Comparison of Voice Handicap Index in Patients with Esophageal and Tracheoesophageal Speech after Total Laryngectomy.

BACKGROUND: Successful speech rehabilitation has a great impact on the quality of life in totally laryngectomized patients. OBJECTIVES: The aim of this paper was to compare the self-assessed voice handicap of totally laryngectomized patients with two different methods of alaryngeal speech - esophageal (ES) and tracheoesophageal speech (TES). METHOD: The research comprised 83 totally laryngectomized, disease-free patients, split into two groups. The first group included 43 participants with successfully rehabilitated ES, and the second group included 40 participants with successfully established TES after secondary implantation of Provox 2TM voice prosthesis. All subjects filled in the Serbian version of the Voice Handicap Index (VHI-30). The results (overall score and three VHI subscales) were analyzed and compared with those of the subjects of both groups. The impact of age in the subgroups (<65 years old and ≥65 years old) and previous irradiation on the examined VHI values were also analyzed. RESULTS: The median value of the overall VHI score in the participants with TES was 29.03 ± 23.479 (range: 0-97), and in the participants with ES it was 64.51 ± 21.089 (range: 19-99). The VHI scores (overall and three VHI subscales) were significantly higher in participants with ES compared to those with TES (p < 0.01), indicating a larger voice handicap. No significant difference was found in the overall VHI score and VHI subgroups in terms of age subgroups and previous irradiation (p > 0.05). CONCLUSIONS: Our data reveal a significantly higher voice handicap in participants with ES compared to the TES group, with a large interindividual variation within both groups. VHI values are not significantly different between the two age subgroups, nor are they significantly influenced by irradiation.

Clinical stage of laryngeal carcinoma and lost time at the moment of diagnosis with 15-year-long interval. Are there any changes?

PURPOSE: Despite the fact that laryngeal cancer causes symptoms early, the patients often present with advanced disease. The aim of this paper was to determine how much time had been lost from the beginning of the symptoms to establishing the diagnosis, and what was the clinical stage of the laryngeal cancer at the time of diagnosis in two examination years (2001 and 2016). METHODS: The research involved 108 patients of both genders, 54 during each examination year, with whom the diagnosis of laryngeal carcinoma was established. The charts of the patients were reviewed, and the data were analyzed and compared. RESULTS: The median lost time from the time when the symptoms started to the time of diagnosis was 8.22 months during 2001 versus 8.77 months during 2016, with no statistically significant difference (p=0.774). Early clinical T stage of the disease in 2001 was present in 57.4% of the cases and 70.4% in 2016, with no statistically significant difference (p=0.161). Early clinical TNM stage in 2001 was in 48.1%, and 64.8% in 2016, with no statistically significant difference (p=0.081). Tracheotomy at the time of establishing the diagnosis was necessary in statistically significantly greater number of patients in 2001 compared to 2016 (59.3% versus 31.5% ;p=0.004). CONCLUSION: The diagnosis of laryngeal carcinoma is established late, with a long lost time. Favourable is the statistically significant decrease in the number of patients who require tracheotomy at the time of establishing the diagnosis with a 15-year-long interval.

Clinical stage of laryngeal carcinoma and lost time at the moment of diagnosis with 15-year-long interval. Are there any changes?

PURPOSE: Despite the fact that laryngeal cancer causes symptoms early, the patients often present with advanced disease. The aim of this paper was to determine how much time had been lost from the beginning of the symptoms to establishing the diagnosis, and what was the clinical stage of the laryngeal cancer at the time of diagnosis in two examination years (2001 and 2016). METHODS: The research involved 108 patients of both genders, 54 during each examination year, with whom the diagnosis of laryngeal carcinoma was established. The charts of the patients were reviewed, and the data were analyzed and compared. RESULTS: The median lost time from the time when the symptoms started to the time of diagnosis was 8.22 months during 2001 versus 8.77 months during 2016, with no statistically significant difference (p=0.774). Early clinical T stage of the disease in 2001 was present in 57.4% of the cases and 70.4% in 2016, with no statistically significant difference (p=0.161). Early clinical TNM stage in 2001 was in 48.1%, and 64.8% in 2016, with no statistically significant difference (p=0.081). Tracheotomy at the time of establishing the diagnosis was necessary in statistically significantly greater number of patients in 2001 compared to 2016 (59.3% versus 31.5% ;p=0.004). CONCLUSION: The diagnosis of laryngeal carcinoma is established late, with a long lost time. Favourable is the statistically significant decrease in the number of patients who require tracheotomy at the time of establishing the diagnosis with a 15-year-long interval.

[Role of surgery in modern treatment of laryngeal carcinoma].

The strategy of organ preservation by applying chemoradiotherapy in the treatment of laryngeal carcinoma, which has been extensively used since 1990s, is now being reviewed regarding its further justification. Despite good results in other localization of head and neck cancer, it has not met the expectations in case of laryngeal cancer. One explanation is the lower participation of human papillomavirus type 16 in the etiology of laryngeal cancer. A lot of developing countries base their concept on primary surgery with subsequent radiotherapy, because the cost of operations for cancer of the larynx is much lower than in developed countries. Endoscopic surgery of T1 cancers is feasible in all environments using cold surgery thanks to modern management of anesthesia with the possibility of local application of adrenaline. Its price is 481.46 euros, and if it is performed through laryngofissure, the price is 785.46 euros. The introduction of lasers into the treatment would justify the initial investment and extend indications, and the surgery of T1 and T2 cancers with laser application should be the standard practice in all countries and regions dealing with laryngeal pathology. T2 and some T3 cancers can be treated by conservation surgery of the larynx. Most of T3 and T4 cancers are indications for total laryngectomy or near-total laryngectomy in selected cases. If it is the primary surgery, wound healing is good and complications are rare. This greatly reduces the cost of operation, which is 1910.15 euros. Surgery after radiotherapy, particularly after chemoradiotherapy, may result in complications that significantly prolong the treatment and increase its costs. Thus, the biological nature of laryngeal cancer and its specificity make this approach to the treatment of cancer available in all regions of the world.

Laryngotracheal stenosis and restenosis. What has the influence on the final outcome?

The aim of this study is to analyze the impact of various parameters on the course and treatment outcome in patients with laryngotracheal stenosis and recurrent stenosis. Two groups of patients were compared: Group I included 29 patients with primary stenosis, and Group II included 22 patients with recurrent stenosis. The most frequent etiological factor for the development of stenosis was prolonged endotracheal intubation (79.3:77.3%), with subglottic-tracheal (44.8:45.5%) and tracheal (48.3:36.4%) localization being the most affected. Subglottic-tracheal stenosis was more common in men. There were no significant differences between the groups in regard to the grade of lumen obstruction and the length of the resected segment. In male patients, the length of the resected stenotic segment was significantly longer. Subglottic-tracheal stenoses were longer than tracheal ones. Various surgical procedures were performed, with additional management of recurrent laryngeal nerve paralysis, if necessary. Laryngotracheal reconstruction (LTR) with costal cartilage grafting (CCG) was statistically significantly more often performed in Group II, while cricotracheal resection (CTR) was more common in Group I. The incidence of complications in Group I was 24.1%, and in Group II it was 31.8%. Satisfactory airway lumen with undisturbed breathing was achieved in 93.1% of patients in Group I, and in 95.3% in Group II. Since the success rate was similar in both groups of the patients, it could be concluded that treatment outcome depends less on the factors associated with the stenosis, and more on adequate choice of surgical procedure and surgical team know-how.

Subglottic high frequency jet ventilation in surgical management of bilateral vocal fold paralysis after thyroidectomy.

Lesion of the recurrent laryngeal nerves as a consequence of thyroid surgery results in bilateral vocal fold paralysis and respiratory obstruction. The initial treatment involves ensuring an adequate airway and it ranges from tracheostomy to endo-extralaryngeal laterofixating operations in general anesthesia. Subglottic high frequency jet ventilation (HFJV) is an alternative ventilatory approach in airway surgery. HFJV offers optimal endolaryngeal working conditions, immobility of vocal cords, adequate oxygenation and ventilation. The HFJV was prospectively studied in 20 consecutive female patients with bilateral vocal fold paralysis. Ventilation was performed as subglottic HFJV via jet catheter inserted through the vocal cord. Anesthesia was administered as total intravenous anesthesia. At the end of the procedure, the jet catheter was exchanged with LMA laryngeal mask until spontaneous breathing was established. Subglottic HFJV was used in 20 patients undergoing endo-extralaryngeal laterofixating operations with suspension microlaryngoscopy. The mean duration of surgery was 32.25 minutes, mean age 47.35 (SD 9.75) years, and mean body mass index 26.39 kg m(-2) (SD 5.03). The mean arterial PaCO2 5 min before surgical procedure was 5.39 (SD 0.86) kPa, at 5 min of starting jet ventilation 6.19 (SD 0.91) kPa, and at the end of surgical procedure 5.93 (SD 0.99) kPa. There was significant correlation between PaCO2 obtained 5 min before starting jet ventilation and PaCO2 at 5 min of starting jet ventilation (p < 0.05). No complications secondary to the ventilation technique were observed. No perioperative tracheotomy was necessary. It is concluded that subglottic HFJV is an easy and safe way to ventilate patients with bilateral vocal fold paralysis when endoscopic intervention is performed.

Comparison between auditory steady-state responses and pure-tone audiometry.

BACKGROUND/AIM: A more recent method, the auditory steady-state response (ASSR), has become more and more important test method due to difference that was found in previous investigations between hearing thresholds determined by the ASSR and the pure-tone audiometry (PTA). The aim of this study was to evaluate the reliability of the ASSR in determining the frequency specific hearing thresholds by establishing a correlation between the thresholds determined by PTA, as well as to evaluate the reliability of ASSR in determining the hearing threshold with respect to the level of hearing loss and the configuration of the PTA findings. METHODS: The prospective study included 46 subjects (92 ears) which were assigned to groups based on their level of hearing loss and audiometric configuration. All the subjects underwent determination of hearing thresholds by PTA and ASSR without insight into their previously obtained PTA results. RESULTS: The overall sample differences between the ASSR and PTA thresholds were 4.1, 2.5, 4.4, and 4.2 dB at 0.5, 1, 2, and 4 kHz, respectively. A high level of correlation was achieved in groups with different configurations of PTA findings. The correlation coefficients between the hearing thresholds determined by ASSR and PTA were significant in subjects with all levels of hearing loss. The differences between hearing thresholds determined by ASSR and PTA were less than 10 dB in 85% of subjects (ranging from 4 dB for moderately severe hearing loss to 7.2 dB for normal hearing). CONCLUSION: The ASSR is an excellent complementary method for the determination of hearing thresholds at the 4 carrier frequencies, as well as determination of the level of hearing loss and the audiometric configuration.

Acute otitis media: to follow-up or treat?

Acute otitis media (AOM) is the most common diagnosis for which antibiotics are prescribed in children. However, due to their widespread use, we are witnesses to increased development of bacterial resistance to antibiotics. The purpose of this study was to evaluate the necessity of antibiotic treatment in patients with AOM. Our study included 314 children, aged between 2 months and 6 years. Children were divided into two groups: the first group included children with less severe forms of AOM, who received symptomatic therapy and "wait-and-see" approach (237 children); the second group presented with purulent ear infection and received antibiotic treatment from the beginning (77 children). After symptomatic therapy, resolution of the disease, without use of any antibiotics, was established in 61% of patients, compared to the overall sample of children with AOM. None of the children developed complications that would require surgical treatment. In the second group of children, receiving antibiotics, almost the same therapeutic effects (80%) were achieved with the use of amoxicillin, amoxicillin-clavulanate and cefixime, while the worst results were obtained after using azithromycin. The wait-and-see approach is recommended in forms of AOM without serious signs and symptoms, because it significantly reduces the use of antibiotics and their potential adverse effects.

Transient evoked otoacoustic emissions in young children with otitis media with effusion before and after surgery.

OBJECTIVE: Otitis media with effusion (OME) is one of the commonest causes of acquired hearing loss in children with increasing incidence. In young children the diagnosis is restricted to clinical trials and tympanometry whereas evaluation of the auditory function is impossible due to noncompliance during pure tone audiometry. For this purpose, measurement of otoacoustic emissions, especially transient evoked ones (TEOAE), can be applied. The aim of this study is to evaluate the parameters of TEOAE in young children with OME prior and after surgery. METHODS: Prospective study included 50 children with OME, both sexes, aged 2-5 years. Preoperatively tympanometric examination was performed and TEOAE were recorded. Surgery was performed under general anesthesia and included myringotomy with/without ventilation tube insertion. Measurements of TEOAEs (correlation percentage, signal to noise ratio and amplitude) were repeated on the first and six day postoperatively as well as 6 weeks and 6 months postoperatively. RESULTS: The preoperative TEOAEs were not recorded in 93.5%, with values of all TEOAE parameters being the most affected on highest frequencies. Significant changes of all TEOAE parameters were found 6 weeks postoperatively with further improvement 6 months postoperatively. Statistically highly significant difference of TEOAE between examinees with and without inserted ventilation tubes was established only in regard to preoperative results. CONCLUSION: In small children with OME, application of TEOAEs in follow-up of surgical effects is a method of choice for hearing screening due to its objectivity, simplicity and ease of use even after insertion of ventilation tubes. Follow-ups of TEOAE correlation percentage and signal to noise ratio reflect the condition earlier than follow-ups of TEOAE amplitude.

Surgical treatment of primary tracheal dyskinesia in a 14-month-old child--case report.

The primary form of tracheal dyskinesia in early childhood is a rare congenital malformation of unknown origin. The degree of the posterior membranous tracheal wall involvement determines the intensity of obstruction and the severity of the clinical picture. The aim of this paper is to present a case of a 14-month-old child with severe tracheal dyskinesia that required surgical treatment. Fascia lata graft fixated with fibrin glue was used in strengthening the posterior tracheal wall. Three years following the surgery, the child is without breathing difficulties. In severe cases of primary dyskinesia, surgical treatment using fascia lata graft, fixated with fibrin glue is recommended in strengthening the posterior tracheal wall.

[Radiotherapeutical chromosomal aberrations in laryngeal cancer patients]. / Radioterapijska ostecenja hromozoma kod karcinoma larinksa.

INTRODUCTION: The authors present the results of cytogenetic analysis of 21 patients with laryngeal carcinomas diagnosed and treated in the period 1995-2000 at the Institute of Otorhinolaryngology and Maxillofacial Surgery, Clinical Center of Serbia and Clinical Center of Novi Sad. MATERIAL AND METHODS: The patients were specially monitored and the material was analyzed at the Institute of Human Genetics of the School of Medicine in Belgrade as well as in the Laboratory for Radiological Protection of the Institute of Occupational and Radiological Health "Dr Dragomir Karajovic" in Belgrade. RESULTS: The incidence of chromosomal aberrations and incidence of exchange of material between sister chromatids were observed in the preparation of the metaphasic lymphocyte chromosomes of the peripheral blood obtained in the culture. Structural aberrations were found on the chromosomes in the form of breakups, rings, translocations and dicentrics as early as after a single exposure of patients to tumor radiation dose of 2 Gy in the field sized 5x7. Out of the total number of 35 cultivated blood samples obtained from 13 patients, 21 were successfully cultivated and they were proved to contain chromosomal aberrations. Some of the peripheral blood samples failed to show cell growth in vitro due to the lethal cell damages in vivo. DISCUSSION: We have concluded that the number of structural aberrations cannot be used as a biological measure of the absorbed ionizing radiation dose. The presence of aberrations per se is indicative of the mutagenic effect of the ionizing radiation, which was also confirmed in our series on the original model by cultivation of the peripheral blood lymphocytes in the culture of the cells of the volunteer donors upon in vitro radiation. Using the method of bromdeoxyuridylreductase, the increased incidence of SCE as a mutagenic effect was registered. CONCLUSION: It has been concluded that the increase of absorbed radiation dose in vitro leads to prolonged duration of cell cycle in the same conditions, which proves cytostatic effect of radiation. Further fundamental studies are required for clinical implementation of the findings.

[High Frequency Jet Ventilation and laryngeal surgery, clinical practice].

High Frequency Jet Ventilation is one in a group of alternative ventilatory techniques characterized by the application of small tidal volumes delivered at higher than physiological rates, followed by the passive expiration. There are two groups of indications: first, High Frequency Jet ventilation was used as a special ventilation mode during diagnostic or surgical procedures in patients with airway pathology; and second, High Frequency Jet Ventilation was employed as a respiratory support technique to improve gas exchange during severe pulmonary failure in infants, children and adults. Diagnostic or surgery laryngoscopy requires a method that can give good exposure of the larynx, continuing control of the airway patency and immobility of the vocal cords. High frequency Jet Ventilation overcomes the disadventage of an anaesthetic technique using a tracheal tube which can hide the posterior part of the glottis and which carries the risk of the fire in the airway. Small plastic cannulae have been introduced by the nasotracheal, orotracheal or transtracheal route for supraglottic or subglottic application of jet streams, employing tubeless HFJV. Jet ventilation via a catheter placed through the cricothyroid membrane, is an easy and safe way to ventilate patients with an abnormality of the upper airway, such as in cases of head and neck cancer. Inappropriate airway pressure monitoring and/or an insufficient expiratory airflow enhances the risk of pulmonary barotrauma. Despite a large body of published evidence describing its benefits as an alternative ventilatory approach in anaesthesia and intensive care medicine, its application has not gained widespread acceptance and is restricted to specialized centres only.

[Difficulties and complications of using endo-extralaryngeal laterofixation of vocal cords in bilateral recurrent laryngeal nerve palsy].

INTRODUCTION: The aim of this study is to show our experience in using the endo-extralaryngeal laterofixation of vocal cords in treatment of bilateral recurrent laryngeal nerve palsy, and to point out the difficulties and complications of this procedure and the ways of their managing. MATERIAL AND METHODS: During the period from 2003 to 2006, 14 patients with bilateral palsy of the recurrent laryngeal nerve were treated with method of Lichtenberger's endo-extra laryngeal laterofixation of the vocal cord The patients were 12 female and 2 male from 26 to 78 (average 57.4) years old. The earliest intervention was performed 8 day after the onset of paresis and not later than 40 days. RESULTS: In 11/14 (78.6%) of the patients bilateral palsy of the recurrent laryngeal nerve occured as a result of thyroid gland surgery. At the admission 2 (14.3%) patients had tracheostomy while 12 (85.7%) had no tracheostomy. Edema was the most often complication of the endo extra laryngeal laterofixation and it appeared in 8/14 (57.1%) patients. The earliest swelling of the laryngeal tissue was recorded on the first postoperative day and the latest one started 7 days after the intervention. Edema developed in 7/11 (63.6%) after total thyreoidectomy, in 1/3 (33.3%) with traumatic injuries in the neck Because of progression of the edema which provoked narrowing of the airway at the laryngeal level tracheostoma was peformed in 2 patients. Inflammation of laryngeal tissue with sudden obstruction of the airway resulted in death in one patient. Malposition of the thread toward the midle part of the vocal cord happened very often if intervention was not performed in JET ventilation anesthesia. The vocal card function was repaired bilaterally in 2 patients and unilaterally in 1 patient (the total being 3 out of 14 patients, i.e. 21.4%) four months after the laterofixation, and the threads were removed. Lung functional test showed the increase in average value PEF% from 26.53 before to 39.43 after laterofixation, and PIF from 0.83 before to 1.19 after intervention. Resistance R% in the upper airway decreased from the average 257.95 as before to 215.83 after the intervention, while the index FEV1.0/PEF (ml/L/min) remained almost the same before 13.25 and after the intervention 13.50 and that showed that the upper airway obstruction, in spite of good clinical tolerance by the patients, still persisted in all patients after the laterofixation. CONCLUSIONS: Lichtenberger's endo-extra laryngeal laterofixation of the vocal cord is a good alternative method for bilateral palsy of the recurrent laryngeal nerve which provide sufficient upper airway without tracheostomy.

[Surgical techniques and outcomes in the treatment of malignant tongue base tumors].

INTRODUCTION: Prognosis of patients with malignant tongue base tumors is poor. Survival is low, in spite of different treatment modalities. Most patients seek treatment too late, when their disease has already progressed to stage III or IV. The aim of this investigation was to compare different treatment modalities in patients with malignant tongue base tumors. MATERIAL AND METHODS: We have analyzed a total of 82 patients (72 men and 6 women) treated at the ENT Clinic, Clinical Center Novi Sad, between 1992 and 2004. The average age of our patients was 59 years. In regard to lifestyle habits, out of 82 patients, 67 were smokers and 57 were alcohol users (16 of the latter were treated alcoholics). The majority (54/82) of patients were both smokers and alcohol users. RESULTS: There were 6% of patients (5/82) with stage I disease, 15% ofJ patients (12/82) with stage 11, 24% of patients (20/82) with stage III and 55% of patient (45/82) with stage IV disease. Planocellular cancer was diagnosed in 79/82 patients, and the remaining (3182) had transitional cell carcinoma. Surgical treatment alone was performed in 17 patients, seven were treated with radiation only, and nine only with chemotherapy. Combined surgical and radiation therapy was performed in 28 patients, and 5 were treated with all three. Ten patients were not treated with any therapy. Tongue base resection only was performed in 12 patients, tongue base resection with epiglottectomy in 20, tongue base resection with supraglottic laryngectomy in 13 and tongue base resection with total laryngectomy in 5 patients. In radiation only cases, 25% of patients survived 20 months, whereas in surger) only cases, 25% of patients survived 27 months. Five-year survival after combined surgical and radiation therapy was 35% CONCLUSION: Development of tongue base carcinoma is strongly associated with alcohol and tobacco consumption. Survival is low, despite various treatment modalities. However, combined therapy is the therapy of choice in cases with tongue base carcinoma.

[Our results in surgical treatment of laryngotracheal stenosis--ten years experience].

INTRODUCTION: There are numerous techniques for the treatment of laryngotracheal stenosis. The aim of this paper was to present surgical techniques and results of treatment of laryngeal and laryngotracheal stenosis in a ten-year period by retrospective analysis. MATERIAL AND METHODS: Medical records of 34 patients (17 male and 17 female) surgically treated for laryngeal or laryngotracheal stenosis between 1995 and 2004 were analyzed. 19 (55.9%) patients had previous surgical procedures, whereas fifteen patients (44.1%) were diagnosed and treated for the first time. RESULTS: 5 patients had a glottic-subglottic stenosis, 11 patients had a subglottic stenosis, 16 patients had subglottic-tracheal stenosis and 2 patients had a glottic-subglottic-tracheal stenosis. 21 patients had normal vocal cord motion, 8 patients showed unilateral vocal cord fixation, and 5 had bilateral vocal cord fixation. Laryngotracheoplasty with anterior-posterior costal cartilage graft was performed in 24 patients, while single stage segmental laryngotracheal resection of the stenotic part was performed in 8 patients. One patient was operated in direct laryngomicroscopy and one with dilatation of the stenotic segment with T tube insertion. The most common complication was the development of granulation due to use of the Montgomery T-tube which was removed in direct laryngomicroscopy. Except for one patient, 33 (97%) patients were decannulated. There was no perioperative mortality. CONCLUSION: Although laryngotracheoplasty with anterior-posterior costal cartilage graft placement cannot be used in all cases of laryngotracheal stenosis, it was the method of choice in previously operated patients with segmental resection of the stenotic segment. This method requires use of Montgomery T-tube or anesthesiological tube, which is very hard to keep clean. Better recovery, short hospitalization and excellent results were obtained with the cricotracheal segmental resection.

[Dysphagia aortica--case report].

INTRODUCTION: Dysphagia aortica is a swallowing condition caused by external compression of the esophagus due to aortic aneurysm or atherosclerotic changes affecting the aorta. The case report on this rare cause of dysphagia should contribute to better diagnosis of dysphagia aortica and swallowing difficulties in general. CASE REPORT: A 63-year-old male patient was hospitalized duo to a four month history of intermittent swallowing difficulties. Chest radiography showed a widened mediastinum and an enlarged aortic arch. Rigid esophagus endoscopy was done in general endotracheal anesthesia. At 28 cm from the upper incisors, a difficulty in passing the endoscope appeared, revealing an external compression as a probable cause, since the whole esophagus had no intraluminal pathological changes. Contrast esophagography revealed an aortic aneurysm. The esophagus had a normal lumen width, wall tension and elasticity, and smooth contours. After cardiovascular examination and magnetic resonance imaging, a giant aneurysm of the aortic arch was diagnosed. DISCUSSION: Patients with dysphagia aortica as well as patients with any other swallowing difficulties should be managed by multidisciplinary "dysphagia team". The team should include an otorhinolaryngologist, neurologist, radiologist, gastroenterologist, surgeon, dietitian, speech and language therapist and specially trained nurses. CONCLUSION: Aneurysm of the thoracic aorta is a very rare cause of dysphagia. Mild to moderate symptoms can be in great disproportion with the severe condition which causes them.

[One thousand laryngectomies performed at the Novi Sad University ENT Clinic--historical review and important data on treatment of laryngeal tumors].

INTRODUCTION: The first ENT Department in Novi Sad was established in 1926. In 1960 the ENT Clinic became a part of the Faculty of Medicine Novi Sad and treatment of malignant disease started in 1973 at the Laryngology Department. SURGICAL TREATMENT OF MALIGNANT LARYNGEAL TUMORS: Treatment of laryngeal cancers in Novi Sad started in 1960's. Until 1971, the treatment of choice was radiotherapy, and surgical treatment started in 1971, when the first laryngectomy was performed After the first surgery, 31 years have passed until we have reached the number of one thousand performed laryngectomies at ENT Clinic in Novi Sad. PERIOD: 1971-1988: During this period, 138 laryngectomies were performed at ENT Clinic. Total laryngectomies were done as salvage surgeries in 136 cases, and 2 patients underwent functional partial laryngectomies. Direct laryngomicroscopy was introduced by Zivko Majdevac in 1972. Oncology consilium was founded. PERIOD: 1990-2002: New protocol was adopted. Surgery became the primary treatment of laryngeal carcinoma, while radiotherapy remained a valid therapeutic alternative. All known surgical techniques were introduced, including Pearson's near-total laryngectomy. In this period 834 patients were operated, and 873 laryngectomies were performed, out of which 388 total laryngectomies. Year after year the number of patients increased and in 2002, 90 laryngectomies were performed. The number of functional reconstructive operations has increased to 67.8% in comparison to 32.2 % of total laryngectomies.

[Value of panendoscopy in metastases of unknown origin].

INTRODUCTION: Neck metastases of unknown origin are metastatic solid tumors wth primary undetactable by physical examination, chest x-ray, rutine blood and urine studies and histologic evaluation. MATERIAL AND METHODS: This study included 77 patients of both sexes, average age 57 years, undergoing a diagnostic procedure at ENT clinic, Clinical Center Novi Sad, in the period from 1992 to 2001. RESULTS: The prymary tumor was detected in 51% of all cases by panendoscopy and bilateral tonsillectomy. In 14 of 26 patients (54%), in whom the site of the primary tumor was not detected, after telecobalt therapy and radical neck dissection, no relapses occurred. Pathohistological examination revealed planocellular carcinoma in 50 (65%) cases, transitional cell carcinoma in 9 (11.7%) cases and lymphoma in 7 (9.1%) cases. CONCLUSION: Cervical metastases with unknown primary tumor are the first sign of head and neck malignant disease. Panendoscopy with bilateral tonsillectomy and multiple mucosal biopsies are necessary procedures in detecting the primary tumor site.

[Selective neck dissection in the treatment of pN1/2 lymph node metastases in the neck]. / Selektivna disekcija vrata u terapiji pN1/2 metastatskih limfnih cvorova vrata.

INTRODUCTION: As yet there is no single reliable and accurate method for detection of neck lymph node metastases. Therapeutic approaches differ from one author to other. The aim of this paper was to establish the extent to which, with good control of primary process, we can control spreading of malignant disease by means of selective neck dissection. MATERIAL AND METHOD: This retrospective study included 595 surgically treated patients in the period 1990-1998. There were 525 patients with malignant laryngeal tumors, and 70 patients with malignant hypopharyngeal tumors. Preoperative diagnostics of enlarged lymph nodes was based on palpation of the neck, without CT, US, NMR diagnostics. With all risky N0 patients, selective neck dissection was performed for presence of occult metastases. Intraoperative frozen section analysis was not performed. Adjuvant radiatitherapy was performed in all patients in whom presence of neck lymph node metastases was histologically proved. RESULTS: Selective lateral neck dissection was performed in 389 (65.4%) patients. In 78 (20%) patients, lymph node metastases were pathohistologically detected. In 5 (6.4%) transitional cellular cancer was histologically diagnosed, and the remaining 73 (93.6%) presented with squamous cell cancer. Postoperative radiation therapy was applied in 54 patients (69.2%) while 24 (30.8%) were not irradiated. 5-year survival was achieved in 18 (23.1%), and 3-year survival was achieved in 15 (19.2%) patients. Out of 45 patients who lived less than tree year, 18 (40%) presented with metastatic relapse and fatal outcome. Relapse of neck metastases appeared in 12 (11.9%) on the side and in the zones of lymph nodes which were included in neck dissection. Recurrence of neck metastases appeared in 8.3% of patients who were not irradiated postoperatively and in 32.1% of cases irradiated postoperatively. DISCUSSION: This study includes comparison of our results with results of literature data. CONCLUSION: Neck lymph node metastases point to advanced malignant process of the third or forth stage of the disease when results are the worst and 5-year survival decreases with or without adjuvant radiotherapy.

[Unilateral laryngeal paralysis]. / Unilateralne pareze larinksa.

INTRODUCTION: Phoniatric rehabilitation is mainly aimed at restoring satisfactory phonation. Voice quality depends on the capacity of intact vocal cords to compensate the deficiency involved, as well as on automatism of phonation. MATERIAL AND METHODS: The study included 50 patients. All subjects underwent history taking, reported symptoms that urged them to visit a phoniatrician; they were submitted to a clinical otorhinolaryngologic and phoniatric examinations, voice assessment by subjective acoustic analysis, spectral analysis by digital sonography and laryngostroboscopy. All patients underwent Seeman's method of laryngeal compression. RESULTS: The examined group of 50 subjects included 17 males (34%) and 33 females (66%). Vocal cord palsy was most often due to neck surgery (strumectomy) in 19 patients (38%), followed by an idiopathic palsy involved in 12 patients (24%). Disocclusion of 1-2 mm and 3-3 mm was registered in 54% and 24% patients, respectively. After treatment total occlusion was established in 20% of patients, while disocclusion of up to 1 mm, 1-2 mm or 2-3 mm persisted in 36%, 20% and 2% of patients, respectively. T-test revealed a statistically significant difference in glottic incompetence prior to and after treatment (p < 0.01). After treatment, using Seeman's method of digital compression of the larynx, 48% of patients regained satisfactory speech and voice clarity and 50% of them still presented mild dysphonia. Moderate dysphonia was registered in 2%, but none of the patients had severe dysphonia. DISCUSSION: Central laryngeal palsies made 4% of our examined group, while according to the literature they make 1.2-8.7% of all laryngeal palsies. In majority of cases, paralysis of the recurrent laryngeal nerve was due to neck surgery (38%), but literature reports indicate that iatrogenic palsies are mostly due to operation of the thyroid. The well known fact that the left recurrent nerve is more frequently paralysed, has been confirmed in our study as well. CONCLUSION: Accurate and efficient treatment of unilateral laryngeal palsies requires team work. Phoniatric rehabilitation of the disorder using Seeman's method has proved efficient in diminishing the glottic incompetence and dysphonia. Patients who fail to respond to phoniatric rehabilitation should be treated using other therapeutic modalities.