Time course of subacute pain after transoral robotic surgery (TORS) for oropharyngeal squamous cell carcinoma versus traditional bilateral tonsillectomy in adults – a case–control study

Objective: To examine pain after Transoral Robotic Surgery (TORS) for oropharyngeal squamous cell carcinoma (OPSCC) versus traditional bilateral tonsillectomy in adults.

Methods: Pain evolvement was assessed in a prospective case–control design of 16 consecutive patients treated with TORS for early stage OPSCC versus 12 patients, who underwent bilateral tonsillectomy on suspicion of malignant disease. The TORS group received an optimized analgesia regime of preoperative oral celecoxib and gabapentin, intra- and postoperative high-dose intravenous dexamethasone, and regular postoperative oral contalgin, gabapentin, celecoxib, paracetamol and rescue morphine. The tonsillectomy group received the departmental standard analgesia regime with low-dose preoperative oral dexamethasone, celecoxib and paracetamol. Postoperative regular analgesia consisted of oral NSAID and paracetamol with weak opioids prescribed as required. Pain intensity was recorded at rest and during swallowing twice a day.

Results: The median pain intensity on postoperative day (POD) 1–4 was 2 in the TORS group versus 4.5 in the tonsillectomy group. From POD 5-10 median pain intensity was 3.5 and 4, respectively. The median length of stay was 5 days in the TORS group and less than 24?hours in the tonsillectomy group.

Conclusion: With an optimized analgesia regime TORS for OPSCC can be performed with postoperative pain levels comparable to bilateral tonsillectomy in adults.     

The emerging role of trans-oral robotic surgery for the detection of the primary tumour site in patients with head-neck unknown primary cancers: A meta-analysis

The identification of the site in head neck unknown primary (HNUP) tumour is of utmost importance to help select best treatment while decreasing treatment-related morbidity and mortality. The primary purpose of this study is to demonstrate that TORS may be a valuable tool in detecting primary tumour. Studies were systematically searched in the PubMed, EMBASE, the Cochrane Library and CENTRAL electronic databases. A total of 12 selected studies (349 patients) were analyzed. The primary tumour detection and positive surgical margins rates were 70.8% and 19.4%, respectively. The rate of HPV-related tumour was 71.3%. The primary tumour was mainly in base of tongue (64%).In conclusion, TORS seems to be an effective surgical approach both in terms of detection of primary tumour site and in terms of therapeutic perspective for HNUP. In particular, a subset of HPV-related tumours might benefits all advantages from this surgical modality.     

Comparison of radiofrequency and transoral robotic surgery in obstructive sleep apnea syndrome treatment

Introduction: Radiofrequency tissue ablation (RFTA) and transoral robotic surgery (TORS) are the methods used in OSAS surgery. We also aimed to compare the advantages and disadvantages of RF and TORS as treatment methods applied in OSAS patients in terms of many parameters, especially apnea hypopnea index (AHI).

Materials and methods: Patients were classified by performing a detailed examination and evaluation before surgery. 20 patients treated with anterior palatoplasty and uvulectomy ?/+ tonsillectomy?+?RFTA (17 males, 3 females) and 20 patients treated with anterior palatoplasty and uvulectomy ?/+ tonsillectomy?+?TORS (16 males, 4 females) were included in the study. PSG was performed preoperatively and postoperatively in all patients and Epworth sleepiness questionnaire was applied. All operations were performed by the same surgeon and these surgical methods -RF and TORS- were compared in terms of many parameters.

Results: When the patients treated with RF and TORS were compared in operation time, length of hospitalization and duration of transition to oral feeding; all parameters were significantly greater in the patients treated with TORS.

Conclusions: TORS technique was found to be more successful than RF in terms of reduction of AHI value, correcting minimum arterial oxygen saturation value and decreasing Epworth Sleepiness Scale score.     

Occult tonsillar carcinoma in the unknown primary

Objectives: Evaluate effectiveness of routine tonsillectomy in the assessment of patients with squamous cell carcinoma of the neck of unknown primary, and evaluate outcomes of this group compared with patients without a primary identified initially. Study Design: A retrospective review of the medical records of 37 patients presenting with an unknown primary tumor over a 10-year period. Methods: Charts were reviewed for age and sex of patients, methods of evaluation and diagnosis, sites of tissues obtained on biopsy, N stage of disease, and presence of extracapsular spread. Recurrence and survival data were collected over a mean follow-up period of 34 months. Results: All primary lesions discovered through pathologic evaluation arose from the tonsil (9/9), and all were detected in patients undergoing tonsillectomy in conjunction with direct laryngoscopy. None of the patients (0/9) with occult tonsillar carcinoma have had recurrence, in contrast to 60% (15/25) of remaining patients. Patients with tonsillar primary lesions demonstrated less extracapsular spread of disease (25%) than patients without tonsillar primaries (67%), despite similar N staging within the two groups. Conclusions: Occult tonsillar carcinoma accounts for the unknown primary more frequently than was previously recognized. Bilateral tonsillectomy is recommended to increase the detection yield and to capture the rare case of bilateral disease. A lower incidence of extracapsular spread and reduced recurrence rates in patients with unknown primary tumors presenting as occult tonsillar carcinoma may contribute to the improved prognosis observed in this group. Laryngoscope, 108:1605–1610, 1998     

A new paradigm for the diagnosis and management of unknown primary tumors of the head and neck: A role for transoral robotic surgery

Objectives/Hypothesis:

In 2% to 3% of patients with cancer metastatic to cervical lymph nodes, a primary tumor will not be found despite exhaustive diagnostic efforts. The treatment for these patients includes cervical lymphadenectomy followed by radiation to areas with increased risk of harboring a mucosal primary. Wide‐field radiation therapy increases the incidence of xerostomia and dysphagia. Localizing a primary tumor has thus both therapeutic and quality‐of‐life implications, allowing possible complete surgical excision, concentrated radiation therapy, and potential deintensification of adjuvant therapy. With improved visualization and freedom of motion, transoral robotic surgery (TORS) is an innovative surgical modality that allows resection of oropharyngeal subsites with minimal morbidity.

Study Design:

Retrospective chart review.

Methods:

Ten patients with unknown primary tumors of the head and neck were identified. All patients underwent a cervical biopsy, positron‐emission tomography/computed tomography, formal endoscopy, and bilateral tonsillectomy. When the initial endoscopy and biopsies did not localize a primary tumor, all patients underwent transoral robotic base of tongue resection.

Results:

Evaluation of the patients' oropharyngeal mucosa using the robot did not reveal an obvious lesion and no palpable tumors were appreciated in the resected specimens. In 9/10 (90%) patients, pathologic examination revealed invasive squamous cell carcinoma (SCCA) with a mean diameter of 0.9 cm.

Conclusions:

Unknown primary SCCA presents a diagnostic challenge to the head and neck surgeon. We present a small series of tumors that would have been treated as unknown primaries under traditional diagnostic and therapeutic algorithms. TORS base of tongue resection identified primary tumors in 90% patients with minimal morbidity. Laryngoscope, 2013     

Diagnostic work-up and outcome of cervical metastases from an unknown primary

Conclusions. An intensive diagnostic work-up including ¹⁸F-fluorodeoxyglucose positron emission tomography (FDG-PET) detects many unknown primary tumours, leads to a low emergence rate of primary tumours, and selects carcinoma of unknown primary with much more favourable results after neck dissection and postoperative radiotherapy. Objective. To investigate the optimal diagnostic approach and best treatment modality for rare head and neck cancer of unknown primary. Patients and methods. In a retrospective study, 69 patients admitted from 1987 to 2002 with cervical lymph node metastases without apparent primary were reviewed. Test characteristics of all diagnostic procedures were calculated. Disease-free and overall survival rates were calculated. Major prognostic factors were analysed univariately. Results. At the primary site FDG-PET showed the best sensitivity with 69% and the highest negative predictive value with 87%. Computed tomography and magnetic resonance imaging had a better specificity with 87% and 95%, respectively. The primary tumour was detected in 23 cases (33%). Frequent primary tumour origin was the palatine tonsil (n=8, 35%), base of the tongue (n=6, 26%) and lung (n=4, 17%). All patients with unknown primary were treated by neck dissection. Adjuvant radiotherapy was performed in 26 patients (57%), concurrent radiochemotherapy was performed in 12 patients (26%). The primary emergence rate was 7%. The 5-year overall survival rate was inferior in patients with detected primary in comparison with patients with unknown primary (22% versus 52%). Significant prognostic factors in case of unknown primary were M stage, smoking, alcohol consumption and tonsillectomy. Radiotherapy but not chemotherapy with carboplatin influenced the overall survival.     

Prevalence of synchronous bilateral tonsil squamous cell carcinoma: A retrospective study

Objectives

The prevalence of synchronous bilateral tonsil cancer remains unexplored. To date, only 38 cases have been described in the literature. With an aim to substantiate the Danish recommendation of performing bilateral tonsillectomy in patients with suspected or proven tonsil cancer and in patients with cervical carcinoma metastasis from an unknown primary tumour, this study was undertaken to determine the prevalence of synchronous bilateral tonsil cancer.

Design

A retrospective review of all patients diagnosed with tonsil cancer in the period 2000‐2015, Aarhus University Hospital, Denmark, was performed.

Results

Seven of 211 (3.3%) consecutive patients with tonsil cancer, who had undergone bilateral tonsillectomy (n = 180) or unilateral tonsillectomy (clinically normal side) combined with contralateral tonsil biopsy (side with suspected cancer) (n = 31), had synchronous bilateral tonsil cancer. Furthermore, dysplasia was found in the contralateral tonsil in two patients with unilateral tonsil cancer. Four of 171 (2.3%) patients with suspected unilateral tonsillar cancer had additional contralateral tonsil cancer. Three of 34 (8.8%) patients without clinical signs of tonsillar malignancy on any side (32 patients with carcinoma of unknown primary) had synchronous bilateral tonsil cancer. In none of the patients were bilateral tonsil cancer suspected. Patients with unilateral vs synchronous bilateral tonsil cancer had similar clinical and tumour characteristics.

Conclusion

Knowledge on additional contralateral synchronous tonsil cancer is crucial for avoidance of early recurrence of oropharyngeal cancer in patients with tonsil cancer. Based on our findings, we recommend bilateral tonsillectomy in all patients with suspected or proven tonsil cancer and carcinoma of unknown primary.     

Transoral robotic lingual tonsillectomy in adults: preliminary results

Conclusion: Hypertrophy of lingual tonsils can be safely and effectively managed by transoral robotic surgery via a minimally invasive approach. The operating costs can be relatively high although the advantages to patients seem to justify the procedure. Transoral robotic surgery can represent the definitive treatment in hypertrophy of the lingual tonsils. Objective: The purpose of this work was to assess the feasibility, safety, and outcomes of transoral robotic surgery for lingual tonsillar hypertrophy in adults with obstructive sleep apnea. Methods: Retrospective medical records of six patients who underwent tongue base resection using the da Vinci Surgical Robotic System from September, 2012 through December, 2013 in a tertiary care hospital were evaluated. Demographic data, preoperative and postoperative polysomnography and Epworth Sleepiness Scale (ESS) scores, robot docking time, operative and postoperative aspects including surgical time, amount of bleeding, and early and late complications were collected and analyzed. Results: All patients successfully underwent lingual tonsillectomy using the da Vinci Surgical system. Transnasal endotracheal entubation was performed in all patients and they were all extubated before leaving the operation room. No tracheotomies were performed perioperatively for airway management. The patients were discharged on the fifth postoperative day. Operative time, estimated blood loss, and postoperative complication profiles were within the expected and acceptable limits for lingual tonsillectomy. There was a statistically significant decrease in apnea hypopnea index (AHI) (mean AHI from 27.5 to 6.3) and ESS scores (from 14.1 to 7.1).     

Bilateral synchronous tonsillar carcinoma: a case series and review of the literature

We present the first dedicated case series of bilateral synchronous tonsillar carcinoma and discuss the role of bilateral tonsillectomy as a diagnostic tool. The occurrence of multiple head and neck tumours is well recognised; however, reports of bilateral synchronous tonsillar carcinoma are rare. A literature review reveals only 12 cases of bilateral synchronous tonsillar carcinoma described in the international literature in the past 15 years. We present a further three cases confirmed following bilateral tonsillectomy. In conclusion, bilateral tonsillectomy has in many centres been established as a standard diagnostic and therapeutic procedure for patients who have cervical metastases from a head and neck cancer of unknown primary site. It is likely the true incidence of bilateral synchronous tonsillar carcinoma is underestimated and under-reported. We recommend bilateral tonsillectomy for patients with suspected or proven unilateral tonsillar carcinoma as well as those with cervical metastases from unknown primary site.     

Metastatic squamous cell carcinoma in cervical lymph nodes from an unknown primary tumour: prognostic factors

The aim of this retrospective review is the study of the prognostic factors related to cervical metastases of squamous cell carcinoma from an unknown primary tumour. Sixty-seven patients were selected and surgery and postoperative radiotherapy was the treatment used. Nineteen tumours were subsequently found (27%). The 5-year actuarial survival rate of all patients was 22%. Survival rates were significantly related to lymph node stages and to the histological degree of differentiation. Nevertheless, actuarial survival rates were not related to the appearance of the primary tumour (P = 0.07). In our series, the single most important prognostic factor was the neck stage. The value close to statistical significance observed when the primary tumour subsequently appeared (P = 0.07), suggests that this could worsen the prognosis.     

Demographics of benign parotid tumours: Warthin’s tumour versus other benign salivary tumours

Conclusion: Some variation from the ‘classical’ clinical picture for Warthin’s tumours is evident in these patients. A predilection for the parotid tail and a propensity for multiplicity has been confirmed. Objectives: This study sought to analyse demographic and clinical features of a Warthin’s patient population. Methods: Retrospective review of patients presenting with a benign parotid tumour. The group of Warthin’s tumours was compared with the group of patients with other benign parotid tumours. Results: Of 170 primary parotid tumours, 41 (24%) were Warthin’s tumour. Mean age of Warthins patients was significantly older (60 years vs 48 years, p?=?0.001) and male gender more prevalent (61% vs 33%, p?=?0.015) than in other benign tumours. Most (86%) Warthin’s tumours were found in the parotid tail, compared with 61% of other benign tumours (p?=?0.002). There was no significant ethnic predilection for Warthin’s tumours. Bilaterality (30%) and multiplicity (27%) were common. Significance of gender differences disappeared with logistic regression analysis.     

Tonsil size and body mass index are important factors for efficacy of simple tonsillectomy in obstructive sleep apnoea syndrome

Objectives: To evaluate the efficacy of simple tonsillectomy to treat obstructive sleep apnoea syndrome (OSAS) in adults. Design: Prospective study. Setting: Tertiary referral centre. Participants: Thirty patients (28 males) underwent simple tonsillectomy under general anaesthesia. The patients’ mean age was 33.2 ± 6.8 years and body mass index was 30.7 ± 6.0 kg/m². Seven patients (23%) were classified with grade 4, 16 patients (53%) with grade 3, and seven patients (23%) with grade 2 according to the tonsil size of Friedman's classification. Main outcome measures: The number of apnoea episodes per hour (apnoea index), the number of apnoea and hypopnoea episodes per hour (apnoea‐hypopnoea index), lowest nocturnal oxygen saturation and oxygen desaturation time were measured during overnight polysomnography before and after surgery. A successful tonsillectomy was defined as an apnoea–hypopnoea index improvement ratio of ≥50% and an apnoea–hypopnoea index <20 after operation. Results: Apnoea–hypopnoea index decreased from 69.0 ± 28.4/h to 30.1 ± 24.0/h (P < 0.0001). Simple tonsillectomy was successful in all six patients with body mass index <25 kg/m². Concerning success rate of simple tonsillectomy with tonsil, size 2 was lowest (42.9%). Eight of the 13 patients who used continuous positive airway pressure before simple tonsillectomy did not use continuous positive airway pressure after simple tonsillectomy because of a significant reduction of excessive daytime sleepiness. Continuous positive airway pressure decreased significantly after simple tonsillectomy from 13.6 ± 2.5 cmH₂O preoperatively to 10.6 ± 1.3 cmH₂O postoperatively (P < 0.05). Conclusions: These data suggest that simple tonsillectomy is a beneficial modality to treat OSAS in selected patients (larger tonsil, low body mass index), even in adults.     

Lingual tonsils hypertrophy; a cause of obstructive sleep apnea in children after adenotonsillectomy: operative problems and management

Objective

Although adenotonsillar hypertrophy has been reported to be the commonest cause of pediatric obstructive sleep apnea (OSA), enlargement of the lingual tonsils is increasingly being recognized as a cause, even after adenotonsillectomy. The aim of our study was to elucidate the lingual tonsils hypertrophy as a cause of pediatric OSA and also to evaluate the efficacy of lingual tonsillectomy in relieving symptoms of the disease considering the peri-operative problems and management.

Methods

Sixteen children with lingual tonsils hypertrophy after adenotonsillectomy were included in the study. Computerized tomography (CT) and/or magnetic resonance imaging (MRI) were used for detection of the lesions. They underwent lingual tonsillectomy with special anesthetic care, flexible laryngoscopy and polysomnography were done pre- and post-operatively. Follow up of the patients was carried out for at least 1 year.

Results

Three cases developed post-operative airway obstruction that is caused by tongue base edema. Complete improvement of snoring and apnea was achieved in 10 cases. Despite complete ablation of lingual tonsils, persistent snoring was detected in six cases, while apnea was detected in two cases. Down's syndrome, mucopolysaccharidoses, and obesity may be underlying factors for persistent symptoms.

Conclusions

Lingual tonsils hypertrophy could be the cause of obstructive sleep apnea in children after adenotonsillectomy, lingual tonsillectomy is an effective treatment for these cases, however peri-operative airway problems should be expected and can be managed safely. Persistent symptoms after lingual tonsillectomy may be due to the presence of co-morbidities such as cranio-facial deformities, obesity, and/or mucopolysaccharidoses.     

Conservative management of vestibular schwannomas: third review of a 10‐year prospective study

• ? Seventy‐two patients with a unilateral vestibular schwannoma have been treated conservatively for a median of 121 months. They have been followed prospectively by serial clinical examination, MRI scans and audiometry.
• ? Twenty‐five patients (35%, 95% CI: 24–47) failed conservative management and required active intervention during the study. No factors predictive of tumour growth or failure of conservative management could be identified. Seventy‐five per cent of failures occurred in the first half of the 10‐year study.
• ? The median growth rate for all tumours at 10 years was 1 mm/year (range ?0.53–7.84). Cerebellopontine angle tumours grew faster (1.4 mm/year) than intracanalicular tumours (0 mm/year, P < 0.01); 92% had growth rates under 2 mm/year.
• ? Hearing deteriorated substantially even in tumours that did not grow, but did so faster in tumours that grew significantly (mean deterioration in pure tone average at 0.5, 1, 2 and 3 kHz was 36 dB; speech discrimination scores deteriorated by 40%).
• ? Patients who failed conservative management had clinical outcomes that were not different from those who underwent primary treatment without a period of conservative management.

     

The safety and efficacy of pediatric lingual tonsillectomy

ObjectiveLingual tonsillar hypertrophy is recognized as a cause of persistent obstructive sleep apnea (OSA) after adenotonsillectomy in children. However, little has been reported regarding the complications, postoperative course and effectiveness of lingual tonsillectomy (LT). Our objective was to review the safety and effectiveness of LT in children.MethodsRetrospective review of children undergoing LT from January 2009 to December 2015 at a tertiary children's hospital. Complications, postoperative course and polysomnographic (PSG) outcomes were recorded for all patients.ResultsWe identified 92 children (mean age = 8.6 years, 50% female) who underwent LT; 43.5% had a syndromic diagnosis. The most common complications were emergency department presentation for bleeding (4.4%) and poor oral intake (3.3%). The readmission rate was 4.4% including 2 children (2.2%) who required operative control of hemorrhage. No children required unplanned reintubation or ICU admission. In children with PSG data (n = 18), the median apnea-hypopnea index (AHI) decreased from 8.5 to 3.8 events/hour (p = 0.022) and the median obstructive AHI (oAHI) decreased from 8.3 to 3.1 events/hour (p = 0.021). In addition, the oxygen saturation nadir increased from 83.8% to 89.0% (p = 0.0007). After surgery the percentage of patients with oAHI<5 events/hour increased from 27.8% to 61.1% (p = 0.08).ConclusionsReadmission and bleeding rates after lingual tonsillectomy in children were similar to that seen with tonsillectomy. Polysomnographic data showed that lingual tonsillectomy resulted in a significant reduction of both AHI and oAHI with a postoperative oAHI <5 achieved in 61% of patients.     

Return to theatre in secondary post-tonsillectomy haemorrhage: a comparison of coblation and dissection techniques

The aim of this study is to examine the incidence of return to theatre (RTT) for post-operative haemorrhage following coblation and dissection tonsillectomy and to investigate those that required RTT more than 10 days post-surgery. Retrospective review of post-tonsillectomy haemorrhages requiring RTT from April 2005 to March 2009 was conducted. Of 2,541 tonsillectomies performed, 81% were by coblation and 19% by dissection methods. The overall RTT rate was 1.7%. No difference was found in the overall RTT rates for primary and secondary haemorrhage between the two techniques. However, the overall RTT rates for primary and secondary haemorrhage were higher in adults than children (P = 0.0456 and P = 0.0215, respectively). RTT for secondary haemorrhage during the first ten post-operative days occurred in both coblation and dissection tonsillectomy with no significant difference. After the first post-operative week, late secondary bleeding requiring RTT occurred only in the coblation group (P = 0.0676). Four patients required blood transfusion; all were in the coblation group, three of which were required during RTT in the late secondary haemorrhage (after 10 days). The post-operative RTT rates for coblation tonsillectomy did not reveal a change of trend over the 4-year study period. Our RTT rate for secondary haemorrhage is higher than earlier published results. A learning curve could not be identified in RTT for coblation tonsillectomy haemorrhage. Late secondary haemorrhages requiring surgical intervention have only been identified in cases performed by coblation and could potentially be life threatening as 33% (3/9) required blood transfusion. This phenomenon may be explained by a particular physiological healing process associated with coblation.     

Photodynamic therapy in the treatment of multiple primary tumours in the head and neck,located to the oral cavity and oropharynx

Objectives: Multiple primary tumours are a common problem in the head and neck cancer patients. Curative surgery or radiotherapy of these tumours can be very mutilating or even impossible. This study aims at evaluating meta‐tetrahydroxy‐phenyl chlorin‐mediated photodynamic therapy for second or multiple primary tumours in the head and neck. Design: Retrospective study of all patients with second or multiple primary tumours treated by photodynamic therapy over a 10‐year period. Setting: All patients were treated in the Netherlands Cancer Institute, a tertiary referral centre for the head and neck cancer patients. Participants: A total of 27 patients with 42 the second or the multiple primary head and neck tumours were treated by photodynamic therapy (0.15 mg/kg meta‐tetrahydroxy‐phenyl chlorin). Main outcomes measures: Cure rates. Results: Twenty‐eight of 42 tumours were cured (67%). Cure rates for stage I or in situ disease were 85%versus 38% for stage II/III. Conclusions: Cure rates for photodynamic therapy of the multiple primary head and neck tumours were lower than previously described for first primaries, but were still very encouraging for this difficult patient population. The high cure rate obtained in stage I multiple primaries emphasises the importance of a meticulous follow‐up of patients treated for the head and neck cancer to detect new tumours at a curable stage.     

Bipolar scissors versus cold dissection tonsillectomy: a prospective, randomized, multi-unit study.

OBJECTIVE: To evaluate bipolar scissors tonsillectomy by comparing it with traditional cold dissection tonsillectomy. STUDY DESIGN: A prospective, randomized, multi-unit study. SETTINGS: Belfast City Hospital, Royal Victoria Hospital Belfast, and Ulster Hospital Dundonald. PATIENTS: Two hundred consecutive patients undergoing tonsillectomy for recurrent or chronic tonsillitis between March 2000 and September 2000. OUTCOME MEASURES: (1) Intraoperative bleeding, (2) operative time, (3) postoperative pain, and (4) complication rates, including primary and secondary hemorrhage. RESULTS: Seventeen patients were excluded from the study for various reasons. The mean age of the study population was 22 years (range, 10-54 y). Seventy-two percent of patients were female. Twenty-seven percent of patients were children aged 16 years or under. Median intraoperative blood loss was 5 mL for bipolar scissors tonsillectomy and 115 mL for cold dissection tonsillectomy (P < .001). The mean operative time was 13 minutes for bipolar scissors tonsillectomy compared with 20 minutes for the cold dissection method (P < .001). There was no statistically significant difference in the pain scores between the two methods (independent samples t = 1.35; P > .05). The overall primary hemorrhage rate was 2.1%, whereas the overall secondary hemorrhage rate was 16.9%. The hospital readmission rate was 10.3%. The primary and secondary hemorrhage rates were unaffected by the surgical method. CONCLUSIONS: Bipolar scissors tonsillectomy is a safe technique with a similar morbidity to the cold dissection method. Its use is associated with a significant decrease in both surgical time and blood loss compared with the cold dissection method.     

T3 Laryngeal cancer: a retrospective study of the Dutch Head and Neck Oncology Cooperative Group: study design and general results

511 Patients with T₃ N_0-3M ₀ squamous cell carcinoma of the larynx, treated in the Netherlands from 1975 until 1984, were retrospectively analysed. Four different treatment policies were followed: primary surgery, planned combination of radiotherapy and surgery, primary radical radiotherapy, and selective radiotherapy. General results are presented. Local control rate was 72%. Regional control rate was 90% for clinically N₀ patients and 78% for clinically N₊ patients. Salvage therapy was overall successful in 38%. Surgical salvage for local radiation failures (with regional relapse) was successful in 69%, and for regional failures (without local relapse) in 46%. Ultimate locoregional control was 78% and, due to 8% distant metastases, 5-year actuarial corrected survival was 70%. Prognosis did not improve over the years. Corrected survival was independently correlated with tumour extension, involvement of neck nodes and treatment strategy. Corrected survival was similar for primary radiotherapy and primary surgery, but significantly better for planned combined therapy. Multiple primary tumours occurred significantly more often in male (19.5%) than in female patients (7.3%) (P = 0.05), the bronchus being most commonly affected. Cumulative actuarial risk for metachronous tumour was 15% after 5 years and 30% after 10 years so prevention and early detection of these second tumours may play the most important role in improving overall survival rates in the future.     

An evaluation of the diagnostic methods in head and neck cancer of unknown primary site

Abstract

Background: Various detection methods to identify the primary in head and neck cancer of unknown primary (HN-CUP) require evaluation to improve and standardize management.

Objectives: To evaluate the use of different diagnostic methods, which aim at decreasing the incidence of HN-CUP.

Material and methods: We conducted a retrospective analysis of patients with HN-CUP at the Helsinki University Hospital during 1995–2011. We evaluated clinical assessment, definitive treatment, histopathology, and follow up. We analyzed the success in identifying the primary site to show any changes in diagnostic methods over time.

Results: Frequency of HN-CUP and success in identifying the primary site have remained constant despite the addition of PET-CT and determination of human papilloma virus (HPV) status in diagnostics. Among 133 patients, the diagnostic work up identified the primary site in 53% and the oropharynx predominated (69%). This left 85 patients with HN-CUP and 5-year overall and disease-free survival rates were 71 and 69%, respectively.

Conclusions: Panendoscopy including tonsillectomy should not be omitted in the work up.

Significance: We demonstrate a steady frequency of HN-CUP and constant success in identifying the primary site. Detection of a primary later in the follow up did not impact the survival.