcomes between total glossectomy with and without total laryngectomy: A narrative review

BackgroundA total glossectomy (TG) may be required for advanced tongue tumors. TG with total laryngectomy (TGL) may be indicated in some cases with tumor extension into the larynx or high risk of aspiration. Total glossectomy with laryngeal preservation (TGLP) may preserve phonation ability relative to TGL, yet TGLP may increase the risk of aspiration.MethodsFor this narrative review, we performed a comprehensive literature search of studies relevant to TG and TGL. Clinical studies investigating survival, functional outcomes, and quality of life in following TGLP or TGL were of particular interest.ResultsFew studies in the literature directly compare survival, functional, and quality of life (QOL) outcomes between TGLP and TGL. TGLP is associated with intelligible speech. However, studies investigating gastrostomy tube dependence following TGLP versus TGL have generated conflicting results.ConclusionFurther research on functional and QOL outcomes in patients undergoing TGL or TGLP is needed.     

High-performance liquid chromatographic identification of enkephalin-like peptides in the cochlea

Met-enkephalin was identified in cochleae from guinea pigs by a combined reversed-phase high-performance liquid chromatographic separation and subsequent radioimmunoassay of the chromatographic fractions. A second Met-enkephalin-immunoreactive fraction was found in the cochlea, with a retention time shorter than that of Met-enkephalin. These findings confirm and extend earlier cytochemical observations, and suggest the differential immunocytochemical staining seen under inner and outer hair cells in the cochlea may be related to different peptides in the two efferent systems innervating the cochlea. Different molecular forms of enkephalin-related peptides may serve different functional or metabolic roles in complex efferent or local regulation of peripheral sensory processing.     

Cytodifferentiation within the developing human endolymphatic sac.

The cytodifferentiation of the human endolymphatic sac was studied in the period between gestational weeks 8 and 20. This period is of particular interest since it covers the major part of the morphological and functional maturation of the human inner ear. The studied time, i.e. 8-20 weeks of gestation, may be divided into three periods. Before week 10, between weeks 11 and 15 and weeks 15-20. While the endolymphatic sac appears as a simple slit-like appendage in the first period, until week 10 with cells of uniform size and shape, a beginning cytodifferentiation occurs in the second period between weeks 10 and 15. Thus the cells attain a more mature shape with different stainability, i.e. light- and dark-staining cells, as well as open lateral intercellular spaces indicating some functional maturity. In the third period, after week 15, the endolymphatic sac more or less seems mature with a rugose appearance in its proximal portion and a more even, slit-like appearance in the distal portion. The cells are differentiated with morphological signs of functional maturation. It may be concluded that the development of the endolymphatic sac roughly follows that of the cochlea which is regarded to be functionally mature in the beginning of the second half of pregnancy.     

Functional recovery in the avian ear after hair cell regeneration.

Trauma to the inner ear in birds, due to acoustic overstimulation or ototoxic aminoglycosides, can lead to hair cell loss which is followed by regeneration of new hair cells. These processes are paralleled by hearing loss followed by significant functional recovery. After acoustic trauma, functional recovery is rapid and nearly complete. The early and major part of functional recovery after sound trauma occurs before regenerated hair cells become functional. Even very intense sound trauma causes loss of only a proportion of the hair cell population, mainly so-called short hair cells residing on the abneural mobile part of the avian basilar membrane. Uncoupling of the tectorial membrane from the hair cells during sound overexposure may serve as a protection mechanism. The rapid functional recovery after sound trauma appears not to be associated with regeneration of the lost hair cells, but with repair processes involving the surviving hair cells. Small residual functional deficits after recovery are most likely associated with the missing upper fibrous layer of the tectorial membrane which fails to regenerate after sound trauma. After aminoglycoside trauma, functional recovery is slower and parallels the structural regeneration more closely. Aminoglycosides cause damage to both types of hair cells, starting at the basal (high frequency) part of the basilar papilla. However, functional hearing loss and recovery also occur at lower frequencies, associated with areas of the papilla where hair cells survive. Functional recovery in these low frequency areas is complete, whereas functional recovery in high frequency areas with complete hair cell loss is incomplete, despite regeneration of the hair cells. Permanent residual functional deficits remain. This indicates that in low frequency regions functional recovery after aminoglycosides involves repair of nonlethal injury to hair cells and/or hair cell-neural synapses. In the high frequency regions functional recovery involves regenerated hair cells. The permanent functional deficits after the regeneration process in these areas are most likely associated with functional deficits in the regenerated hair cells or shortcomings in the synaptic reconnections of nerve fibers with the regenerated hair cells. In conclusion, the avian inner ear appears to be much more resistant to trauma than the mammalian ear and possesses a considerable capacity for functional recovery based on repair processes along with its capacity to regenerate hair cells. The functional recovery in areas with regenerated hair cells is considerable but incomplete.     

Early surgery of immature hemangiomas with the aid of an ultrasonic scalpel. Apropos of 81 cases

BACKGROUND: The natural course of immature hemangiomas in infants is well-known. A rapid phase of growth from 6 to 8 months is followed by a period of stability then regression. Since approximately 70% of these immature hemangiomas resolve spontaneously, abstention is generally the rule. The volume or localization of certain lesions may nevertheless have a serious functional or morphological impact. MATERIAL AND METHODS: This retrospective study included 81 children who underwent surgery between October 1994 and March 2000. The children were aged 2 to 38 months at the time of surgery. Orbital localizations predominated (33 children). The indication for surgery was based on two criteria: risk of a functional impairment or risk of morphological sequela. All children with orbital hemangiomas with a functional risk of amblyopia were initially treated with corticosteroids. Surgery was performed in case of failure. The CAVITRON was used for 77 children and DISSECTRON for 4. These two ultrasound devices allowed easy dissection with little hemorrhage. RESULTS: There were no peroperative hemorrhagic complications. Few postoperative complications were observed. After resection of the orbital hemangiomas there was little functional impact and the postoperative ophthalmologic examinations were normal within several weeks. Mean follow-up was 12 months after surgery. Use of an ultrasound dissector allowed early and safe treatment of immature hemangiomas. DISCUSSION: Certain voluminous or poorly localized hemangiomas, particularly on the face, can have a serious function, morphological or psychological impact. Medical treatment is not always active and surgical resection may be required before the development of definitive sequelae. Ultrasound dissection, not previously used in this indication, can contribute significantly to the surgical outcome as demonstrated in these children operated on early. This technique is safe and shortens operative time. In light of these results, we believe early resection of immature hemangiomas should be reevaluated. It should not be considered as a last resort but rather as a complementary treatment.     

Postoperative functional results in oral and oropharyngeal tumors

The functional results of surgery for intraoral tumours were evaluated in a retrospective study. Among the many reconstructive techniques there is a place for healing by secondary intention or for primary closure of the defect. Bony reconstruction after lateral mandibulectomy may be omitted. The determining factors for good postoperative results were motivation, functional deglutition and speech exercises.     

Microsurgical neurolysis of the 8th cranial nerve in cochleo-vestibular disorders using an extended transtemporal approach

A series of 17 patients suffering from progressive cochleovestibular disturbances (8), severe attacks of Menière's disease (5), progressive or sudden sensori-neural deafness (2), vestibular neuronitis (1) or unbearable tinnitus (1) is reported. The eighth cranial nerve was exposed from its root at the brainstem to its exit into the fundus of the internal auditory canal (CAI), by an extended middle fossa approach. The surgical technique and the intraoperative observations are described. All cases showed morphological abnormalities such as neuro-vascular compression of the nerve by arterial or venous vessels, either at the brainstem or laterally at the CAI. Horizontal or vertical dislocations of the nerve were also noticed. Traction, compression or even strangulation of the nerve fibres or of their accompanying vessels may be co-factors of the functional disturbances. Striking improvement of the vestibular disorders was recorded following neurolysis of the eighth nerve, showing that retrolabyrinthine abnormalities may be possible causes of Menière's disease and other supposedly labyrinthine disorders. The preliminary results regarding hearing and tinnitus were hitherto unsatisfactory. This fact may be explained by the, as yet, imperfect technique of neurolysis.     

How I do it: salivary duct preservation in the excision of small oral tumors

Benign tumors, in-situ carcinomas and small carcinomas of the anterior floor mouth or of the internal surface of the cheek may require resection of salivary duct papilla i.e. papilla of submandibular duct or Stensen's duct. If a lymph node dissection is not required, excision of submandibular or parotid duct which papilla is interested in the resection can be avoided using a surgical technique not reported. The authors present two cases illustrating a simple surgical proceeding of salivary duct resection/transposition. The present method can be used to keep a functional principal salivary gland with an optimal oncologic result.     

Oralism and the deaf child's brain: a reply to Dr. Conrad

One of the most contentious and important issues in the education of deaf children concerns the nature of the medium that should be used. The argument is whether the language of the hearing society should be used (Oralism) or a visual manual language together with speech (Total Communication or bilingualism). Recently Conrad [6,7] has claimed that the exclusive use of Oral methods fails to provide the deaf child's brain with sufficient linguistic information at an early enough age and so runs the risk of obstructing neurological growth so that functional atrophy may occur. In this situation Conrad argues ‘we should not ignore the possibility that the “functional atrophy” … may come to involve structural atrophy as well.’ He concludes that Oral schools “virtually are cognitively destroying deaf children.”Conrad's case rests on his interpretation of 3 kinds of circumstantial evidence. These are animal studies of auditory deprivation, hemispheric lateralization studies of deaf and hearing subjects, and finally his own data. In the present paper each of these 3 kinds of evidence is reviewed and alternative interpretations are advanced against Conrad's hypothesis of functional atrophy. It is argued that the case that Oralism is responsible for brain atrophy is not proven. It is concluded that the main problem facing deaf children and their teachers is deafness itself, and not any particular educational philosophy and group of methods such as Oralism.     

Reconsidering the concept of the aided threshold for nonlinear hearing AIDS

The aided threshold (and functional gain) has been discussed in the context of linear hearing aids since the early 1960s. The use of nonlinear hearing aids, however, could change the meaningfulness of this verification tool because of their unique characteristics. The interpretation of the aided threshold (and functional gain) as it pertains to linear and nonlinear hearing aids is reviewed. Also discussed are the ideas of an optimal aided threshold, factors that may affect its magnitude, and a comparison between functional gain and insertion gain measures. Finally, how to improve the accuracy of the aided thresholds (and functional gain) through the use of in-situ unaided threshold measurements is discussed.     

Voice disorders in the elderly

A review of the literature clearly shows that connective tissue degeneration in the larynx, particularly of elastic and collagen fibers, is more prevalent in males than in females. Reinke's edema or polypoidal degeneration of vocal cords may or may not be more common in females. Whether or not the above statements are true, tissue atrophy causes a problem in males because the voice becomes higher pitched, weak or reedy, less masculine, whereas polypoidal change in the older female larynx results in a lower pitch, husky voice that would be acceptable in a male but makes the female voice more male-like and undesirable. Functional misuses of laryngeal muscles come into play when patients try to compensate for these changes. The etiology of dysphonia in the elderly gets even more confusing when psychological factors such as loneliness and depression add their effects to laryngeal muscle misuse. Laryngeal cancer is still probably the most common cause of hoarseness in older persons. Unfortunately the biopsy to rule out cancer in a person who is hoarse from degenerative or functional causes will often greatly worsen the dysphonia and render voice therapy less effective.     

Total glossectomy for advanced carcinoma of the base of the tongue

The treatment of patients with advanced carcinoma of the base of the tongue is difficult. Selected patients with this lesion can be aided by an aggressive therapeutic approach to this problem. Combined therapy consisting of irradiation therapy followed by composite resection of the entire tongue and larynx and neck dissection may offer the best opportunity for cure or palliation in these patients. Reconstruction of the defect with a non-delayed full forehead flap has provided a very satisfactory floor of the mouth. The postoperative functional abilities of these patients have clearly been compatible with useful life.     

Skull base reconstruction and rehabilitation.

This article separates skull base reconstruction into the surgical procedures available for immediate reconstruction of a small base defect and the secondary rehabilitative procedures that may be performed at a later date, usually for functional or cosmetic needs.     

Behavioral management of pediatric dysphonia

Children's voice disorders may be functional or organic in cause and a thorough evaluation by the otolaryngologist and speech-language pathologist is necessary to obtain the proper diagnosis, to understand the underlying etiologic factors, and to prepare a plan of treatment that is appropriate for the child. Because voice disorders may be present with developmental communication problems, treatment must include all factors that affect growth and development of the child.     

Comparing criteria of hearing impairment in the elderly: a functional approach

We determined and compared the associations of four commonly used audiometric criteria of hearing impairment with two functional outcome measures in 152 aged persons screened in primary care medicine practices. The outcome measures were the Sickness Impact Profile (SIP, a measure of global function), and the Hearing Handicap Inventory for the Elderly-Screening Version (HHIE-S, a communication-specific measure of functional impairment). There were five main findings. (1) The four criteria of hearing loss were not independent. (2) The criterion of loss chosen depends on the functional measure of impairment. (3) Functional hearing impairment may also be classified by the number of criteria met. (4) A large subset (21%) of aged persons met one criterion but had little in the way of communicative or global dysfunction. (5) Hearing handicap as measured by the HHIE-S was directly associated with global dysfunction as measured by the SIP.     

Catheter implantation for intra-arterial chemotherapy of malignant tumors of the head and neck

Tumors of the head and neck are mainly squamous cell carcinomas of varying differentiation. If the tumor is advanced (T3-T4) or distant metastases are present, the tumor is often to be regarded as inoperable. If cure is unlikely or substantial functional impairment is to be expected, surgery may no longer seem reasonable, even for tumors limited to one side. Since either radiotherapy or chemotherapy alone or in combination are often disappointing or have considerable side-effects, it seems reasonable to try to inhibit malignant cell growth by administering a cytostatic agent by intra-arterial "superselective" chemotherapy using an implantable catheter. The method is simple, and the patients may also receive combined radiotherapy if necessary. Furthermore, ambulant treatment is possible, with a substantially reduced risk of infection. This is an advantage compared with other catheter techniques, particularly in view of the restricted expectation of life of patients with advanced tumor. The disadvantage of "A-port implantation" is that chemotherapy can only start after complete wound healing.