Sonographic findings of the neopharynx after total laryngectomy: comparison with CT

BACKGROUND AND PURPOSE: To our knowledge, sonographic findings in the neopharynx have not been well characterized. We describe our results and assess the role of sonography versus CT in patients who have undergone total laryngectomy. METHODS: We examined 25 patients (24 men and one woman; 44-78 years old) who had had a total laryngectomy. Sonography (with a 10-MHz transducer) and contrast-enhanced CT were performed in all patients. We evaluated the normal shape of the neopharynx and assessed the accuracy of sonography versus CT in detecting tumor recurrence in the neck. RESULTS: The neopharynx appears as a round or ovoid structure on imaging studies. On sonograms, the neopharyngeal wall has five layers of alternating echogenicity: an innermost hyperechoic layer of superficial mucosa, an inner hypoechoic layer of deep mucosa, a middle hyperechoic layer of submucosa, an outer hypoechoic layer of muscle, and an outermost hyperechoic layer of adventitia. On CT scans, the neopharynx appears as a three-layered structure, with an inner hyperdense layer of mucosa, a middle hypodense layer of submucosa, and an outer isodense layer of pharyngeal constrictor muscles. Nine pathologically proved recurrences were found: three local recurrences, one local recurrence with lymph node metastasis, and five cases of lymph node metastasis only. One instance of false-negative lymph node metastasis was seen at sonography and one case of false-positive local recurrence was seen at CT. CONCLUSION: The neopharynx has a unique sonographic appearance, and this imaging technique is useful for detecting local tumor recurrence in the neopharynx in patients who have had a total laryngectomy.     

Digital cineradiography of the pharynx and the oesophagus after total or partial laryngectomy

PURPOSE: The aim of the present study is to report our experience using digital cineradiography to assess morphological and functional disorders of the pharynx in patients with prior partial or total laryngectomy. MATERIALS AND METHODS: From March 2000 to October 2002, 21 patients (18 males and 3 females) with prior total laryngectomy (12 patients), total laryngopharyngectomy (2 patients) and partial laryngectomy (7 patients) were examined. A digital cineradiography with 12 frames/second acquisition was performed in all patients. In four patients the procedure was interrupted for massive barium aspiration, without cough (silent aspiration). In 17 patients standing in the left posterior oblique position and prone in the right posterior oblique position the oesophagus and oesophagogastric junction were also examined. The water siphon test was performed at the end of the procedure. Small boluses (10 ml) of liquid (60% w/v) and high-density (250% w/v) barium, barium paste (110% w/v), and solid meal (obtained spreading a dry biscuit with barium paste) were used. RESULTS: All patients with prior total laryngectomy and total laryngopharyngectomy showed morphological and functional disorders of the neopharynx: parapharyngeal diverticulum (2 cases), submandibular pouch (6 cases), fistulas (2 cases), lumen narrowing and post-surgical stenoses (2 cases), tumour recurrence (1 case), prominent cricopharynx (5 cases) and rhinopharyngeal reflux (4 cases). All patients with prior partial laryngectomy (7 cases) presented silent aspiration. Eleven patients had an oesophageal motility disorder, which was very serious in three of them with decrease in oesophageal clearing and barium retention in the oesophagus. Oesophagogastric junction evaluation showed hiatus hernia in six cases, two of them with associated gastro-oesophageal reflux. CONCLUSIONS: Digital cineradiography appears able to identify the organic and functional postoperative complications of patient treated with partial or total laryngectomy. A special swallowing study can suggest to the speech therapist the best compensatory mechanism for improving patient swallowing and therefore quality of life.     

Usefulness of high-density barium for detection of leaks after esophagogastrectomy,total gastrectomy,and total laryngectomy

OBJECTIVE: The purpose of this study was to determine the usefulness of a high-density (250% weight/volume) barium compared with a water-soluble contrast agent for the detection of esophageal leaks in patients who had undergone esophagogastrectomy, total gastrectomy, or total laryngectomy. MATERIALS AND METHODS:A search of our radiology database from 1998 to 2001 revealed 46 eligible radiographic studies performed using a water-soluble contrast agent alone or a water-soluble contrast agent followed by barium that showed leaks in patients who had undergone esophagogastrectomy, total gastrectomy, or total laryngectomy. The images were reviewed to determine the morphology of the leaks (i.e., blind-ending tracks, sealed-off collections, or free extravasation of contrast material). Medical records were also reviewed to determine whether detection of the leaks seen on the radiographic studies affected patient management. RESULTS: Of the 46 leaks seen on radiographic studies, 23 (50%) were detected with a water-soluble contrast agent and 23 (50%) were detected only with high-density barium. Of the 23 leaks visualized with water-soluble contrast media, six (26%) were characterized by blind-ending tracks, 14 (61%) by sealed-off collections, and three (13%) by free extravasation of contrast material into the mediastinum or neck. Of the 23 leaks visualized only with high-density barium, 19 (83%) were characterized by blind-ending tracks and four (17%) by sealed-off collections. Thus, leaks detected only on images obtained with high-density barium were significantly more likely to be characterized by blind-ending tracks than those detected on images obtained with a water-soluble contrast agent (p = 0.0007). Of the 33 patients with clinical follow-up, the findings seen on these imaging studies affected management in 12 (86%) of 14 patients with leaks depicted by water-soluble contrast media and in 10 (53%) of 19 with leaks depicted only by high-density barium. CONCLUSION: Our findings support the use of high-density barium as part of the routine postoperative radiographic examination when no leaks are detected on images obtained with a water-soluble contrast agent.     

Air esophagram after laryngectomy

Air in the esophagus is frequently visible on chest radiographs of patients who have undergone laryngectomy (15/30; 50%). It is more frequently seen in those who successfully use esophageal speech (11/18; 61%) than in those who do not (4/12; 33%). The esophagus may be dilated, totally air filled, and contain an air-fluid level. A discussion of the physiology of esophageal speech and a differential diagnosis of esophageal air are presented. An air esophagram in patients using esophageal speech after laryngectomy in the absence of symptoms of an obstructing lesion should not be considered abnormal.     

Radiologic findings following supraglottic and total laryngectomy

The treatment of carcinoma of the larynx has recently been greatly improved with the development of supraglottic and total laryngectomy. This has also led to a high five year survival rate. The normal postoperative radiological appearances are presented together with the spectrum of relevant radiological investigations and their indications. The most frequently seen postoperative complications and findings in patients with dysphagia are described with special reference to pharyngograms and cineradiography. The morphology of the vibrating segment after laryngectomy in patients who do not develop effective alaryngeal speech is demonstrated.     

Esophageal carcinoma. Radiologic appearance of minimal lesions

Twelve minimal lesions were found over a period of 18 months at the Istituto Nazionale Tumori of Milan at the end of the radiologic, endoscopic and histologic procedures. Eleven lesions were radiologically detected, and a radiologic diagnosis of malignancy was perspectively made in 10 of the identified lesions. The radiologic aspects of minimal lesions are described. Double contrast study of the esophagus allows excellent mucosal detail and good reproduction of lesions. Simplicity and minimal discomfort for the patient justify it as a first diagnostic step for detection of neoplastic pathology.     

Esophageal insufflation and videofluoroscopy for evaluation of esophageal speech in laryngectomy patients: clinical implications

Esophageal speech proficiency in 75 laryngectomy patients was rated on a seven-point scale by a speech therapist. Radiologic evaluation of the reconstructed pharyngoesophageal (PE) region during swallowing, attempted phonation, and phonation, by means of esophageal insufflation and barium-enhanced videofluoroscopy and spot radiography revealed the PE segment to be normal in 13 patients and hypotonic in 21. Hypertonicity or spasm of the PE segment was detected in 28 patients. Three patients had a postoperative stricture. Speech in 24 patients was fluent at the time of assessment; the remainder had negligible speech. Correlation between esophageal speech fluency and response at insufflation was highly positive. Esophageal insufflation, when combined with radiologic assessment, provides a reproducible method for accurate evaluation of the PE transition zone. Videofluoroscopy allowed good visualization of tracheoesophageal dynamics. Results indicated anatomic factors in the reconstructed PE region to profoundly affect the acquisition of esophageal speech.     

Normal laryngeal CT findings after supracricoid partial laryngectomy.

BACKGROUND AND PURPOSE: Supracricoid horizontal partial laryngectomy (SCPL) is increasingly used to treat endolaryngeal carcinoma. However, few radiologic reports of these procedures exist. Our purpose was to evaluate the normal CT appearance of the neolarynx after surgery. METHODS: SCPL includes cricohyoidopexy (CHP), cricohyoidoepiglottopexy (CHEP), and tracheocricohyoidoepiglottopexy (TCHEP). We examined CT scans obtained from 18 patients without local superficial recurrence who underwent SCPL: 10, CHEP; seven, CHP; and one, TCHEP. Three reference sections were used to analyze the main surgical reconstruction: an upper section through the hyoid bone, a lower section through the cricoid cartilage, and a middle section in between. The distance between the hyoid bone and cricoid cartilage was measured. RESULTS: The epiglottis and valleculae were visible in the upper section in seven of 10 patients who underwent CHEP; this finding allowed distinction between CHEP and CHP. The arytenoids were depicted in 13 of 18 cases and reflected neolaryngeal shortening. The lower section showed the empty cricoid lumen lined by a thin mucosa; the anterior arch of the cricoid was amputated at TCHEP. The middle section showed the neovestibule, the lateral boundaries of which were the hypertrophic neoaryepiglottic folds; the anterior limit was the epiglottis for CHEP or the base of the tongue for CHP. The average distance between the hyoid bone and cricoid cartilage was 11 mm. CONCLUSION: Normal CT anatomy of the larynx after SCPL is defined. Three key sections may accurately distinguish the various types of SCPL. CT is a valuable tool for depicting tumor recurrence, especially when the tumor is submucosal.     

食管内支架置入术后脱落原因分析

目的:针对食管支架治疗食管良恶性狭窄和瘘的置入术后效果及由治疗可能引起的并发症,从中总结出一些经验及体会。方法:本组56例,均为失去手术时机或有手术禁忌症的恶性肿瘤患者,共置入覆膜镍钛合金支架及覆膜不锈钢Z型支架59枚(其中有防返流支架5枚)。结果:56例患者共置入59枚支架均一次成功,支架置入后食管狭窄改善,瘘道封闭,饮食得到恢复。有效率达100%。但在术后一段时间内有5例患者支架发生移位和/或脱落。结论:食管支架治疗食管恶性狭窄应根据患者不同情况制定不同治疗方案以最大程度减少并发症的发生。     

Correlation of local outcome after partial laryngectomy with cartilage abnormalities on CT

BACKGROUND AND PURPOSE: The prognostic significance of laryngeal cartilage abnormalities, as seen on CT or MR imaging, in laryngeal or hypopharyngeal cancer, is unclear. The purpose is to determine whether cartilage abnormalities as seen on preoperative CT in laryngeal and pyriform sinus cancer are predictive of local outcome after partial laryngectomy. METHODS: The preoperative CT studies in a consecutive series of 16 patients who underwent extended hemilaryngectomy for squamous cell carcinoma of the glottis (n = 12), supraglottis (n = 1), or pyriform sinus (n = 3) were reviewed retrospectively. Cartilage abnormalities were defined as asymmetric cartilage sclerosis, lysis of ossified cartilage, or tumor visible on both sides of the cartilage. Tumor volume was calculated by using the summation-of-areas technique. Seven patients underwent postoperative radiation therapy. All patients had a follow-up of at least 24 months after treatment or until local recurrence. RESULTS: Eleven patients showed cartilage abnormalities. In six patients, only a single cartilage was abnormal, whereas three patients showed involvement of two cartilages and two patients of three cartilages. The overall average tumor volume was 2.7 mL; the average tumor volume was 1.5 mL in the patients without and 3.3 mL in those with cartilage involvement on CT (P > .05). Two patients suffered a local recurrence. One patient (tumor volume, 1.5 mL) did not show any cartilage abnormalities. The other patient (tumor volume, 1.9 mL) showed abnormalities in all three cartilages and also had evidence of early transcartilaginous tumor spread. CONCLUSION: In patients whose cancer is anatomically suitable for partial laryngectomy, cartilage abnormalities on CT do not preclude speech-preserving surgery.     

Neck evaluation with barium-enhanced radiographs and CT scans after supraglottic subtotal laryngectomy

Supraglottic subtotal laryngectomy (SSL) is a radical, yet voice-conserving, surgical procedure commonly performed for carcinoma of the supraglottic larynx. The pharyngograms and computed tomographic (CT) scans of 35 patients obtained after SSL were evaluated retrospectively. These examinations reliably demonstrated the changes in anatomy caused by removal of the epiglottis, aryepiglottic folds, and false vocal cords. Fourteen patients had documented recurrence of cancer; five mucosal, nine extramucosal. Three of five macroscopic mucosal recurrences in the larynx/pharynx were detected on the barium pharyngograms; the two mucosal lesions not seen were in the base of the tongue and tonsillar fossa. CT enabled detection of five of five recurrences and was superior to pharyngography in demonstrating the soft-tissue extent of disease. CT findings mimicking recurrence were seen in two patients: one with diffuse histiocytic lymphoma; the second, with benign hyperkeratosis. Barium and CT examinations are useful adjuncts to the clinical examination in detecting recurrent squamous cell carcinoma in patients following SSL.     

Tennis after total knee arthroplasty

In this study, patients who played tennis after undergoing a total knee arthroplasty were analyzed in terms of their functional abilities and degree of satisfaction. The patients were recruited by means of a questionnaire that was sent to players from lists supplied by the United States Tennis Association. The study group consisted of 28 men and 5 women (46 total knee replacements) with a mean age of 64 years. Only 21% (7 of 33) of the patients' surgeons approved of their patients undertaking tennis activity, with 45% (15 of 33) recommending only doubles tennis. At both 1 year and a mean of 7 years after arthroplasty, players were playing both singles and doubles tennis approximately three times per week (range, one to seven). All tennis players polled were satisfied with their knee arthroplasties and their ability to resume playing tennis. Because the study patients played at a high level, future studies are needed to determine the effect of tennis on the general population, which does not play at such a uniformly high level. The long-term (15 to 20 years) effect of tennis activity on the clinical and radiologic outcome of total knee arthroplasty also needs to be determined.     

Sports after total joint replacement

Today's patients require additional guidance in their expectations after replacement surgery. Failure rates for shoulder, hip, and knee replacements across most studies are approximately 0.5% to 1% per year, including infection, loosening, and wear of the parts. Elbow and ankle replacements will likely require more restrictions and have slightly higher revision rates.