Long-term results of open cordectomy for the treatment of T1a glottic laryngeal carcinoma.

OBJECTIVE: To assess the long-term results and prognostic factors in patients who have undergone open cordectomy (OC) for the treatment of T(1a) glottic laryngeal carcinoma. METHODS: One hundred four epidermoid cancer patients operated from January 1989 through December 1999 were included in the study. Clinical parameters, postoperative complications, and postoperative stay were retrospectively evaluated in all cases. RESULTS: Mean survival for the patients included in the study was 61.5+/-24.8 months after the date of operation (range: 11-121 months). Ninety-four patients did not have recurrent tumor (90.4%). Local, regional and distant recurrence were linked with a statistical negative impact on survival rates (p<0.05). Only sero-hematoma was significantly related to local recurrence (p<0.05), whereas the remainder complications did not. None of the complications was associated with neck recurrence or distant metastasis (p>0.05). CONCLUSIONS: Open cordectomy is nowadays a valid technique for the surgical treatment of T(1a) glottic laryngeal carcinoma. Its results are comparable with those of other more recent techniques.

[History of the tonsil surgery]. / Historia de la cirugía amigdalar.

Tonsillectomy is one of the more frequent surgical techniques in the otolaryngological practice. In the first century A. D., Cornelius Celsus in Rome described the removal of the tonsils. Since them, devices used for tonsillectomy included a wide variety of instruments as snares, guillotines, scalpels ("cold" and ultrasonic), forceps and lasers. Likewise, the improvement of the anesthetic procedures and the perioperative management have contributed greatly to success with this surgical procedure. To sum up, the instruments and procedures used for tonsillectomy have evolved to render it a precise operation.

Utility of prophylactic antibiotics in pediatric adenoidectomy.

OBJECTIVE: To determine the utility of prophylactic antibiotics in non-risk pediatric patients undergoing adenoidectomy. METHODS: We performed a prospective, controlled, randomized, and double-blind study on patients under 14 years of age, scheduled for adenoidectomy who accomplished the following criteria: absence of immunosuppressive and/or cardiovascular risk factors, no antimicrobial therapy for at least 15 days prior to operation, and no fever 1 week before surgery. Venous blood samples for culture were obtained at 30s and 20 min after the curettage of adenoidal tissue. Likewise, immediate and delayed complications were registered in all cases. The usefulness of prophylaxis was analyzed according to three major standpoints: bacteremia, immediate complications, and delayed complications. RESULTS: One-hundred one patients fulfilled the inclusion criteria and were included in the study. Fifty-one children received prophylaxis and the remainder did not. In the non-prophylactic group incidence of bacteremia at 30s was significantly higher than in the prophylactic group (32.7% versus 4.0%) (p<0.001). Neither bacteremia at 20 min, nor immediate or delayed complications showed statistical differences between both treatment groups. CONCLUSIONS: Preoperative antimicrobial prophylaxis in pediatric adenoidectomy did not offer advantages preventing complications in non-risk patients. Only bacteremia that occurs 30s after the curettage of adenoid tissue is reduced with the employment of prophylactic antibiotics.

Neurological complications following functional neck dissection.

A retrospective study was done to assess the incidence and factors associated with neurological complications in patients who have undergone a functional neck dissection (FND). Four hundred forty-two epidermoid cancer patients operated on from January 1984 to December 2002 were included in the study. Clinical parameters, neurological sequelae, and other complications were evaluated in all cases. The incidence of neural damage was calculated on the nerves at risk (n =714). Paralysis of the 11th nerve occurred in 12 cases (1.68%). A lesion of the marginal branch of the 7th cranial nerve was observed in nine cases (1.26%). Bernard-Horner's syndrome and hypoglossal nerve paralysis were noted in four and three cases (0.56 and 0.42%), respectively. Thus, the incidence of neurological sequelae after FND is low. Neurological complications were not associated with either clinical parameters or non-neurological complications (P >0.05). None of the factors studied can predict the appearance of neural problems in the postoperative period.

Bacteremia following pediatric adenoidectomy.

OBJECTIVE: Adenoidectomy is frequently performed in children. The goals of this work were to determine the incidence of bacteremia during the adenoidectomy, to identify the microorganisms implicated, and to analyze the possible association of bacteremia with postoperative complications. METHODS: One hundred pediatric patients operated of adenoidectomy without preoperative antibiotic prophylaxis were prospectively included in this study. They had no immunosuppressive and/or cardiovascular risk factors, no antimicrobial therapy for at least 15 days prior to operation, and no fever 1 week before surgery. Venous blood samples were obtained 30 s and 20 min after the curettage of adenoidal tissue. RESULTS: The 33 and 14% of the samples were positive at 30 s and 20 min. The organism more commonly isolated was the streptococcus viridans. Bacteremia was only related to postoperative acute otitis media (p=0.012). CONCLUSIONS: Bacteremia exists after pediatric adenoidectomy, although it seldom correlates with clinical signs or symptoms. Postoperative acute otitis media is the only complication related to postsurgical bacteremia.

Status of internal jugular veins in patients with carcinomas of the head and neck area.

OBJECTIVE: To assess the status of internal jugular veins (IJV) in patients with head and neck carcinomas. STUDY DESIGN AND SETTING: This study included 108 IJV of 54 cancer patients who were prospectively evaluated between September 1994 and February 1997. Patency, presence of thrombosis, characteristics of vein wall, compressibility, area of the veins both in rest and during Valsalva maneuver, expiratory flow speed, Valsalva flow speed, jugular flow in each side, and total jugular flow were registered in all cases. Also, 30 IJV of 15 normal volunteers were used as a control group. The study was performed in a tertiary care referral center. RESULTS: Right expiratory flow speed was higher in volunteers (P = 0.0280), and left basal area was bigger in oncologic patients (P = 0.0394). No significant changes were found between cancer patients and controls in the remaining parameters (P > 0.05). CONCLUSIONS AND SIGNIFICANCE: According to these results, head and neck carcinomas do not seem to affect the ultrasonographic characteristics of IJV. Thus, preoperative evaluation of IJV is not mandatory in these patients.

Analysis of the causes of immediate unanticipated bleeding after pediatric adenotonsillectomy.

OBJECTIVES: To assess the incidence of unexpected postoperative bleeding in children undergoing adenoidectomy and/or tonsillectomy (T&A), and to investigate its possible undetected haematological causes. METHODS: We prospectively collected all patients under 14 years of age with a normal preoperative haematologic work-up (activated partial thromboplastic time, prothrombin time, fibrinogen, and platelet count), who underwent surgery of adenoids and/or tonsils at our institution between January 1997 and November 2000. RESULTS: There were 1516 cases that accomplished the inclusion criteria in the period of survey. Thirteen patients bled after surgery. This represents an incidence of 0.8% of immediate postoperative haemorrhage among the 1516 procedures analyzed. No statistical differences were found between bleeding and non-bleeding patients according to age, sex, and type of procedure (P>0.05). In 6 of the 13 bleeding patients (46.1%) an alteration of the coagulation system was subsequently found: 5 von Willebrand's disease, and 1 releasing thrombopathy. CONCLUSIONS: The incidence of bleeding after adeno and/or tonsillectomy at our institution is comparable with series previously reported in the current medical literature. In nearly one half of the cases, undetected coagulation diseases (mainly von Willebrand's disease) are diagnosed after surgery in the haematological study.

[The value of waiting in spontaneous remission of recurrent tonsillitis without associated adenoid pathology]. / Utilidad de la espera en la remisión espontánea de la amigdalitis de repetición sin patología adenoidea asociada.

In order to assess the rate of spontaneous remission in children with recurrent acute tonsillitis (RAT), we revised the pediatric patients who were seen between 1994 and 1999. For this purpose, 123 cases that were on the waiting list for tonsillectomy under the indication of RAT without associated adenoid disease were selected. Only 23 (18.7%) of the children who were included in the study were removed from the waiting list after a mean time of 9 months because of spontaneous remission of the disease. Thus, there is no justification for claiming that long waiting lists for tonsillectomy are frequently associated with spontaneous remission of RAT.

Spontaneous resolution of recurrent tonsillitis in pediatric patients on the surgical waiting list.

OBJECTIVE: To assess the impact of the waiting list on the spontaneous resolution of recurrent acute tonsillitis in children. METHODS: We have evaluated 623 cases placed on the waiting list for elective tonsillectomy (with or without adenoidectomy) between February 1994 and May 1999 at our institution. In each child, age, time on the waiting list, type of procedure and outcome were registered. There were two possible outcomes after the preoperative evaluation: tonsillectomy was still indicated or tonsillectomy was not necessary. RESULTS: Mean length of time on the waiting list was 10.8 months (range: 3.0-35.6 months; median: 8.2 months). In 507 of the 623 children (81.4%), the operation was still indicated. However, 116 patients (18.6%) did not need surgery because of spontaneous resolution of the clinical picture. No relation was found between outcome and age, time on the waiting list or type of procedure (P>0.05). CONCLUSION: There was no clinical evidence for claiming that resolution of recurrent acute tonsillitis in children is spontaneous with time.

Effect of atmospheric factors on the incidence of Bell's palsy.

To assess the possible influence of atmospheric factors on the incidence of Bell's palsy, a retrospective case review of patients seen between 1 January 1992 and 30 June 1996, was designed. The population included all Bell's palsy patients in whom the exact date of onset of paralysis (day, month, year) was known. The following parameters were registered daily by the Spanish National Service of Meteorology throughout the period of survey: temperature, atmospheric pressure and air pollutants (total number of particles and levels of SO2, CO, O3, NO2, NO, CH4 and total organic carbon). The only factor significantly related to Bell's palsy was temperature (P = 0.0164). Lower temperatures were associated with a higher incidence of Bell's palsy. A relationship between atmospheric pressure and/or air pollutants and Bell's palsy was not found.

[Vestibular and oculomotor changes in subjects treated with cisplatin]. / Alteraciones vestibulares y del sistema oculomotor en sujetos tratados con cisplatino.

Cisplatin is an agent used in the treatment of distinct oncologic diseases. We present the electrooculographic (EOG) findings of 6 patients which were seen at our Department under the diagnosis of chronic toxicity for cisplatin and associated vestibular alterations. Mean of age was 45 years. Three subjects were female (50%). The most frequent pathologic finding was ataxic pursuit tracking (100%). Additionally, spontaneous nystagmus, alterations in positional test, and vestibulo-ocular reflex suppression were also found. These results are discussed and the main literature concerning this matter is reviewed.

Graft-vs-host disease as a cause of enlargement of the epiglottis in an immunocompromised child.

We report a rare case of dyspnea due to enlargement of the epiglottis in a severely immunocompromised patient. The child underwent a previous tracheostomy at another hospital because of respiratory distress under the diagnosis of acute epiglottitis. The patient was subsequently decannulated without incident. One year later, the child developed a new episode of dyspnea with inspiratory stridor. A new tracheostomy was neccessary, and a biopsy specimen of the enlarged epiglottis was taken to confirm the diagnosis of graft-vs-host disease. The therapeutic measures in these situations are discussed below, and a review of the current literature concerning the etiology and management of epiglottic enlargement is performed.

Post-transplant lymphoproliferative disease in tonsils of children with liver transplantation.

OBJECTIVE: To assess the incidence and characteristics of post-transplant lymphoproliferative disease (PTLD) in tonsils of the liver transplanted children. METHODS: All patients under 14 years of age recipients of a liver transplant at the institution and operated on for tonsillectomy under suspicion of malignancy were included in this study. RESULTS: Seven patients underwent surgery on their tonsils under suspicion of PTLD. One case of B-cell lymphoma, and three cases of polymorphic diffuse B-cell hyperplasia were found. This represents an incidence of 1.4% of PTLD in the tonsils of the 283 pediatric liver transplants performed at the hospital. CONCLUSION: The incidence of PTLD in tonsils after liver transplantation is very low at the institution. However, it is very important to follow-up allograft recipients for early diagnosis of this entity.

Factors related to nerve injury and hypocalcemia in thyroid gland surgery.

To identify potential risk factors related to complications after thyroidectomy, a study was designed that included 675 patients. Recurrent laryngeal nerve (RLN) paralysis, hypocalcemia, serohematoma, wound infection, and postoperative hemorrhage were evaluated. The rate of paralysis of the RLN was calculated on nerves at risk for hypocalcemia (n = 890) in patients undergoing bilateral procedures or unilateral procedures if they had previously undergone a contralateral operation (n = 321). Multivariate analysis was used to identify the relationships between the variables included in the study. All statistical tests received the same level of significance of 0.05. Permanent hypocalcemia occurred in 2.2% of the patients, whereas unilateral paralysis of the RLN developed in 0.9%. Mortality was 0.1% in this series. The RLN paralysis had a significant relationship with preoperative diagnosis of malignancy (P < 0.03). Likewise, hypocalcemia was related to sex and surgical procedure (P < 0.03). Serohematoma was linked with age (P < 0.001), and hemorrhage was associated with previous radiation of the neck (P < 0.03).

Sarcomatoid carcinoma of the pyriform sinus with brain and subcutaneous metastases: an unusual metastatic spread pattern.

A 63-year-old man presented a polypoid tumor in the laryngeal space involving the right pyriform fossa. The patient underwent a total laryngectomy with bilateral functional neck dissection, and the diagnosis of sarcomatoid carcinoma with malignant fibrous histiocytoma-like stroma was established. The tumor showed an uncommon behavior, with distant metastases to the brain and to the subcutaneous tissue of the abdominal wall. The patient died 1 year after the development of the metastases. Despite its polypoid pattern of growth, sarcomatoid carcinoma of the larynx may behave very aggressively. It is important for clinicians to be aware of the possibility of distant subcutaneous and brain metastases in sarcomatoid tumors of the laryngeal space. If such metastases develop, the prognosis is ominous, with an average life expectancy of 3 months.

[Blood flow changes in the internal jugular veins after oncological neck surgery without lymph node dissection]. / Cambios de flujo en las venas yugulares internas tras cirugía oncológica cervical no ganglionar.

The effect of oncological surgery of the head and neck area without lymph node dissection on the patency and blood flow of the internal jugular veins (IJV) was assessed in a prospective study. Ten IJV of 8 patients who underwent surgery between September 1994 and February 1997 were evaluated. Ultrasound Doppler (UD) of both IJV was performed before and after surgery. Mean age of patients was 56.3 years (range, 38 to 72 years), and all but one were men. There was no case of postoperative thrombosis. No significant differences were found between the preoperative and postoperative measurements. Consequently, oncological surgery of the head and neck area without lymph node dissection did not seem to affect the patency and UD characteristics of the IJV.

Postoperative radiotherapy in patients with positive nodes after functional neck dissection.

A study was designed to assess the usefulness of postoperative radiotherapy (RT) in patients with surgically treated laryngeal and hypopharyngeal cancer with histologically proven positive neck nodes. Patients underwent operation between 1984 and 1995, with functional neck dissection (FND) being part of the treatment in all cases. The selection criteria included squamous cell carcinoma, negative margins for the primary tumor, and no previous treatment. For evaluation purposes, patients were divided into 2 groups: surgery alone versus surgery with postoperative RT. Eighty-three patients fulfilled the inclusion criteria and entered the study. All but 1 of the patients were men. The mean age was 58 years (range, 35 to 77 years). A multivariate analysis was used to analyze the prognostic parameters selected by univariate analysis, eg, age, alcohol, tumor location, T and N stages, and presence or absence of extracapsular spread and a desmoplastic pattern. Postoperative RT was not selected by univariate analysis as a prognostic factor, but was included in the multivariate analysis in order to assess its impact on survival and recurrence rates. Using the statistical method of multivariate analysis, we could not find evidence of a benefit to survival or local recurrence rates with postoperative RT in this series. Patients younger than 55 years and those with extracapsular spread had a decreased survival rate and a higher neck recurrence rate, irrespective of the treatment method.

Eficacia de la punción aspiración con aguja fina en las enfermedades de la glándula tiroides / Value of fine needle aspiration in surgical diseases of the thryroid gland

Con el objeto de evaluar la eficacia de la punción aspiración con aguja fina (PAAF) en las enfermedades quirúrgicas de la glándula tiroides se realizó un estudio retrospectivo histórico. Se incluyeron 443 pacientes cuya media de edad fue de 46.5+-15.7 años (rango: 16-82 años). Del total, 65 eran hombres (14.7 por ciento). La prueba de contingencia de la Chi-cuadrado fue el utilizado para el análisis. Los resultados en función de la definición de la prueba positiva fueron los siguientes. De acuerdo con la definición amplia de la prueba, la sensibilidad de la PAAF resultó ser del 75.2 por ciento, y la especificidad del 57.4 por ciento, con una eficacia de 62.1 por ciento (Kappa=0.25032). Sin embargo, con la definición estrecha, la sensibilidad fue del 35.0 por ciento, y la especificidad del 97.2 por ciento, con una eficacia del 80.8 por ciento (Kappa=0.39540). Estos resultados muestran la utilidad de la PAAF como prueba de despistaje. Además, el diagnóstico se puede obtener en ciertos casos.

Patency and flow of the internal jugular vein after functional neck dissection.

OBJECTIVES: To assess the patency and flow of the internal jugular vein after functional neck dissection. STUDY DESIGN: Prospective study of 54 internal jugular veins in 29 oncologic patients undergoing functional neck dissection between September 1994 and February 1997. METHODS: Patency, presence of thrombosis, characteristics of the vein wall, compressibility, area of the vein both in rest and during Valsalva maneuver, expiratory flow speed, Valsalva flow speed, jugular flow in each side, and total jugular flow were assessed in all veins before and after dissection. All patients were evaluated before and after the procedure by means of duplex Doppler ultrasonography. RESULTS: In no case was there thrombosis before or after the operation. Although total jugular flow decreases during the early postoperative period, it recovers to normal parameters within 3 months after surgery. CONCLUSIONS: According to these results, the patency of the internal jugular vein remains unaltered after functional neck dissection. Ultrasonographically there is no thrombosis after this procedure.

[Influence of radiotherapy on the permeability of the internal jugular veins after functional neck dissection]. / Influencia de la radioterapia sobre la permeabilidad de las venas yugulares internas tras el vaciamiento cervical funcional.

The influence of postoperative radiotherapy (RT) on the patency and blood flow of the internal jugular veins (IJV) after functional neck dissection (FND) was assessed in a prospective study. Doppler ultrasonography of the IJV was performed before and after surgery. Fifty-four FND were evaluated in 29 oncological patients who underwent surgery between September 1994 and February 1997. Twelve IJV received postoperative RT. There were no cases of thrombosis before or after surgery in any case. Blood-flow speed in the right Valsalva maneuver was the only parameter affected in irradiated patients.