Upper eyelid platinum chain placement for treating paralytic lagophthalmos.

For the definitive treatment of lagophthalmos and satisfactory rehabilitation of the affected eye, different surgical strategies have been proposed, including static or dynamic procedures. Although some of these can have good results, lid loading is now the most common technique for treating paralytic long-term lagophthalmos. Among the different types of loading, the use of a platinum chain is preferred to the use of a standard gold weight because platinum has a higher density than gold and is also more biocompatible. In this paper authors retrospectively analyzed 43 patients with regards to functional and cosmetic results. Questionnaires were also employed to assess changes and improvements in the patients' quality of life. Analysis of the excellent results achieved confirmed that platinum chain lid loading should be considered as a first-line treatment for paralytic lagophthalmos rehabilitation. It is a simple, reliable, and effective technique that significantly improves the health-related quality of life of patients.

The submental island flap: pedicle elongation and indications in head and neck reconstruction.

BACKGROUND: The submental island flap is an axial pattern skin flap first described by Martin et al. in 1993. When used to reconstruct skin defects it matches the recipient site in terms of colour, texture and thickness. One of the main limitations to its application is the arc of the pedicle allowing coverage of only the lower two thirds of the face. METHODS: A retrospective review was performed of all patients who had had a submental island flap reconstruction at the Operative Unit of Maxillo-Facial Surgery of the University Hospital of Parma, Italy, between 2001 and 2011. The Authors focused on the surgical technique adopted, the clinical indications and the results obtained. They analysed the different ways to elongate the pedicle and discuss their thoughts on the choice of reconstruction. A flowchart was created to help in the decisional process. RESULTS: Between 2001 and 2011 the submental island flap was used to reconstruct head and neck defects in 22 patients. Thirteen patients had defects of the oral cavity; the remaining 9 patients had skin defects involving the pre-auricular region, the temporal area and the peri-nasal cheek skin. No major complications occurred and in one case a partial necrosis of the distal portion of the flap was observed. Five patients underwent surgical revision involving intraoral flap debulking 6-10 months after the primary procedure. DISCUSSION AND CONCLUSIONS: The techniques to elongate the pedicle used and described were: additional dissection of the pedicle, Y-V procedure, reverse flow flap, section of facial vein and microvascular anastomosis. Their choice is mainly conditioned by the site of the defect.

Selective deep lobe parotidectomy for pleomorphic adenomas.

The authors' experience of the selective deep lobe parotidectomy for the treatment of pleomorphic adenomas of the deep parotid lobe is presented. A retrospective analysis of 11 patients treated between 1997 and 2010 was performed; seven were males and four were females, ranging in age from 35 to 51 years. Parameters evaluated included facial nerve weakness, the occurrence of Frey's syndrome, cosmetic outcome, and recurrence. Follow-up ranged from 18 months to 11 years. No major complications, permanent facial nerve weakness, or Frey's syndrome occurred. Four patients developed temporary facial nerve impairments that lasted between 2 and 6 weeks, and two developed a sialocele that healed in 9 days in one case and 12 days in the other. The overall cosmetic assessment was excellent in eight patients, good in two, and satisfactory in the remaining one. No recurrences occurred. The selective deep lobe parotidectomy can be considered an effective technique for the management of deep parotid lobe pleomorphic adenomas. The major advantages of this procedure include a reduction in complications such as facial nerve impairments and Frey's syndrome, and an improved cosmetic outcome.

Rehabilitation with endosseous implants in fibula free-flap mandibular reconstruction: a case series of up to 10 years.

PURPOSE: To evaluate the clinical outcome and the aesthetic and functional results of implant rehabilitation of fibula free-flap reconstructed mandibles. MATERIALS AND METHODS: The charts of patients who underwent mandibular reconstruction with fibula free flap and implant prosthodontic rehabilitation between 1998 and 2008 at the Operative Unit of Maxillofacial Surgery of Parma, Italy, were reviewed. In the study the estimated survival rates of implants placed in reconstructed mandibles we identified the prognostic factors and evaluated the functional outcomes. RESULTS: Fourteen patients with a mean age of 50 years (range 15-63 years), were included in the study. A total of 62 implants were positioned. Complications occurred in 7 cases, an improvement in function and aesthetics was reported by the majority of patients. CONCLUSIONS: A high survival rate for implants placed in fibula free-flap reconstructed mandibles was observed. Although different factors were believed to be associated with a poorer prognosis (radiotherapy, composite defects, etc.) no statistically significance was found, showing no absolute contraindications to implant placement.

Orthognathic surgery for the complete rehabilitation of Moebius patients: principles, timing and our experience.

Moebius syndrome is a rare disorder found in approximately 1/100,000 neonates and the treatment of facial palsy is now well established worldwide and consists of free-muscle transplants reinnervated with motor nerves. Dentofacial deformities are often detected in Moebius patients, and different degrees of micrognathia are often present, particularly in patients with complete expressions of Moebius syndrome. However only two published reports have described the surgical treatment of such anomalies in these patients; in both cases, the suggested approach consisted of orthognathic surgery followed by soft-tissue management. In this paper we discuss the indications and correct timing of orthognathic surgery and suggest to perform facial animation at an early age and then to wait for the completion of maxillofacial skeletal growth before performing orthognathic surgery. Finally, facial animation should precede orthognathic surgery in adult patients to prevent lower lip deformities and to ensure more predictable and satisfactory results.

Free flaps in elderly patients: outcomes and complications in head and neck reconstruction after oncological resection.

INTRODUCTION: Free flaps represent the first reconstructive option for many head and neck defects. The increasing life expectancy of the population results in increasing numbers of ageing patients facing complex reconstructive surgery. In this study we evaluated our experience with free-flap transfers in older patients, analysing the post-operative reconstructive and systemic complications. MATERIALS AND METHODS: Between 2000 and 2009, 360 patients underwent free flap reconstruction of defects resulting from the treatment of head and neck tumours at the Operative Unit of Maxillofacial Surgery, University - Hospital of Parma, Italy. Fifty-five patients (15.3%) were more than 75 years old at the time of treatment. RESULTS: At the end of the follow-up successful free-flap transfer was achieved in 360 of the 373 flaps harvested (96.5%). The overall reconstructive complication rate was 31.4%, (31.8% in the younger group and 29.1% in the remaining patients). Medical complications were observed in 29.2% of cases (less than 75 years: 28.8%; more than 75 years: 30.9%). The ASA status was associated with a statistically significantly higher incidence of complications within patients less than 75 years old (p < 0.0001). DISCUSSION AND CONCLUSIONS: The results of this study, in agreement with previous studies, provide evidence that free-tissue transfer may be performed in ageing patients with a high degree of technical success. The chronologic age cannot be considered an appropriate criterion in the reconstructive decision. On the contrary, a careful selection of the patients based on comorbidities and general conditions (ASA status) is of primary importance in reducing post-operative complications and to improving the results of surgery.

Treatment and prognostic factors of papillary thyroid microcarcinoma.

OBJECTIVE: To discuss the prognostic factors and outcomes of treatment in patients diagnosed with papillary thyroid microcarcinoma. DESIGN: Retrospective observational case review. SETTING: Department of Otorhinolaryngology of the tertiary referral teaching hospital of Parma. PARTICIPANTS: Ninety-seven patients diagnosed with PTMC and surgically treated between January 1998 and December 2007. MAIN OUTCOME MEASURES: Clinical and histopathological characteristics of the study group were identified and statistically analysed. RESULTS: No cancer-related deaths were registered. Incidence of recurrent disease was 9% after a 43 month mean follow-up (range 12-120). Univariate analysis detected that metastases in neck lymph nodes at diagnosis (p = 0.025), a tumour >5 mm in size (p = 0.011), the presence of bilateral tumoural foci (p = 0.007), the presence of capsular invasion (p = 0.001), and the presence of vascular invasion (p = 0.004) were related to recurrent disease. On multivariate analysis, the presence of bilateral tumoural foci (p = 0.030), and the presence of capsular invasion (p = 0.005) were significantly related to tumour recurrence. CONCLUSION: The prognosis for patients with papillary thyroid microcarcinoma in this series was excellent, with a 100% survival rate and minimal surgical-related morbidity. Nevertheless, approximately 10% of patients developed recurrent disease; aggressive treatment may be justified depending on the presence or absence of prognostic risk factors.

The role of surgery in children with head and neck rhabdomyosarcoma and Ewing's sarcoma.

Rhabdomyosarcoma and Ewing's sarcoma are relatively common malignant tumours in paediatric population. In the past, surgery was the mainstay of treatment and survival rates were poor. Afterwards, the development of multi-agent chemotherapy protocols during the past four decades resulted in a dramatic improvement in long-term survival. As a consequence, the significance of surgery has been the subject of critical discussion in the literature. Nowadays the standard treatment of rhabdomyosarcoma and Ewing's sarcoma consists in a multimodal therapy involving chemotherapy, radiotherapy and surgery. Nevertheless, the role of surgery still remains controversial. In particular, the cure of head and neck localizations presents debatable aspects since defined criteria to establish the risks and the benefits of surgical treatment do not exist at this time. This article reviews the role of surgery in children with head and neck rhabdomyosarcoma and Ewing's sarcoma. Indications, feasibility and timing criteria of surgical treatment have been reviewed and extracted from literature. Our case series is also presented.

Salvage surgery after radiation failure in squamous cell carcinoma of the larynx.

AIM AND BACKGROUND: To investigate patients treated with radiotherapy (RT) for laryngeal squamous cell carcinoma (SCC) in order to estimate the recurrence rate and treatment used as salvage surgery. The survival rate in the group of patients treated with salvage surgery was compared to that of patients who had chemotherapy rather than surgery or who refused any treatment. METHODS: From 1989 to 1999, 185 patients came to our institution for laryngeal SCC. All of them underwent RT as primary treatment. Only patients with a minimum of three years follow-up (n = 143) were included in the study group. RESULTS: The 143 cases included 22 loco-regional recurrences (15.3%) during the minimum three years of follow-up. Recurrence was observed in the larynx in eighteen cases (81.8%), in cervical nodes in one case (4.55%) and in both the larynx and cervical nodes in one case (4.55%). There was peristomal recurrence in two cases (9.1%). Recurrence was observed after an average of 16.3 months. Fourteen patients (63.6%) out of the twenty-two cases of recurrence underwent salvage surgery. Surgery was not performed on the remaining eight patients (36.4%). The global survival rate was 92.3% after three years and 66.6% after five years in the group of patients treated with surgery. The actuarial survival rate was 100% after three years and 83.3% after five years. The global and actuarial survival rate was 20% after three years and 0% after five years in the group of patients who received chemotherapy rather than surgery or who refused any kind of treatment. CONCLUSION: The RT seems to play an important role in the loco-regional control of laryngeal SCC (especially in glottic T1). Salvage surgery for recurrence results in a good survival rate.

Effects of gastroesophageal reflux disease in laryngeal carcinoma.

Gastroesophageal reflux disease is associated with various otolaryngological disorders. The aim of this retrospective study was to determine the role of gastroesophageal reflux disease in the development of laryngeal squamous cell carcinoma (SCC) in non-smoking and non-drinking patients. The study population consisted of 36 consecutive non-smoking and non-drinking patients with histologically confirmed SCC of the larynx. As a control, a group of 125 lifetime non-smoking and non-drinking cancer-free subjects were selected. Patients with laryngeal cancer had a higher prevalence of gastroesophageal reflux disease than the control subjects (P < 0.0001). Our results confirm the fact that gastroesophageal reflux disease in itself is associated with an increased risk of laryngeal cancer.

Gastroesophageal reflux as a possible co-promoting factor in the development of the squamous-cell carcinoma of the oral cavity, of the larynx and of the pharynx.

According to recent advances it is assumed that the gastroesophageal reflux (GER) is a possible co-promoting factor of the squamous-cell carcinoma development in the upper parts of the gastro-intestinal and respiratory systems, considering the higher frequency of lesions due to acid in the studied population interested by GER. The aim of this study is to investigate 274 patients with malignant neoplasm of the oral cavity, of the pharynx and of the larynx, by esophago-gastro-duodenoscopy (EGD) and to compare the incidence of GER in this group with a control group of healthy patients from their hospital. Acid exposure in the upper level of the esophagus often remains unknown using traditional pH-monitoring, especially if no pharyngeal probe is used. When necessary a good diagnostic test is EGD with mucosa biopsy; it allows to directly examine the lesion. We retrospectively studied the data of 274 patients suffering from a cancer of the upper aero-digestive tracts by EGD in order to diagnose lesions caused by GER. We compared non-smoking patients affected by GER and tumours a control group of healthy patients. Statistical analysis revealed a significant difference between the two groups using the z-Test (p = 0.0001). In our study, based on endoscopic data, we observed a high percentage of non-smoking patients affected by GER and squamous-cell carcinoma of the upper parts of the airways and the gastrointestinal system. For this reason we consider GER as a possible co-promoting factor of cancer in some patients.

The value of CT scans in improving laryngoscopy in patients with laryngeal cancer.

This retrospective study assessed the value of computed tomography (CT) scan with contrast in improving the staging accuracy of indirect and direct laryngoscopy. We compared the preoperative staging obtained by the two latter procedures with postoperative histopathological findings in 187 patients operated on for laryngeal cancer. Of these cancers, 98 were supraglottic, 82 glottic and 7 subglottic in origin. The staging accuracy of laryngoscopy was 51.3% and CT was 70.1%. When the two procedures were combined, the staging accuracy was 80.2%. The accuracy of the CT increased from glottic to supraglottic to subglottic tumors, although the accuracy of laryngoscopy decreased in the same direction. Laryngoscopy alone tended to understage larger tumors (pT3 and pT4), whereas CT underestimated the smaller ones (pT1 and pT2). Our data suggest that in order to plan the best treatment both laryngoscopy and CT should be used in making the diagnosis.

The pectoralis major myocutaneous flap in head and neck reconstructive surgery: 16 years of experience.

Wide defects resulting after resection of malignant tumors of the head and neck need an adeguate closure. In the last 16 years, 85 pectoralis major myocutaneous island flap procedures were carried out for the immediate reconstruction of surgical defects following extirpation of malignant tumors at various sites of the upper aerodigestive tract. The final functional and cosmetic results were satisfactory. Partial necrosis was observed in four cases. We did not have any cases of total flap necrosis. Post-operative fistulas were encountered in 14 cases (surgical closure was not necessary). The application and complications of the pectoralis major myocutaneous flap placed at cervical level are reviewed. The aspects of postoperative swallowing function of such surgery are discussed. Reconstruction with the pectoralis major myocutaneous flap is a safe and versatile procedure, yielding good clinical and functional results in patients with advanced head and neck tumors.

[Panendoscopy in the research of multiple malignant synchronous occult tumors in patients with cancer of the upper aero-digestive tract]. / La panendoscopia nella ricerca dei tumori maligni multipli sincroni occulti in pazienti portatori di cancro delle vie aero-digestive superiori.

The Authors consider the result obtained in the diagnosis of malignancies simultaneous neoplasia in patients with a tumour of the head and neck. The study was conducted on 337 patients on 750 observed in the last seven years with a squamous-cell carcinoma at different stages of keratinization, who underwent an ORL examination, bronchoscopy and esophagogastroduodenoscopy, sometimes with intravital staining. Bronchoscopy was conducted on 297 patients, esophagogastruoduodenoscopy on 300. Altogether 260 were subject to both techniques and 77 to only one procedure. Endoscopy released a second tumour in 4 cases on 297 (1.34%) of the bronchus and in 5 cases on 300 (1.66%) of the esophagus. The percentage amounts to 3.46% in 260 patients subject to both examinations. Our study released a malignancies cells (18 cases on 216); this number was not confirmed by istological examination on bronchial biopsy. Our collaborators consider this result as pollution derived from cells coming from clear tumour in expansion. Our study, obtained from a substantial number of cases, justify the use of panendoscopy screening in conjunction with routine studies; although this procedure is aggressive, it is acceptable, because these second tumours have been discovered in early and asintomatic stage and were not found in the radiological examination.

Vital staining of oesophagus in patients with head and neck cancer: still a worthwhile procedure.

One hundred three patients with upper aerodigestive cancer were consecutively submitted to upper GI endoscopy with vital staining (Toluidine Blue 1%) of the oesophagus. The aim of the study was not only to confirm the prevalence of synchronous or metachronous tumour but also to verify the usefulness of the vital stain compared to simple endoscopy. Staining was positive in 29 patients (28.1%) for oesophagitis, leukoplakia, Barrett's oesophagus and 3 oesophageal neoplasms (2.9%), two of them unsuspected at endoscopy. We did not observe false positives while 13 cases (13/29-44.8%) were considered normal at endoscopy. Five cases with some endoscopic abnormality of the mucosa did not stain and were considered false negatives. Specificity of the method was 100%, sensibility 85.2%. The recognition of dysplastic changes and neoplasms not suspected at endoscopy should recommend in our opinion the use of vital staining of oesophagus in high-risk groups.

[Granular cell tumor of the larynx: apropos of a case]. / Tumore a cellule granulose della laringe: a proposito di un caso.

Granular cell tumor of the larynx is a rare benign lesion. The Authors present a literature survey and report a case observed in the E.N.T. Institute of Parma University. The patient was a 22 year-old woman, smoker, whose right vocal cord was affected. Hoarseness represented the only symptom. The tumor was removed by the microsurgical method and histologically examined.

[The glosso-crico-arytenoid unit as a phonatory organ in sub-total reconstructive laryngectomy using the Labayle technic]. / L'unità glosso-crico-aritenoidea quale organo fonatorio nella laringectomia sub-totale ricostruttiva secondo Labayle.

The present study was carried out in order to assess characteristics of vicarious voice in patients undergoing Labayle's reconstructive sub-total laryngectomy. This type of surgery, which permits air passage for both respiration and phonation, makes it possible to preserve pneumophonic coordination. During phonation the expiratory air column is used and sound is generated as it passes through a vibrating structure having a sphincteric function. In the opinion of the authors this structure is not only made up of the cricoid orifice, against which the base of the tongue presses like an operculum, but also of the mobile residual arytenoid and, at times, of the lateral walls of the pharynx. Thus a single dynamic unit is formed involving several structures and their synergism guarantees the neoglottic occlusion required for a speaking voice. In the present study, glottography gave no significant results. In phonation a rapid vibration of the neoglottid mucosa is obtained thus producing a phonetically valid acoustic phenomenon. However, this does not result in an electroglottographic recording of adduction. On the other hand, interesting data were recorded when comparing the morpho-functional aspects of the neoglottis with characteristics of the vibrating voice, as recorded by spectrography. Spectrographic tracings are markedly better in cases of valid occlusion of the glosso-pharyngeal-arytenoid unit and this may be achieved regardless of the mobility of the remaining arytenoid. It is thus clear that several patients with a fixed arytenoid, but having valid sphincteric action of the other structures (i.e. base of the tongue or pharynx), had excellent speech quality and intelligibility. Therefore, Labayle's surgery, which reconstructs a pharyngo-tracheal continuity and consequently restores natural breathing, makes speech continuity possible. Such subjects have mixed vocal output (periodic components together with noise) although, on the whole, the voice produced has the fundamental requirements for intelligibility (i.e. intensity, pitch, harmonic structure, emission time) and may thus be considered valid for interpersonal verbal communication.

[Our experience in esthetic and functional surgery of the nose]. / Nostre esperienze in chirurgia estetica e funzionale del naso.

The authors report their experiences on functional and aesthetic nose surgery. The patients selection, the pre-operating test are based both on the rhinologic functionality and the photografic studies. Operative techniques are described together with pictures of most important stages. Results are shown with patients pictures before and after intervention.