Quality of life after intensity-modulated radiotherapy for prostate cancer with a hydrogel spacer. Matched-pair analysis.

BACKGROUND: Hydrogel spacer is an innovative method to protect the rectal wall during prostate cancer radiotherapy. Clinical effects are not well known. METHODS: Patients have been surveyed before, at the last day, and 2-3 months after radiotherapy using a validated questionnaire (Expanded Prostate Cancer Index Composite). Median dose to the prostate in the spacer subgroup (SP) was 78 Gy in 2 Gy fractions. The results were independently compared with two matched-pair subgroups (treated conventionally without spacer): 3D conformal 70.2 Gy in 1.8 Gy fractions (3DCRT) and intensity-modulated radiotherapy (IMRT) 76 Gy in 2 Gy fractions. There were 28 patients in each of the three groups. RESULTS: Baseline mean bowel bother scores were 96 points in all subgroups. Similar mean changes (SP 16, 3DCRT 14, IMRT 17 points) were observed at the end of radiotherapy. The smallest difference resulted in the spacer subgroup 2-3 months after radiotherapy (SP 2, 3DCRT 8, IMRT 6 points). Bowel bother scores were only significantly different in comparison to baseline levels in the spacer subgroup. The percentage of patients reporting moderate/big bother with specific symptoms did not increase for any item (urgency, frequency, diarrhoea, incontinence, bloody stools, pain). CONCLUSION: Moderate bowel quality-of-life changes can be expected during radiotherapy irrespective of spacer application or total dose. Advantages with a spacer can be expected a few weeks after treatment.

[Challenges and advances in the care of injuries in the Republic of Serbia].

There are many problems that trauma care system in Serbia is facing today. Few of them are: 1) Lack of categorization of trauma centers; 2) Diversity in managing of trauma patients among institutions; 3) There is no trauma management training, 4) Inappropriate cooperation between pre hospital trauma care and hospital trauma care; 5) There is no standard in managing of trauma patients as well as procedures. To improve trauma care quality throughout the country we must learn from the experiences of other countries. The aim of this paper was to report representative data about organization, management, stuff and equipment of ambulance and emergency services in Serbia. We analyzed 12 out of 138 parameters we obtained from the relevant institutions.

[Damage control surgery in abdominal trauma].

The damage control laparotomy is an advancement in the management of massively injured trauma patients. Massive liver injuries, pelvic trauma and some retroperitoneal injuries are some of the indications for this approach. The damage control laparotomy is the phased approach to severe abdominal injury that might best be described with the acronym STIR (Staged Trauma Injury Repair). The initial procedure requires rapid abdominal exploration with hemorrhage and contamination control, using suture repair combined with abdominal packing. Temporary abdominal wall closure without tension is recommended. After abrevated initial surgical procedure, the patient is transferred to the intensive care unit where continued resuscitation is performed. Careful replacement of blood and blood products along with correction of hypothermia, acidosis and optimalization of oxygen transport represents a critical phase in this management approach. Once the coagulation profile has normalized, planned re-intervention, with repeat abdominal exploration to remove the packs and perform definitive surgical repair and reconstruction takes place. When applied judiciously, the damage control laparotomy with the staged abdominal repair and reconstruction for severe trauma is associated with an improved outcome in the selected group of patients.

[Open fracture of the shin as an occupational injury and work capacity evaluation--case report].

Injuries at work (occupational injuries) represent a big social and economic problem. This case report presents the patient who suffered occupational injury--open fracture of the left shin. He has been hospitalized for several times at Orthopedic-Surgical Hospital "Banjica" and underwent several surgical procedures, physical therapy and Hyperbaric Oxygen Therapy. After this treatment, he was hospitalized at Institute of Occupational Health for disability evaluation and work capacity evaluation.

[The effect of smoking and forced use of the voice to development of the vocal polyps].

Dysphonia is often caused by polyps which are benign changes of pseudotumors. With their presence they are hampering with glotis oclusion. Laryngomicroscopy of general and endotracheal anaesthesia has been preformed on all of the patients. Microsurgical technique has been used to remove the polyps. Bioptic material was analyzed in pathophysiological laboratory of clinic of pathology in Banjaluka. All of the results were presented through tables and graphic representations. Frequency of polyps through age and sex groups, along with the examination of ethyological factors in emergence of polyps of vocal cords. Results are in accordance with the results of other authors who were involved in similar problematics. Through analysis of our data we percieve that the abuse of voice is part of ethiological factors that lead not only to emergence of vocal fold lesions but aswell as other benign changes.

[What do we need to help laryngectomized speeking?].

Multidisciplinary approach in rehabilitation of laryngectomized patients is the basic of esophageal voice and speech establishing. Well trained and dedicated stuff is cornerstone for such helpless patients. Communication Disorders Care Center and Laryngectomized Patients Society are minimal administrative precautions in organized community. Modern technology implementation gives us objective evaluation of therapy effects, that is 84% of successful treatment in our daily work.

[Preliminary results of applying the inverse stapedotomy].

The authors have analyzed a group of 90 patients (105 operations) that have underwent stapes surgery over three years period. First group of 40 patients (45 operations) have been operated on by a classic stapedotomy from 2006 to 2007 and the second group of 50 patients (60 operations) by inverse stapedotomy in 2007. Manual perforator has been used in all of the patients. In a group of patients operated by inverse technique not a single case of floating basal plate has occurred during surgery. Rate of postoperative complaints regarding nausea and balance disorders was considerably lower when reversal of the steps has been used. Closure of air bone gap better than 20dB in about 80% patients in both series, with slight advantage of the inverse technique, but no statistically significant difference was proven. Inverse stapedotomy is efficient procedure as compared to classic stapedotomy with less intraoperative complications and postoperative complaints. Postoperative audiograms have shown similar improvement of hearing thresholds in both groups.

Nonvibrating segment predicting glottis carcinoma.

Endovideolaryngostroboscopy is the obliged evaluation tool in our everyday practice. Standardized protocol in management of broad spectrum of vocal pathology is useful in clinical, scientific and educational evaluation of patient from the first interview till the end of the treatment. Using of contemporary computerised multidimensional analysis of stroboscopic image we are approaching to optimum evaluation of any kind of interpersonal communication disorder. There were 66 patients in prospective clinical study of correlation between suspect endovideolaryngostroboscopic findings and histo-pathology verification of glottis carcinoma. Asymmetric and irregular vibrations with absent mucosal wave or absent vibrations of one part or of the whole vocal fold was improved as carcinoma in 85% of patients. The most frequent diagnosis was Ca planocellularae invasivum G2 NG 2, with subsequent open chordectomy. In every case of hoarseness longer more than 14 days, endovideolaryngostroboscopy is the golden standard for evaluating the need for microlaryngoscopy and biopsy.

[Phoniatricians aspect of international statistical classification of diseases and related health problems].

INTRODUCTION: In everyday phoniatrician practice there are problems in finding adequate coding in current version of International Classification of Diseases. There is grey area for additional explanation under the official diagnosis and its code in Computer program window, but that has bad consequences on efficacy in writing the final medical report. OBJECTIVE: Suggestions for solving this problem that can contribute in next Revision are presented. METHOD: The comparation between diagnoses in 7 years period of Phoniatric Department everyday practice and given diagnoses in current version of International Classification of Diseases. RESULTS: Certain percent of diagnoses that are overviewed during last 7 years in our Phoniatric Department has no adequate expression in given diagnoses in Tenth Revision. One can say that there is some kind of communication disorder. CONCLUSION: This is the moment for Communication Disorders Care Center experts to participate in constitution of widespread acceptable nomenclature. The role of phoniatrician is necessary and logical in this system. The phoniatrician aspect of contribution in next Revision, is presented.

[Hearing damage caused by noise].

INTRODUCTION: Noise is most common profession risk, as well as risk from environment, for hearing loss. Top limit for industrial noise is 85 dB. OBJECTIVES: Aim of our study was to determined all number of recognized professional diseases in our country, as well as to see which of industries are with highest prevalence of professional hearing damage caused by noise. MATERIALS AND METHOD: We use an cohort study for analyzing patient histories which were hospitalised in the Institute of occupational health. All of them have recognized professional disease hearing loss. In order to be recognized as cases of a professional hearing damage, all of them had to satisfy all legal requirements. RESULTS: Average age of patients with professional damage of cochlear nerve was 50 y. They have high total time period as well as exposed time period. In 2003 and 2004 there was highest number of detected and recognized cases of such professional diseases. More than half of examined patients had lesion between 30 and 40 percent following tables of F. S. Most of them were metal and mining industry workers. CONCLUSION: Following results of the study we can conclude that regular medical examinations of workers in all industries are necessary, specially in metal and mining industry. It is also needed to use personal protection items and to provide appropriate medical education of both workers and the management staff of said industries in order to prevent this kind of profession disease.

[Laser surgery of supraglottic laryngeal carcinoma].

The limited excision addresses small superficial lesions affecting free edge of the epiglottis, the aryepiglottic fold or the superior edge of the arytenoid. The median supraglottic laryngectomy excluding the pre-epiglottic space addresses small superficial T1 lesions of the endolaryngeal epiglottis. The incision line extends to the pre-epiglottic space but does not aim at removing the pre-epiglottic space entirely. The pharyngo-epiglottic folds, aryepiglottic folds, and ventricular folds are preserved. The median supraglottic laryngectomy including the pre-epiglottic space addresses T1 and T2 lesions of the endolaryngeal epiglottis. The entire pre-epiglottic space is removed as far as possible. Depending on extent of the lesion, the resection can include one or two ventricular bands and the aryepiglottic folds. The lateral supraglottic laryngectomy addresses lesions affecting the three folds or T1 and T2 lesions of the aryepiglottic fold. The procedure removes free edge of the epiglottis ipsilateral to the lesion, the area of the three folds and the aryepiglottic fold. The resection can include the inner wall and anterior angle of the pyriform sinus, the entire ventricular fold and the arytenoid (provided it is mobile).

[Functional results of treatment of early carcinoma in the glottic region of the larynx].

Early stage glottic cancer can be successfully treated with open surgery, LASER surgery or radiotherapy. During this treatment the physician obviously has to bear in mind principles of oncological radicality, but also, none the less, the preservation of all the functions of the larynx, and especially the preservation of voice quality. The aim of the study is to compare, in a specifically designed prospective study, the method of treatment with the functional results of basic characteristics of spoken voice of patients with early stage cancer of the glottis region. Then, based on the analysis of the results, to try and determine the most successful method of treatment. The first study group consisted of 72 patients operated using transoral laser microsurgery; the second study group consisted of 75 patients operated using open surgery; and the third study group consisted of 74 patients treated with radiotherapy. The voice quality is much better after laser chordectomy compared to open surgery chordectomy with reconstruction. Furthermore, the functional results of voice quality, after a laser chordectomy, are worse when compared to the group of patients treated with radiotherapy. Taking into account all objective and subjective phoniatric parameters, we determined that there is no crucial difference in the voice quality of patients operated using laser chordectomy and patients primarily treated with radiotherapy. From a functional point of view these two methods are superior to open surgery chordectomy.

[Laser surgery of malignant tumors of the glottic region of the larynx].

The Nomenclature Committee of the European Laryngological Society taken the personal classification used by various members were analyzed and integrated into a common format. Thus, a new classification (Remacle et al., 2000) end next modification (Remacle et al., 2007) in was proposed and accepted by the members. This nomenclature takes into account both the histological and anatomical extent of surgery, and groups it into several categories. Subepithelial cordectomy--excision of the epithelium and the superficial layer of the lamina propria. Subligamentous cordectomy--excision of the epithelium, Reinke's space, and vocal ligament is undertaken. Transmuscular cordectomy--resection consists of the epithelium, lamina propria, and part of the vocal fold muscle, and may extend from the vocal process to the anterior commissure. Total or complete cordectomy--excision extends from the vocal process to the anterior commissure. Anteriorly, the incision is made at the anterior commissure. Type Va extended cordectomy--includes the anterior commissure and contralateral vocal fold, if necessary. In type Vb extended cordectomy, the excision is extended to remove part or all of the arytenoids. The posterior arytenoids mucosa is preserved. In Type Vc extended cordectomy, the whole of the ventricle and the ventricular fold is removed together with the vocal fold. In Type Vd extended cordectomy, surgery is extended inferiorly to include the subglottic mucosa. Type VI cordectomy--Anterior billateral cordectomy in this operation surgical intervention is focused on anterior commissure, therefore some authors name it commissurectomy.

[Bilateral vocal paralysis phonosurgery in adults].

Ordinary clinical manifestation of the patient with bilateral vocal fold paralysis is inability of abducting the cords with a result of narrowing the glottic space, causing inspiratory stridor and mild dysphonia. Such patients can be life threatened due to narrowing airway. Some kind of surgery has to be performed on these patients in order to enlarge the airway. When we treat patients with OPG, the most reasonable way is to gradually enlarge airway at glotic level and there are several surgical methods for achieving this. The least agresive and the safest procedures are posterior transversal cordectomy (PTC) or medial arytenoidectomy (MA), after which we can perform extended versions of some of these methods or combination of both. Bilateral vocal fold paralysis has to be diagnostically different from stenosis of posterior commissure, even though the procedures such as medial arytenoidectomy, posterior transversal cordectomy and total arytenoidectomy can be performed in both cases. The patients have to be explained that the aim of the procedure is to enlarge airway to the detriment of voice quality and voice capabilities.

[Foreign bodies of the lower respiratory tract].

Aspiration of foreign bodies of the lower respiratory tract is the most common cause of accidental death in children under 6 years of age in the United States. The aim of the study was to actualize the problem of foreign bodies in modern society, to determine the most common types of foreign body, who and why usually aspires foreign body, whether the incidence is changing, and to define principles for optimal prevention. During our five-year study, we had 166 cases of aspiration of foreign bodies of the lower respiratory tract. The incidence is highest in children under three years of age (54.8%). Cough (94.6%) and breathing difficulties (78.9%) were the dominated symptoms. The majority of aspirated objects were grain (peanuts, walnuts, sunflower seeds)--29.5%. Localization of foreign bodies was mainly in the right and left main bronchus, and the most common complications were atelectasis and emphysema. All patients had undergone a rigid upper tracheobronchoscopy and foreign body was found in 80 patients (48%). There was no need to perform neither tracheotomy, nor any further surgical treatment, as for example thoracotomy, in any patient. Good education is the best prevention.

[Forensic importance of face, mouth, teeth, ear, throat, nose and labyrinth injuries].

Evaluation of bodily injuries and diminished general vital activity from face and facial bones injuries accompanied by scars and disfiguration ranges from 5 to 50 percent depending on the disfiguration, loss of function and degree of aesthetic marring. They are graded accordingly and they may be: mild (5 to 20%), medium (20 to 35%) and serious when the degree of bodily injury and diminished general vital activity is 35 to 50%. Percentage of bodily injuries and diminished general vital activity from jaw defects ranges from 30 to 80 percent depending on the disfiguration, loss of function and degree of aesthetic marring. Percentage of bodily injuries and diminished general vital activity from nose structure nasal pyramid defects ranges from 10 to 20 percent depending on the disfiguration, loss of function and degree of aesthetic marring. Partial loss of nose structure is estimated at 15%, whereas the complete one may go up to 30%. Diminished general vital activity and percentage of bodily injury with partial laryngectomy ranges from 20 to 40%. In case of subtotal laryngectomy, this is up to 60% and with total one, it reaches 80%.

[Postoperative morbidity and quality of live in patients after radical and modified radical neck dissection].

Useful of radical neck dissection would not be questioned if the effects would be perfect. When postoperative morbidity is associated with oncological shortage of radical neck dissection in functional and cosmetics disfunction, looking for a new therapeutics procedures are justify. In our study were 319 patients. They were treated in period from 01 January 2000 to 31 December 2002. The follow-up was 5 year. We tried to consolidate distribition of n. accesorius operative injuries in modified radical neck dissection and relationship beetwen shoulder pain and shoulder droop after modified and radical neck dissection. Injured n.accesorius in modified radical neck dissection was significantly decreased in patients with modified radical neck dissection. The frequence of patients is significantly different (chi m2=26.662; df = 1; p<0.01) in categories of complications of n.accesorius (shoulder pain, shoulder droop). Shoulder pain and shoulder droop were significantly decreased in modified radical neck dissection (p<0.01).

[Hemodynamic effect of local infiltrative 2% lidocaine adrenaline anesthesia in general balanced anesthesia during middle ear surgery].

Hemodynamic effect of different techniques and type of anesthesia are defined. The volume of reduced hemorrhage in surgical field is debatable, without any definite conclusion. The objective of the study is to investigate the effects of local infiltrative anesthesia with adrenaline during general balanced anesthesia and nitroglicerol on blood presure and hemorrhage reduction in middle ear operations. Prospective, randomized study included 58 adult patients planned for the otorhinolaryngological surgery. Studied group of patient (n 30) planned for middle ear operations. Befora incision surgeon was administered local infiltrative anesthesia using 2% lidocaine with adrenaline (1:200,000) The controls group (n 28), planned for other surgery had no local infiltrative anesthesia with adrenaline. Hemodinamic parameters were monitored before surgical incision and 30 minutes after that. Surgeon's verbal reply on hemorrhage reduction during surgery was recorded. Statistical analysis of parametric data was carried out by Mann-Whitney sum test. Blood pressure and heart rate was not different between the two groups. But, intraoperatively, the study showed lowering of sistolic and diastolic blood pressure. This mode of treatment and surgeon's verbal reply confirmed that local infiltrative anesthesia with adrenaline under balanced anesthesia had no effect on hemorrhage reductionin surgical field.

Vocal fold masses removal--the sub epithelial micro flap technique.

Vocal fold mass removal techniques were significantly modified back in 1970s by Hirano's laminar vocal structure and physiology of phonation works, as well as Titze's vibratory vocal cycle works. New methods were to come. Removing the lession by maximum preservation of vocal laminar microstructure (lamina propria and epithelium) and minimal damage of surrounding normal vocal tissue, was pointed out. Microflap technique is based on presenting the superficial layer of lamina propria with the lesion and removing the lession without damage of the mucosa. Preserving of the mucosal layer provides the shield for vibratory substructures. There are two elementary approaches for microflap: lateral and medial. Lateral microflap technique enables better identification of vocal ligament and lowers the risk of it's injury, particulary when scars and tightly adherent lessions are present. This technique has been used in case of big or diffuse lesions, such as vocal oedema or vocal lygament identification difficulties (e.g. vocal scarification). Medial microflap technique seems to be appropriate in removing smaller, localised lessions, such as cysts and vocal polyps. Our 45 patients experience is presented in this article, in 30 patients lessions were removed by lateral microflap technique (46 vocal cords in total), while 15 patients were treated by medial microflap technique. The outcome was assumed by endovideolaryngostroboscopic analysis of glottal occlussion and mucosal wave prior and following to the procedure. Reinke oedema management results were analysed separately.

Conservative treatment vs phonosurgery.

In Phoniatric Dpt. everyday practice we try to keep specific multidisciplinary approach to the communication disorders, that includes an expert team using modern technology. Over the last six years we have treated 110 singers (3% of all new cases) and the results of their diagnostic and therapeutic management are presented here. There were 67 women and 43 men, 41 were smokers and 69 nonsmokers. The singing genres included 24 pop, 41 folk, 8 ethnic, 29 choral and 8 opera singers. The therapy success was compared with the demographic parameters, level of education and music genres across the subjects. A precise history, clinical examination, endovideolaryngostroboscopy and multidimensional computer analysis of voice and speech was carried out by two phoniatricians, two logopeds, two nurses and one clinical psychologist. Additional consultations were carried out by audiologists, allergists, endocrinologists, chest physicians, gastroenterologists and neurologists where necessary. We suggest that the gold standard is conservative therapy, with phonosurgery if conservative measures fail. We also suggest that an annual systematic examination is optimal in preventing disease in professional singers.