Retrospective study evaluating dental side effects of radiotherapy in patients treated for head and neck cancer.

INTRODUCTION: Head and neck cancer squamous cell carcinoma (HNSCC) is the seventh most common cancer worldwide with around 600,000 new diagnosis each year. Nowadays, in locally advanced disease, radiotherapy (RT) play an important role, this with or without chemotherapy in organ preservation strategies. More specific for early stage localized disease, RT (or surgery) seems to give similar results on locoregional control (LRC) and choice is made according to the organ preservation issue. Despite the fact that technical improvements have been made to optimize the radiation dose delivery and minimize the normal tissue toxicity, RT is associated with potential early and late toxicities. Osteoradionecrosis of the jaw (ORNJ), especially seen after teeth extraction, is one of the associated toxicities and can significantly impair the patient's quality of life. Because of the fear of developing ORNJ, one is very reluctant to extract or place a dental implant post-radiotherapy, especially in high irradiation dose zones (>40 Gy). Hence, it is important to define teeth at risk of future extraction before initiating RT and to handle those in high-risk irradiation zones. In order to optimise extractions, we created a predictive model of the expected irradiation dose, and thus the need for extraction, to the teeth bearing bones. The aim of this study is to validate our model and to define the potential relationship between the radiation dose received by each tooth and the dental complications observed. MATERIAL AND METHODS: Between March 2012 and March 2018, patients with HNSCC treated by intensity modulated RT were retrospectively analysed. The mean irradiation dose for each tooth was generated on the administered treatment plan by contouring each tooth separately on each dosimetric scan section using dedicated software (Eclipse, Varian). In order to validate our predictive model, we compared the actual generated/administered teeth irradiation doses with the irradiation doses predicted by our model. RESULTS: Our predictive model was accurate in 69.6% of the cases. In 12.5% of cases the predicted dose was higher than the calculated dose and lower in 17,8% of the cases. A correct- or over-estimation (is the latter being clinically less worrying than an underestimated dose) was achieved in 82% of cases. For the 18% of cases underfitting, the mean margin of error was 5.7 Gy. No statistically significant association was found between the development of caries and doses to the teeth, doses to the parotid glands or dental hygiene. However, a significant association between dental irradiation at more than 40 Gy and the occurrence of dental fractures (p = 0.0002) were demonstrated. CONCLUSIONS: Our predictive model seems to be 82% accurate for dose prediction, hence might be helpful for optimizing/minimizing prophylactic extractions. Indeed, following our model, professionals could decide not to extract damaged teeth in areas not at risk of ORNJ, lowering morbidity during and after RT. Contrary to the literature, no relationship was found between the occurrence of dental caries and parotid irradiation and the patient's oral hygiene. However, for the first time, a highly significant correlation between the occurrence of dental fracture and dental irradiation at more than 40 Gy was observed.

Effective diagnosis and surgical management of primary signet ring cell carcinoma of the eyelid.

Primary signet ring cell carcinoma of the eyelid is an aggressive and rare neoplasm. It generally develops from the eccrine sweat gland and diffuses to the dermis and subcutis of the eyelid or axillae. The lesion usually presents as a progressive, diffuse and painless swelling of the eyelid with or without erythema and is frequently misdiagnosed as a chalazion or a chronic blepharoconjunctivitis leading to delayed management. The histology typically shows a signet ring cell or histiocytoid morphology. The authors present a case of a 76-year-old woman with a diagnosis of a primary signet ring cell carcinoma of the eyelid with atypical presentations. With this report, we seek to increase clinician awareness toward this tumor and to highlight the need for systematic recommendations in order to improve the management of these patients.

Ranula as the First Symptom of HIV Infection in Young Patients.

INTRODUCTION: Oral manifestations are often the earliest HIV signs. Salivary gland diseases are a common form of HIV expression. A ranula can occur in association with HIV. However, this manifestation is rarely considered as the disease sentinel sign. We present two cases of children consulting for a ranula, leading to the diagnosis of a previously unknown HIV infection. Case Reports. Two children, respectively, 5 and 13, were treated for a ranula by marsupialization. Relapse occurred in both cases, and thereafter, a ranula excision was performed. While the follow-up was uneventful, HIV infection was diagnosed during the patients' care. The only sign or symptom observed was the ranula. A routine HIV testing of ranula patients would have allowed earlier care. CONCLUSION: Routine HIV testing of patients with a ranula is justified and may be recommended, especially for children. Ranula excision associated with the sublingual gland resection is suggested in order to avoid recurrence.

Risk factors assessment in fibular free flap mandibular reconstruction.

INTRODUCTION: The fibular free flap (FFF) is the best choice method for mandibular reconstruction. However, the failure and the complications risk factors (RF) are not yet fully identified. This study aims to analyze these RF in order to improve the success rate. MATERIAL: This retrospective study includes all patients who benefited from a FFF mandibular reconstruction between the first of January, 2014 and the thirty-first of December, 2018 in the Department of Stomatology and Maxillofacial Surgery department of the CHU Saint-Pierre Hospital, Brussels, Belgium. RESULTS: Thirty patients benefited from this intervention. The overall success rate was 90%. Majority of the patients were men (67%) (mean age: 52 years). The main associated co-morbidities were: alcohol (50%), tobacco consumption (67%) and previous radiotherapy (20%). The mean operative time was 9,5hours. The morbidities rates at the receiving site (RS) and the donor site (DS) were respectively 43% and 30%. Infection and dehiscence of the RS were the main complications. Statistical analysis identified RF for RS infections: atherosclerosis and operative time; RS dehiscence (previous cervical dissection and secondary reconstruction); flap necrosis (ischemia time, rate of infection at the recipient site, history of radiation therapy, alcohol consumption, National Nosocomial Infection Surveillance score (NNISS), and history of cervical dissection); and DS morbidities (NNISS and dehiscence rate at the DS in the early period). CONCLUSION: The FFF mandibular reconstruction offers a significant success rate. Nevertheless, this study highlighted several failure and complications RF of the procedure. Previous neck dissection and radiotherapy, operative and the ischemia time, were RF associated with complication at the RS. Furthermore, the NNIS score and the dehiscence rate were also reported as RF for FFF necrosis.

Head and neck reconstruction: The supraclavicular flap: technical note.

INTRODUCTION: Defects reconstruction after oncologic resection is challenging and complex in head and neck tumors. The aim of this retrospective study is to evaluate the use of the supraclavicular artery island flap (SCAIF) in head and neck reconstruction, in particular, when traditional free flaps is not recommended. METHODS: We reviewed our two years' experience of the use of SCAIF on a total of 15 cases. In 10 cases, it was used as an alternative to free flaps after head and neck tumors resection. In 5 cases, SCAIF was used for revision surgery after a free flap failure. The indications for flap use have been defects due to resection of stage II-IV cancer in the head and neck region. The operative site, time, complications and functional outcomes were assessed. RESULTS: We identified 15 patients with a total of 16 SCAIF. One patient had received bilateral SCAIF. Out of the patients, 10 were men and 5 were women. Head and neck oncologic patients underwent tumor resection followed by immediate reconstruction using SCAIF. Among those 15 patients, 10 received previous radiotherapy in the head and neck region. All the patients had undergone multiple surgical procedures. Mean flap dimensions were 6.0cm (range, 5-7cm) wide and 22.0cm (range, 14-26cm) long. The proximal part of the flap was de-epithelialized to match the defect, resulting in a mean skin paddle length of 8.0cm (range, 5-12cm). After an average follow-up duration of 13 months (range 3-20 months), the flap survival rate was 90%. Two patients had had a partial loss of the flap. All the flaps were harvested in less than one hour. The donor sites were closed primarily and did not require any additional surgery. No donor site wound dehiscence had been reported. No infection or cellulitis were observed. None of the patients reported any functional donor site morbidity. CONCLUSIONS: The supraclavicular flap provides a safe option for head and neck reconstruction of oncologic defects when traditional free flap is not recommended. It is also an excellent alternative to radial forearm free flap (RFFF) in head and neck soft tissue reconstruction, especially in vessel-depleted neck.

Malnutrition in head and neck cancer patients: Impacts and indications of a prophylactic percutaneous endoscopic gastrostomy.

INTRODUCTION: Head and neck cancer (HNC) patients often experience malnutrition before and during treatment. Prophylactic gastrostomy has emerged as an efficient tool for ensuring adequate nutrition. However, there is no suitable algorithm able to identify patients at high risk of malnutrition. The aim of this study was to describe the nutritional management, to assess the impact of prophylactic gastrostomy, and to identify predictors of malnutrition. METHODS: This retrospective study included 152 patients treated with surgery, radiotherapy, or chemotherapy for HNC. The patients were classified according to their gastrostomy status (prophylactic or non-prophylactic). Nutritional, tumoral and treatment characteristics were reported. Clinical and nutritional outcomes were measured 6 weeks after the beginning of treatment. In order to describe the nutritional management and the impact of prophylactic gastrostomy on patients, univariate analysis was generated using chi-square test and Mann-Whitney test or Student's t-test. Logistic regression was performed to identify factors associated with malnutrition. RESULTS: Forty-one patients received prophylactic gastrostomy whereas 111 patients had no nutritional support. Prophylactic gastrostomy placement was associated with a lower initial body mass index, with severe malnutrition, and with initial oral intake disorder. Patients who did not experienced prophylactic gastrostomy had much worse outcomes such as hospital readmissions (P=0.042), relative weight loss at 6 weeks (P<0.0001), dysphagia, severe malnutrition, and poor state of health (P=0.001). Our complication rates (4.9%) were lower than the usual range (5.9-9.3%) and no life-threatening complication was reported. Positive N status, oral intake disorder, concomitant radiochemotherapy, nasopharyngeal, and hypopharyngeal tumor site were significant predictive factors for malnutrition. CONCLUSIONS: Prophylactic percutaneous endoscopic gastrostomy showed advantages in terms of hospital readmissions, relative weight loss at 6 weeks, dysphagia, severe malnutrition, and poor state of health. Tumoral, nutritional and treatment characteristics seem to be predictors for malnutrition. Hence, physicians should integrate these factors in their nutrition algorithm approach.

Mandibular incisive canal and lingual foramina characterization by cone-beam computed tomography.

INTRODUCTION: Many patients have haemorrhagic and neurologic complications after surgery at the symphysis region, while this area between the mental foramina is commonly considered to be risk-free because the presence of vasculo-nervous anastomoses found in the mandibular incisive canal (MIC) and lingual foramina (LF). The purpose of our study was to better analyse these anatomical structures to better identify and preserve them during surgery. PATIENTS AND METHODS: This prospective radio-anatomical study evaluated the presence, morphology and topography of MIC and median LF (MLF) and paramedian LF (PLF) by cone-beam computed tomography according to age, gender and dentition of 50 consecutive patients. RESULTS: Among the MIC, 99% were visualized at their origin. Their visibility decreased gradually towards the symphysis. The MIC had a larger diameter and followed a significantly more superficial and more vestibular way in older patients. At least, one MLF by hemimandible was found whereas PLF were found only in 68% of the cases. The mean distance from the basal border was 7.11mm for the lower MLF, 16.33mm for the upper MLF and varied from 11.15 to 10.85mm for the left and right PLF. CONCLUSION: Our study suggests that MIC and LF are constant structures with anatomical variations and that three-dimensional topographic study of the interforaminal region would be beneficial in patients requiring surgery in this area to reduce the risk of haemorrhage and neurologic complications.

The development of new clinical instruments in laryngopharyngeal reflux disease: The international project of young otolaryngologists of the International Federation of Oto-rhino-laryngological Societies.

INTRODUCTION: To analyze the epidemiological characteristics of placebo controlled randomized trials (RCTs) that evaluated the effectiveness of medical treatments over placebo in laryngopharyngeal reflux (LPR). MATERIAL AND METHODS: PubMed, Cochrane database, and Scopus were assessed for subject headings using the PRISMA recommendations. Placebo RCTs published between 1990 and 2018 describing clinical evolution throughout LPR treatment were extracted and analyzed for evidence-based level, number of patients, inclusion and exclusion criteria, gender, age, symptoms and signs used as therapeutic outcomes, and treatment schemes. RESULTS: The database search identified 15 placebo RCTs with a total of 763 patients. The mean age of patients was 48.59 years and 52.68% of patients were female. Among the 15 placebo RCTs, 9 have demonstrated a partial or total superiority of a medical treatment over placebo. Most of authors based the LPR diagnosis on symptoms and signs without additional examination. Our analysis reveals an important heterogeneity between studies with regard to the diagnosis criteria, treatment schemes and signs and symptoms used as therapeutic outcomes. Many commonly reported signs and symptoms related to LPR were not used as therapeutic outcomes. Half of the authors did not prescribe diet and behavioral changes along the treatment. CONCLUSION: The controversy in the RCTs about the superiority of medical treatment over placebo in LPR disease is probably due to discrepancies in the diagnosis method, exclusion criteria, therapeutic schemes and the lack of comprehensive tools for the assessment of signs and symptoms. In this context, the LPR Study Group of Young-Otolaryngologists of the International Federations of Oto-Rhino-Laryngological Societies developed two new instruments to precisely assess signs and symptoms throughout the treatment. These two instruments could be used in future trials comparing medical treatment over placebo in LPR disease.

[Value of Doppler ultrasound for the assessment of carotid artery invasion by tumours of the upper aerodigestive tract]. / Intérêt de l'échographie Doppler dans l'évaluation de l'envahissement de l'artère carotidienne dans les tumeurs des voies aérodigestives supérieures.

The diagnosis of invasion of the carotid axis preoperatively is extremely helpful and determines the therapeutic approach as well as the prognosis for patients with tumours of the upper aerodigestive tract. A review of literature to refine the radiological choice between the different existing techniques is provided. It appears that echography gives excellent results.

Le diagnostic d'un envahissement de l'axe carotidien en période préopératoire est très utile et détermine l'attitude thérapeutique de même que le pronostic des patients présentant une tumeur des voies aérodigestives supérieures. A l'aide de cas cliniques, les différentes techniques d'imagerie ont été évaluées et une revue de littérature a été réalisée pour affiner le choix de la méthode radiologique. Il apparaît que l'échographie est particulièrement performante.

Basal oxidative stress ratio of head and neck squamous cell carcinomas correlates with nodal metastatic spread in patients under therapy.

BACKGROUND: Head and neck squamous cell carcinoma (HNSCC) is a type of cancer that is strongly associated with oxidative damage and oxidative stress. Tobacco and alcohol - sources of massive quantities of reactive oxygen species (ROS) - have been clearly identified as etiologic factors that contribute to these malignancies. Considering the role of glutathione (GSH) in ROS detoxification, we hypothesized that potential biological markers can be found in addition to the parameters of oxidative stress. In line with previous studies that emphasized the accumulation of GSH in tumor cells, in this study, we have reported a lower ratio of oxidized versus reduced GSH in head and neck tumors. OBJECTIVE: The aim of the paper was to evaluate the prognostic and clinical significance of the ratio of oxidized versus reduced GSH in patients with head and neck cancers. METHODS: Thirty-six patients with HNSCC were included in this study. The tumoral redox status was determined by measuring the ratio of oxidized/reduced GSH (GSSG/GSH) by capillary electrophoresis. Statistical analysis was performed to assess the correlation between patient, clinical factors and the redox status. RESULTS: The results showed a low tumoral ratio of GSSG/GSH and a better locoregional control. Moreover, a significant correlation between the tumoral redox status ratio (GSSG/GSH) and nodal stage (N0 versus N1, N2 and N3) was also observed. A higher tumoral redox status ratio was found to be associated with the presence of lymph node metastasis (N1, N2 and N3). CONCLUSION: A strong correlation was observed between the oxidative status and locoregional control of the tumors. Moreover, a higher basal tumoral redox status ratio was found to be correlated with the presence of lymph node metastasis.

Recalcitrant hypocalcemia after total thyroidectomy and bariatric surgery.

PROBLEM: Patients with Roux en Y gastric bypass (RYGBP) who undergo total thyroidectomy may be at increased risk for recalcitrant symptomatic hypocalcemia. METHODS: All patients who underwent total thyroidectomy with a history of preceding RYGBP from 2007 to 2012 were identified retrospectively. Cases were matched 2:1 for age, gender, and BMI to a control group undergoing total thyroidectomy without previous RYGBP during the same study period. RESULTS: Age and body mass index were equivalent between cases (n = 14) and controls (n = 23). A comparison between groups demonstrated that cases had a significantly higher incidence of symptomatic hypocalcemia resulting in paresthesia and tetany (38% vs. 0%; P <0 .01), received intravenous calcium more often (18% vs. 0%; P < 0.01), and had longer hospital stays (2.2 vs. 1.2 days, P = 0.02) than controls. CONCLUSIONS: Physicians and surgeons need to be aware of this complication and take measures to identify and prevent it, and patients should be informed. In this patient population, calcium levels should be closely monitored and early calcium and vitamin D spplementation should be initiated preemptively.

Prognostic value of FDG PET/CT in head and neck squamous cell carcinomas.

INTRODUCTION: The purpose of this study was to evaluate the use of (18)F-fluorodeoxyglucose positron emission tomography/computed tomography ((18)F-FDG PET/CT) to identify the presence of cervical lymph nodes metastases and extracapsular spread with histologic correlations in head and neck squamous cell carcinoma. METHODS: The medical records of 54 patients who underwent (18)F-FDG PET/CT for head and neck squamous cell carcinoma before surgery were reviewed. Receiver operating characteristic (ROC) analysis was performed to differentiate patients with cervical lymph node metastasis from those without lymph node metastasis. The same statistical analysis was done to differentiate cervical lymph nodes with extracapsular spread from those without extracapsular spread. RESULTS: Metastatic disease was diagnosed histologically in 49% (26 of 54) of the patients. Extracapsular spread was present in ten of the 54 patients (19%). When ROC curve analysis and maximum standardized uptake (SUVmax) values were used to detect cervical lymph node metastasis, the area under the ROC curve was 0.96 and the optimal cutoff value for SUVmax was 4.05 based on ROC curve analysis. The sensitivity and specificity of SUVmax for the detection of cervical lymph node metastasis using this cutoff point were 92% and 88%, respectively. When ROC curve analysis and SUVmax values were used in order to detect extracapsular spread, the area under the ROC curve was 0.86, and the optimal cutoff value for SUVmax was 4.15 based on ROC curve analysis. Using this cutoff value, the sensitivity and specificity of SUVmax for the detection of extracapsular spread were 83% and 88%, respectively. CONCLUSION: In our study, a median (18)F-FDG PET/CT SUVmax cutoff value of 4.15 was found to be related with cervical lymph node metastasis and extracapsular spread in patients with head and neck cancer.

Chemoradiation for advanced oral and (pharyngo) laryngeal carcinoma: single institution outcome analysis.

AIM: Chemoradiation ( CRT) is a valuable treatment option for(pharyngo)laryngeal squamous cell cancer and a palliative cure in advanced oral cancers. However, toxicity is scarcely reported. Therefore, efficacy, acute and toxic effects of chemoradiation for advanced head and neck squamous cell carcinomas were evaluated, using retrospective study. METHODS: Previously untreated patients with stage III-IV head and neck squamous cell carcinomas were included. Radiotherapy consisted of 70 Gy/7 weeks/35 fractions. All patients received concurrent Cisplatin 40 mg/m2 weekly. RESULTS: The most common acute toxic effects were dysphagia and mucositis. Dysphagia and xerostomia remained problematic during follow-up. Loco regional disease control was respectively 91% and 98% after 6 months. The median overall survival (calculating starting form the end of the treatment) was 33 months (range 0-111months). The 5-year disease specific survival was 41%. CONCLUSION: The results indicated that concurrent chemoradiotherapy for advanced head and neck squamous cell carcinoma is associated with high locoregional control and disease-specific survival. However, significant acute and long-term toxic effects occur, and organ preservation appears not necessarily equivalent to preservation of function in pharyngolaryngeal cancers.

Usefulness of neuromonitoring in thyroid surgery.

One of the most important complications during thyroid surgery is injury to the recurrent laryngeal nerve (RLN) which leads to dysfunction and palsy of the vocal folds. Adequate knowledge about the location of the RLN supported by neuromonitoring can help the operating surgeon to prevent this complication. Visualization of the nerve alone seems not enough. An estimation of the function of the RLN is very important. Recently, the use of neuromonitoring has been increasingly employed to predict and document nerve function at the end of thyroidectomy. The aim of the study was to verify the usefulness of neuromonitoring in identifying the recurrent laryngeal nerve and to predict postoperative outcome in patients undergoing thyroid surgery for different indications. Between March 2009 and October 2010, 91 patients (26 men, 65 women; mean age 53 (range 26-83) underwent thyroidectomy. Intraoperative neuromonitoring (IONM) was registered for 91 patients. Eighty-four total thyroidectomies and seven lobectomies were performed with IONM. Eight unilateral postoperative transient paresis were identified without any permanent paralysis. Intraoperative neuromonitoring has an excellent specificity and negative predictive value in which an unchanged positive signal is highly predictive of intact nerve function. Intraoperative neuromonitoring during thyroid surgery is a reliable tool for early recurrent laryngeal nerve localization and identification, certainly in complicated thyroid operations. The probability is high for correctly predicting an intact postoperative nerve function by neuromonitoring.

Rhabdomyolysis in head and neck surgery.

OBJECTIVES: Rhabdomyolysis is increasingly recognized as a cause of acute renal failure. Although it is often the result of extensive trauma, rhabdomyolysis may also appear as a rare and serious complication during the postoperative period. Postoperative rhabdomyolysis is a rare but serious complication. Early diagnosis of postoperative rhabdomyolysis is based on laboratory tests and clinical examination. Renal hyperperfusion with hydration and diuretics may prevent a nephrotoxic reaction. We describe two recent cases in patients undergoing head and neck surgery. METHODOLOGY: Between 2007 and 2010, 22 patients with advanced pharyngo laryngeal cancer were treated. Patients records were retrospectively analyzed for preoperative, operative, postoperative, and convalescence data. Demographics, co-morbidities, duration of operation, and postoperative creatine kinase (CK) levels were evaluated. RESULTS: All patients (n = 20 men; n = 2 women) underwent (pharyngo)laryngectomy to treat advanced (stage T4) head and neck tumors. The mean surgical procedure time among these patients was 6.4 h. (range 5.0 to 7.5 h.). The mean peak serum CK was 1725 U/L (range 456 to 3745 U/L). The mean rise of CK level was 268 U/L, in affected patients ranged from 2636 to 3745 U/L. Rhabdomyolysis occurred in two patients, presenting as excessive, immediate postoperative muscular pain in the "downside" hip/flank. These two patients experienced acute renal failure with an average peak CK of 2700 U/L. Bicarbonate alkalinization and diuretic administration were initiated at a mean of 24 h. (range, 4 to 48 h.). One patient required hemodialysis for 1 month postoperatively, but had stable serum within 2 months. Patients did not experience extended recovery. CONCLUSION: Early recognition and aggressive treatment with intravenous fluids and diuresis may prevent the development of acute renal failure due to rhabdomyolysis. Rhabdomyolysis causing acute renal failure is a rare but serious postoperative complication. Adequate prevention in high-risk patients, early diagnosis and, aggressive treatment are the keys to a successful recovery.

The effect of hyperbaric oxygen therapy on treatment of wound complications after oral, pharyngeal and laryngeal salvage surgery.

INTRODUCTION: Radiation therapy alone, or combined with chemotherapy, are both used for cancer in the head and neck. This can lead to damage of tissue cells and vasculature. Surgery in such compromised tissues has increased complication rates, because wound healing with angiogenesis and fibroplasias requires normal cell growth conditions. Hyperbaric oxygen therapy raises oxygen levels in hypoxic tissue, stimulates angiogenesis and fibroplasia. In this report, we review the clinical value of hyperbaric oxygen therapy for major wounds that had shown no signs of healing as well as fistulas after salvage surgery in patients treated with (chemo)radiation of the head and neck regions. METHODS: In this retrospective study, 16 patients with soft-tissue wounds without signs of healing after salvage surgery, after radiation, and most after chemotherapy were treated in the head and neck regions with hyperbaric oxygen therapy. The patients were treated by HBO2, 2.5 bars 90 minutes daily, usually 20 treatments. RESULTS: The healing processes seemed to be initiated and accelerated by HBO2. Fourteen of the 16 patients healed completely. There were no life-threatening complications. CONCLUSION: Radiotherapy and combined chemoradiation therapy leads to damage of tissue cells and vasculature. Salvage surgery in such tissues has an increased complications rate, because wound healing requires angiogenesis and fibroplasias, all of which are jeopardized. Hyperbaric oxygen therapy raises oxygen levels in hypoxic tissue, stimulates angiogenesis and fibroplasias and is an effective and powerful treatment for postoperative wounds in oral, pharyngeal and laryngeal carcinomas surgery.

Transarterial endovascular treatment in the management of life-threatening carotid blowout syndrome in head and neck cancer patients: review of the literature.

OBJECTIVES: Carotid blowout syndrome is a rare but devastating complication in patients with head and neck malignancy, and is associated with high morbidity and mortality. Bleeding from the carotid artery or its branches is a well-recognized complication following treatment or recurrence of head and neck cancer. It is an emergency situation, and the classical approach to save the patient's life is to ligate the carotid artery. But the surgical treatment is often technically difficult. Endovascular therapies were recently reported as good alternatives to surgical ligation. METHODS: Retrospective review of three cases of acute or threatened carotid hemorrhage managed by endovascular therapies. RESULTS: Two patients presented with acute carotid blowout, and one patient with a sentinel bleed. Two patients had previously been treated with surgery and chemo radiation. One patient was treated by chemo radiation. Two had developed pharyngocutaneous fistulas, and one had an open necrosis filled wound that surrounded the carotid artery. In two patients, stent placement resolved the acute hemorrhage. In one patient, superselective embolization was done. Mean duration follow-up was 10.2 months. No patient had residual sequelae of stenting or embolization. CONCLUSION: Management of carotid blow syndrome is very critical and difficult. A multidisciplinary approach is very important in the management of carotid blow syndrome. Correct and suitable management can be life saving. An endovascular technique is a good and effective alternative with much lower morbidity rates than surgical repair or ligation.

The role of thyroidectomy in advanced laryngeal and pharyngolaryngeal carcinoma.

Total thyroidectomy or hemithyroidectomy together with a total laryngectomy (TL) or pharyngo laryngectomy (TPL) for (pharyngo) laryngeal cancer often renders the patient hypothyroid and commits them to life-long thyroid hormone replacement. To determine the incidence of thyroid gland invasion (TG) in patients undergoing TL or TPL with total thyroidectomy (TThy) or lobectomy (HThy) for advanced laryngeal or hypo pharyngeal cancer and to assess predicative factors. Retrospective analysis of 35 patients from 2007 to 2010. Specimens were examined to determine the incidence of TG invasion and relevant predicative factors such as histological grade and subglottic extension. Pre-operative imaging was reviewed to assess for radiological evidence of TG invasion. TL and TThy was performed in 13 patients. TL and HThy was performed in four patients and TPL and TThy was performed in 18 patients. Surgery was performed for primary and recurrent cancer in 29 and six patients, respectively. Histological evidence of invasion of the TG was found in three patients. Relationship was found between TG invasion and subsite of primary carcinoma and the presence of subglottic extension. No relationship was found between TG invasion and patient's sex, stage of primary disease at surgery, degree of differentiation. In addition, no significant relationship was found between the presence of TG invasion and recurrent disease. Invasion of the TG in patients undergoing a TL or TPL is a rare event and limits the need for a TTHy in most cases.

Neck and mediastinal node dissection in pharyngolaryngeal tumors.

INTRODUCTION: The present study sought to determine the necessity and prognostic impact of superior mediastinum (SM) dissection in advanced upper aerodigestive tract squamous cell carcinoma (SCC). METHODS: A retrospective review was made of the records of 31 patients who had undergone (pharyngo-) laryngectomy for advanced SCC. Statistical analysis examined correlations between the presence of SM lymph node metastasis and clinical factors, with a significance threshold of P<0.05. RESULTS: Positive cervical and/or SM lymph nodes were found in 20 cases, including six with isolated positive SM nodes. Positive SM nodes were found in none of the patients with laryngeal SCC, versus six of the 13 patients with hypopharyngeal SCC, where they were associated with tumors greater than 35 mm. Presence of paratracheal lymph node metastasis showed a strong but not statistically significant association with the primary site (larynx vs. hypopharynx: P=0.08). CONCLUSIONS: In the present series, advanced laryngeal carcinoma was never associated with positive SM nodes, whereas advanced hypopharyngeal carcinoma showed a trend in favor of paratracheal lymph node involvement.

Epidemiology and clinical characteristics of larynx and hypopharynx carcinoma: a comparative study in the Hainaut and review of the literature.

INTRODUCTION: The epidemiology and clinical picture of laryngeal and hypopharyngeal carcinomas have changed significantly in the past 50 years. The aim of this study was to analyze selected epidemiological and clinical characteristics of laryngeal and hypopharyngeal carcinoma. METHODS: A complete chart review of all patients records was conducted. All the patients who were diagnosed as having laryngeal or hypopharyngeal cancer from January 1, 2004 through December 31, 2009 were included in the study. The demographics of the patient population, the disease profile were analyzed. RESULTS: 138 patients with laryngeal or hypopharyngeal disease were treated. 76 patients presented a laryngeal cancer. Disease characteristics indicated that most cases of supraglottic cancer were in a locally advanced stage (84.4%), whereas most patients with glottis cancer were diagnosed with early stage (63.3%). A hypopharyngeal cancer was diagnosed in 62 cases. A significant increasing trend in hypopharyngeal cancer has been seen in males. The majority of the patients was alcohol consumers and had a histology showing squamous cell carcinoma. There were 33 females and 105 males whose ages ranged at presentation from 47 to 86 years. Of the 138 patients treated, 24 and 47 patients were respectively T3 and T4 and 37 patients were N1, 37 patients N2 and 10 patients N3 (Table I). Most patients had stage IV disease (65/138). Majority of cases presented with local advanced stage. Of the 138 patients treated, 24 and 47 patients were respectively T3 and T4. The highest rate of local advanced stage was observed in patients with pyriform sinus carcinomas (81%); the lowest rate was observed for glottis tumors (41.8%). Regional lymph node metastases were diagnosed in 61% of the analyzed cases. 37 patients were N1, 37 patients N2 and 10 patients N3. The highest rate (82.2%) of regional lymph node metastases were observed in cases of pyriform sinus carcinomas, and the lowest (31.7%) in glottis carcinomas. Most patients had stage IV disease (65/138). 49 patients received radiotherapy; 48 patients were treated by surgery followed by (chemo)radiotherapy. 41 patients were treated initially by concomitant chemoradiotherapy. CONCLUSION: A tendency for increasingly younger patients to develop larynx and hypopharynx carcinomas was observed. Most patients had stage IV disease but no trend for a percentage increase in locally advanced tumors was observed. A significant increasing trend in hypopharyngeal cancer has been seen in males.