Quadruple cancer, including triple cancers in the head and neck region.

Multiple primary tumors are not rare: they are encountered in 3-5% of malignant tumors. They are particularly frequent in the head and neck [20]. They are most often met with secondary malignant tumors; triple tumors occur in only 0.5%, quadruple tumors in 0.3% of malignant tumors. The possibility of developing a second metachronous cancer 5 years after undergoing treatment of the initial head and neck cancer is approximately 22%. Multiple metachronous tumors often appear 3-4 years after the observation of the primary tumor, or even after 5-10 years in the case of laryngeal tumors. The frequency of multiple primary tumors in the head and neck region supports the "field cancerization" theory, according to which the inducing agents (primarily smoking and alcohol consumption) can initiate the tumorous degeneration at a number of sites in the oropharyngeal region. The authors report on a case in whom surgery for bladder tumor was followed 101 months later by tumor development in the region of the head and neck: 3 such tumors were treated within a period of 21 months. The histologic result on the bladder tumor was transitiocellular carcinoma, while the latter ones were squamous cell carcinomas. Three of the tumors were treated effectively (no local recurrence or metastasis developed), but the fourth led to the death of the patient. The literature on multiple tumors of the head and neck is reviewed, and possible etiologic factors are discussed. It is pointed out that, besides primary and secondary prevention, close observation of these patients is required, repeated panendoscopy of the upper aerodigestive tract and genetic examinations are recommended.

Pharyngeal and hypopharyngeal reconstruction after multilating surgery for malignant hypopharyngeal cancers.

The authors summarise their reconstructive surgical experience after the radical excision of hypopharyngeal tumours. In selective cases the preservation of the larynx is a reliable surgical option and supraglottic surgery is sufficient to remove the tumour. Myocutaneous paddle flaps were used in every case after the surgical resection for the reconstruction of the pharyngo-oesophageal entrance. After total circular pharyngo-laryngectomy, the continuity of the upper digestive tract was reconstructed by tubed myocutanous flaps.

Distortion-product otoacoustic emission (DPOAE) following pure tone and wide-band noise exposures.

The aim of our investigations was to determine how the intensity of distortion-product otoacoustic emission (DPOAE) changes following different sound and noise exposures. We performed examinations on 20 healthy people with normal hearing. DPOAEs were recorded scanning the 0.5-6 kHz frequency interval before and after the exposures. We exposed the subjects to 0.5, 1, 2, 4 and 6 kHz pure tones and wide-band noise (intensity: 80 dB HL, duration: 3 minutes). We conclude that the amplitudes of DPOAEs changed immediately after exposures at most frequencies. DPOAE intensities decreased at some frequencies in the middle frequency range (1-2 kHz), and increased at low and particularly at high frequencies.

Brainstem auditory-evoked potential examinations in diabetic patients.

Brainstem auditory-evoked potential (BAEP) examinations were performed in 15 patients with long-standing type-1 diabetes mellitus (DM). Cardiovascular reflex tests were applied for assessment of autonomic neuropathy. The aim of our investigation was to compare the BAEP results of this patient group with controls and to look for a possible correlation between the alteration of the auditory brainstem function and the cardiovascular autonomic neuropathy. Analysis of the latencies (waves I, II, III and V) and the inter-peak latencies (waves I-III and I-V) of BAEPs revealed a significant difference between diabetics and healthy controls. The amplitudes of waves I, III and V were definitely lower in comparison with those of healthy controls. A positive correlation was observed between the overall autonomic score and the latencies (waves III and V) and inter-peak latencies (waves I-III and I-V). These data support the hypothesis that long-standing DM and diabetic neuropathy might be related as a cause of certain dysfunctions of the central auditory pathways.

"Early" vocal cord laterofixation for the treatment of bilateral vocal cord immobility.

OBJECTIVES: Vocal cord immobility (VCI) is commonly caused by a nonlaryngeal malignancy, thyroid surgery, or a presumed viral insult etc. The paralysis is often transient or temporary, thus the care of the patient should be optimized to avoid unnecessary diagnostic and therapeutic endeavours. This article reports on the result of the concept of early vocal cord laterofixation, which provides a minimally invasive solution to dyspnea in the critical early, potentially reversible, period of bilateral VCI. STUDY DESIGN: A prospective study of 25 consecutive patients (ages 33 to 81 years) who were diagnosed with a bilateral VCI. This condition had developed after thyroid surgery in 22 of the patients and after a blunt trauma of the neck in one case. In another case, a cricoarytenoid joint fixation was revealed, and aetiology remained unknown in one further patient. METHODS: The surgical procedure was performed endoscopically with a modification of Lichtenberger's endo-extralaryngeal suture lateralization technique. The abducted vocal cord position was achieved by inserting a non-resorbable thread around the vocal process and tying on to the prelaryngeal muscles. Regular spirometric measurements and radiological aspiration tests were conducted on the patients. RESULTS: Adequate postoperative airway was achieved in all patients except one. Significant spontaneous vocal cord medialization was observed in two cases within a year and in three patients in the second and the third year. Partial or complete vocal cord recovery was observed in 17 cases. Further voice improvement followed in 9 patients when the threads were removed, due to vocal cord medialization or recovery. The mild postoperative aspirations ceased in the first postoperative days in all cases except one. CONCLUSIONS: The concept of "early" laterofixation satisfies the important criteria: it can provide an immediate and long-lasting adequate airway, and it can be considered potentially reversible from the point of view of laryngeal functions. Thus the procedure is a reliable primary treatment for bilateral VCI.

Airway complication after thyroid surgery: minimally invasive management of bilateral recurrent nerve injury.

OBJECTIVES: After bilateral vocal cord paralysis, the consequent paramedian position usually necessitates tracheostomy for at least 6 months, when the paralysis is potentially reversible. In the present study a reversible endoscopic vocal cord laterofixation procedure was used instead of tracheotomy. STUDY DESIGN: Prospective study of 15 consecutive patients aged 33 to 73 years who suffered bilateral recurrent laryngeal nerve paralysis after thyroid surgery. METHODS: The operation was performed endoscopically with a special endo-extralaryngeal needle carrier instrument. Two ends of a monofilament nonresorbable thread were passed above and under the posterior third of the vocal cord and knotted on the prelaryngeal muscles, permitting the creation of an abducted vocal cord position. If movement of one or both vocal cords recovered, the suture was removed. Regular spirometric measurements and radiological aspiration tests were conducted on the patients. RESULTS: During the follow-up period of 3 to 40 months, airway stability was demonstrated in all but one patient. After the repeated lateralization procedure, this patient's breathing improved. Partial or complete vocal cord recovery was observed in eight patients. In six patients further voice improvement was achieved when the threads were removed after vocal cord medialization or recovery. Mild postoperative aspirations ceased in the first postoperative days. CONCLUSIONS: This management approach offers an alternative to tracheostomy in the early period of paralysis, avoids terminal loss of voice quality, and provides a "one-stage" solution for permanent bilateral recurrent nerve injuries.

Endoscopic CO(2) laser therapy of selected cases of supraglottic marginal tumors.

Endoscopic CO(2) laser intervention can be used as conservation surgery for supraglottic laryngeal carcinomas in carefully selected patients. We analyzed retrospectively our experience in managing patients with early supraglottic carcinomas operated on at the Clinic of Otorhinolaryngology, Szeged, Hungary, during the 10-year period between 1987 and 1997. Conservation surgery was the treatment of choice in 187 patients, but only 23 (12%) were selected for endoscopic CO(2) laser surgery. Laser surgery was indicated predominantly for T1 cancer of the epiglottis (n = 15), but was also performed for T2 cancers (n = 8). Of the 23 supraglottic tumors treated, 16 had no signs of recurrence to date (1.5 to 9 years after surgery) a local control rate of 70%. Six patients with recurrences underwent salvage therapies that included repeated laser excisions (n = 3), radiotherapy (to 60 Gy), horizontal supraglottic laryngectomy and total laryngectomy. One patient was not resectable because of multiple metastases. Our experience with endolaryngeal CO(2) laser excision indicates that it is a reasonable method in selected cases of supraglottic tumors, but one-third of the patients required salvage treatment.

Leiomyosarcoma of the larynx. Review of the literature and report of two cases.

Leiomyosarcoma of the larynx is an extremely rare malignancy. Until now, only 35 cases have been reported, and only 19 were reported in English. We present 2 new cases observed in the last 3 years at our department. Correct histologic diagnosis can only be made on immunohistochemical and electron microscopic grounds. A 65-year-old man previously treated for a premalignant vocal cord lesion and a 31-year-old woman who previously underwent operation on a benign vocal cord lesion are presented. Only surgical treatment (total laryngectomy and endolaryngeal laser resection) was performed. Thirty-six and 22 months after the initial surgical intervention, both patients are alive and well, with no evidence of local recurrence or distant metastasis.

Minimally invasive surgery for posterior glottic stenosis.

Posterior glottic stenosis most commonly results from prolonged endotracheal intubation. The tube causes decubitus and perichondritis with a consequent scar tissue formation in the posterior commissure that often limits the abduction of the vocal cords. Many different surgical methods are known for the treatment, but in most cases temporary tracheostomy is required. We recommend a minimally invasive method to avoid tracheostomy, which is a very inconvenient state for the patient. The scar of the posterior commissure is excised endoscopically with the CO2 laser, and a modification of the endoextralaryngeal vocal cord laterofixation described by Lichtenberger is used to lateralize 1 or both vocal cords until the posterior commissure is completely reepithelialized. In this article we report on the first 5 cases. All patients had satisfactory airways immediately after the laterofixation procedure, which proved to be stable later on as well. In the cases of moderate stenosis, further scarring was prevented, and after the healing of the mucosa in the posterior glottic area, the laterofixation sutures were removed. The vocal cord mobility was recovered in the cases in which the cricoarytenoid joint was not fixed. In 1 case of severe stenosis (bilateral cricoarytenoid joint fixation), the procedure yielded only partial improvement.

Carotid artery resection and reconstruction in patients with squamous cell carcinomas of the neck.

The authors performed a retrospective review of their 10-year experience of carotid artery resection with vascular reconstruction for advanced squamous cell carcinoma of the neck. From 1986 to 1997, four patients underwent elective and one patient acute carotid artery resection with revascularization at the Department of Otolaryngology, Albert Szent-Györgyi Medical University, Szeged, Hungary. Primary lesions were three laryngeal and two hypopharyngeal squamous cell carcinomas. All five resected specimens had metastatic invasion by tumor of the carotid adventitia on pathological examination, while only four specimens exhibited tumorous destruction of the arterial wall. No cerebrovascular accident occurred in any patient, although one patient died postoperatively from cardiac failure. The four remaining patients died of local-regional recurrences or metastatic disease within 17 months after their carotid artery resections. Our findings show that carotid artery resection with replacement is superior to ligation alone in avoiding neurological complications. This approach can provide local control of tumor, but may fail to achieve significant disease-free survival.

[Endolaryngeal lipoaugmentation of the vocal cords]. / Endolaryngealna lipoaugmentacja strun glosowych.

Unilateral vocal cord paralysis or the loss of vocal cord tissue results in incomplete glottic closure (internal-paresis) with a consequent hoarseness and poor voice quality. Improving glottic incompetence, instead of the previously used paraffin, teflon is a widely accepted and most commonly used substance at present for vocal cord medialization. Using intracordal teflon injection of for decades had proven that it has limitations and potential complications to the human body. Beside the well-known external "phono-surgical" methods, a wide interest has been shown in endolaryngeal phono-surgery and in finding the ideal and most available biocompatible substances for the procedure. Papers have been issued about the promising results of autologus fat injection for medialization of the paralyzed vocal fold in the early '90s. In this paper the authors report on their slightly modified endolaryngeal intracordal autologus fat injection procedure, and its promising results. The first three patients (a left side glottic paralysis, a bilateral internal paresis and a left side internal paresis) experienced an improvement in their voice right after the medialization procedure, what remained the same during the 11 months follow-up period. Using supraglottic jet ventilation during general anaesthesia provides very good access to the operating field. Monitoring of neuro-muscular block makes possible an intraoperative examination of glottic closure by the protective reflex of the larynx. Incouraged by this initial results the authors suggest the autologus fat as an easy available, ideal substance for increasing (augmenting) the loss of vocal cord tissue.

Cochlear implantation in osteogenesis imperfecta.

A case is reported in which a Nucleus 22 channel intracochlear implant was applied to a Hungarian woman (age 50 yr) with profound deafness associated with osteogenesis imperfecta. Successful intracochlear insertion of the 22 electrodes resulted in a 70 dB hearing improvement at frequencies 250-2000 HZ. Nevertheless, a characteristic facial twitching appeared upon activation of electrodes 9-13. Inactivation of these electrodes abolished the non-acoustic nerve excitation with preservation of acoustic performance. Osteogenesis imperfecta may involve a state of risk for non-acoustic nerve activation in cochlear implant patients possibly resulting from a reduced impedance to current spread by abnormal bone tissue. This, however can be overcome by simple programming manoeuvres.

Pharyngeal localizations of branchial cysts.

Two cases with unusual pharyngeal localizations of branchial cysts medial to the great neck vessels and pharyngeal constrictor muscle are presented. The authors reviewed the theories of origin of the branchial cysts and the surgical treatment options. In their first case the transoral approach was chosen. Because of previous unsuccessful attempts at surgical treatment, the pharyngeal cyst was extremely adherent to adjacent tissue with much scar tissue, and it was very difficult to remove. As a result of this disappointing operation, an external neck exploration was indicated in the second patient. Histological examinations confirmed that the excised cysts were branchial in both cases.

Vocal cord laterofixation as early treatment for acute bilateral abductor paralysis after thyroid surgery.

Bilateral vocal cord palsy due to a lesion of the recurrent laryngeal nerves is a serious complication of thyroid operations, with the airway obstruction usually necessitating tracheostomy. In the cases presented, a stable airway was ensured with endolaryngeal cord laterofixation instead of tracheostomy. The operation was performed with the endo-extralaryngeal needle carrier instrument devised by Lichtenberger. During the operation, only minor surgical trauma occurred in the larynx. The fixing thread was then removed following recovery of contralateral vocal cord function, resulting in an improvement in the voice. Four patients are described who suffered bilateral recurrent laryngeal nerve palsy after thyroid gland operations. During the follow-up period of 3-12 months, airway stability was demonstrated by regular spirometric measurements. The simple method recommended spares patients the possible complications of tracheostomy.

Cochlear implantation in a patient with grand mal epilepsy.

A case is reported in which a Nucleus 22 channel intracochlear implant was used to treat a deaf Hungarian woman (aged 37 years) with a 34-year history of grand mal (GM) epilepsy maintained on carbamazepine-diazepam combination therapy who had not benefited from conventional hearing aids. Pre-operative electrical stimulation of the acoustic nerve, however, exhibited a good nerve function with no evidence of abnormal waveforms in the electroencephalogram (EEG). Successful intracochlear insertion of the 22 electrode resulted in a 40 dB hearing improvement at frequencies 250-2000 Hz in the implanted ear with no signs of pathologic wave activity at either the previously recognized epileptic focus (fronto-precentral region) or indeed, in other regions of the brain at use of the implant. We conclude that intracochlear implantation per se is not a hazardous intervention in patients with fronto-precentral epileptic foci.

Cochlear implantation of a Hungarian deaf and blind patient with discharging ears suffering from Behçet's disease.

A case is reported in which a Nucleus 22 channel intracochlear device was implanted a deaf/blind Hungarian adult with discharging ears suffering from Behçet's disease. Preconditioning surgery was employed three months prior to the implantation procedure to ensure a sterile, dry protected environment for the electrodes. One month after implantation, the patient exhibited excellent auditory discrimination capability at the time of the first switch on. We suggest that some deaf/blind individuals may serve as very good candidates for intracochlear implantation.

Involvement of glibenclamide-sensitive potassium channels in vasorelaxation by cochlear nerve stimulation.

Rabbit aortic rings relaxed with an increase in cyclic guanosine monophosphate and cyclic adenosine monophosphate content in response to exposure to organ fluid of isolated cochleas of the guinea pig following field stimulation (50 Hz, 80 V, 0.2 ms). Relaxations were blocked by 30 microM N(G)-nitro-L-arginine methyl ester added to the vessel rings. This inhibitory effect was reversed by 3 mM L-arginine. Removal of the vascular endothelium also blocked the relaxation response. Glibenclamide attenuated vasorelaxation in a concentration-dependent manner. We conclude that cochlear nerve stimulation induces an endothelium-dependent vasorelaxation involving activation of adenosine triphosphate-sensitive potassium channels.

[Primary CO2 laser chordectomy in vocal cord carcinoma]. / Primäre CO2-Laser-Chordektomie beim Stimmlippenkarzinom.

A study was performed with laryngo-microscopic CO2 laser surgery on 55 patients suffering from histologically verified glottic cancer. They were treated by either "superficial laser chordectomy", or "partial cordectomy", "total chordectomy", or "extended chordectomy" in stages Tis = 7, T1a = 34, T1b = 11, and T2 = 3. All patients with Tis remained free of tumours, in stage T1a 88% (30/34) of the patients after laser chordectomy and 2 patients after partial- and total laryngectomy. In stage T1b the recurrence rate was higher (3/11 = 27%), but 2 patients after partial laryngectomy, and one patient after radiotherapy have become tumour-free, and thus all patients in this group are free from tumours. One of the 3 patients in stage T2 developed a local tumour recurrence, but after partial laryngectomy he is free from tumour and hence all 3 patients are still alive. Laser chordectomy proved a sufficient therapeutic procedure in 47 (85%) of 55 patients; eventually 95% of the patients became tumour-free. The authors emphasise that CO2 laser chordectomy is a modern and useful surgical method in the therapy of a vocal cord carcinoma, provided adequate follow-up and the possibility of "salvage" surgery are available.