Epiglottoplasty for reconstruction of defects after laryngectomy with partial pharyngectomy.

OBJECTIVES: We present a novel use of sliding epiglottoplasty as an alternative method for closing mucosal defects in selected laryngectomies with partial pharyngectomy. METHODS: Sliding epiglottoplasty as described and advocated by Sedlacek, Bouche, Kambic, and Tucker for reconstruction in partial laryngectomies was used to close the defects after laryngectomy with partial pharyngectomy in 17 patients with advanced hypopharyngeal cancers as primary therapy (16 patients) and as post-radiochemotherapy therapy (1 patient). RESULTS: All reconstructions were successful. Primary closures were achieved without additional morbidity, there were no pharyngocutaneous fistulas, and all patients resumed deglutition. Ten patients acquired esophageal speech, speech valves were inserted in 5 cases, and 2 patients required the use of an electrolarynx. CONCLUSIONS: If the oncological circumstances allow its preservation in laryngectomy with partial pharyngectomy, the epiglottis is an ideal structure for closing the defect; it is a local tissue with shape, thickness, rigidity, and borders that match the recipient site. In comparison to distant pedicled or free microvascular flaps, the epiglottoplasty is a shorter procedure, requires a smaller surgical team, results in less trauma, has a lower incidence of complications, and enables faster recovery. It is surprising that this elegant, successful, and generally accepted larynx preservation procedure has not been recognized as useful for larger reconstructions.

Laryngeal Myxoglobulosis: A Rare Histologic Variant of Mucocele. The First Reported Case.

Myxoglobulosis is a rare histologic variant of mucocele that is characterized by transformation of mucin into eosinophilic globules. The globules frequently demonstrate a lamellar pattern and are surrounded by an inflammatory cell infiltrate. Myxoglobulosis has not yet been described in laryngeal mucosa. A 62 year old man presented for a check-up with hoarseness of 2 months duration. He was a current smoker and reported a 40 year habit. An asymmetrical swelling along the length of both vocal cords was consistent with a clinical diagnosis of Reinke's edema. The histopathologic examination demonstrated bilateral pseudocyst formation within Reinke's space. Extravasated mucin was present in the form of eosinophilic globules that filled the left Reinke's space almost entirely and were also seen on the right side. The pseudocyst, mucinous globules, and accompanying inflammatory cells were characteristic of myxoglobulosis. The sequelae of nicotine abuse, including inflammation, increased mucous secretion, and a rasping cough, are considered to be the main etiological factors of laryngeal myxoglobulosis. The patient had no evidence of voice disorder at 18 month follow-up. This case report contributes to the recognition of an exceptionally rare histologic variant of laryngeal mucocele.

CT comparison of primary snoring and obstructive sleep apnea syndrome: role of pharyngeal narrowing ratio and soft palate-tongue contact in awake patient.

Soft palate-tongue contact and automatically calculated pharyngeal narrowing ratio (PNR), defined as a ratio between the airway cross-section at the hard palate level and the narrowest cross-section from the hard palate to the epiglottis, could assist in earlier identification of potential obstructive sleep apnea syndrome (OSA) patients even on awake individuals. Parameters were studied on carotid CTA images from 67 consecutively included awake Caucasians who were later classified by second independent physician into the primary snorers (SNORE, n = 34) or obstructive sleep apnea syndrome patient (OSA, n = 33) group according to the clinical examination, laboratory testing and a full-night video polysomnography (PSG) in the sleep laboratory. Imaging and clinical data were statistically compared between groups. The odd's ratio calculation showed a 2.95 (P = 0.0354) higher risk for OSA development in snoring person with a PNR greater than 8.6. The loose-contact subgroup among OSA patients showed significantly (P = 0.002) higher values of AHI in contrast to the in-contact subgroup.

concomitant chemoradiotherapy with mitomycin C and cisplatin in advanced unresectable carcinoma of the head and neck: phase I-II clinical study.

PURPOSE: To evaluate the toxicity and efficacy of concomitant chemoradiotherapy with mitomycin C and cisplatin in the treatment of advanced unresectable squamous cell carcinoma of the head and neck. PATIENTS AND METHODS: Treatment consisted of conventional radiotherapy (70 Gy in 35 fractions), mitomycin C 15 mg/m(2) IV, applied after the delivery of 10 Gy, and cisplatin at an initial dose of 10 mg/m(2)/d IV, applied during the last 10 fractions of irradiation ("chemoboost"). The cisplatin dose was escalated with respect to the toxic side effects by 2 mg/m(2)/d up to the maximum tolerated dose (MTD) or at the most 14 mg/m(2)/d (Phase I study), which was tested in the subsequent Phase II study. RESULTS: All 36 patients had Stage T4 and/or N3 disease, and the majority had oropharyngeal (50%) or hypopharyngeal (39%) primary tumors. Six patients were treated at each of the three cisplatin dose levels tested (Phase I study). Dose-limiting toxicity was not reached even at 14 mg/m(2)/d of cisplatin, which was determined as the MTD and tested in an additional 18 patients (Phase II study). After a median follow-up time of 48 months, 4-year locoregional control, failure-free, and overall survival rates were 30%, 14%, and 20%, respectively. In 24 patients treated at the cisplatin dose level of 14 mg/m(2)/d, the corresponding rates were 40%, 20%, and 22%, respectively. CONCLUSION: Concomitant chemoradiotherapy with mitomycin C and cisplatin "chemoboost" at 14 mg/m(2)/d is feasible, with encouraging survival results if the extremely poor disease profile of the treated patients is considered.

Epiglottic suture for treatment of laryngomalacia.

OBJECTIVES: To present a technique for surgical management of laryngomalacia directed against the basic abnormality of the disease. Considering the cause-consequence relations of the abnormalities, we can distinguish two types of laryngomalacia. In the first, the basic abnormality is the pathological shape of the epiglottis: the epiglottis, which normally stands in an upright position, is characteristically excessively folded, restricting the supraglottic space directly as well as indirectly due to the proximity of the aryepiglottic folds that are attached to its lateral edges. In the second type the abnormality is the backward displacement (ptosis) of a normally shaped epiglottis. All other abnormalities are the consequences of these basic abnormalities. We present a new procedure, the epiglottic suture, to correct the pathological shape of the epiglottis. It is a suture placed transversely on the lingual surface of the epiglottis that unfolds the folded epiglottis and shifts apart the adjacent aryepiglottic folds. PATIENTS AND METHODS: Prospective non-randomized study performed on eight severely distressed patients with laryngomalacia at the University Department for Otorhinolaryngology and Cervicofacial Surgery, Ljubljana, Slovenia. RESULTS AND CONCLUSION: The epiglottic suture enabled normal breathing in all treated children without compromising the airway-protection function of the epiglottis. After an average follow up time of 19.12 months (minimum 7 months and maximum 27 months), we have not noticed any complications or deteriorations of breathing.

Patterns of failure in patients with locally advanced head and neck cancer treated postoperatively with irradiation or concomitant irradiation with Mitomycin C and Bleomycin.

PURPOSE: The long term results and patterns of failure in patients with squamous cell head and neck carcinoma (SCHNC) treated in a prospective randomized trial in which concomitant postoperative radiochemotherapy with Mitomycin C and Bleomycin (CRT) was compared with radiotherapy only (RT), were analyzed. PATIENTS AND METHODS: Between March 1997 and December 2001, 114 eligible patients with Stage III or IV SCHNC were randomized. Primary surgical treatment was performed with curative intent in all patients. Patients in both groups were postoperatively irradiated to the total dose of 56-70 Gy. Chemotherapy included Mitomycin C 15 mg/m2 after 10 Gy and 5 mg of Bleomycin twice weekly during irradiation. Median follow-up was 76 months (48-103 months). RESULTS: At 5 years in the RT and CRT arms, the locoregional control was 65% and 88% (p = 0.026), disease-free survival 33% and 53% (p = 0.035), and overall survival 37% and 55% (p = 0.091) respectively. Patients who benefited from chemotherapy were those with high-risk factors. The probability of distant metastases was 22% in RT and 20% in CRT arm (p = 0.913), of grade III or higher late toxicity 19% in RT and 26% in CRT arm (p = 0.52) and of thyroid dysfunction 36% in RT and 56% in CRT arm (p = 0.24). The probability to develop a second primary malignancy (SPM) was 34% in the RT and 8% in the CRT arm (p = 0.023). One third of deaths were due to infection, but there was no difference between the 2 groups. CONCLUSION: With concomitant radiochemotherapy, locoregional control and disease free survival were significantly improved. Second primary malignancies in the CRT arm compared to RT arm were significantly less frequent. The high probability of post treatment hypothyroidism in both arms warrants regular laboratory evaluation.

Snoring imaging: could Bernoulli explain it all?

STUDY OBJECTIVES: To identify upper airway changes in snoring using CT scanning, to clarify the snoring mechanism, and to identify the key structures involved. PARTICIPANTS: Forty patients underwent CT examination of the head and neck region according to snoring habits; patients were classified into non-snoring (n = 14), moderately loud snoring (n = 13), and loud snoring (n = 13) groups. DESIGN: Comparative analysis. MEASUREMENTS: Using CT images, areas, the anteroposterior and transversal distances of the pharyngeal space at different levels, and the thickness and length of the soft palate and uvula and their angle against the hard palate were measured; evidence of impaired nasal passages was noted; the extent of pharyngeal inspiratory narrowing was the ratio between the area at the hard palate level and most narrow area; and expiratory narrowing was the ratio between the area behind the root of the tongue and the most narrow area. RESULTS: Greater pharyngeal inspiratory narrowing (p = 0.0015) proportional to the loudness of snoring (p = 0.0016), and a longer soft palate with uvula (p = 0.0173) were significant for snoring. Impaired nasal breathing was significantly related (p = 0.029) only to the loud snoring group. The body mass index and age of snoring persons were also significantly higher. CONCLUSIONS: Snoring is associated with typical changes that can be revealed by CT scanning. Greater pharyngeal narrowing is the most important factor. Given the "Venturi tube" shape of the pharynx, the Bernoulli pressure principle plays a major role in snoring. The key structure in snoring is the soft palate: it defines the constriction and is sucked into vibrating by negative pressure that develops at this site. Its repetitive closures present an obstruction to breathing, producing the snoring sound, and should therefore be the target for causal treatment of snoring. Obstacles in the upper airway that increase negative inspiratory pressure could not be confirmed as important for the development of snoring, although they may increase its loudness.

Computational fluid-structure interaction simulation of airflow in the human upper airway.

Obstructive sleep apnoea syndrome (OSAS) is a breathing disorder in sleep developed as a consequence of upper airway anatomical characteristics and sleep-related muscle relaxation. Fluid-structure interaction (FSI) simulation was adopted to explain the mechanism of pharyngeal collapse and snoring. The focus was put on the velopharyngeal region where the greatest level of upper airway compliance was estimated to occur. The velopharyngeal tissue was considered in a way that ensures proper boundary conditions, at the regions where the tissue adheres to the bone structures. The soft palate with uvula was not cut out from the surrounding tissue and considered as an isolated structure. Both, soft palate flutter as well as airway narrowing have been obtained by 3D FSI simulations which can be considered as a step forward to explain snoring and eventual occlusion. It was found out that during the inspiratory phase of breathing, at given elastic properties of the tissue and without taking gravity into consideration, velopharyngeal narrowing due to negative suction pressure occurs. Furthermore, soft palate flutter as the main attribute of snoring was predicted during the expiratory phase of breathing. The evaluated flutter frequency of 17.8 Hz is in close correlation with the frequency of explosive peaks of sound that are produced in palatal snoring in inspiratory phase, as reported in literature.

Sleep magnetic resonance imaging with electroencephalogram in obstructive sleep apnea syndrome.

OBJECTIVE: To evaluate the mechanism and level of upper airway obstruction in obstructive sleep apnea (OSA) patients during natural sleep, together with synchronous electroencephalogram and respiratory events registration at 3-Tesla magnetic resonance imaging (MRI) platform with high spatial and temporal resolution. STUDY DESIGN: A prospective cohort study of 20 randomly selected OSA patients. METHODS: Fifteen of 20 patients were able to complete spontaneous sleep during MRI. While asleep, dynamic MR images of pharynx were obtained in the midline sagittal view. During the scan, nasal and oral airflow, thoracoabdominal wall effort, and electroencephalogram were synchronously recorded. The physiologic data were retrospectively scored to identify periods of apneas and synchronized with dynamic MR images. RESULTS: In all 15 patients, the site of complete airway obstruction occurred at the retropalatal space. We noticed different positions of the soft palate during apneic events. In seven of 15 patients (47%), the soft palate was attached to the tongue base and moved backward, compressing the airway. In five of 15 patients (33%), the soft palate was detached from the tongue base and solely moved backward, compressing the airway. In three patients (20%), we recorded both mechanisms of complete airway obstruction. In cases with attached soft palate to the tongue base, we noticed significant narrowing of the retrolingual space during apneic events. CONCLUSION: We describe a novel mechanism of obstruction dependent on the position of soft palate. This mechanism might play an important role in selecting candidates for surgery or treatment with hypoglossal nerve stimulation. LEVEL OF EVIDENCE: 2b.

Postoperative concomitant irradiation and chemotherapy with mitomycin C and bleomycin for advanced head-and-neck carcinoma.

PURPOSE: In a prospective randomized clinical study, simultaneous postoperative application of irradiation (RT), mitomycin C, and bleomycin was tested in a group of patients with operable advanced head-and-neck carcinoma. It was expected that the planned combined postoperative therapy would reduce the number of locoregional recurrences and prolong survival. METHODS AND MATERIALS: A total of 114 eligible patients with Stage III or IV squamous cell head-and-neck carcinoma were randomized to receive postoperative RT alone (Group 1) or RT combined with simultaneous mitomycin C and bleomycin (Group 2). Patients were stratified according to the stage and site of the primary tumor and the presence or absence of high-risk prognostic factors. Primary surgical treatment was performed with curative intent in all patients. Patients in both groups were postoperatively irradiated to the total dose of 56-70 Gy. Chemotherapy included mitomycin C 15 mg/m(2) after 10 Gy and 5 mg of bleomycin twice a week during RT to the planned total dose of 70 mg. RESULTS: At 2 years, patients in the radiochemotherapy group had better locoregional control (86%) than those in the RT alone group (69%; p = 0.037). Disease-free survival and overall survival was also better in the radiochemotherapy group compared with the RT-alone group (76% vs. 60%, p = 0.099; and 74% vs. 64%, p = 0.036, respectively). Patients who benefited from chemotherapy were those with high-risk factors. CONCLUSION: The results of the present study indicate that concomitant postoperative radiochemotherapy with mitomycin C and bleomycin improves locoregional control and survival in patients with advanced head-and-neck carcinoma. The patients who benefited from chemotherapy were those with high-risk factors.

TPF induction chemotherapy and concomitant irradiation with cisplatin and cetuximab in unresectable squamous cell carcinoma of the head and neck.

BACKGROUND: The purpose of this study was to assess the efficacy and toxicity of docetaxel, cisplatin/5-fluorouracil (TPF) induction chemotherapy and concomitant immunochemoradiotherapy with cetuximab and cisplatin in unresectable head and neck carcinoma. METHODS: Treatment consisted of TPF induction chemotherapy (docetaxel 75 mg/m(2) day 2; cisplatin, 75 mg/m(2) day 2; and 5-fluorouracil 750 mg/m(2) days 1-4; 4 cycles), followed by radiotherapy (RT) and concomitant weekly cetuximab, (250 mg/m(2), after a loading dose of 400 mg/m(2)) and cisplatin (30 mg/m(2)). RESULTS: Twenty-five of 30 patients completed 4 cycles of induction chemotherapy. Six or more concomitant infusions of cisplatin and cetuximab were administered in 13 of 25 and 18 of 25 patients, respectively. The 2-year locoregional control, disease-free survival (DFS), and overall survival (OS) were 47%, 47%, and 50%, respectively. Patients with grade ≥ 2 skin reaction to cetuximab had a superior outcome. CONCLUSION: The tested regimen was effective; however, cetuximab and low-dose cisplatin after induction TPF increased the treatment toxicity. A grade ≥ 2 skin rash correlated with improved efficacy.