Review of surgical techniques and guide for decision making in the treatment of benign parotid tumors.

PURPOSE: Surgical treatment of benign parotid tumors has developed in the direction of less invasive procedures in recent years and has raised great debate about the best surgical approach. Aim of this article is to analyse anatomical and other factors that are important in selection of the appropriate surgical technique in treatment of benign parotid tumors. Furthermore, to discuss the risk of complications and recurrent disease according to selected operation. Finally, to define patient selection criteria to facilitate decision making in parotid surgery and become a guide for younger surgeons. METHODS: Literature review and authors' personal opinions based on their surgical experience. RESULTS: All possible surgical techniques for benign parotid surgery with advantages and disadvantages are being described. An algorithm with anatomical and other criteria influencing decision making in benign parotid surgery is presented. CONCLUSION: Surgeons nowadays have many options to choose from for benign parotid surgery. ECD is one of the many surgical techniques available in parotid surgery and can achieve excellent results with proper training and if used for proper indications. PSP is mainly indicated in large tumors of the caudal part of the PG (ESGS level II). SP represents a universal solution in parotid surgery and should be the first technique young surgeons learn. TP has only few but important indications in benign parotid surgery. Surgeons need to carefully consider the patient and his/her preoperative imaging as well as her or his own special expertise to select the most appropriate surgical technique.

Warthin's tumour seems to be the most common benign neoplasm of the parotid gland in Germany.

PURPOSE: Recent reports indicate an increase in the prevalence of Warthin's tumours (adenolymphoma) with percentages which exceed that of pleomorphic adenomas (PA) in the same registries. The purpose of this study is to analyse a large cohort of benign parotid tumours in relation to various demographic and other patients' characteristics that might affect their incidence. METHODS: A retrospective review of prospective collected data was performed on all patients who have been operated for a parotid mass in the last 5 years. A total of 474 patients with benign lesion were included in the study. Age, gender, smoking status, histological diagnosis, site of lesion, and size of tumour were recorded. RESULTS: Warthin's tumours were the most common benign lesions, found in 201 (42.4%) parotic glands followed by pleomorphic adenomas found in 138 (29.1%) of these surgical cases. Patients with WT had a mean age of 61.6 years instead of 52 years for PA patients (t = 6.589, p < 0.001). The vast majority (93%) of patients with WT had a current or previous history of smoking compared with 47% of PA patients (p = 0.001). There was a male predominance regarding WT with a male:female (M:F) ratio of 2.3:1, whereas the corresponding ratio of PA was 1:1.4. CONCLUSIONS: This study confirms the increased regional prevalence of WT reported in studies mainly carried out in central Europe. This could affect future management of WT, which remains largely controversial due to the extremely low malignant potential reported, concurrently with its higher rates of multiplicity and recurrence, as well as the moderately accurate results of FNA biopsies.

Thyroglossal duct cysts: 20 years' experience (1992-2011).

The objective of the present study is to report on the clinical course and management of thyroglossal duct cysts. Retrospective review of all patients who underwent surgery for thyroglossal duct cysts between 2000 and 2013 at a tertiary referral center was carried out. The operations were performed using a modification of the Sistrunk operation: transcervical cystectomy, partial dissection of the hyoid bone, and dissection of all tracts identified during surgery. A total of 352 patients (176 men, 176 women) underwent surgery for a cyst (n = 282) or discharging sinus (n = 70). The mean age for the incidence of cysts was 26 years. Four of the patients (1.4 %) had a papillary thyroid carcinoma in the epithelium of the cyst. The follow-up period ranged from 7 months to 10 years. The overall recurrence rate was 4.5 %. Resection is often regarded as an elective surgical procedure in patients with thyroglossal duct cysts, but surgery should always be considered. Papillary thyroid carcinoma in the epithelium of the cyst is a rare but possible differential diagnosis. Dissection of all tracts found is recommended and partial dissection of the hyoid bone is mandatory. Dissection of the foramen cecum is not imperative. The recurrence rates with this approach are comparable to more extensive methods such as those described by Sistrunk.

Lymph node ratio is of limited value for the decision-making process in the treatment of patients with laryngeal cancer.

The lymph node ratio (LNR) combines two types of information--about the extent of neck dissection and about the extent of the pathological examination of the specimen--and thus represents an interesting variable for risk assessment in patients with head and neck cancer. This retrospective study with data from January 1, 1980, to December 31, 2010, evaluates the utility of the LNR as a potential prognostic predictor in patients with laryngeal squamous cell carcinoma (LSCC). A total of 202 consecutive patients with regionally metastasized LSCC who underwent primary surgery with or without adjuvant treatment were included. The mean follow-up period was 4.4 years. The LNR was calculated as the ratio of positive nodes to the total number of nodes removed during neck dissection. Multivariate analysis was carried out. Peak values as averaged clusters of individual LNRs were registered at three points (LNR 0.05, 0.07, and 0.09). LNR 0.09 was a significant prognostic parameter in the Cox regression model (P = 0.007). Patients with an LNR > 0.09 had a hazard ratio of 2.065 for a disease-specific survival event in comparison with LNR < 0.09. The most accurate LNR for LSCC is expected to be located in the range of 0.08-0.1. The LNR seems to be of limited value for the decision-making process in the treatment of patients with LSCC, in comparison with other locations. Prospective trials will be required in order to allow evidence-based recommendations for treatment decisions based on the LNR.

Lymph node ratio as a predictor of outcome in patients with oropharyngeal cancer.

To evaluate the utility of lymph node ratio (LNR) as a potential prognostic predictor and to test whether LNR may be useful as a potential selection criterion for adjuvant treatment in patients with oropharyngeal squamous cell carcinoma (OPSSC). This retrospective study included 384 patients with regionally metastasized OPSCC who underwent primary surgery with or without adjuvant therapy from 1980 to 2010. LNR was calculated as the ratio of positive lymph nodes to the total number of lymph nodes removed during neck dissection. Statistical analysis using a Cox regression model was carried out. The 5-year disease-specific survival (DSS) was 73%. An individual LNR peak at 0.1 was closest to the median of 0.0909, and both were set as cut-off values. Patients in the group greater than median had a hazard ratio (HR) of 2.472 for a DSS event; this was close to an HR of 2.513 for LNR >0.1. In multivariate analysis, LNR showed a markedly stronger HR with regard to survival in comparison with the grouped pN classification. The covariate treatment modality did not meet the assumption of the Cox regression, and it was therefore not possible to comment reasonably on the issue of whether LNR could be a potential selection criterion for adjuvant treatment. Lymph node ratio is in itself a valuable additional prognostic factor for risk stratification. According to the current results, the most valuable LNR for OPSSC is expected to be located in the range from 0.09 to 0.1. Further investigations in large prospective trials will be required to allow evidence-based recommendations for treatment decisions based on the LNR.

Clinical relevance and prognostic value of radiographic findings in Zenker's diverticulum.

The aim of this study was to evaluate the clinical relevance and prognostic value of preoperative and postoperative oesophagography in patients with Zenker's diverticulum. The medical records of 155 patients who underwent surgical treatment (with an endoscopic or transcervical approach) for Zenker's diverticulum between 1992 and 2010 in a tertiary referral centre were retrospectively evaluated. The size of the diverticula on oesophagography, recognizable muscular septum, and protection of the diverticulum were assessed relative to the surgical procedures performed. The incidence of diverticular remnants on postoperative oesophagography was also assessed relative to the surgical procedure. It was investigated whether the detection of a residual pharyngeal pouch and filling of it with contrast medium were related to the patients' immediate postoperative symptoms and the development of symptomatic recurrence. Larger diverticula (Brombart III-IV) were manageable significantly more often with endoscopic procedures (P = 0.007). Residual diverticulum and filling with contrast medium were strongly associated with prolonged dysphagia immediately postoperatively (P = 0.005 and P = 0.009, respectively). However, these parameters failed to correlate significantly with a symptomatic recurrence. Preoperative oesophagography proved to be extremely important for surgical planning, with the surgeon's personal preference seeming to be the driving indicator in many cases. Postoperative oesophagography is only useful for excluding postoperative complications in the immediate postoperative phase and did not have a prognostic value as to a recurrence of the disease.

Combined Laryngocele and External Approach.

Laryngocele, a dilation of the laryngeal saccule, is an uncommon and benign air-filled lesion that expands upwards into the ventricle of Morgagni. A unilateral growth within the larynx that is in communication with the laryngeal lumen typically signals its presence. The exact cause of the disorder remains uncertain, although there are three main theories which suggest congenital reasons, increased pressure in the larynx, or mechanical obstruction of the ventricle of Morgagni. The classification for laryngoceles is based upon their location with respect to the thyrohyoid membrane, and they may be internal, external, or combined. A laryngocele, along with a gradually enlarging submandibular mass, was located in the region from below the hyoid bone to the anterior sternocleidomastoid muscle on the right side of the neck. The diagnosis of a laryngocele may be confirmed through clinical examination, endoscopic investigation and imaging tests. For cases of combined laryngocele, we recommend its removal using an external approach, which not only ensures safety and accuracy but also allows for a complete removal of the laryngocele. Additionally, this approach guarantees that the surgical intervention is carried out with maximum precision and effectiveness, as all procedures will be performed under direct visualization.

Management of an Atypical Lipomatous Tumor/Well-Differentiated Liposarcoma of the Left Laterocervical Region: Report of a Rare Case.

Liposarcomas are among the most usual cancerous growths of mesenchymal tissues and represent about 1% of head and neck sarcomas. They are extremely rare in childhood and are mostly seen between 30 and 60 years of age. The biologic behavior and histologic features of liposarcomas vary. Although these tumors grow very slowly and have a benign behavior, sometimes they grow rapidly and metastasize early, with fatal results. This case report presents a 63-year-old man with a tumor of the left side of the cervical region which has grown to a large size over four years. For an accurate diagnosis, fine needle aspiration biopsy (FNA) biopsy was performed. The cytological examination showed an adipose tumor. Surgical removal was done under local anesthesia and the pathologic examination showed a well-differentiated liposarcoma. These are usually early stage tumors, with fewer metastases than other sarcomas. Surgical abscission is the gold standard for the treatment of liposarcomas. The efficacy of postoperative radiotherapy or/and chemotherapy is controversial.

Pyogenic Granuloma Gravidarum of the Nasal Cavity Causing Recurrent Epistaxis. A Case Report and Review of the Literature.

Pyogenic granuloma is a benign proliferative fibrovascular lesion commonly arising from the skin and mucous membranes of the head and neck region. Histologically, this tumor is characterized by vascular proliferation and a circumscribed group of capillaries organized in lobules. It is usually located in the oral cavity and nasal location is less frequent. When it occurs in pregnant women, it is usually referred as pyogenic granuloma gravidarum. In this article we present the case of a pyogenic granuloma gravidarum in a young woman with intermittent epistaxis during the last trimester of pregnancy that did not resolve after childbirth and was treated with transnasal endoscopic resection and cautery at the base of the lesion for hemostasis under local anesthesia.

Incidence of occult cervical metastasis in head and neck carcinomas: development over time.

BACKGROUND: With the development of imaging techniques in diagnostics of head and neck carcinomas, especially computed tomography and ultrasonogaphy, one might expect that the incidence of occult metastases would be reduced. The aim of this study was to determine the rate of occult metastases in a large population cohort and explore its changes with improvement of imaging techniques over the last 30 years. METHODS: All patients between 1980 and 2010 with head and neck carcinoma and cN0 neck status were retrospectively evaluated. Six hundred thirty-six patients with cN0 neck who received an elective neck dissection as part of a definitive surgical treatment were included. RESULTS: The overall rate of occult metastases was 24.8% (158/636). The rate was 26.5% (80/302) between 1980 and 1995 and 23.4% (78/334) between 1995 and 2010. Only pT1-2 glottic carcinomas had an occult metastases rate of less than 10%. All other pT1-2 carcinomas had an incidence of occult metastases between 19.1% and 42.5%. pT3-4 tumors showed an occult metastases rate of 24.5-53.3%. CONCLUSION: The occult metastases rate showed only a marginal improvement over the last 30 years and is still above the 20% margin. All but pT1-2 glottic carcinomas should be considered for elective treatment of the neck.

Closure of defects after resection of tumors of the oral cavity and the pharynx: medium- to long-term oncologic and functional results with the myocutaneous platysma flap.

The aim of this study was to assess the medium- to long-term functional and oncologic results when the myocutaneous platysma flap (MPF) was used for defect reconstruction of the oral cavity and the pharynx in selected patients. The MPF was used in 70 patients for closure of small to medium-sized defects. 37.1 % of the tumors were in the oral cavity, 24.3 % in the oropharynx and 38.6 % in the hypopharynx. Histopathological risk factors, adjuvant therapy, recurrence rates, and survival rates were assessed. Rehabilitation of swallowing and airways function was analyzed. UICC staging was I in 18.6 %, II in 15.7 %, III in 18.6 %, and IV in 47.1 %. Histopathological risk factors were noted in 51.4 and 84.3 % patients received adjuvant treatment. Recurrences were observed in 27.2 %. The 5-year recurrence-free survival rate was 63.1 %, and the disease-specific survival rate was 66.7 %. Permanent tracheostomy closure was achieved in 74.4 %, and complete recovery of swallowing in 57.4 %. Analysis of the functional and oncologic data after defect closure with the MPF showed acceptable results. The MPF should be included in the range of surgical methods for closure of small to medium-sized defects in the head and neck region in selected patients.

Hereditary Hemorrhagic Telangiectasia With Multiple Ear, Nose, and Throat (ENT) Manifestations: A Case Report.

Hereditary hemorrhagic telangiectasia (HHT), also known as Rendu-Osler-Weber syndrome, is a rare autosomal dominant multisystem disorder. It is a mucocutaneous and fibrovascular dysplasia, the diagnosis of which is based on the fulfillment of the four Curaçao criteria: 1) recurrent epistaxis; 2) dermatovascular mucosal telangiectasias at characteristic sites: skin of the face, ears, fingertips, lips, tongue, and oral and nasal cavity; 3) arteriovenous malformations (AVMs) of visceral organs and central nervous system; and 4) family history: diagnosis of HHT in a first-degree relative. We describe a case of a 76-year-old patient who presented to our department with clinical manifestations of HHT in the skin (face, fingertips), lips, hard palate, tongue, ears, and nasal cavities. Individual and family history was obtained, as well as clinical laboratory examination, pan-endoscopy of the ear, nose, and throat (ENT) systems, and treatment of active foci of bleeding from the above areas. The otolaryngologist may be the first doctor to suspect Rendu-Osler-Weber syndrome and the one responsible for treating patients with HHT since recurrent epistaxis is the most frequent (90-96% of patients) and the earlier manifestation of the disease and the main reason for the arrival of these patients in the Emergency Department. The purpose of this study is to present a clinical case of Rendu-Osler-Weber syndrome with multiple ENT manifestations, as well as a review of the literature on their management and treatment.

Differential Diagnosis of Cervical Lymph Nodes with Ultrasound and Virtual Touch Imaging Quantification: a Report of Three Cases.

Cervical lymphadenopathy is a common clinical presentation, and its differential diagnosis is challenging. In this article we present three cases with enlarged cervical lymph nodes evaluated with combination of ultrasound (US) and virtual touch imaging quantification (VTIQ) performed by the head and neck surgeon G.P. with a 10-year experience in ultrasound elastography (USE). In the first two cases, US and VTIQ evaluation showed predominance of areas with increased stiffness and higher share wave velocities compared with those in the third case. Malignancy was suspected in the first and second cases. The histology report revealed metastatic squamous cell carcinoma in the first two cases and chronic non-specific lymphadenopathy in the third case. The development of VTIQ share wave elastography has improved the diagnostic accuracy of ultrasonography and can guide clinical decision when dealing with cervical lymphadenopathy.

Hemorrhage of Upper Digestive and Respiratory Tracts in a Child with Glanzmann Thrombasthenia.

Glanzmann thrombasthenia (GT) is an autosomal recessive platelet disorder that could cause mild to severe bleeding episodes. The incidence is approximately 1 per 1,000,000 births. Patients with GT frequently have mucocutaneous bleeding with absent platelet aggregation in response to all physiologic stimuli, but a normal platelet count and morphology. Specifically, the glycoprotein IIb/IIIa (GP IIb/IIIa) complex is either inadequate or dysfunctional. This case reports a 3.5-year-old boy with Glanzmann thrombasthenia who had two episodes with uncontrolled hemorrhage from upper digestive and respiratory tracts, the first with the bleeding point found in the left tonsil and the second in the adenoids.

Management of an Acute Airway Obstruction Due to Tracheal Carcinoma in a Patient With Severe Glottic Stenosis.

In this paper, we present the case of acute airway obstruction due to tracheal carcinoma in a patient with glottic stenosis due to previously treated laryngeal carcinoma. Because of severe dyspnea from the obstructive endotracheal mass, tracheotomy under local anesthesia was immediately performed. Intubation with pediatric size (I.D. 4.5 mm) cuffed endotracheal tube was performed by the surgeon through tracheostomy under endoscopic visualization. Blakesley forceps and electrocautery were used for tumor debulking. Postoperatively there were no complications and the patient was discharged after four days. The histopathology report showed a squamous cell carcinoma. The tumor board decided on adjuvant chemoradiotherapy for the treatment of the patient.

Resection of Primary and Recurrent Parapharyngeal Space Pleomorphic Adenomas via a Combined Transcervical-Transparotid Approach: A Case Series.

Primary parapharyngeal space tumors are rare, and due to the complex anatomy of the parapharyngeal space, their diagnosis and treatment are challenging. Pleomorphic adenoma is the most common histologic type followed by paragangliomas and neurogenic tumors. They can present as a neck lump or an intraoral submucosal mass with the displacement of the ipsilateral tonsil or might be asymptomatic and discovered incidentally on imaging obtained for other reasons. Magnetic resonance imaging (MRI) with gadolinium is the imaging of choice. Surgery remains the treatment of choice and many approaches have been described. In this study, we present three patients with PPS pleomorphic adenoma (two primary and one recurrent), which were resected successfully with a transcervical-transparotid approach without mandibulotomy. Division of the following anatomical structures: the posterior belly of the digastric muscle, stylomandibular ligament, stylohyoid muscle and ligament, and styloglossus muscle is a very important tip for the surgeons because enables displacement of the mandible providing excellent exposure for complete tumor excision. The only postoperative complication was temporary facial nerve palsy in two patients who fully recovered within two months. The aim of this mini case series is to present our experience, together with some tips and benefits of the transcervical-transparotid approach for the resection of pleomorphic adenomas of the PPS.

The Utility of Stroboscopy in Evaluating Patients with Benign Vocal Fold Lesions.

Purpose: The present study aims to provide a comprehensive analysis of the use of stroboscopy as an assessment tool for patients with benign lesions of the vocal folds. Methods: The current study was based on an extensive review of the international bibliography regarding the evaluation of voice in patients with benign lesions of the vocal cords using videostroboscopy. Results: Stroboscopy is a convenient technique used by otolaryngologists that has been established as a valuable diagnostic tool for assessing patients with dysphonia and benign vocal cords lesions. Conclusions: Stroboscopy is recommended in the literature as the preferred method for assessing vocal cord vibratory function. The future poses challenges in standardizing guidelines and quantifying measurements of stroboscopic findings.

Sonoelastography of parotid gland tumours: initial experience and identification of characteristic patterns.

OBJECTIVES: The aim of this study was to investigate B-mode and elastographical ultrasound criteria capable of differentiating between benign and malignant parotid tumours and to define characteristic elastographical patterns for pleomorphic adenomas and Warthin's tumours. METHODS: Fifty-seven patients with parotid gland tumours were examined using a combination of B-mode and elastographic ultrasounds. The data acquired were analysed retrospectively by two experienced ultrasound operators to identify specific sonographical features of benign and malignant lesions. Additionally, elastographical patterns were defined and analysed for their specificity. RESULTS: A blurred margin proved to be the only significant criterion in B-mode ultrasound capable of differentiating between malignant and benign tumours. The garland sign was defined as an elastographical pattern found significantly more frequently in malignant tumours, improving sonographical prediction of the benign or malignant nature of a parotid lesion. A logistic regression model was developed that achieved a correct prediction in 87.7% of cases. A "dense core" sign was also specifically defined for pleomorphic adenomas and a "half-half" sign for Warthin's tumours. CONCLUSIONS: Elastography is an innovative and powerful diagnostic tool that can improve the sonographical examination of parotid gland tumours by revealing easily recognised and characteristic patterns of tissue distribution. KEY POINTS: • Elastography can help differentiate benign from malignant parotid tumours during parotid ultrasound. • The elastographical "garland sign" is more frequent in malignant than benign parotid tumours. • Pleomorphic adenomas show an elastographical "dense core sign". • Warthin's tumours show an elastographical "half-half sign". • Parotid cysts show an elastographical "bull's-eye sign".