放疗对鼻咽癌患者嗅觉的影响

目的 :探讨放疗对鼻咽癌 (NPC)患者嗅觉的影响。方法 :对 10 0例 NPC患者于放疗前、后 3和 6个月 ,1、2、3年 ,分别进行嗅觉检测 ,比较其变化。结果 :与放疗前比较 ,放疗后 3个月患者嗅觉锐度明显减退 ;0 .5～1年 ,嗅觉有所改善 ,但未能达到放疗前水平 ,且感觉阈与识别阈出现分离 ;此后 ,再次出现嗅觉锐度减退现象。结论 :放疗可影响 NPC患者嗅觉 ,放疗后患者嗅觉呈波浪式、永久性减退。     

Olfaction in patients with nasal polyposis: effects of systemic steroids and radical ethmoidectomy with middle turbinate resection (nasalization)

AIM: In this prospective study the effect of medical and surgical treatment on subjective olfaction was studied in patients with nasal polyposis (NPS). The effects on nasal obstruction, anterior and posterior rhinorrhea, sneezing and itching are reported in another article in this issue. PATIENTS AND METHODS: Protocol 1. Twenty-four patients with NPS who complained about anosmia were treated with a 7-days course of systemic steroids. Their subjective overall sense of smell was determined with a visual analog scale (VAS) before treatment, immediately after treatment, and two months later. Subsequently all patients underwent surgery bilaterally according to the nasalization principles. The sense of smell was re-evaluated at 1, 3, 6, 9, and 12 months postoperatively. Protocol 2. Thirty-two patients with NPS not responding to medical therapy who, for different reasons, did not receive oral steroid treatment, received surgery only and were followed up during one year after nasalization. Of these patients, 25 were anosmic and 7 normosmic. RESULTS: Protocol 1. Following the 7-day treatment with systemic steroids the olfactory score increased significantly. During the waiting time for surgery (64 +/- 39 days) this score deteriorated again in a significant way. One month after nasalization which included a depot injection of triamcinolone 80 mg the day after surgery, the olfactory score ameliorated again and remained stable at 3, 6, 9, and 12 months. None of the patients reported any intake of systemic steroids during the one-year of follow-up. Statistically, there was a trend suggesting that the 12 month post-nasalization score was better than the immediate post-oral steroid score. A good correlation between the improvement of the sense of smell after 7 days of systemic steroids and one year after nasalization was found. Protocol 2 One month after the nasalization protocol, olfaction in patients of the hypo-anosmic group had improved considerably. Scores at 3, 6, 9, and 12 remained very stable. The sense of smell in the normosmic group did not change after surgery and remained stable during the year of follow-up. In total, 49 patients with a severe loss of smell showed a significant improvement at 12 months after surgery. CONCLUSION: The present study shows that 1) long-lasting correction of olfactory dysfunction produced by nasal polyposis can be achieved through the combination of nasalization and low dose of nasal steroids, 2) middle turbinate resection does not alter the possibilities to restore the sense of smell.     

Improvement in smell and taste dysfunction after repetitive transcranial magnetic stimulation

Background

Olfactory and gustatory distortions in the absence of odors or tastants (phantosmia and phantageusia, respectively) with accompanying loss of smell and taste acuity are relatively common symptoms that can occur without other otolaryngologic symptoms. Although treatment of these symptoms has been elusive, repetitive transcranial magnetic stimulation (rTMS) has been suggested as an effective corrective therapy.

Objective

The objective of the study was to assess the efficacy of rTMS treatment in patients with phantosmia and phantageusia.

Methods

Seventeen patients with symptoms of persistent phantosmia and phantageusia with accompanying loss of smell and taste acuity were studied. Before and after treatment, patients were monitored by subjective responses and with psychophysical tests of smell function (olfactometry) and taste function (gustometry). Each patient was treated with rTMS that consisted of 2 sham procedures followed by a real rTMS procedure.

Results

After sham rTMS, no change in measurements of distortions or acuity occurred in any patient; after initial real rTMS, 2 patients received no benefit; but in the other 15, distortions decreased and acuity increased. Two of these 15 exhibited total inhibition of distortions and return of normal sensory acuity that persisted for over 5 years of follow-up. In the other 13, inhibition of distortions and improvement in sensory acuity gradually decreased; but repeated rTMS again inhibited their distortions and improved their acuity. Eighty-eight percent of patients responded to this therapeutic method, although repeated rTMS was necessary to induce these positive changes.

Interpretation

These results suggest that rTMS is a potential future therapeutic option to treat patients with the relatively common problems of persistent phantosmia and phantageusia with accompanying loss of taste and smell acuity. Additional systematic studies are necessary to confirm these results.     

Importance of unilateral examination in olfactometry

Hyposmia, the decreased sense of smell, and anosmia, the loss of sense of smell, may be unilateral or bilateral. If the olfactory acuity examined by means of bilateral test is normal, olfactory disorders are not found; unilateral examination is therefore necessary for definite evaluation of olfactory acuity. As evidence, 7 cases out of 94 patients with chronic rhinosinusitis and 6 cases out of 12 patients who received the surgery of anterior cranial fossa showed definite different olfactory threshold between nasal cavities, and there were no patients who recognized the diminished sense of smell in spite of unilateral high olfactory threshold. Additionally, we have experienced that a patient with brain tumor was diagnosed by the help of unilateral olfactory test. We thus strongly recommend the unilateral olfactometry as a method for simple and reliable test in clinical measurement of the sense of smell.     

Ceruminous gland tumors: report of three cases

Three patients with ceruminomata were treated by radiation therapy, surgery or a combination of both of them. One patient was treated by surgery followed by radiation treatment and then, after recurrence of the tumor, by radical surgery, and another patient treated by surgery only, are free from disease six and five years respectively. One patient treated by incomplete radiation therapy only, has had recurrence of the tumor three months later, but after a full treatment by Cobalt teletherapy is free from recurrence four months later. Surgery is considered the treatment of choice; however, radiation therapy may be indicated when the tumor, either primary or recurrent, has extended beyond limits of surgical resection, or because of distant metastases, due to the patient's general condition precluded surgery, or finally, when surgery is refused.     

手术联合药物治疗外伤性视神经病的疗效分析

目的 评价手术联合药物治疗外伤性视神经病(traumatic optic neuropathy,TON)的疗效,分析影响临床疗效的因素.方法 对69例(70眼)确诊为TON并行鼻内镜下视神经管减压术联合药物治疗患者的临床资料作回顾分析.将入院时视力分为无光感、光感、眼前手动、眼前指数和能见标准视力表(0.02以上)5个级别,分别计为Ⅰ～Ⅴ级.入院视力Ⅰ级(无光感)者40眼,18眼因CT证实严重视神经管骨折,急诊行鼻内镜下视神经管减压术;22眼入院后先行糖皮质激素冲击治疗后再行手术治疗.入院视力I级以上者30眼,CT显示视神经管骨折的16眼行急诊手术;14眼行糖皮质激素冲击治疗3 d后行手术治疗.随访3～12个月,观察视力恢复情况.结果 入院视力有光感者疗效显著优于入院视力无光感者(90.0%比27.5%),两组疗效相比差异有统计学意义(χ2=26.98,P<0.001).入院视力Ⅰ级患眼,糖皮质激素冲击治疗后视力提高者手术疗效(80.0%)优于无改变者(5.9%),两组疗效相比差异有统计学意义(χ2=12.09,P<0.001).结论 对于无光感的患者,经药物冲击治疗后视力仍无改善者,手术疗效较差;治疗前视力是影响疗效的主要因素.影像学检查有无视神经管骨折,不应作为是否手术的决定因素.     

Early swallowing problems in a cohort of patients with nasopharyngeal carcinoma: Symptomatology and videofluoroscopic findings

OBJECTIVE: To study the incidence and the degree of swallowing dysfunction in patients with nasopharyngeal carcinoma (NPC) who underwent radiation therapy treatment. INSTITUTION: The study was conducted in the Prince of Wales Hospital, a tertiary teaching hospital of the Chinese University of Hong Kong. MATERIALS AND METHODS: From October 1999 to July 2001, a cohort of 20 consecutive patients with newly diagnosed NPC was prospectively studied. Questions about symptoms, including swallowing functions, were asked, and head and neck examination including oromotor examination was performed in the subjects before radiation therapy. All patients were subjected to videofluoroscopy (VFSS) to assess their swallowing function. Abnormalities were scored if they were present on two of three swallow attempts. The patients were reassessed at 6 months and 12 months after radiotherapy by symptom assessment and VFSS. RESULTS: There were 14 male and 6 female patients. The mean age was 43.9 years. Nine patients had early (stage I and II) disease, whereas 11 patients had advanced (stage III and IV) disease. Nine patients were treated by radiation therapy only and 11 patients by concurrent chemoirradiation. Ninety-five percent of the subjects had subjective dysphagia at 6 and 12 months after radiation therapy. Ninety percent had xerostomia, and 80% had to avoid certain foods at 12 months postradiation therapy. All subjects had to alternate solid food with fluid intake to facilitate swallowing. An average reduction of jaw movement by 1 cm was noted. A large proportion of patients had stasis of food in the pharynx (100% in valleculae and 60% in pyriform fossae) and impaired pharyngeal peristalsis (60%). One quarter of patients had laryngeal penetration. CONCLUSIONS: Subjective swallowing difficulties were common in patients in the early follow-up period after radiation therapy for NPC according to questionnaire assessment. An objective swallowing study revealed that swallowing dysfunction was persistent 12 months after radiation therapy.     

Radiation therapy for paragangliomas of the temporal bone

Treatment of paragangliomas of the temporal bone (glomus jugulare and glomus tympanicum tumors) is controversial, with both surgery and radiation therapy having their advocates. This paper discusses the experience at the University of Arizona Health Sciences Center in treating 10 cases of this uncommon tumor between 1971 and 1988. Seven of 10 cases were initially treated using irradiation and achieved complete tumor control for a mean of 67 months (range = 23-107 months). Two patients, one treated surgically and the other by embolization, had recurrences and were salvaged by radiation, and neither has recurred. The final patient is disease-free 9 months after embolization and surgery. There have been no serious sequelae of treatment. We conclude that moderate-dose irradiation can safely control most temporal bone paragangliomas.     

Small cell carcinoma of the larynx: results of therapy

Primary small cell carcinoma of the larynx is a rare malignancy with a dismal prognosis. A survey of the long-term follow-up from reported cases of small cell carcinoma of the larynx and a review of the recent experience with this tumor at the University of Michigan Hospitals was undertaken to determine if newer treatment approaches incorporating adjuvant chemotherapy were associated with prolonged survival. Median survival for those patients receiving adjuvant chemotherapy was 19 months compared to 11 months for patients treated with surgery and/or radiation therapy alone. Among patients treated initially with primary radiation therapy and adjuvant chemotherapy median survival was 55 months, which was significantly longer than any other treatment regimen (P = 0.02). Systemic chemotherapy and therapeutic irradiation appears to offer the least disabling and most efficacious form of current therapy.     

Primary radiation therapy for juvenile nasopharyngeal angiofibroma

Evidence is presented of the effectiveness and relative lack of serious toxicity of external beam megavoltage radiation therapy (RT) as primary treatment for juvenile nasopharyngenl angiofibroma. The importance of careful radiological evaluation of tumor extent prior to irradiation is stressed, and only moderate dose RT is required. Fifty-five patients have been treated by RT and followed for from 3 to 26 years. Forty-four of 55 patients (80%) had permanent tumor control following a single course of 3000 cGy to 3500 cGy over 3 weeks. Surgical resection or a second course of RT controlled the tumor in all 11 patients in whom regrowth occurred. Angiofibromas involute slowly after RT so that 50% of patients still had visible masses in the nasopharynx 12 months after treatment, but only 10% had any visible abnormality 36 months after RT. Retreatment was necessary only if symptoms recurred, and continued follow-up showed that most asymptomatic nasopharyngeal masses resolved completely. Acute and late toxicity rates were low. Two patients developed tumors in the head or neck following RT. There was no significant clinical impairment of growth or endocrine function. A single course of external beam megavoltage radiation to 3000 cGy in 3 weeks is an effective first treatment for patients with juvenile nasopharyngeal angiofibroma.     

Change in olfaction after radiotherapy for nasopharyngeal cancer--a prospective study

PURPOSE: To evaluate the changes in olfactory function in patients with nasopharyngeal carcinoma who have received radiation to the head and neck. MATERIALS AND METHODS: Olfactory function of consecutive patients with nasopharyngeal carcinoma was assessed prospectively before irradiation and serially up to 1 year after radiotherapy by the Sniffin' Sticks (Erlangen, Germany) olfactory function test and by a patient symptom visual analogue scale. RESULTS: Fifty-eight patients were recruited before radiotherapy was commenced. Three patients could not give a reliable response to the Sniffin' Sticks test even in this first assessment, and 7 patients did not return for evaluation after irradiation. Forty-eight patients were available for follow-up assessment. Mean olfactory threshold scores by the Sniffin' Sticks test were found to deteriorate significantly at 12 months when compared with the scores before irradiation (8.3 at 12 months vs 11.5 before irradiation; P =.001). Scores for olfactory discrimination and for identification did not exhibit any significant changes when assessed at 12 months (P >.05 for both). Subjective patient assessment of olfactory function with the visual analogue scale at 12 months did not demonstrate any significant differences when compared with patients' assessment before irradiation (P =.90). An increase in discharge was the only nasal symptom that demonstrated a significant change at 12 months when compared with the assessment before irradiation (P < 001). CONCLUSIONS: Deterioration in olfactory threshold scores was found at 12 months after irradiation and was not noticed by the patients.     

Partial laryngectomy to treat early glottic cancer after failure of radiation therapy

OBJECTIVE: To evaluate the role of partial laryngectomy to treat glottic cancer after failure of radiation therapy. DESIGN: A 12-year retrospective outcome analysis. SETTING: University referral center. PATIENTS: A total of 19 patients who underwent partial laryngectomy to treat glottic cancer after failure of radiation therapy. RESULTS: The follow-up period in this group ranged from 31 to 144 months. After surgery, a laryngocutaneous fistula was observed in 4 cases, and flap necrosis occurred in 2, but these complications were successfully managed. Maximum phonation time after surgery ranged from 3 to 28 seconds (median phonation time, 10.2 seconds). Of these 19 patients, 3 developed local recurrence. These cases were successfully treated with total laryngectomy. A surgical margin of less than 1 mm was found to be a significant risk factor for local recurrence after partial laryngectomy. CONCLUSIONS: These results indicate that partial laryngectomy is a useful option for the treatment of irradiation failure in the treatment of stage I and stage II vocal cord carcinomas. However, careful follow-up is mandatory for patients with a small surgical margin.     

Incidence of hypothyroidism following multimodality treatment for advanced squamous cell cancer of the head and neck

The incidence of chemical hypothyroidism, as manifested by elevated thyroid stimulating hormone (TSH) levels, has been estimated to be as high as 25% after radiation therapy and 45% after radiation therapy and surgery to the neck for treatment of nodal metastases from squamous carcinoma of the head and neck. We prospectively evaluated 43 previously untreated patients seen in the Dana Farber Cancer Institute Interdisciplinary Head and Neck Service who were treated with aggressive combination chemotherapy in addition to standard surgery and/or radiotherapy. All patients were serially monitored for serum TSH, serum T4, and clincial evidence of hypothyroidism. Following cis-platinum, bleomycin, and methotrexate chemotherapy and subsequent surgery and/or radiotherapy, decreased thyroid reserve appeared in 37% of patients at a median follow-up of 9 months. Thirty percent of patients receiving radiotherapy alone and 43% of patients receiving surgery and radiotherapy developed elevated TSH levels. Only one patient developed clinical symptoms. Other patients were asymptomatic despite persistently elevated TSH levels. Abnormalities appeared within the first 4 months after completion of all therapy and were slowly progressive. The addition of combination chemotherapy does not appear to increase the incidence or severity of thyroid dysfunction following radiation therapy and surgery to the neck. In view of the extended survival seen in patients treated with interdisciplinary regimens, we recommend that all patients receiving irradiation to the neck – particularly those patients having neck dissections or total laryngectomies – have routine thyroid function studies performed following the cessation of treatment.     

Changes in olfactory acuity induced by total inferior turbinectomy

The short-term and long-term effects of total inferior turbinectomy on smell acuity was assessed in two groups of patients. Olfactory thresholds were determined by a three-way forced-choice method, using four odorants. Resection of obstructive inferior turbinates resulted in a decrease in olfactory thresholds in 22 of 24 tested patients. No deleterious effect on smell acuity was observed in 16 patients tested 2 1/2 years or more after surgery. Subjective assessment of olfactory acuity is unreliable. It is our intention to focus attention on an aspect of intranasal surgery not frequently reported.     

The degree and time-course assessment of radiation-induced trismus occurring after radiotherapy for nasopharyngeal cancer

OBJECTIVES/HYPOTHESIS: The objectives were to measure the degree of trismus induced after radiation therapy for nasopharyngeal cancer and assess its progress over time. STUDY DESIGN: A prospective, single-armed measurement study with long-term follow-up. METHODS: Seventeen patients with nasopharyngeal cancer treated between 1997 and 1999 were studied. Patients were given radiation therapy with bilateral parallel-opposing ports of 45 Gy, 25 fractions, then with a reduced volume to 68.4 to 70.2 Gy. The end point was the degree of trismus, which was measured by serial changes of the maximal interincisal distance (MID) at various specified time points before, during, and after radiation therapy. RESULTS: During the 9 weeks of radiation therapy there was no significant change of MID (normalized MID ranged from 99.8% to 97%). The rate of decrease during this period was 1.3% per month. After radiation therapy there was a rapid decrease of MID between 1 and 9 months (normalized MID values at 1 and 9 mo were 95.5% +/- 3.1% and 74.2% +/- 5.7%, respectively). The rate of decrease during this period was dramatic (2.4%/mo). One year after radiation therapy, the rate of decrease became slower but was still measurable (0.2%/mo for the period from 12 to 24 mo). For the period from 24 to 48 months. the rate dropped to 0.1% per month. By the end of 48 months, normalized MID was 67.8% +/- 7.6%. CONCLUSION: By means of measurement over a period of time, it was found that patients with nasopharyngeal cancer had a mean decrease in initial interincisal distance of 32% at 4 years after radiotherapy. The trismus process evolved at different rates. It was rapid at 1 to 9 months after radiation therapy, then became slower and protracted over later years.     

Salvage split course brachytherapy for tonsil and soft palate carcinoma: Treatment techniques and results

From December 1981 to October 1990, 28 patients with prior irradiation of the oropharynx underwent salvage brachytherapy for a squamous cell carcinoma of the tonsil and/or the soft palate. The patients were free of cervical nodes and without metastatic disease. There were 4 immediate failures of radiotherapy, 14 local recurrences, and 10 new malignancies. The mean size of the lesion was 2.7 ± 1.7 cm (range, 0.5 to 7 cm). The initial irradiation had delivered 40 to 80 Gy (mean, 69 Gy) to the oropharynx with a mean interval between external therapy and salvage treatment of 22 ± 28 months. Salvage brachytherapy consisted of two split course implants done 1 month apart, delivering 35 and 30 Gy, respectively. Fifteen patients (46.5%) were clinically disease-free before the second implant and 23 (82%) were clinically disease-free at the end of treatment. Five local failures have been observed without any influence of the tumor size, the topographic site of the tumor, or the histological differentiation. Of the 4 patients who previously had failed with external beam therapy, 3 were disease-free after salvage brachytherapy. Among the 23 patients in complete remission, 4 (17%) presented a local recurrence within a mean time of 5 months. The overall local control rate was 68% with a mean follow-up of 41 ± 29 months. The overall actuarial survival was 25% and 19% at 2 and 5 years, respectively; it was 30% at 5 years for the patients presenting with lesions less than or equal to 3 cm. Tolerance was acceptable. Among the 23 patients who achieved complete remission, subsequent soft-tissue necrosis was observed in 4 cases. For these 4 patients, the interval between previous radiation therapy and salvage treatment was short (mean, 7 months). Interstitial split course brachytherapy offers an effective and reasonable option for salvage therapy in patients with recurrent and second cancers occurring in the tonsillar region and in the soft palate, even when the tumor arises in a zone that has previously received high-dose irradiation.     

Quality of life after treatment for advanced laryngeal and hypopharyngeal cancer

OBJECTIVES: To compare health-related quality of life measures after treatment for advanced (stages III and IV) laryngeal and hypopharyngeal cancers. STUDY DESIGN: Retrospective chart review and patient response to Health Status Questionnaire-12 (HSQ-12). METHODS: Our study included 54 patients identified from the Tumor Registry of the University of Louisville Brown Cancer Center who were diagnosed and treated between 1995 and 2000. Demographics, tumor data, and treatment information were obtained from the Tumor Registry database. Questionnaires were mailed to all patients and included telephone follow-up. Comparative data and responses were analyzed for the 24 patients who responded to the survey. RESULTS: Fifteen patients were treated with chemotherapy and radiation therapy (CRT). Six patients underwent surgery with postoperative radiation therapy (SRT). The remaining three patients were treated with radiation therapy but were not used in this analysis. The average follow-up was 35 months after treatment. The CRT and SRT groups were statistically similar regarding age, sex, duration of follow-up, tumor grade, and tumor stage. Laryngeal primary tumors were more common in the SRT group than in the CRT group (P =.005). Eight domains were assessed by the HSQ-12: physical functioning, role-physical, bodily pain, health perception, energy/fatigue, social functioning, role-mental, and mental health. No statistical differences were found between the CRT and SRT groups, except for role limitations attributable to physical health (P =.007). CONCLUSIONS: These results indicate that only one of eight domains differs significantly between treatment groups when using the HSQ-12. Two-year survival end-point analysis of global health assessment may represent a simplified and meaningful way to compare treatment modalities in patients with advanced-stage head and neck cancer.     

Local control of oropharyngeal carcinoma by irradiation alone

The authors of this study reviewed the management of 402 patients with squamous cell carcinomas of the faucial tonsil and the base of the tongue. These patients received radiation therapy at Massachusetts General Hospital and the Massachusetts Eye and Ear Infirmary from 1970 through 1993. Radiation therapy remains the treatment of choice for these lesions. Although the data from this review were not randomized, the accelerated hyperfractionated radiation therapy twice-daily program was shown to achieve significantly higher 5-year local tumor control rates and disease-specific survival rates than the conventional once-daily radiation therapy program (historical control). In patients with early tumors of the faucial tonsil (cancer stages T1 and T2), the 5-year actuarial local tumor control and disease-specific survival rates following the twice-daily radiation therapy program were 91% and 77%, respectively. In patients with advanced tumors (T3), the corresponding rates following twice-daily radiation therapy showed marked improvement and were 80% and 68%. While the treatment results for carcinoma of the base of the tongue generally were inferior to those for carcinoma of the faucial tonsil, they were still much better after the twice-daily program than after conventional once-daily irradiation. For patients with carcinoma of the base of the tongue, the local tumor control and disease-specific survival rates for T1 and T2 lesions were 85% and 76%, respectively. For T3 lesions, the corresponding rates were 54% and 53%. Extensive T4 tumors are better managed by combined surgery and postoperative irradiation. Residual metastatic nodal disease is managed by neck dissection.     

Mandibular reconstruction using free bone flap after preoperative chemoradiation

When treating head and neck cancer of an advanced stage, additional therapy modalities are often combined with surgery. This sets new challenges for the reconstructive surgery, especially after segmental mandibulectomy. There is continuous discussion considering the optimal timing of the surgery with relation to other treatment methods such as radiation therapy and chemotherapy. In this work, we have analyzed a series of 10 patients treated with segmental mandibulectomy and preoperative irradiation or chemoradiation in our institute between 1999 and 2006. Surgery was scheduled within 5 weeks from the radiation therapy. 9 out of 10 reconstruction flaps were vital at the last follow-up. In general the outcome of these patients was consistent with the results published earlier by other institutes using postoperative irradiation or chemoradiation. We conclude that preoperative irradiation does not have negative impact on microvascular reconstruction with free bone flap and this procedure offers an equal option for the treatment of these patients.     

Palliative radiotherapy for lingual metastasis of renal cell carcinoma

The report is of a 50-year-old man with renal cell carcinoma (RCC) who had rapidly progressing metastasis to the tongue at 10 months after the left radical nephrectomy. The metastatic lingual tumor was not resectable, therefore treated with radiation (50 Gy). The tumor disappeared macroscopically after the radiation therapy, but enlarged again 4 months later. The patient died of respiratory failure due to multiple lung metastases 12 months after the appearance of the lingual metastasis. Radiation therapy is an acceptable palliative strategy for advanced lingual metastasis of RCC.