Zenker's diverticulostomy with cricopharyngeal myotomy: the endoscopic approach.

BACKGROUND: The gold standard for the surgical treatment of Zenker's diverticulum is diverticulectomy and cricopharyngeal myotomy by an external approach. Unfortunately, many of the patients who present with this entity are elderly and have significant comorbidities that increase operative risk. Traditional minimally invasive approaches have not met with widespread success. However, by combining the exposure afforded by the otolaryngologist's newer bivalved operating laryngoscopes with the operative techniques made possible by the general surgeon's laparoscopic instrumentation and staplers, it is possible to achieve reliable and safe endoscopic outpatient management of this disease entity, with resumption of a normal diet on the same day. METHODS: We reviewed the physiologic basis, instrumentation, and technical considerations for this endoscopic procedure. We also documented our operative experience with 21 patients treated over an 18-month period. RESULTS: Successful minimally invasive management of Zenker's diverticulum was possible in 18 of 21 patients. In two patients, anatomic limitations of mouth and neck anatomy precluded exposure of the diverticulum; in another patient, the diverticulum was too small. Small operative perforations of the apex of the diverticulum occurred in three cases. Two of these perforations were repaired primarily with minimally invasive techniques; in the other case, treatment consisted of observation alone. In all but this last patient, oral diet was resumed on the day of the operation. Eleven of the patients were discharged from the hospital on the same day; the remaining patients went home the following morning. CONCLUSIONS: With proper patient selection, minimally invasive management of Zenker's diverticulum is a safe and effective surgical technique that allows for outpatient management of the majority of patients who present with this disease.

The relative value of fine-needle aspiration and imaging in the preoperative evaluation of parotid masses.

BACKGROUND: To establish the sensitivity, specificity, and accuracy of imaging and fine-needle aspiration (FNA), alone or in combination, in distinguishing benign from malignant histologic findings for parotid lesions. METHODS: Retrospective blinded review of preoperative imaging and FNA studies of parotid masses and comparison with histologic findings after excision. RESULTS: Forty-eight patients were identified (13 with CT, 35 with MRI); 23 (48%) of the lesions were malignant, 25 (52%) were benign. MRI, CT, and FNA misclassified 17%, 46%, and 21% of the lesions, respectively. The sensitivity/specificity/accuracy of these tests for detecting malignant lesions were as follows: MRI (88%,77%,83%), CT (100%,42%, 69%), and FNA (83%,86%,85%) and were not significantly different. Combinations of imaging and FNA were not significantly better in detecting malignancy. CONCLUSIONS: Imaging and FNA are comparable in their ability to correctly identify malignant parotid lesions preoperatively. Combining these two modalities yields no advantage in terms of specificity, sensitivity, or accuracy of a malignant diagnosis.

Microvascular reconstruction and tracheotomy are significant determinants of resource utilization in head and neck surgery.

BACKGROUND: Successful "critical pathway" design and implementation are dependent on appropriate patient stratification according to those factors that are primary determinants of resource utilization. OBJECTIVES: To test the validity of our previously reported critical pathway design and to determine whether tracheotomy and microvascular reconstruction (MR) are primary determinants of resource utilization. DESIGN: Cost-effectiveness analysis. SETTING: Tertiary referral academic institution. METHODS: Retrospective analysis of data from 133 head and neck surgery cases in which the treatment regimen was based on critical pathways over a 26-month period. OUTCOME MEASURES: Length of stay and total patient charges were used as indices of resource utilization. One-way analysis of variance and t tests were used for statistical analysis of significance. RESULTS: Ninety patients (67.7%) underwent MR; 43 (32. 3%) did not. Seventy-five patients (56.4%) underwent tracheotomy; 58 (43.6%) did not. Four patient groups were constructed in decreasing order of complexity as follows: group 1, patients who underwent both tracheotomy and MR (n = 58); group 2, patients who underwent MR alone (n = 32); group 3, patients who underwent tracheotomy alone (n = 17); and group 4, patients who did not undergo either procedure (n = 26). Both tracheotomy and MR were found to be independent determinants of resource utilization and were additive when both were present. The length of stay varied from 8.4 days (in patients who underwent both procedures) to 6.7 days (in patients who did not undergo either procedure), with intermediate values in cases in which only 1 procedure was performed. The total charges varied in a similar manner from a high of $33,371 to a low of $19,994. Subanalysis with respect to intensive care unit, ward, and operating room charges showed a similar stratification. CONCLUSION: Tracheotomy and MR are both significant determinants of charges and length of stay in head and neck surgery cases and must be considered in the design of strategies to promote efficient resource utilization.

Genetic polymorphisms in head and neck cancer risk.

OBJECTIVE: To assess whether genetic polymorphisms implicated as risk factors for other tobacco-associated malignancies are associated with altered risk of head and neck squamous cell carcinoma. DESIGN: Case-control study. SUBJECTS: One hundred sixty patients with head and neck squamous cell carcinoma recruited from a university-based head and neck oncology clinic and 149 population-based controls. METHODS: Genotyping of the CYP1A1 (Ile462Val), GSTM1 (null), GSTP1 (Ile105Val), GSTT1 (null), and P53 (Arg72Pro) genes was performed by polymerase chain reaction-based techniques on DNA prepared from peripheral blood. In addition, a questionnaire was used to collect demographic information from each subject. RESULTS: Cases were significantly older (p <.0001) and had significantly greater tobacco use (p <.0001) and were more likely to be male (p <.0001) than were control subjects, thus confirming known risk factors for this disease. When cases and controls were compared by simple chi-square analysis, only the frequency of CYP1A1 (Ile462Val) polymorphism was significantly different between cases and controls (OR =.42; 95% CI =.18-.99; p <.04). However, with a logistic regression model to control for known risk factors, we were unable to demonstrate a significant association with head and neck cancer for any of the polymorphisms tested, including CYP1A1. CONCLUSIONS: This population fails to identify a relationship between the above-mentioned polymorphisms and head and neck cancer.

Congenital laryngeal webs: surgical management and clinical embryology.

Laryngeal webs are uncommon congenital anomalies. The formation of a laryngeal web represents anomalous embryologic development of the larynx. The extent of airway involvement varies which ultimately affects surgical management. A series of five congenital laryngeal webs each with subglottic involvement is reported. One patient also had a ventral laryngeal cleft. All patients ultimately required open laryngeal reconstruction, either laryngotracheal reconstruction (LTR) or thyrotomy (laryngofissure) and silastic keel, to correct the defect and all were decannulated. Findings at surgery correlate with recent descriptions of embryonic laryngeal development though the actual mechanism by which webs develop remains unknown. The findings suggest that congenital glottic webs require accurate endoscopic diagnosis and open airway reconstruction for definitive treatment.

Acid/pepsin promotion of carcinogenesis in the hamster cheek pouch.

OBJECTIVE: While clinical observation has suggested an association between gastroesophageal reflux and laryngeal carcinoma, the nature of this relationship has yet to be defined. The purpose of this study is to determine the carcinogenic potential of acid and pepsin mixtures in the hamster cheek pouch animal model. DESIGN: A blinded intervention study. SUBJECTS: One hundred male Syrian hamsters aged approximately 5 weeks. INTERVENTIONS: A control group of 20 hamsters received application of the carcinogen 9,10-dimethyl-1,2-henzanthracene (DMBA) to their cheek pouch mucosa. One experimental group (n = 20) received applications of DMBA plus hydrochloric acid, and another (n = 20) received DMBA plus an acid and pepsin solution. Latency to squamous cell tumor production, size of tumors, and numbers of tumors were compared among groups. RESULTS: Latency to tumor production and size of tumor were similar among groups, with both experimental and control groups developing tumors of comparable size after 12 weeks of chemical application. However, the number of tumors produced was significantly higher in the DMBA/acid and DMBA/acid/ pepsin groups than in the DMBA only group at 18 weeks, with 23, 27, and 10 tumors in these groups, respectively (P<.02). Likewise, a cumulative dysplasia score was different among groups at 18 weeks with the DMBA/acid and DMBA/acid/pepsin groups scoring higher degrees of dysplasia than the DMBA only group. CONCLUSION: These results suggest that application of acid and acid/pepsin mixtures may promote experimental carcinogenesis in the hamster cheek pouch.

Sensory changes associated with selective neck dissection.

OBJECTIVE: To evaluate sensory changes in the head and neck region associated with selective neck dissection with or without preservation of cervical root branches. DESIGN: Retrospective cohort study. SETTING: University tertiary referral hospital and a Veterans Affairs hospital. PATIENTS: Fifty-seven patients who had undergone 84 neck dissections with or without preservation of the sensory cervical root branches 3 or more months before evaluation. INTERVENTIONS: Questionnaire combined with head and neck sensory examination. MAIN OUTCOME MEASURES: Neck and facial sensory function. RESULTS: Neck dissections with preservation of the cervical rootlets were most likely to be associated with a small area of anesthesia in the upper neck below the body of the mandible and anterior to the mid-body of the mandible (P=.03). Neck dissections without rootlet-preserving technique increased the area of anesthesia to include all other areas of the neck (P= .02). CONCLUSIONS: Preservation of the cervical root branches resulted in a small, limited, and uniform area of the neck rendered permanently anesthetic. Conversely, sacrifice of the nerve branches led to a pattern of anesthesia involving the entire neck.

The long-term indwelling tracheoesophageal prosthesis for alaryngeal voice rehabilitation.

OBJECTIVE: To analyze the initial experience at Oregon Health Sciences University, Portland, with the use of long-term indwelling tracheoesophageal voice prostheses. DESIGN: Retrospective case series. SETTING: Tertiary referral academic medical center. PATIENTS: Thirty patients undergoing speech rehabilitation after laryngectomy during a period of 18 months. INTERVENTION: Insertion of a long-term indwelling tracheoesophageal voice prosthesis. MAIN OUTCOME MEASURES: Duration of use, complications. RESULTS: The mean duration of placement for a single prosthesis was 4.9 months (148 days), with a range of 14 to 330 days. Sixteen of the 30 patients encountered problems with leakage because of fungal colonization, the majority of which (15 of 16 cases) were solved with either oral or topical application of nystatin. Size matching in terms of prosthesis length and tract length was critical, and problems of this nature were encountered in 11 of 30 patients. The incorporation of a second system of prostheses that offered an increased number of size options solved these problems in all of these patients. Ultimately, 27 of 30 patients were able to successfully wear these prostheses. CONCLUSIONS: The indwelling tracheoesophageal voice prosthesis offers patients all the advantages of tracheoesophageal speech rehabilitation after laryngectomy without the inconvenience of frequent prosthesis changes. With careful attention to the details of fitting and care, it can be worn by the majority of patients successfully.

Fourth branchial arch sinus: clinical presentation, diagnostic workup, and surgical treatment.

OBJECTIVES/HYPOTHESIS: Abnormalities of the fourth branchial arch are much less common than those of the second arch and present in a different manner. The authors report their experience with five cases of fourth arch sinuses. METHODS: Retrospective chart review of patients at a tertiary care center. RESULTS: All patients presented in the first or second decade of life, and all but one had left-sided neck involvement. Four patients presented with recurrent low neck inflammatory episodes, and one with respiratory compromise. Diagnostic studies performed included ultrasound, computed tomography (CT) scan, barium swallow, magnetic resonance imaging, and fine-needle aspiration. Barium contrast studies and CT scan were the most useful in demonstrating a fourth arch sinus tract preoperatively. Surgical treatment with an emphasis on complete exposure of the recurrent laryngeal nerve and exposure of the lateral piriform sinus to facilitate complete sinus tract excision was successful in all patients. CONCLUSION: The clinical history of recurrent low neck inflammatory episodes in young patients, especially on the left side, should raise the suspicion of this entity. Investigation using barium swallow in combination with CT scanning is useful. Excision of the sinus tract taking care not to injure the recurrent laryngeal nerve is curative.

Early postoperative calcium levels as predictors of hypocalcemia.

OBJECTIVE: Early, safe postoperative hospital discharge has become a priority in the current environment of cost containment and managed care. One determinant for this following operations of the thyroid or parathyroid glands is a stable postoperative calcium level. This study sought to determine whether early postoperative calcium levels could safely predict hypocalcemia following operations of the thyroid or parathyroid glands. STUDY DESIGN: A retrospective chart review of 197 patients undergoing such operations was undertaken. METHODS: The study population was divided into patients undergoing parathyroid exploration with removal of one or more glands for parathyroid disease ("parathyroid" group) and patients undergoing bilateral thyroid operations ("nonparathyroid" group). Postoperative calcium levels were plotted as a function of time, and the slope between the first two postoperative calcium levels examined. RESULTS: A positive slope predicted normocalcemia in 100% of "nonparathyroid" and 90% of "parathyroid" surgeries. A negative slope was predictive in its magnitude. The nonparathyroid patients who developed postoperative hypocalcemia had an average slope significantly more negative (-0.84% change/h) than patients remaining normocalcemic (-0.49% change/h) (P = .03). Similarly, the parathyroid patients who became hypocalcemic had an average initial slope nearly twice as negative (-1.4% change/h) as patients remaining normocalcemic (-0.78% change/h) (P = .005). CONCLUSIONS: These results indicate that an initial upsloping postoperative calcium curve based on two early postoperative calcium measurements is strongly predictive of a stable postoperative calcium level, and a steeply downsloping initial calcium curve is worrisome for eventual hypocalcemia.

Nodal disease in purely glottic carcinoma: is elective neck treatment worthwhile?

OBJECTIVE: Although there is a generalized understanding of the relatively low overall incidence of nodal disease from purely glottic carcinoma, the exact role for elective neck treatment in the management of this disease remains controversial. The purpose of this study was to identify the incidence of occult nodal disease (including paratracheal) in patients who have glottic carcinoma without significant extraglottic extension and to identify which patients are at risk for this. A retrospective chart review of 92 such patients who had either undergone neck dissection or been observed for a minimum of 2 years was performed. RESULTS: For the 92 patients, neck treatment consisted of observation in 68 patients, paratracheal node dissection in four, unilateral neck dissection in four, unilateral neck dissection and excision of paratracheal nodes in 14, and bilateral neck dissection with paratracheal node excision in two. Of the 24 nodal dissections performed, four were positive for occult metastatic disease. No patient in the observation group developed nodal disease. CONCLUSION: The incidence of occult nodal disease in NO glottic carcinoma is low, 0% in early stage disease (T1-T2) and 19% in late stage disease (T3-T4). Nodes at highest risk included only the paratracheal, level II, and level III. Elective neck treatment should only be undertaken for advanced (T3-T4) disease and even then is of questionable benefit. If undertaken, it should have a low potential morbidity, such as selective neck dissection or radiation. Computed tomography was not useful in staging the neck for this subset of patients.

Appropriate timing and velocity of infusion for the selective staining of parathyroid glands by intravenous methylene blue.

BACKGROUND: Intraoperative parathyroid gland (PTG) identification by selective staining using methylene blue dye (MB) infusion has been shown effective but the degree of gland staining is inconsistent. METHODS: The effect of timing and rate of MB infusion on gland uptake was investigated in a canine model by infusing MB either rapidly over 3 to 5 minutes (n = 8) or slowly over 30 minutes (n = 4). The pattern of dye uptake in an exposed PTG was determined by standardized serial photography. RESULTS: Earliest uptake occurred between 10 and 20 minutes after infusion, and maximum uptake averaged 21 minutes, earlier than previously described. Rate of infusion did not affect staining. CONCLUSIONS: This rapid uptake of methylene blue by the parathyroid glands suggests that its selective intraoperative use when glands are difficult to locate intraoperatively, rather than a routine preoperative infusion, is possible without significant operative delay. Clinical experience has confirmed this impression.

Preoperative evaluation of patients with primary hyperparathyroidism: role of high-resolution ultrasound.

Unilateral parathyroid exploration with adenoma removal and identification of a normal parathyroid gland is an accepted surgical approach for the treatment of patients with primary hyperparathyroidism. This study prospectively evaluated the ability of high-resolution sonography to localize adenomas preoperatively and the effect of this localization on operative time and cost in 37 previously untreated patients undergoing surgical treatment for primary hyperparathyroidism. The sensitivity and positive predictive value of the sonographic examination were 84% and 90%, respectively. A true positive sonographic examination decreased surgical time by an average of 40 minutes and reduced operative charges by $564, including the cost of the test ($156). In experienced hands high-resolution sonography can be a cost-effective means of localizing parathyroid adenomas where unilateral exploration is considered an accepted surgical approach.

Midline mandibular osteotomy: an analysis of functional outcomes.

Although the oncologic validity and perioperative complications of midline mandibular osteotomy are well described, little attention has been directed toward the long-term functional problems that may be associated with its use. Thirty-one patients who had undergone this procedure were examined to assess postoperative sensation, temporomandibular joint (TMJ) function, occlusion, and cosmesis. The majority (27 of 31) patients had some sequelae but these were minor in nature. Twenty of 31 patients had abnormal sensation, 24 of 31 noted a changed occlusion, and 15 of 31 had signs or symptoms of TMJ myofascial pain. Although patients should be advised of the potential for functional problems with this procedure, they can be reassured that these are likely to be relatively minor in significance. If technically feasible and if an exact restoration of occlusion is a priority, a prefabricated lingual splint should be used.

Critical pathways for head and neck surgery. Development and implementation.

OBJECTIVE: To design, implement, and study the effectiveness of 4 new critical pathways relevant to head and neck oncological care. DESIGN: Before-after trial. SETTING: Tertiary referral academic institution. PATIENTS: Sixty-eight patients admitted for head and neck oncological surgery or chemotherapy from December 1, 1995, through May 31, 1996; 30 patients with similar diagnoses and who underwent surgical procedures from December 1, 1994, to December 1, 1995, who served as historical controls. INTERVENTIONS: Implementation of 4 critical pathways: chemotherapy, clean head and neck surgery, clean contaminated head and neck surgery, clean contaminated head and neck surgery with reconstructive flap. MAIN OUTCOME MEASURES: Length of stay, cost of hospitalization, and variance tracking (deviations from established standards). RESULTS: The length of stay for the clean contaminated group without flap reconstruction decreased by 1.5 days, and costs decreased by $7407 per patient (P < .05, Student t test). The length of stay decreased 1.6 days in the clean contaminated group with flap reconstruction, and costs decreased $9845 per patient (P < .05, Student t test). Nine patients (13%) experienced a prolonged length of stay while on a critical pathway. CONCLUSIONS: Implementation of critical pathways has resulted in a decreased overall length of stay and cost of hospitalization. It has also allowed for better coordination and documentation of patient care, while the tracking of variances has simplified problem identification and correction.

Endovascular management of hemorrhage in patients with head and neck cancer.

OBJECTIVE: To present selective endovascular embolization as a therapeutic alternative to surgical ligation in the management of hemorrhage in patients with head and neck squamous cell carcinoma. DESIGN: Retrospective chart review of patients with head and neck cancer and significant hemorrhage who were treated with selective endovascular embolization. SETTING: A university medical center. PATIENTS: A total of 12 patients, aged 26 to 72 years, with 13 episodes of hemorrhage were treated at Oregon Health Sciences University, Portland, between November 1991 and January 1996. INTERVENTION: All patients underwent angiography with selective endovascular embolization at the interventional radiology suite using a combination of endovascular balloons, platinum coils, and microparticles. OUTCOME MEASURES: All charts were reviewed for diagnosis, treatment, factors that may have contributed to hemorrhage, bleeding site, therapeutic measures, control of hemorrhage, postembolization course, complications, and number of hospital days. RESULTS: The cause of the bleeding was tumor in 5 patients, pharyngocutaneous fistula in 4 patients, radiation necrosis in 3 patients, and postoperative complication in 1 patient. Bleeding arose from the common carotid artery in 4 patients, external carotid artery and its branches in 8 patients, and internal jugular vein in 1 patient. Hemorrhage was successfully controlled in all patients; a permanent left-sided hemiplegia and facial weakness developed in 1 patient. There were no recurrences of hemorrhage. All patients were discharged from the hospital. CONCLUSION: Angiography with selective embolization is a safe and effective alternative to surgical ligation for control of hemorrhage in patients with squamous cell carcinoma of the head and neck.

Selective neck dissection and the management of the node-positive neck.

OBJECTIVE: To assess the oncologic effectiveness of the selective neck dissection (SND) in patients with both clinically and pathologically proven regional metastases. METHODS: A 4-year retrospective medical chart review was conducted in an academic tertiary care referral center. Twenty-nine patients with a newly diagnosed upper aerodigestive tract squamous cell carcinoma, and both clinically and histologically proven cervical metastases who underwent 36 SND, had their records reviewed. Minimum follow-up was 2 years. RESULTS: Regional metastasis were staged N1 in 13 patients, N2A in 1, N2B in 8, and N2C in 7. Seventeen supraomohyoid and 19 lateral neck dissections were performed. Extracapsular spread of tumor was present in 11 patients. Postoperative radiation therapy was administered to 20 patients. Actuarial disease-specific survival at 4 years was 47% overall, 67% in N1 patients, and 41% in N2 patients. Only 1 failure in the treated neck occurred for a 4-year actuarial regional failure rate of 4%. The actuarial local failure and distant metastasis rate were 36% each. CONCLUSIONS: In carefully selected patients with clinically and histologically apparent regional metastases, the selective neck dissection can be an oncologically effective procedure.

Near-total laryngectomy. Patient selection and technical considerations.

OBJECTIVES: To investigate the speech and swallowing outcomes of patients undergoing near-total laryngectomy and to determine those perioperative factors that are associated with success. DESIGN AND SETTING: Retrospective analysis of a case series obtained from a hospital-based academic tertiary care center. PARTICIPANTS AND INTERVENTION: Records of all patients who underwent near-total laryngectomy at this institution were reviewed. OUTCOME MEASURES: Wound healing problems, quality of speech, degree of aspiration, and need for shunt revision were recorded. RESULTS: Thirty-nine patients during a 10-year period underwent near-total laryngectomy. Good speech was obtained in 30 (76%). Severe aspiration was a complication in eight patients (21%), necessitating reversal of the shunt in four (10%). Certain technical aspects of this procedure that produce a "hooded" myomucosal shunt were crucial to proper shunt function. Severe aspiration and poor voice outcome were most likely in patients who experienced a postoperative pharyngocutaneous fistula. These fistulas tended to occur at the junction of the pharynx and the upper end of the myomucosal shunt. When this region broke down, the hooding of the shunt was disrupted and its function impaired. CONCLUSIONS: Careful patient selection is crucial to the creation of a functional myomucosal speaking shunt after near-total laryngectomy. In patients at high risk for developing a pharyngocutaneous fistula, where irreversible aspiration through the shunt is then likely, this operation should be avoided and a total laryngectomy with tracheoesophageal puncture considered instead.