How I do it: modified lichtenberger-brown tracheoesophageal puncture procedure.

BACKGROUND: Tracheoesophageal puncture (TEP) with use of a prosthesis is nowadays a standard for voice restoration after laryngectomy. Different TEP approaches exist. METHODS: We retrospectively reviewed our series of patients who underwent TEP by a novel technique, based partially on the Lichtenberger endo-extralaryngeal needle carrier. The instrument is covered with a protective Nelaton catheter and introduced via the mouth to the neopharynx/esophagus. No rigid endoscope is used for visualization of the TEP site. The tip is palpated through the stoma at the posterior tracheal wall and incision is done to the catheter tip. The prosthesis is introduced through the mouth and the neopharynx in a retrograde fashion. RESULTS: In 14 laryngectomees with postoperative radiation voice prosthesis was successfully placed with this technique. A total of 18 procedures were performed. One misplacement occurred. No other early or late complications were observed or any other TEP or prosthesis related problems. CONCLUSIONS: The rationale of our technique is to simplify the procedure, avoid risk-bearing approaches and instruments such as rigid endoscopes, simplify the armamentarium and reduce tissue trauma. The initial clinical experience in 18 TEPs confirmed it usefulness in both standard and anatomically challenging situations. TRIAL REGISTRATION: The current study obtained the ethical approval from the Faculty of Medicine at Medical University "Prof. Dr. Paraskev Stoyanov"-Varna, Bulgaria (Protocol 087/24.10.2019 (retrospectively registered).

Radiation-induced low grade fibromyxoid sarcoma of the larynx: a case report and literature review.

Low grade fibromyxoid sarcoma (LGFMS) is an uncommon variant of fibrosarcoma with high risk of local recurrence, immense metastatic potential and frequently protracted period between tumour presentation and metastasis. This unusual malignancy rarely affects the region of the head and neck which makes cases of laryngeal LGFMS extremely infrequent. To date, LGFMS of the larynx has been scatteredly mentioned in the literature. Neither incidence nor causes and risk factors for laryngeal LGFMS have been clarified so far. To the authors' knowledge, this is the first case report that discusses the clinical course, imaging diagnosis, histopathological evaluation and surgical approach to radiation-induced laryngeal LGFMS.We present a case of a 70-year-old man who developed a LGFMS after previous radiotherapy (RT) for squamous cell carcinoma (SCC) of the larynx. The latency period between the time of radiation exposure and the diagnosis of LGFMS was twenty-seven months. After re-confirming the diagnosis with second biopsy and extensive imaging evaluation the patient was subjected to an open partial resection of the larynx. Owing to the rarity of the tumour, there is no established protocol with follow-up recommendations.This case highlights the importance of considering the RT history of the patient in order to monitor radiotherapy-related complications, including the occurrence of LGFMS.

Propranolol treatment of infantile subglottic hemangioma: a report of two cases and a literature review.

Infantile hemangioma is one of the most common benign tumors of infancy. The natural evolution includes rapid growth followed by gradual involution. Airway hemangiomas are not that common, but they can lead to dyspnoea, as well as to life-threatening complications.Two children aged 3 months were admitted to the Pediatric Department with difficulties in breathing and with biphasic stridor. They had previously been hospitalized because of the same symptoms and misdiagnosed as having an upper respiratory tract infection. The previous treatment included intravenous or inhaled corticosteroids, without any significant improvement. Laryngoscopy was performed for both of the children. There was a mass in the subglottic area with the appearance of a hemangioma causing significant airway stenosis. We started treatment with propranolol at a dose of 1 mg/kg/day twice daily. The dose was gradually increased up to 3 mg/kg/day, under close monitoring. In the first 7 to 10 days after initiation of treatment, we observed a significant improvement of the respiratory distress. The second laryngoscopy showed an almost complete involution of the mass in the subglottis. The focus of this article will be primarily on the clinical presentation and the therapeutic response of subglottic hemangioma, along with a literature review on the subject.

Losing One's Voice to Save One's Life: A Brief History of Laryngectomy.

Laryngectomy is a surgical procedure that involves the surgical removal of the laryngeal complex, thereby separating the upper from the lower respiratory tracts, resulting in a tracheostomy. In this way, respiration is achieved at the expense of the patient's voice. A neopharynx is formed, serving only as a digestive passage between the mouth and the esophagus. Until the introduction of the procedure, patients with laryngeal cancer were considered terminally ill. Most often, the title of "First recorded laryngectomy" is held by Theodor Billroth in 1873; however, the outcome of the operation itself was doubtful, with later attempts having a 50% mortality rate. The first major leap in reducing patient mortality rates was the introduction of the two-step laryngectomy, performed by Themistocles Gluck in 1881. This achievement, along with the general advancements in the field of surgery at the time allowed his student Johannes Sørensen to perfect the method and further develop it into a modified single-stage laryngectomy. This procedure is the basis of contemporary methods.

Endoscopic Repair of Pharyngocutaneous Fistula Following Laryngectomy.

Pharyngocutaneous fistula (PCF) is a typical complication after total laryngectomy. It is managed predominantly via conservative techniques, but in cases of a large orifice or a substantial loss of surrounding soft tissue, surgical management is mandatory. Our aim was to apply a new endoscopic surgical approach for closure of a pharyngocutaneous fistula. We report a case of a 61-year-old patient, who had been subjected to total laryngectomy with partial resection of tongue base and postoperative radiotherapy for advanced laryngeal carcinoma. Pharyngocutaneous fistula developed two years after the initial treatment. Barium swallow radiographs revealed a fistula between the neopharynx and the skin at the C2-C4 level. An endoscopic surgical repair was performed. Fat tissue harvested from the abdomen was injected into the area surrounding the pharyngeal opening of the fistula. The opening was sclerosed and sutured. The patient resumed a normal diet after several days and the fistula did not recur throughout the follow-up period. The management of pharyngocutaneous fistula is mainly conservative and only in therapy-refractory cases, surgery is considered. In well-selected cases, an endoscopic approach can be used. Autologous fat injection around the hypopharyngeal opening of the PCF may be one of the possible options.

Harmonic Shears in the Surgical Treatment of Laryngomalacia.

Introduction Laryngomalacia (LM) is a condition that is clinically diagnosed in the pediatric period with inspiratory stridor and is caused by a congenital or acquired collapse of laryngeal suprastructures. Endoscopic supraglottoplasty is the modern gold standard surgical treatment for severe or complicated laryngomalacia. Various cold and powered surgical devices have been used to approach the aryepiglottic folds, and their advantages and drawbacks have been widely discussed. The applicability of Ultracision Harmonic shears (Ethicon Inc., NJ, US) for the sake of supraglottoplasty has not been previously advocated in the literature and is the subject of this study. Methods This was a review of the medical records of pediatric patients, with moderate to severe congenital laryngomalacia, who underwent supraglottoplasty with Harmonic at a single institution, from 2013 to 2019. Results A total of six patients underwent bilateral aryepiglottic fold division with the use of Ultracision in the study period (4 male, 2 female; mean age 7+/-9 months, age range 1m-24m). Postoperatively, all of the children were extubated and admitted to the pediatric intensive care unit (PICU) as a precaution measure. There were no early or late complications after the intervention. The postoperative endoscopic picture was evaluated in three patients (two of which for another reason). A stable laryngeal frame with no collapse or excessive scarring was observed. None of the patients required repeat surgery. Conclusion Based on the ease of surgical access, performance, surgical precision, and postoperative results, the use of Harmonic scissors appears to be a safe, practical, affordable, and easily applicable alternative for supraglottoplasty Type 2.

Anesthesia-related Safety Profile of a High-energy Ultrasonic Scalpel in Oropharyngeal and Laryngeal Surgery: An Ex Vivo Model.

Introduction The aim of this study was to evaluate the fire risks associated with a harmonic scalpel, with an established avian model simulating oropharyngeal/laryngeal surgery.  Methods A standard polyvinyl-chloride (PVC) endotracheal tube (ETT) was inserted into a degutted, whole raw chicken through which 100% oxygen was piped at 10 L/min. The inflated cuff of the tube was grasped and sectioned with the jaws of a standard high-power ultrasonic dissection system Ultracision (Ethicon Endosurgery, Cincinnati, Ohio, USA). Then, the whole ETT was grasped and cut, leaving the device in contact with the ETT for two more minutes. In a second step under the same conditions, an electrosurgical device was placed into the chicken cavity and activated at the chicken tissue near the ETT at a setting of 20 W. All trials were repeated to ensure accuracy. Results No ignition could be produced with the harmonic scalpel under any operation mode settings. In all cases, the ETT was cut through with some fumes and brown discoloration at the site of contact. The electrosurgical device easily caused flash ignition within seconds. Conclusion The harmonic scalpel appears to be a safer tool than electrosurgical devices in the setting of open cavity surgery in oxygen-enriched environments with respect to the presence of flammable medical PVC devices as ETT or catheters.

Histopathological Findings in an Unclassifiable Case of Empty Nose Syndrome with Long-term Follow-up.

One of the major components of the functional process in the nasal cavity is taken up by the respiratory epithelium covering the posterior two-thirds of the nasal cavity. Disruption in the cytoarchitectonics and subcellular changes in this epithelium results in a number of functional changes in the nasal cavity. One of the rare and usually iatrogenic disturbances of this type is described in 1996, although noticed and discussed significantly earlier, by Kern and Stenkvist empty nose syndrome (ENS) or secondary atrophic rhinitis. The clinical hallmarks of ENS are described as paradoxical feeling for nasal obstruction in the presence of actually widened nasal airways. This phenomenon is attributed to the efferent neuronal signal dissociation accompanying the changes in the nasal mucosa. Herein we report the findings in a 50-year-old male. The patient presented with chronic right-sided headache, foul discharge and complaints of a stuffed nose in 2011. Endoscopy and computed tomography (CT) showed complete destruction of the hard plane, nasal septum, and right maxillary septum, leading to a formation of a huge neocavity. Due to the past medical history and the severity of the case biopsy specimens were obtained under general anesthesia. The sections showed severe but unspecific changes of the nasal epithelium with areas of minimal remaining preserved respiratory epithelium. Based on the clinical data and endoscopic, CT and histomorphologic data, despite the case is not applicable to the current classification of ENS, the diagnosis of ENS was accepted based on the combined extensive but unspecific findings. A seven-year follow-up period included multiple hospital admissions for monitoring of the condition and extensive sinus lavage. No advancement was noticed.

Demographics of Head and Neck Cancer Patients: A Single Institution Experience.

Introduction Head and neck cancer (HNC) comprises a diverse group of oncological entities, originating from various tissue types and organ localizations, situated in the topographical regions of the head and neck (H&N). This single institution retrospective study was aimed at establishing the HNC patient demographics and categorizing the individual incidence of H&N malignancies, regarding their organ of origin and main histopathological type. Materials and methods All histologically verified cases of HNC from a single tertiary referral center were reviewed in a descriptive retrospective manner. Data sampling period was 47 months. Results Male to female ratio of the registered HNC cases was 3.24:1. The mean age of diagnosis was 63.84 ± 12.65 years, median 65 years. The most common HNC locations include the larynx 30.37% (n = 188), lips and oral cavity 29.08% (n = 180), pharynx 20.03% (n = 124) and salivary glands 10.94% (n = 68), with other locations such as the external nose, nasal cavity and sinuses and auricle and external ear canal harboring a minority of the cases. The main histopathological groups include squamous cell carcinoma 76.74% (n = 475) and adenocarcinoma 6.14% (n = 38), with other malignant entries such as other epithelial malignancies, primary tonsillar, mucosa-associated lymphoid tissue or parenchymal lymphomas, connective tissue neoplasias, neuroendocrine and vascular malignancies diagnosed in a minority of cases. Conclusion Considered to be relatively rare, HNC represents a diverse group of oncological entities with individual and specific demographic characteristics. The reported single institution results appear representative of the national incidence and characteristics of HNC.

Surgery of adult bilateral vocal fold paralysis in adduction: history and trends.

Bilateral vocal fold paralysis (BVFP) in adduction is characterised by inspiratory dyspnea, due to the paramedian position of the vocal folds with narrowing of the airway at the glottic level. The condition is often life threatening and therefore requires surgical intervention to prevent acute asphyxiation or pulmonary consequences of chronic airway obstruction. Aside from corticosteroid administration and intubation, which are only temporary measures, the standard approach for improving respiration is to perform a tracheotomy. Over the past century, a vast majority of surgical interventions have been developed and applied to restore the patency of the airway and achieve decannulation. Surgeons can generally choose for every individual patient from various well-established treatment options, which have a predictable outcome. An overview of the surgical techniques for laryngeal airway enlargement in BVFP is presented. Included are operative techniques, which have found application in clinical practice, and only to a small extent in purely anatomic or animal studies. The focus is on two major groups of interventions--for temporary and for definitive glottic enlargement. The major types of interventions include the following: (1) resection of anatomical structures; (2) retailoring and displacing the existing structures, with minimal tissue removal; (3) displacing existing structures, without tissue resection; (4) restoration or substitution of the missing innervation of the laryngeal musculature. The single interventions of these four major types have always followed the development of the medical equipment and anaesthesia. At the beginning of the twentieth century, when medicine was unable to counteract surgical infection, endoscopic or extramucosal surgical techniques were dominant. In the 1950s, the microscopic endoscopic laryngeal surgery boomed. At the end of the twentieth century many of the classical endoscopic operations were performed either with the help of surgical lasers alone, or in combination with other interventions.

The auricular VX2 carcinoma: feasibility of complete tumor resection.

BACKGROUND: The aim of the study was to test the feasibility of resection of VX2 auricular squamous cell carcinoma (SCC) in New Zealand White rabbits (NZW), its influence on the regional and distant metastases and the general prognosis. MATERIALS AND METHODS: In 71 NZW rabbits, successful in sano wide margin resection of auricular VX2 SCC was performed 7 days after tumor induction. The animals were sacrificed and examined for metastases after 6 weeks. RESULTS: Local recurrences occured in 7% of the animals. In 28.2% lymph node (LN) and in 15.5% distant metastases developed. Regional metastases presented in 100% of the animals with recurrence and in 22.7% of the RO animals (p < 0.001). Distant metastases presented in 80% of the animals with local recurrence and in 10.6% of the R0 animals (p < 0.001). Of the animals with local control, those with N+ had a significantly higher incidence of distant metastases (46.7%) compared to those with N0 (0%, p < 0.001). Local control and LN involvement were found to be important prognostic factors for early tumor-related death. CONCLUSION: The VX2 auricular model resembles head and neck (HN) SCC in humans morphologically, pathophysiologically and as a complex neoplastic disease. In the experimental setting it behaved similarly to the clinical situation of wait-and-see in N0 HNSCC patients. Tumoral microemboli present a possible mechanism for the development of recurrences.

Lymph node metastasis in an animal model: effect of piecemeal laser surgical resection.

BACKGROUND AND OBJECTIVES: Endoscopic laser surgical resection of advanced squamous cell carcinoma (SCC) often requires division of the tumor into several pieces. It is unknown if this approach influences the incidence of regional and distant metastases. STUDY DESIGN/MATERIALS AND METHODS: In 143 rabbits VX2 SCC was induced. Eight days later the tumor was resected by two different methods. In the first group en bloc cold steel resection was performed. In the second group piecemeal laser resection was performed. On the 51th day the animals were sacrificed and examined for lymph node and distant metastases. RESULTS: After piecemeal laser resection 47.7% of the animals had lymph node metastases compared to 24.6% after en bloc resection (P = 0.01). The incidence of distant metastases did not differ for the two groups. CONCLUSIONS: In our model narrow margin piecemeal laser resection was associated with a higher incidence of metastases compared to wide en bloc surgical resection. The exact mechanism responsible for this increase is unclear.

Effectiveness of radiochemotherapy on lymph node metastases in patients with stage IV oropharyngeal cancer.

Radiochemotherapy plays a leading role in the treatment of patients with advanced squamous cell carcinomas (SCC) of the oropharynx. The aim of the present study was to estimate its effectiveness on lymph node (LN) metastases. Seventeen patients with advanced UICC stage IV oropharyngeal SCC (1xT2, 4xT3, 12xT4, 2xN1, 15xN2) were observed prospectively. They were treated with radiochemotherapy (total radiation doses 60-70.6 Gy). One to four months after neck dissection (ND) was performed. Specimens were histologically examined for metastases according to the neck levels obtained from. Local control was achieved in 14/17 (82.4%) patients and regional-in 10/17 (58.8%) patients. Of 566 LN studied, 29 exhibited signs of involvement. Two from 29 were found in neck level I, 20/29 in II, 6/29 in III and 1/29 in IV. In 13/29 LN the metastases had completely regressed under treatment whereas 16/29 LN (7 patients) contained vital tumoral tissue. The observed high incidence of vital LN metastases, which abide the radiochemotherapy, advocates further studies, concerning the value of planed ND after radiochemotherapy.

Nasal snuff: historical review and health related aspects.

With cigarette smoking declining in the modern world, the tobacco industry has to look for other products that can keep the old customers and attract new ones. Different forms of smokeless tobacco are currently massively promoted and are gaining in importance. Dry nasal snuff--the oldest known form of tobacco in Europe--is one of them. The health risks associated with it are different to those attributed to smoking and oral wet snuff. The nicotine contained leads to dependency. Its resorption rate is similar to that of smoking, so it could be seen as an adequate substitutional therapy. The risk for cardiovascular diseases is lower, compared to that for smokers. Chronic abuse leads to morphological and functional changes in the nasal mucosa. Although it contains substances that are potentially carcinogenic, at present, there is no firm evidence, relating the use of nasal snuff to a higher incidence of head and neck or other malignancies.