Scar contracture prevention with local steroid injections in transoral videolaryngoscopic surgery

ObjectiveThe aim of this study was to evaluate the efficacy and safety of local steroid injections to prevent scar contracture after transoral videolaryngoscopic surgery (TOVS) in hypopharyngeal cancer patients.MethodsPatients were enrolled in this study if they had received a local steroid injection during TOVS and had attended an outpatient clinic after at least three months. All patients were being treated for hypopharyngeal cancer and received a single session of triamcinolone acetonide, injected using a 21-gage needle. Retrospective chart reviews were performed, and the degree of scar contracture, pharyngeal stenosis, vocal fold movements, and adverse events were evaluated. Scar contracture was assessed using a scoring system, which compared the endoscopic findings of treatment and matched pair control groups.ResultsA total of 20 patients received local steroid injections during TOVS and were enrolled in the treatment. Scar contracture was seen in 14 patients (70%); however, the degree of scar contracture was significantly decreased when compared to control cases. Vocal fold immobility was observed in five patients, but no pharyngeal stenosis was noted. Adverse effects, such as postoperative laryngeal chondritis or cervical spondylitis, were seen in three patients who had previously been treated with resection to the muscularis propria or definitive irradiation.ConclusionLocal steroid injection during TOVS significantly reduced the degree of postoperative scar contracture. However, caution should be used when treating with local steroid injection during TOVS, as this may complicate wound healing in patients who have already received treatment.     

Vocal function after transoral videolaryngoscopic surgery (TOVS) for hypopharyngeal and supraglottic cancer

Abstract

Conclusion: The resection of the medial and lateral pyriform sinus was associated with post-operative voice impairment after TOVS. Scar contracture around the cricoarytenoid joint lead to arytenoid fixation toward lateral position, and this wound healing process caused insufficient glottis closure. Although oncological and functional outcomes of TOVS was satisfactory, surgeons should mention the risk of post-operative voice impairment in pre-operative counseling.

Objectives: Transoral surgery is a minimally invasive treatment option for hypopharyngeal and supraglottic cancer. Post-operative vocal function was satisfactory in most cases, but in some cases vocal cord was fixed and occasionally voice impairment persists.

Methods: Vocal function of 55 patients who underwent transoral videolaryngoscopic surgery (TOVS) for hypopharyngeal and supraglottic cancers was evaluated by the GRBAS perceptive scale, aerodynamic tests and acoustic analyses, and the Voice Handicap Index questionnaire. The risk factors for voice impairment were identified.

Results: Voice impairment (G score ≧2) was found in 16 cases (29.1%). Univariate analysis revealed that the resection of medial and lateral pyriform sinus (p?=?.0018) and neck dissection (p?=?.0421) were associated with post-operative voice impairment. Multivariate analysis revealed that the resection of medial and lateral pyriform sinus (p?=?.0021) was associated with post-operative voice impairment.     

Successful transoral videolaryngoscopic surgery for leiomyoma in the base of the tongue

Leiomyomas are benign tumors with smooth muscle differentiation that occur most frequently in the uterine myometrium. They are uncommon in the head and neck region. We report a rare case of tongue base leiomyoma successfully resected with transoral endoscopic surgery.A 14-year-old male was found to have a tongue base tumor. The tumor located in the right tongue base. It had a smooth surface and no deep invasion. The tumor was resected with transoral videolaryngoscopic surgery. There were no serious adverse events requiring further intervention. Histologically, the tumor was composed of densely cellular fascicles of spindle-shaped cells with smooth muscle differentiation with diffuse and intense reactivity for α-smooth muscle actin, desmin, calponin, and anaplastic lymphoma kinase on immunohistochemistry. After careful consideration of the differential diagnosis, the tumor was diagnosed a smooth muscle tumor, mostly consistent with leiomyoma.This is the first report of leiomyoma arising from the tongue base that was completely resected by transoral videolaryngoscopic surgery without adverse events. For tongue base tumors, endoscopic transoral surgery can be considered as an option for complete resection without impairment of postoperative function.     

Maintenance of hemostasis in transoral robotic surgery

BACKGROUND: The last decade has seen a tremendous growth in the field of robotic surgery with an increasing number of cardiac and urologic procedures performed each year. Several attributes of this technology may offer advantages to laryngeal and pharyngeal surgery in that it allows for exceptional visualization of the operative field, precise handling of soft tissues, and multiplanar transection of tissues. One potential limitation is the management of bleeding in transoral pharyngeal and laryngeal surgery, which is critical to prevent both intravascular volume loss and aspiration. OBJECTIVES: To demonstrate methods for management of bleeding in the surgical field during transoral robotic surgery (TORS). METHODS: We developed a canine robotic surgery model for the evaluation of the ability to control bleeding in laryngeal and pharyngeal procedures using the daVinci surgical robot (Intuitive Surgical, Inc., Sunnyvale, Calif., USA). Both large- and small-vessel hemostasis was obtained with both robotically controlled monopolar and bipolar cautery and with robotically controlled small hemoclips. Additionally, manually controlled large hemoclips were applied by an assistant surgeon viewing on a video monitor for management of large arterial vessels. Suction was performed with both flexible suction catheters controlled by the robotic arms and with manually controlled conventional suction catheters. Data were collected with still and video photography. RESULTS: The lingual artery as well as small arteries and veins were easily controlled and there were no difficulties with maintenance of hemostasis. CONCLUSIONS: Effective hemostasis with control of both large and small vessels can be obtained using both surgical hemoclips and electrocautery during TORS in a canine model.     

Audiovestibular findings prior to and after acoustic neuroma surgery

We performed a retrospective study of 131 patients who underwent microsurgical removal of statoacoustic neuroma at the University of Wuerzburg. Our goal was to evaluate objective audiovestibular findings prior to and after surgery. Our analysis focused on the evaluation of quantitative parameters in speech and pure-tone audiometry and on the reactivity of the vestibular system.     

Outcomes of transoral laser microsurgery and transoral robotic surgery in oropharyngeal squamous cell carcinoma

ObjectiveTransoral robotic surgery (TORS) has evolved to a standard therapy modality for oropharyngeal carcinoma, especially in T1/ T2 tumors involving the base of the tongue due to its advantages compared with open surgery. However, knowledge about its benefits compared with transoral laser microsurgery (TLM) are scarce. This study compares oncological and functional results of TLM or TORS in the treatment of oropharyngeal squamous cell carcinoma (OPSCC).MethodsThis retrospective analysis comprises all patients with OPSCC treated with TLM (n = 30) or TORS (n = 24) between April 2003 and May 2018 (follow-up 43 ± 38.3 months). Both treatment groups (TLM and TORS) were comparable in terms of the stage of the disease, prognosis-determining factors, and adjuvant therapy modalities.ResultsThere were no significant differences regarding to the resection status (p = 0.272), the rate of local- (p = 0.834) and distant- recurrence (p = 0.416), with a disease-free survival of 86.7 % and 87.5 %, respectively (p = 0.892). In addition, we could not confirm any differences regarding to operating time (p = 0.860), intraoperative blood loss (p = 0.660), inpatient stay (p = 0.585) and postoperative bleeding rate (p = 0.245). The frequency of tracheostomy and percutaneous endoscopic gastrostomy between both groups is comparable, with a longer duration of tube feeding in patients who have received TLM (p = 0.030).ConclusionIn conclusion, TORS allows for similar oncological outcomes compared with TLM at comparable perioperative risks. The postoperative swallowing function may benefit from TORS.     

How to optimize laryngeal and hypopharyngeal exposure in transoral robotic surgery

Objective

The aim of this study was to present the various strategies adopted in our center to improve and overcome problems with exposure of the operative field in 48 patients who underwent TORS for the treatment of laryngeal and hypopharyngeal cancer.

Methods

We present our operative and preoperative treatment protocols for patients undergoing TORS for laryngeal and hypopharyngeal cancer. In particular, we emphasize the role of preoperative exposure assessment and the usefulness of simple measures to overcome problems with exposure of the operative field.

Results

In 12 patients (25%), we experienced difficult laryngeal–hypopharyngeal exposure. However the correct positioning of the robotic arms, the proper use of the laryngeal and tongue blade and some simple maneuvers, such as the anterior traction of the tongue and the partial epiglottectomy, ensured the feasibility of TORS with negative margins in all patients.

Conclusion

In TORS, the exposure of larynx and hypopharynx can be difficult, but the adoption of certain methods may make it possible in most patients. An accurate preoperative evaluation under general anesthesia is the primary strategy for reducing the number of cases terminated intraoperatively. Currently, TORS is not feasible in all patients, but in our opinion, reductions in the size of robotic equipment and development of new devices will extend the application of TORS to a larger number of patients.     

Assessment of intraoperative safety in transoral robotic surgery

INTRODUCTION: Robotic technology has been safely integrated into thoracic and abdominopelvic surgery, and the early experience has been very promising with very rare complications related to robotic device failure. Recently, several reports have documented the technical feasibility of transoral robotic surgery (TORS) with the daVinci Surgical System. Proposed pharyngeal and laryngeal applications include radical tonsillectomy, base-of-tongue resection, supraglottic laryngectomy, and phonomicrosurgery. The safety of transoral placement of the robotic endoscope and instruments has not been established. Potential risks specific to the transoral use of the surgical robot include facial skin laceration, tooth injury, mucosal laceration, mandible fracture, cervical spine fracture, and ocular injury. We hypothesize that these particular risks of transoral surgery are similar with robotic assistance compared with conventional transoral surgery. METHODS: To test this hypothesis, we attempted to intentionally injure a human cadaver with the daVinci Surgical System by impaling the facial skin and pharyngeal and laryngeal mucosa with the robotic instruments and endoscope. We also attempted to extract or fracture teeth and fracture the cadaver's mandible and cervical spine by applying maximal pressure and torque with the robotic arms. Experiments were documented with still and video photography. RESULTS: Impaling the cadaver's skin and mucosa resulted in only superficial lacerations. Tooth, mandible, and cervical spine fracture could not be achieved. CONCLUSIONS: Initial experiments performing TORS on a human cadaver with the daVinci Surgical System demonstrate a safety profile similar to conventional transoral surgery. Additionally, we discuss several strategies to increase patient safety in TORS.     

经口入路机器人手术在耳鼻咽喉头颈外科中的应用

摘要：目的总结经口入路机器人手术（transoral robotic surgery,TORS）在耳鼻咽喉头颈外科应用的临床经验。方法2010年11月~2015年7月南京军区南京总医院耳鼻咽喉科应用“达芬奇”机器人手术系统对10例咽喉部病变患者行TORS, 回顾性分析患者临床资料,总结手术体会。结果10例患者均顺利完成手术。术野暴露平均用时34 min（20～60 min）,调整开口器次数2~5次,平均手术时间为67 min（30～130 min）。患者平均住院时间为8 d（6～14 d）,恢复经口进食平均需要5 d（2～10 d）,出院时均可经口进食。术中及术后均未出现并发症。恶性肿瘤患者的术后病理学检查示切缘均未见癌细胞残留。结论在掌握好适应证的前提下,应用“达芬奇”机器人手术系统可以独立完成多种类型耳鼻咽喉头颈外科手术,其手术创伤小,患者术后恢复快,有着巨大的临床应用价值。     

Role of local flaps in the prevention of soft tissue necrosis after transoral robotic surgery for tonsillar cancer

ObjectiveSoft tissue necrosis (STN) can occur after transoral robotic surgery (TORS) with radiation therapy (RT). We investigated the usefulness of local flap reconstruction for preventing STN after TORS in patients with tonsillar cancer.MethodsThis case-control study retrospectively reviewed clinicopathological data of patients who underwent TORS for tonsillar cancer at a tertiary referral center. The incidence of STN was compared in patients who underwent secondary intention healing or local flap reconstruction, and factors predicting STN were identified.ResultsSTN occurred in 20 (25%) of 80 patients in the study. The incidence of STN was higher in the secondary intention healing than the flap reconstruction group. Mucositis grade (odds ratio [OR] 3.694, p = 0.02), RT dose (OR 4.667, p = 0.001), and secondary intention healing (OR 14.985, p = 0.035) were predictive factors for STN.ConclusionFlap reconstruction can prevent STN after TORS with RT in patients with tonsillar cancer. The use of local flaps preserves the minimally invasive nature of TORS.     

Evaluation of ultrastructural changes in paranasal sinus mucosa after functional endoscopic sinus surgery in patients with chronic rhinosinusitis

The purpose of this study was to compare the preoperative and postoperative ultrastructural changes of paranasal sinus mucosa in patients treated with functional endoscopic sinus surgery for chronic rhinosinusitis. Twelve patients undergoing functional endoscopic sinus surgery for the treatment of chronic rhinosinusitis were involved. The ethmoid sinus mucosa was sampled during the operation and approximately 6 months after the operation. The ciliated epithelium of sinus mucosa was evaluated with transmission electron microscopy. The samples were taken at the Otolaryngology Department of Istanbul University School of Medicine. Electron microscopic study was performed at the Histology and Embryology Department of the same University. Preoperatively, ciliated epithelial cells of the sinus mucosa of the patients showed degenerated ultrastructure with decreased number of cilia, cytoplasmic protrusions, cisternal dilatations of endoplasmic reticulum, and mitochondrial swellings. Remnants of degenerated cells and cellular separations at cell junctions were evident in the diseased epithelium. Goblet cells were frequent along the epithelial lining. Postoperatively, normal architecture and ultrastructure of the ciliated epithelium was restored. These observations showed that unlike other surgical operations, paranasal sinus mucosa can regenerate and the ciliated epithelium can return to normal after functional endoscopic sinus surgergy.