Classification of parotidectomies: a proposal of the European Salivary Gland Society.

The objective of this study is to provide a comprehensive classification system for parotidectomy operations. Data sources include Medline publications, author's experience, and consensus round table at the Third European Salivary Gland Society (ESGS) Meeting. The Medline database was searched with the term "parotidectomy" and "definition". The various definitions of parotidectomy procedures and parotid gland subdivisions extracted. Previous classification systems re-examined and a new classification proposed by a consensus. The ESGS proposes to subdivide the parotid parenchyma in five levels: I (lateral superior), II (lateral inferior), III (deep inferior), IV (deep superior), V (accessory). A new classification is proposed where the type of resection is divided into formal parotidectomy with facial nerve dissection and extracapsular dissection. Parotidectomies are further classified according to the levels removed, as well as the extra-parotid structures ablated. A new classification of parotidectomy procedures is proposed.

[Head and neck cancer treatment in the elderly]. / Traitement des carcinomes épidermoïdes ORL chez la personne âgée.

We compared the treatment modalities as well as the oncologic outcome between young elderly (65-79 years old), elderly (>80 years old) and the reference population (<65 years old.) We reviewed 1047 patients treated between 2002 and 2012. Tumor sites, TNM stages, type of treatment, and the oncologic results are compared with survival statistics. The elderly group was associated with an increase in palliative treatment, more women and advanced T stages. For the 947 patients treated with curative intent, 5 year recurrence free survival was comparable. The overall-survival decreases with the age because of intercurrent deaths. Nevertheless, the treatment efficacy is similar. In conclusion, an advanced age is associated with worse survival, without a decrease in loco-regional control. The chronological age should not be used as a predictive factor for treatment response.

[The indication of panendoscopy in the search for synchronous and metachronous head and neck cancer]. / Rôte de la panendoscopie dans la recherche de cancers synchrones et métachrones de ta sphère ORL.

Head and neck cancer result from excessive tobacco and alcohol consumption. The survival has not improved in the last decades despite better loco-regional control, mainly because of secondary cancers. Head and neck cancer is associated to a high rate of synchronous esophageal and lung tumors and an annual 4% rate of new metachronous malignancies. The role of panendoscopy is evolving: a flexible esophagoscopy with Lugol's iodine staining should be performed and a chest CT-scan should replace bronchoscopy. During follow-up, metachronous malignancy should be searched for in the head and neck region; investigation beyond the head and neck is questionable since prognosis is poor.

[Surgery for severe aspirations]. / Chirurgie de la déglutition dans le traitement d'aspirations récidivantes.

Severe dysphagia resulting in repeated aspirations and pneumonia are difficult to treat with swallowing therapy and surgical treatment is often required. Our study retrospectively reviews our experience with 19 such cases operated by laryngeal suspension and laryngotracheal separation. Restoration of oral nutrition was possible in 45% of laryngeal suspension cases and in 75% of laryngotracheal separation operations. These surgical techniques prevent severe aspirations while conserving phonation, contrarily to total laryngectomy. Tracheocutaneous fistulas were frequent, especially after radiation, implying that the surgical technique should be modified in the future.

[Pretherapeutic and posttherapeutic laryngeal imaging]. / Prä- und posttherapeutische Larynxbildgebung.

Cross-sectional imaging with CT, MRI and more recently PET CT plays an indispensable complementary role to endoscopy in the pretherapeutic diagnostic and staging of laryngeal neoplasms and in the evaluation of the operated or irradiated larynx. Adequate interpretation of the CT, PET CT and MR images requires a thorough knowledge of the patterns of submucosal spread and familiarity with the diagnostic signs of neoplastic invasion as seen with each modality. In addition, one should be aware of the implications of imaging for staging and treatment. Both CT and MR imaging are highly sensitive for the detection of neoplastic invasion of the preepiglottic and paraglottic spaces, subglottic region and cartilage. The high negative predictive value of both CT and MRI allows a relatively reliable exclusion of neoplasm cartilage invasion. The specificity of both CT and MRI is, however, moderately high and both methods may, therefore, overestimate the extent of tumor spread. However, recent investigations have shown that the specificity of MRI may be significantly improved by using new diagnostic criteria which allow differentiation of tumor from peritumoral inflammation in many instances. Both cross-sectional imaging methods also significantly improve the pretherapeutic staging accuracy of laryngeal tumors if used in addition to clinical examination and endoscopic biopsy. In the presence of a submucosal mass, CT and MRI play a key role for the diagnosis, as they may characterize the lesion, reliably depict its submucosal extent and guide the endoscopist to perform deep biopsies which allow the definitive histological diagnosis. Cross-sectional imaging also plays a key role in the evaluation of laryngoceles, recurrent laryngeal nerve paralysis and fractures.

[Radiation-induced xerostomia: prevention, treatment, perspectives]. / Xérostomie radio-induite: prevéntion, traitement, perspectives.

Most of head and neck cancer patients will undergo radiotherapy. Xerostomia is probably its most frequent side effect. Subjective and objective criteria allow evaluating and grading xerostomia. New radiotherapy techniques and use of cytoprotectants can help to preserve salivary gland function. Parasym-pathicomimetics and saliva substitutes reduce symptoms. Strict mouth cleaning and fluoride's use prevent teeth deterioration and infections. Important breakthroughs have been made in the pathophysiology of xerostomia and new treatments are developed.

Avoidance of treatment interruption: an unrecognized benefit of accelerated radiotherapy in oropharyngeal carcinomas?

PURPOSE: To assess the impact of treatment interruption on the potential gain in locoregional control obtained with accelerated radiotherapy (RT) compared with conventionally fractionated RT in patients with oropharyngeal carcinomas. METHODS AND MATERIALS: 152 patients treated with radical RT for oropharyngeal carcinomas between 1979 and 1996 were retrospectively analyzed. According to the American Joint Committee on Cancer (AJCC) staging system, there were 6/30/43/73 stages III/III/IV. Sixty-one patients were treated with a conventional RT schedule (median dose 70 Gy in 35 fractions), and 91 patients with either of two 5/5.5-week accelerated RT schedules (median dose 69.6-69.9 Gy in 41 fractions). Discounting weekends, RT was interrupted for 2 consecutive days or more in 53 patients (median duration 11 days, range 2-97), including 67% of the patients in the conventional RT group and 13% in the accelerated RT group. Median follow-up for surviving patients was 55 months (range 23-230). The Cox proportional hazards model was used for the multivariate analysis of factors influencing locoregional control. RESULTS: In univariate analysis, factors associated with a significant decrease in locoregional control included WHO performance status > or =1, advanced AJCC stages (III and IV), conventional RT fractionation, overall treatment time > or =44 days (median), and RT interruption. In the multivariate analysis, when introduced into the model individually, the three significant therapeutic factors remained significant after adjustment for the forced clinical variables. However, when the three therapeutic factors were introduced together into the model, beside the AJCC stage (P = 0.017), only RT interruption remained a significant independent adverse prognostic factor (P = 0.026). CONCLUSIONS: This multivariate analysis highlights the potential negative impact of treatment gaps on locoregional control in oropharyngeal carcinomas. This suggests that treatment interruption may be an even more important parameter than the type of RT schedule per se. Thus, when assessing the relative merit of two RT schedules, inclusion of the other therapeutic factors in a multivariate model is mandatory in order to avoid misinterpretation of the results.

Dose variation at bone/titanium interfaces using titanium hollow screw osseointegrating reconstruction plates.

PURPOSE: To evaluate dose variations at bone/titanium interfaces in an experimental model designed to simulate postoperative radiotherapy in patients with mandibular reconstructions using a titanium hollow-screw osseointegrating reconstruction plate (THORP) system. MATERIALS AND METHODS: The model consisted of a 25 x 25 x 10 mm3 block of fresh bovine femoral diaphysis, to the surface of which a segment of THORP system reconstruction plate was fixed by means of a solid titanium screw 4 mm in diameter and 10 mm in length. Using specially designed thermoluminescent dosimeters (TLD) 2 mm in diameter and 0.13 mm in thickness, dose measurements were carried out at four distances from the screw axis (0.1, 0.3, 0.6, and 1 mm). 60Co and 6-MV photon beams were used at incidences both perpendicular and parallel ("axial") to the screw axis. RESULTS: For 6-MV X-ray beams incident perpendicular to the screw axis, the maximum dose enhancement (due to backscatter) and the maximum dose reduction (due to attenuation) at the bone/titanium interface were 5% (+/- 2%) and 6% (+/- 2%), respectively. The corresponding values for 60Co beams were 6% (+/- 5%) and 10% (+/- 5%). For the axial incidences, a maximum dose enhancement of 5-7% was noted for both 6-MV X-rays and 60Co for beams incident on the surface containing the THORP plate segment, whereas beams incident on the opposite surface induced only a very small dose enhancement (2-3%). CONCLUSION: Using a new experimental model, TLD measurements showed only marginally significant dose variations at bone/titanium interfaces around THORP screws, all measured values being very close to the uncertainty limits (+/- 5%) associated with the method. For both 60Co and 6-MV beams, dose variations appeared smaller for axial than for perpendicular incidences. Because photon beams used in head and neck cancer treatment are most often directed parallel to the screw axes, these results suggest that failures of prosthetic osseointegration are unlikely to be explained by an overdosage at the bone/titanium interface.

Esthesioneuroblastoma: the UCLA experience 1970-1990.

A retrospective review was conducted of all esthesioneuroblastoma cases treated at UCLA Medical Center from 1970 through 1990. Patients were staged according to the staging systems of Kadish, et al., Biller, et al., and a new staging system proposed by the authors. Of 26 patients treated, 74% were alive at 5 years and 60% were alive at 10 years. Combined treatment with surgery and radiation is advocated since a recurrence-free status was achieved in 92% of the patients, compared with 14% for surgery alone and 40% for radiation alone. A craniofacial resection was performed in 7 patients, all of whom have remained disease free. Negative prognostic factors included: age over 50 years at presentation, female sex, tumor recurrence, and metastasis. The proposed new staging system predicted disease-free status better than the other staging systems.

Frey syndrome before Frey: the correct history.

OBJECTIVE: To review the chronology of publications on gustatory sweating before Frey's landmark publication. METHODS: Reports on Frey syndrome were reviewed, and all references given to publications before 1950 were obtained and examined. References to prior publications in the obtained articles were similarly reviewed. The cases described in these publications were analyzed for their compatibility with the accepted clinical symptoms of Frey syndrome. RESULTS: Despite numerous references, the case described by Duphenix in 1757 is most probably a traumatic parotid fistula. The first reported case of Frey syndrome should be attributed to Baillarger in 1853.

Postparotidectomy facial nerve paralysis: possible etiologic factors and results with routine facial nerve monitoring.

OBJECTIVE: Analyze the incidence and factors responsible for postparotidectomy facial nerve paralysis when the surgery is performed with the routine use of facial nerve monitoring. STUDY DESIGN: A prospective, nonrandomized study. METHODS: Seventy consecutive patients underwent parotidectomy with intraoperative facial nerve monitoring. Two devices were used: a custom mechanical transducer and a commercial electromyograph-based apparatus. All patients were analyzed, including those with cancer and those with deliberate or accidental sectioning of facial nerve branches. The outcome variables were the motor facial nerve function according to the House-Brackmann grading scale (HB) at 1 week (temporary paralysis) and 6 to 12 months (definitive paralysis). Facial nerve grading was performed blindly from reviewing videotapes. RESULTS: The overall incidence of facial paralysis (HB>1) was 27% for temporary and 4% for permanent deficits. Most of the deficits were partial, most often concerning the marginal mandibular branch. Temporary deficits with HB scores of greater than 2 were only present in patients with parotid cancer or infection. Permanent deficits were present in three patients, including one patient with facial nerve sacrifice. Factors significantly associated with an increased incidence of temporary facial paralysis include the extent of parotidectomy, the intraoperative sectioning of facial nerve branches, the histopathology and the size of the lesion, and the duration of the operation. CONCLUSIONS: Despite a stringent accounting of postoperative facial nerve deficits, these data compare favorably to the literature with or without the use of monitoring. An overall incidence of 27% for temporary facial paralysis and 4% for permanent facial paralysis was found. Although the lack of a control group precludes definitive conclusions on the role of electromyograph-based facial nerve monitoring in routine parotidectomy, the authors found its use very helpful.

Malignant melanoma of cervical and parotid lymph nodes with an unknown primary site.

Forty-six patients with malignant melanoma metastatic to cervical or parotid lymph nodes with an unknown primary site were treated at UCLA Medical Center from 1964 through 1991. Treatment consisted of parotidectomy and/or neck dissection with or without adjuvant therapy. The initial presentation was a cervical mass in 74% and a parotid mass in 26% of patients. Metastasis distal to the head and neck nodal basins developed in 22% of patients. Involvement of more than four cervical or parotid nodes resulted in a significant increase in distant metastasis (P < .01). Adjuvant therapy was found to have no significant effect on survival rates. However, age at the time of diagnosis influenced the survival rates. The significance of the improved survival of these patients as compared to those with a known primary melanoma is discussed.

Relation of recurrent laryngeal nerve compound action potential to laryngeal biomechanics.

This study was designed to investigate the compound action potential (CAP) of the recurrent laryngeal nerve (RLN) and to correlate this electrophysiologic signal to laryngeal biomechanics and phonatory function. Four adult mongrel canines were anesthetized. The RLN was isolated and stimulated, and recording electrodes were applied. The electromyographic (EMG) electrode was placed in the thyroarytenoid (TA) muscle. The RLN CAP and the EMG of the TA muscle were recorded and compared to the stimulation intensity, subglottic pressure (Psub), and each other. The CAP peak-to-peak and EMG peak-to-peak amplitudes demonstrated a sigmoidal relation to stimulus intensity and a linear relation to Psub and to each other. On the basis of these findings, the RLN CAP appears to be a reliable physiologic measure of laryngeal function.

Bilateral radical neck dissection with unilateral internal jugular vein reconstruction.

OBJECTIVE: To describe and evaluate the functional and oncologic results of one internal jugular vein replacement after bilateral radical neck dissection (RND). STUDY DESIGN: A retrospective historical cohort study. METHODS: Since 1972 all patients (n = 9) undergoing bilateral RND with resection of both internal jugular veins had a reconstruction of one internal jugular vein. In six cases the RNDs were staged, and in three cases the RNDs were performed simultaneously. In every case a vascular reconstruction was performed with an autologous vein graft. All patients received radiation therapy, in five patients before and in four patients after the vein grafting. Functional results were evaluated in terms of postoperative head and neck and neurologic complications. In some patients a Doppler scan was performed to assess vein patency. Oncologic results are reported as relapse-free survival and mortality intervals. RESULTS: In all patients the postoperative course was uneventful, without neurologic complications. Facial edema was noted in four patients, mild in three and moderate in one. Two patients are alive, with follow-ups of 8 and 18 years. Seven patients are dead, two without evidence of recurrence, four with cervical recurrence after a mean survival of 10 months, and one after distant metastasis after a survival of 7 years. In patients with long-term survival a Doppler scan confirmed the patency of the vein graft. CONCLUSION: The lack of operative complications and the absence of postoperative neurologic complications make a unilateral internal jugular vein replacement after bilateral RND attractive, although the oncologic results remain poor.

Specificity of parotid sialendoscopy.

OBJECTIVE: To present our initial experience with sialendoscopy of the parotid duct. METHODS: Diagnostic and interventional sialendoscopy procedures were performed in 79 and 55 cases, respectively. Diagnostic sialendoscopy was used to classify ductal lesions into sialolithiasis, stenosis, sialodochitis, and polyps. Interventional sialendoscopy was used to treat these disorders. The type of endoscope used, the type of sialolithiasis fragmentation and/or extraction device used, the total number of procedures, the type of anesthesia, and the number and size of the sialoliths removed were the dependent variables. The outcome variable was the endoscopic clearing of the ductal tree and resolution of symptoms. RESULTS: Diagnostic sialendoscopy was possible in all cases, with an average duration of 26+/-14 minutes and no complications. Interventional sialendoscopy was successful in 85% of cases, with an average duration of 73+/-43 minutes (+/- standard deviation). Multiple procedures were performed in 45% of cases, general anesthesia was used in 24%, and parotidectomy in 2%. Multiple sialoliths were found in 58% of ducts and associated with more procedures under general anesthesia and longer operations. The average size of sialoliths was 3.2+/-1.3 mm; larger stones were associated with more procedures under general anesthesia, longer and multiple procedures, use of fragmentation, and sialendoscopy failures. Sialolithiasis fragmentation was required in 10% of cases, with a success rate of 70%. Semirigid sialendoscopes performed better than flexible ones. Complications were mostly minor but were encountered in 12% of cases. CONCLUSIONS: Diagnostic sialendoscopy is a new technique for evaluating salivary duct disease, a technique which is associated with low morbidity. Interventional sialendoscopy allows the extraction of sialoliths in most patients, preventing open gland excision.

Endoscopic neck dissection in human cadavers.

OBJECTIVE: To evaluate the feasibility and efficacy of endoscopic neck dissection (END) in human cadavers. STUDY DESIGN: Experimental self-controlled study. METHODS: END on five human cadavers through three openings: one for the camera, one for the dissecting instrument, and one for a grasping one. The tissue specimens removed were divided into traditional neck groups (I to V). After the completion of END, open neck dissection was performed using standard surgical techniques and the remaining tissue within each neck group was retrieved. The important neck structures (carotid artery, internal jugular vein, cranial nerves X, XI, and XII, phrenic nerve) were evaluated for lesions. A pathologist evaluated each specimen, without knowing its exact origin in terms of neck group or side, and type of surgical technique used. For each specimen, the number of retrieved lymph nodes and their anatomic integrity was analyzed. RESULTS: Ten neck dissections were performed on 5 cadavers, without any major difficulty. An injury of the internal jugular vein occurred twice and once the phrenic nerve was cut. Little tissue was usually left for open surgical dissection. The average number of retrieved lymph nodes by endoscopy was 4.9 +/- 2.7 (mean +/- standard deviation). Completion open neck dissection retrieved an additional 0.5 +/- 0.5 lymph nodes. Efficacy of END was 92 +/- 10%. The majority of retrieved lymph nodes were intact but exhibited important postmortem autolysis artifacts. CONCLUSIONS: Endoscopic neck dissection is possible in human cadavers and is free of lesions to major structures. The majority of neck lymph nodes can be removed endoscopically.

Internal carotid artery dissection following rigid esophagoscopy.

A case of internal carotid artery dissection that developed after rigid esophagoscopy is described. The diagnosis was suggested by the clinical presentation and confirmed by the findings of radiological examinations. Internal carotid artery dissection is a rare condition of controversial etiology. Most frequently, the cause is unknown and the condition is termed idiopathic. A few cases have occurred after forceful cervical extensions and manipulations. The pathogenesis in our case is uncertain: while the rigid esophagoscopy is the most probable cause, the intubation and spontaneous carotid artery dissection cannot be ruled out.

Retrograde theory in sialolithiasis formation.

Sialolithiasis is a relatively frequent occurrence; however, cases of sialolithiasis originating around a "foreign body" nidus are rare. We describe a patient with submandibular sialolithiasis organized around a vegetal nidus and discuss the etiology of the case.