Complications associated with free jejunal graft reconstruction of the pharyngoesophagus--a multiinstitutional experience with 52 cases.

Fifty-two patients who underwent reconstruction of the pharynx and esophagus using the free jejunal graft were retrospectively reviewed. The complications were categorized into those associated with the resection, those associated with the harvesting of the graft, and those related to the reconstruction per se. In this series, the graft failure rate was 7.6% with an overall success rate of 90.3%. Graft necrosis was found to be the most serious complication occurring in four patients. Methods of detection of graft necrosis and management of these complications are discussed.

Partial vs total esophagectomy for advanced carcinoma of the hypopharynx.

Cancer of the hypopharynx is an aggressive disease with a poor prognosis irrespective of the therapeutic regimen instituted. Controversy centers around the extent of surgery required to adequately ablate the advanced cancers, particularly related to the role of esophagectomy. A literature review and analysis of 43 cases of advanced hypopharyngeal cancer treated with total laryngopharyngectomy and partial esophagectomy support the argument that in carefully selected situations, a partial esophagectomy is oncologically an adequate operation.

Earache and glue ear.

In most cases, the cause of an earache is obvious. If the cause is not apparent after careful inspection, a systematic approach to the associated causes and sites of referred pain is necessary. Glue ear is the most frequent cause of hearing loss in children. The diagnosis, investigation and management have been described. Recurrent earache from pressure change or from recurrent middle ear infection is an important clue to the presence of a glue ear.

A false aneurysm.

OBJECTIVE: We report a case of a remaining hemi-thyroid following laryngectomy, which was misinterpreted as a pseudoaneurysm. METHODS: Case report and comment on this understandable error which is easily avoidable. RESULTS: A 59-year-old man had undergone salvage laryngectomy for recurrent squamous cell carcinoma of the larynx, which had previously been treated with radiotherapy. Three months after his laryngectomy, he presented with a sore neck and subcutaneous collections. Computed tomography revealed a unilateral mass with high signal contrast uptake anterior to the left common carotid artery, which was thought initially to be a carotid pseudoaneurysm. Further investigation, including ultrasonography and a review by the senior head and neck radiologist, demonstrated that this mass was actually the remnant hemi-thyroid preserved at laryngectomy (which is often misshapen compared with a normal hemi-thyroid). The collections were found to be recurrent tumour, and unnecessary further interventions were avoided. CONCLUSION: Ultrasonography easily distinguishes between a thyroid remnant and a pseudoaneurysm. Furthermore, the opinion of an experienced head and neck radiologist may be vital when interpreting complex post-surgical head and neck radiology.

Predicting regional control based on pretreatment nodal size in squamous cell carcinoma of the head and neck treated with chemoradiotherapy: a clinician's guide.

The aim of this study was to determine the regional control rate with concurrent chemoradiotherapy (CRT) based on pretreatment nodal size in mucosal head and neck squamous cell carcinoma (HNSCC) in patients who achieved a complete response (CR) at the primary site by 12 weeks post-treatment. Between December 1997 and November 2003, 117 patients with node-positive HNSCC were treated with concurrent CRT, with 108 (92%) achieving a CR at the primary site by 12 weeks. There were 93 males (86%), median age 55 (37-79) years and the most common primary site was the oropharynx (65%). Patients were divided into three subgroups: or=6.1 cm 8 (7%). All patients received concurrent platinum-based chemotherapy and the median radiation dose was 70 Gy (60-72 Gy). The 3-year regional control rate based on pretreatment nodal size was or=6.1 cm 50% (95%CI 15-77%) (P = 0.001). The 3-year regional control rate based on pre-treatment nodal size was or=6.1 cm 50% (95%CI 15-77%) (P = 0.001). These results provide a quantitative guide for the clinician as to the likelihood of regional control based on pretreatment nodal size following CRT in patients who achieve a CR at the primary site by 12 weeks post-treatment.

Secretoneurin is released into human airways by topical histamine but not capsaicin.

BACKGROUND: The neuropeptide secretoneurin, with potential relevance to leukocyte trafficking, is present in nerves of the nasal mucosa in allergic rhinitis and may be released in response to allergen and histamine exposure. There is no information on the occurrence and mechanisms of release of secretoneurin in healthy human airways. METHODS: The presence of secretoneurin in nasal biopsies and its release in response to nasal capsaicin and histamine challenges were examined. Symptoms and lavage fluid levels of fucose were recorded as markers of effects in part produced by neural activity. Bronchial histamine challenges followed by sputum induction and analysis of secretoneurin were also carried out. RESULTS: Nerves displaying secretoneurin immunoreactivity abounded in the nasal mucosa. Nasal capsaicin challenge produced local pain (P <0.05) and increased the levels of fucose (P <0.05), but failed to affect the levels of secretoneurin. Nasal histamine challenge produced symptoms (P <0.05) and increased the mucosal output of secretoneurin (P <0.05) and fucose (P <0.05). Bronchial histamine challenge increased the sputum levels of secretoneurin (P <0.05). CONCLUSIONS: We conclude that secretoneurin is present in healthy human airways and that histamine evokes its release in both nasal and bronchial mucosae. The present observations support the possibility that secretoneurin is involved in histamine-dependent responses of the human airway mucosa.

Triple therapy for advanced squamous cell cancer of the head and neck.

This study presents the results of treatment for Stage III and IV squamous cell carcinoma of the head and neck at the Princess Alexandra Hospital and Queensland Radium Institute, Brisbane. Patients were treated using a programme of sequential chemotherapy, surgery and radiotherapy. Between 1980 and 1988, 116 patients commenced the programme and 85 completed the treatment as planned. The Price-Hill regimen of chemotherapy was used until 1986 after which time it was replaced by cisplatin/5-fluorouracil (5FU). Two courses were usually given achieving an overall response rate of 36% (12% complete response). Cisplatin/5FU produced an overall response rate of 56% compared with 24% for the Price-Hill regimen. Radical surgical resections were performed using a free flap reconstruction in the majority of patients. Radiotherapy fields usually covered the primary site and both cervical lymph node areas to a dose of 50-60 Gy in 5-6 weeks. The lengthy treatment was generally well tolerated although there were two chemotherapy and two perioperative deaths. The overall actuarial survival for the 85 patients completing the triple therapy was 60%. These patients were analysed in more detail for possible prognostic factors.

Free jejunal interposition reconstruction after pharyngolaryngectomy: 201 consecutive cases.

BACKGROUND: Reconstruction of tubular defects following pharyngolaryngectomy has required complicated surgery with high perioperative morbidity and mortality. Free jejunal interposition provides an excellent reconstruction with potential for lower immediate complications and better long-term results than other procedures. METHODS: A total of 201 consecutive free jejunal interpositions were performed following pharyngolaryngectomy between 1977 and 1993. Operative details, complications, and outcome were prospectively documented. RESULTS: Perioperative mortality was low (4.5%) and microvascular success rate high (97%), although a small number of late failures were recorded. Average time until swallowing postoperatively was 11 days, and 92% of patients could maintain full nutrition. Voice rehabilitation was mentioned, and increasingly good results are being obtained. Complication rates for the neck (17%) and the abdomen (2.5%) were also low. There were no problems with excess mucus production or reflux. Radiation effect on the jejunal conduit was not detrimental to long-term patency of the vascular anastomoses or to function as a conduit. CONCLUSIONS: Comparison with other published techniques permits the contention that a free jejunal interposition is the reconstruction of choice after pharyngolaryngectomy.

Supracricoid laryngectomy: a significant advance in the management of laryngeal cancer.

Supracricoid laryngectomy is a new development in the treatment of laryngeal cancer in Australia. It allows the removal of both vocal cords, vestibular folds, and the entire thyroid cartilage including the paraglottic space without the loss of laryngeal function. This technique may offer a significant advance in the treatment of squamous cell carcinoma of the larynx. This paper reviews the surgical management of laryngeal cancer and discusses this new technique with modifications, indications for its use and the advantages of supracricoid laryngectomy. Case reports of seven patients operated on in our institution are included.