Horizontal glottectomy.

Horizontal glottectomy is a procedure which allows removal of the whole glottis, together with its cartilaginous framework. It is performed by means of two horizontal incisions, the lower through the cricothyroid membrane, and the upper one across the wings of the thyroid. The gap is then closed by approximating the cricoid to the thyroid remnants (cricothyropexy). The indications for horizontal glottectomy are: 1) "double" cancers (i.e. two independent tumors, one on each vocal cord). 2) Hyperkeratosis of the glottis associated with carcinoma in situ. 3) Verrucous cancers of the glottis. 4) Cancers of one vocal cord invading the opposite one via the anterior commissure. In a period of 4 years, 16 patients have been operated on with good early results.

Occult metastases in cancer of the larynx and their relationship to clinical and histological aspects of the primary tumor: a four-year multicentric research.

The authors have tried to verify whether some clinical or pathological features of laryngeal cancer may favor the occurrence of occult metastases in the lymph nodes of the neck in N0 cases. The purpose of the investigation was to define the possible existence of tumors, where elective neck dissection, in the absence of palpable nodes, could be done without, thus contributing to settlement of a long debated problem. Different parameters, both clinical and pathological, have been considered. The result of a cross comparison of such parameters in 237 cases of cancer of the larynx without palpable nodes, submitted to surgery on the primary and elective neck dissection, indicates that, although the frequency of occult metastases is significantly related to the site and size of the tumor, its grading, and the degree and type of stromal reaction, the favorable concurrence of all said parameters occurs in 2% of cases only. However, if only clinical parameters, viz. site and size of tumor, are taken into account, a favorable concurrence occurs in 18% of cases with an incidence of occult metastases lower than 2%. These cases are almost exclusively represented by T1N0 supraglottic and T2N0 glottic tumors. We can conclude by saying that clinical and pathological preoperative findings may offer a useful clue in evaluating the risk of occult metastases, and hence advising, or not, an elective neck dissection in N0 cases. Nevertheless, in the vast majority of cases, an elective functional neck dissection still offers the best guarantee of oncologic safety while avoiding unnecessary mutilation.

Stage grouping reliability: TNM '97 versus TANIS in laryngeal cancer.

PURPOSE: To compare the correlation of TANIS and TNM '97 with the survival rate in laryngeal cancer. METHODS AND MATERIAL: From 1970 to 1990, 599 patients at the ENT Clinic, University of Ferrara, had a complete follow-up and met the criteria of enrollment. Data were analyzed by means of survival analyses (Kaplan-Meler and Cox algorithms). RESULTS: Both systems showed a significant correlation with the survival rate. TANIS advanced subcategories were better correlated with the mortality rate than TNM stages IVa and IVb. Again, in the final statistical model, TANIS was more highly correlated with survival rate than TNM.

Total laryngectomy with tracheopharyngeal fistula (neoglottis).

Our experience with the so-called "neoglottis" (according to Staffieri) after total laryngectomy is presented. The technique, described in detail, aims at giving the patient good speech by creating a tracheoesophageal fistula through which air passes. In the period from 1973-1979, 63 patients underwent the procedure. The functional results were satisfactory in 68% of the cases. The patient's voice is much more agreeable than the esophageal voice and sounds louder and less monotonous than a laryngophone voice. The spectrographic analyses confirm its resemblance to natural voice. An occasional passage of liquids into the trachea may occur, but is not prejudicial to either speech or swallowing. Some dysfunctional problems may arise early or late after the operation: they are continuous aspiration during swallowing and lack of phonatory function. In most cases, these problems are due to incorrect surgical technique; the possibilities and procedures of correction are described. In conclusion, we maintain that the "neoglottis" which may be applied to nearly all cases of total laryngectomy, represents a worthwhile "phonatory" innovation in the field of mutilating surgery of laryngeal cancer.

Functional neck dissection. Anatomical grounds, surgical technique, clinical observations.

The anatomical grounds of and surgical technique for functional neck dissection are described in detail in order to demonstrate that the radicalism of this procedure, from the viewpoint of surgical anatomy, is by no means less than that of the classical (so-called radical) neck dissection. From 1972 to 1978, 476 operations were performed (211 patients treated bilaterally and 54 unilaterally). The percentage of false negatives (ie, histologically proven metastases in clinically unsuspected nodes) was 14%, while the percentage of false positives (histological negativity in clinically suspected nodes) reached 53%. The total number of local recurrences in a three-year follow-up was nine (3.5%).

Parotid gland carcinoma: analysis of prognostic factors.

The histologic variety of parotid gland carcinomas, their different natural history, and the peculiar anatomy of the parotid region can make prognosis and therapeutic strategy quite controversial. The present study was designed to evaluate those prognostic factors able to affect the long-term results in a group of 167 consecutively treated parotid epithelial malignancies. The continuous or discrete covariants considered as potential prognostic factors are age, sex, histotype, grading, TNM and pTNM classification, facial nerve involvement, type of surgery on the tumor site and on nodes, facial nerve resection, and postoperative radiotherapy. All the material has been statistically analyzed and the results have been compared with the principal data published. According to the analysis, the most relevant prognostic factors in parotid gland carcinomas appear to be pTN staging, tumor grading, facial nerve involvement, and local extension. These factors could reliably predict the patient's chance for survival, and thus influence the therapeutic strategy.

Cancer of the nasal cavity and paranasal sinuses: a new staging system.

This study proposes a new staging system for cancer of the paranasal sinuses on the basis of two concepts. The first concept is that the nasal cavity and the paranasal sinuses form a single unit. Consequently, the mucosa of each sinus may give rise to tumors. The histopathologic variation will be the same for all these cavities. The second concept is that the staging of these tumors depends both on the nature of the neoplastic cells and on the specific bone boundaries which surround the anatomic site and subsites. We analyzed 61 cases and we emphasize the need for a differential analysis of T4 tumors depending on which adjacent region is involved.

Is the new TNM (1997) the best system for predicting prognosis?

In 1997, the U.I.C.C. (International Union against Cancer) modified the previous TNM stage grouping published in 1987. In the present study, TANIS and TNM '97 systems were compared in order to evaluate their prognostic ability. Data from 164 patients affected by primary squamous cell carcinoma cancers of the oral cavity (n=100) and oropharynx (n=64) were analyzed by means of survival analyses. Both systems showed a significant correlation with survival rate. TANIS yielded better results in association with the survival rate as compared with TNM '97.

Extension as a prognostic factor in oropharyngeal cancer: largest mucosal dimension compared with number of (sub)sites involved.

We report a retrospective study of 64 patients with primary squamous cell carcinoma of the oropharynx. The tumours were classified by the UICC (Union Internationale Contre le Cancer) system and a New Tumour Staging (NTS) system. Results showed a crude survival of 29% at 5 years. The most important prognostic factor for survival rate was the tumour (T) stage in both classifications. NTS recommendations that consider the number of sites and subsites involved yield a better correlation between survival and T stage. NTS also discriminates better between the T stages than the UICC criteria.

[Suprahyoid transpharyngeal approach to the median skull base in surgery of rhinoangiofibroma]. / L'accesso transfaringeo soprajoideo all'esobasicranio mediano nella chirurgia del rinoangiofibroma.

Ten young males with rhinopharyngeal angiofibroma (RAG) were studied. Except for one case of IIIb stage the others were all either I or IIIa. They all underwent surgery at the E.N.T. Clinic in Ferrara employing the transpharyngeal suprahyoid approach (TSA) originally described by Bocca. For the one case in the most advanced stage (IIIb), besides the TSA a paralateronasal approach and a complementary RT were also planned. In this series of cases, one recurrence due to a peritubaric residue was treated 8 months later through a transpalatal approach. The follow-up, with NED findings, varied from a maximum of 12 to minimum of 2 years (average 6.4 years), except for the last subject which underwent surgery in 1991. Three minor post-operative complications due to TSA were encountered, while 1 complication was attributed to the transpalatal approach used for the recurrence described. All cases healed completely. The data on the TSA from the international and national literature is reviewed underlining that the negative elements reported have, in the authors' opinion, been overcome by: perfecting the method for RAG exeresis and the method of the tracheotomy; making technological improvements: pre-operatory embolization, microsurgery applied to TSA in order to check any lateral branches and to the transnasal approach in order to check any residue in the choanal area.

[Subtotal reconstructive laryngectomy: author's experience]. / Laringectomia subtotale ricostruttiva: nostra esperienza.

The authors conclude 18 year's experience with reconstructive laryngectomy by adopting two surgical techniques for intrinsic laryngeal tumors. The first, where one or both of the arytenoids are conserved, can be applied in cases of supraglottic neoplasms extending to the glottis as well as in glottic cancers where a simple cordectomy is not feasible. In both cases this technique is indicated when at least one arytenoid is respected. The second technique involves removal of both arytenoids and is used in cases of intrinsic supraglottic or glottic tumors extended to both arytenoids. The anatomic-pathological criteria supporting these techniques are: 1) the presence of a fibrous ligament anterior to the arytenoid vocal process. This makes possible proper exeresis within healthy tissue (as can be done in supraglottic surgery due to the anatomic characteristics at the anterior commissure level); 2) neoplastic infiltration of the cricoid cartilage takes place exceptionally in supraglottic and glottic neoplasms; in such cases neoplastic manifestation can be radiographically identified. Generally removal of the soft tissues and of the perichondrium within the cricoid area grants conservative surgery the same oncological radicality as that of total laryngectomy. Insights into restoration of laryngeal function when employing the arytenoid-preserving technique are as follows: 1) conservation of the recurrent nerve(s) 2) pulling the base of the tongue back and downward; close to the crico-arytenoid structure can be achieved by crico-hyoid-pexy. In the technique involving removal of the arytenoid: 1) reconstruction of two pseudo-arytenoids 2) the base of the tongue has to be brought close to the edge of the cricoid cartilage possibly by crico-hyoid-pexy. A total of 21 patients have undergone surgery with these techniques since 1984 and to date no neoplastic recurrences have been observed. Those who underwent surgery where the arytenoids were preserved (16 cases) showed laryngeal functional recovery times similar to those for supraglottic surgery. The recovery times were longer for those undergoing bilateral arytenoidectomy (5) and this was especially so for swallowing.

[The problem of lymph nodes in malignant epithelial tumors of the parotid gland]. / Il problema linfonodale nei tumori epiteliali maligni della parotide.

Cervical lymph-node treatment in parotid gland epithelial malignancies is still debated. According to Literature, three different strategies (surgery, radiotherapy, "wait and see") have all been proposed theoretically, particularly when dealing with N0 cases. The present study was designed to evaluate the results of different lymphonode treatment strategies in 57 parotid gland carcinomas followed at the ENT Clinic of the University of Ferrara. The most frequent hystological patterns appeared to be the adenoidcystic carcinoma (33.3%) and the mucoepidermoid tumor (21.1%). Total parotidectomy was the treatment of choice in all cases. Ipsilateral neck dissection was performed in 14 cases (24.5%), 5 cases being N0. In 27 patients (47.4%) postsurgical radiotherapy was applied: in 7 cases on T and in 20 on both T and N.T recurrences were 7, while those of N and of both T and N were respectively 2 and 2. No occult metastases were found in N0 dissected patients. The results obtained led the Authors to the following conclusions: -neck dissection is fundamental in treatment of clinical adenopathies in any parotid gland malignancy: -postsurgical radiotherapy on the neck is the treatment of choice in all N0 carcinomas except in cases of acinic cell and mucoepidermoid carcinomas, where a "wait and see" policy seems to be more suitable.

[Phoniatric aspects of reconstructive laryngectomy]. / Aspects phoniatriques des laryngectomies reconstructives.

Reconstructive laryngectomy has been performed at the E.N.T. Clinic in Ferrara for some time. After surgery the patients undergo speech therapy and phoniatric treatment for a period of time varying from 2 to 6 months. In order to better evaluate the vocal quality obtained after such reeducation the vocal emissions of 25 patients were examined and recorded. The recorded material, made up of prolonged vowels and 6 phonetically balanced sentences, was then evaluated by a panel of 7 "trained" listeners. The evaluation score-card proposed by Woiers in 1977 was used in taking the data. This not only provides a scale for evaluating the main voice quality features, but also includes a final judgement on parameters including intelligibility, acceptability and pleasantness. Statistical processing of the data inherent to voice quality indicated a decrease in intensity and pitch when compared to normal values. Nonetheless, the listening test showed a high degree of intelligibility, acceptability and pleasantness. These values confirm the fact that, although the new voice achieved through reconstructive laryngectomy surgery is less sonorous, it allows for perfectly understandable, socially acceptable speech.