Open partial horizontal laryngectomies: a proposal for classification by the working committee on nomenclature of the European Laryngological Society.

We present herein the proposal of the European Laryngological Society working committee on nomenclature for a systematic classification of open partial horizontal laryngectomies (OPHL). This is based on the cranio-caudal extent of laryngeal structures resected, instead of a number of different and heterogeneous variables present in existing nomenclatures, usually referring to eponyms, types of pexy, or inferior limit of resection. According to the proposed classification system, we have defined three types of OPHLs: Type I (formerly defined horizontal supraglottic laryngectomy), Type II (previously called supracricoid laryngectomy), and Type III (also named supratracheal laryngectomy). Use of suffixes "a" and "b" in Type II and III OPHLs reflects sparing or not of the suprahyoid epiglottis. Various extensions to one arytenoid, base of tongue, piriform sinus, and crico-arytenoid unit are indicated by abbreviations (ARY, BOT, PIR, and CAU, respectively). Our proposal is not intended to give a comprehensive algorithm of application of different OPHLs to specific clinical situations, but to serve as the basis for obtaining a common language among the head and neck surgical community. We therefore intend to present this classification system as a simple and intuitive teaching instrument, and a tool to be able to compare surgical series with each other and with non-surgical data.

Influence of formalin fixation on tissue dimensions in palatal tonsils.

AIM: To investigate the change of tissue dimensions after formalin fixation, and to determine the optimal time of fixation. HYPOTHESIS: Formalin fixation may lead to shrinkage in tissue dimensions and may thus alter tumor stages. BACKGROUND: It is often observed in tumor surgery that the dimensions in vivo seem larger than after resection, and tissue appears to shrink further after formalin fixation. This might alter dimensions and assessment of spread of the tumor and thus lead to a lesser tumor classification and stage. In cases where the decision for adjuvant chemoradiation is based upon the stage, it may thus be of relevance for the patient to evaluate the pathologic and not the in vivo dimensions of the tumor. MATERIAL AND METHODS: In order to obtain comparable tissues, we investigated 100 palatal tonsils after cold steel dissection tonsillectomy for chronic tonsillitis. There were four time points investigated: directly after excision in the operating room and after four, 24 and 72 h of fixation in formaldehyde (4% Formaldehyde in phosphate buffer pH 7.4). The tissue was measured in the following dimensions: volume (ml), weight (g) and length, broadness and width (mm). RESULTS: The tissue size did not change significantly in dimensions except for an increase in length. The time of fixation did not influence the size. DISCUSSION: Formalin fixation does not significantly influence the tissue dimensions of palatal tonsils in comparison to direct ex vivo measurements. A minimal time of fixation of 20 h is required in order to stop all degenerative processes; however, longer fixation does not change the dimensions of the specimen. CONCLUSION: The null hypothesis has to be withdrawn that tissue dimensions are altered by formalin fixation. Thus, the histopathological measurements do not influence TNM staging.

[Recent advances in the treatment of laryngeal and hypopharyngeal carcinoma]. / Aktuelle Therapieoptionen bei Larynx- und Hypopharynxkarzinomen.

The prognosis of squamous epithelial cell carcinoma of the upper aerodigestive tract has improved considerably in the last 30 years. Patients presenting with stage I or II disease are treated with surgery or radiation therapy with curative intent. Although the efficacy is comparable between the two methods, surgery is usually preferred so that the side effects and late toxic effects of radiation can be avoided. For the treatment of advanced stages of disease, surgery, radiotherapy, chemotherapy and immunotherapy are usually combined. The introduction of concurrent administration of chemotherapy and radiotherapy (chemoradiotherapy) has been a major advancement. This has resulted in local control and survival rates comparable to those seen following radical surgery and postoperative radiotherapy, but with preservation of the larynx in most patients. However, recent epidemiological observations have shown declining survival rates in laryngeal cancer patients, raising concern about uncritical and too frequent use of this approach. The rationale for choosing treatment options for patients with laryngeal and hypopharyngeal carcinoma is discussed.

[Positron-emission tomography (PET) and PET/CT in head and neck cancer - recommendations of an interdisciplinary consensus conference]. / Positronen-Emissionstomografie (PET) und PET/CT bei Kopf-Hals-Tumoren - ein Vorschlag für einen interdisziplinären Konsensus.

BACKGROUND: Today's available therapeutic options in head and neck cancer patients have led to better treatment modalities tailored to the individually clinical staging of the patients towards a risk adapted tumour management. This, however, is only possible with an accurately pretherapeutic diagnostic regimen and closely posttherapeutic follow-up. METHODS: These issues were discussed by nuclear medicine experts, otorhinolaryngologists, oral surgeons, radiologists, radio-oncologists and oncologists in a meeting that took place in Pörtschach, Austria, on 05 May 2006. The aim was to discuss the impact and indications of performing FDG PET/CT in patients with head and neck cancer and to outline possible future perspectives. RESULTS: FDG PET/CT is recommended for a better pretherapeutic staging in stage IV according to UICC and should be the method of choice in CUP with lymph node metastases. FDG PET/CT should be performed 3 - 4 months after radiation-/radiochemotherapy to diagnose viable tumour and to avoid false positive results. To evaluate the position and effectiveness of FDG PET/CT in therapy-monitoring further studies are needed. In case of radiation therapy FDG PET/CT allows a tailored treatment of patients with an accurate design of the target volume to reduce damage to the surrounding tissues. CONCLUSIONS: The interdisciplinary consensus reached by the experts is not intended to recommend standard guidelines in the management of head and neck cancer but to summarise and stress the impact of FDG PET/CT on the basis of the present literature and current clinical practise.

Transoral laser surgery for laryngeal cancer: outcome, complications and prognostic factors in 275 patients.

AIM: Curative treatment options for laryngeal carcinoma include primary radiation therapy, open surgical techniques and transoral laser surgery (TLS). In the last decade, TLS has become an important tool in the treatment of laryngeal cancer and has become the standard approach in many institutions. The aim of this study was to review the experience of a single center institution with TLS for early and advanced laryngeal cancer. METHODS: We retrospectively analyzed 275 patients who underwent TLS in regard to the survival outcome and surgical complications. RESULTS: The 5-year disease-free survival estimate was 90.3% and the 10-year disease-free survival estimate was 88.2%. The 5-year larynx preservation rate estimate was 88.2% and the 10-year larynx preservation rate estimate was 87.3%. The disease-free survival was significantly worsened by the variables T and N (p=0.0003; p<0.001, respectively). Two percent of all patients required intraoperative tracheostomy and the rate of minor postoperative complications was 17%. There were no fatal complications. CONCLUSIONS: We conclude that TLS is a valid treatment method for early laryngeal carcinoma. Selected cases of advanced carcinomas may also benefit from TLS.

[Laryngeal intraepithelial neoplasia]. / Laryngeale intraepitheliale Neoplasien.

Precancer (carcinoma in situ) or laryngeal intraepithelial neoplasia (LIN) is a non-invasive lesion that has genetic abnormalities, loss of cellular control functions, and some phenotypic characteristics of invasive cancer and that predicts for a substantial likelihood of developing invasive cancer. Several classifications have been proposed but none has received a total agreement. With regard to diagnosis, treatment and prognosis, these lesions differ substantially from infiltrating carcinoma. Known risk factors include cigarette smoking, viral infection with subtypes of the human papilloma virus, exposure to asbestos, and probably the gastro-oesophageal reflux disease. The diagnostic work-up usually includes indirect laryngoscopy with rigid telescopes, microlaryngoscopy and biopsies for histological evaluation. Therapeutic options include wait-and-see-strategies, radiotherapy, transoral laser surgery, vocal cord stripping with cold instruments, and open partial laryngectomy. Data from the literature suggest highest local control rate with radiotherapy as initial treatment compared to other standard methods of management of dysplasia. However, transoral laser surgery can be applied repeatedly and yields excellent final results. Therefore it is now considered the treatment of choice for these lesions in the majority of patients. Local recurrences are observed more frequently than with small infiltrative carcinoma, and second primaries may arise within the upper aero-digestive tract following initial treatment. Therefore systematic follow-up is recommended for these patients.

Single modality and multimodality treatment of nasal and paranasal sinuses cancer: a single institution experience of 229 patients.

AIMS: To assess the single and multimodal treatment results and prognostic factors for sinonasal carcinoma. METHODS: Overall survival (OS), disease-specific survival (DSS), local control (LC), and disease-free survival (DFS) in 229 patients with sinonasal carcinoma treated from 1967 to 2003 were calculated. Prognostic factors were univariately and multivariately analyzed. The median follow-up period for survivors was 126 months. RESULTS: 32% of the patients were operated only, 47% underwent multimodal therapy, and 20% were treated without operation. The 5-year OS rate was 41%, and the DSS rate was 51%. The LC rate was 64%, and the DFS rate was 34%. Prognostic for DSS were M status (p<0.001), UICC stage (p<0.001), T classification (p=0.001), N status (p=0.002), intracranial tumor infiltration (p=0.008), infiltration of the pterygopalatine fossa (p=0.02), infiltration of the skull base (p=0.021), infiltration of the orbita (p=0.041), and the type of therapy (p<0.001): The 5-year DSS rate was 63% for patients operated only, 56% for all operated patients, 46% for patients undergoing surgery and radiotherapy, but only 21% for patients treated with radiotherapy+/-chemotherapy. Multivariate analysis revealed that T classification (p=0.042), N classification (p=0.035), M classification (p=0.007), UICC stage (p=0.038), and type of therapy (p=0.038) were independent prognostic factors for DSS. CONCLUSIONS: Radical surgery is recommended for stage I/II sinonasal carcinomas. Stage III/IV carcinomas still have a poor prognosis, but multimodal treatment seems to favor the outcome.

[Olfactory dysfunctions. Epidemiology and therapy in Germany, Austria and Switzerland]. / Riechstörungen. Epidemiologie und Therapie in Deutschland, Osterreich und der Schweiz.

INTRODUCTION: Olfactory dysfunction has been reported to affect more than 200,000 patients a year in the USA. The aim of this survey was to obtain comparable epidemiological data and treatment information on olfactory dysfunction in German speaking countries. METHODS: Questionnaires were sent to all otorhinolaryngology departments in Germany, Austria and Switzerland; 52% of hospitals completed the survey. RESULTS: An average of 46 patients with olfactory dysfunction were treated per hospital every month. Hyp- and anosmia were most commonly caused by inflammatory diseases of the nose/paranasal sinuses (53%), respiratory dysfunction (19%), or postviral conditions (11%). Steroids were used most frequently for pharmacological treatment (topically 82%; orally 65%). Approximately one third of the clinics used B vitamins, or zinc; 80% of the hospitals performed surgery to treat underlying diseases. Acupuncture and smell training was used by approximately 20%. CONCLUSION: A total of 79,000 patients per year are treated for olfactory dysfunction in German hospitals. The vast majority of these disorders (72%) is caused by sinunasal diseases. The quality control of therapeutic strategies is urgently needed.

Hoarseness after laryngeal blunt trauma: a differential diagnosis between an injury to the external branch of the superior laryngeal nerve and an arytenoid subluxation. A case report and literature review.

Arytenoid subluxation is a well-known cause of hoarseness due to incomplete glottic closure with intact inferior laryngeal nerves after severe laryngeal trauma. We report the case of a young man presenting after laryngeal blunt trauma with hoarseness, easy fatigue during phonation, marked difficulty with his high-pitch and singing voice and decreased phonation time, but intact function of both inferior laryngeal nerves, intact endolaryngeal mucosa sensibility and normal CT scans of the larynx and the neck. Due to the asymmetric anteromedial position of the right arytenoid with incomplete glottic closure, the primary diagnosis was arytenoid subluxation, and the patient was referred for instantaneous relocation therapy. The stroboscopic and electromyographic diagnosis of a unilateral paresis of the external branch of the right superior laryngeal nerve caused the therapy to be changed. Without repositioning, the patient had a total recovery of voice quality when the paresis receded 2 months later. In conclusion, the unilateral paresis of the external branch of the superior laryngeal nerve after laryngeal blunt trauma is reported here for the first time. Although the clinical findings are familiar sequelae of thyroid surgery, they may be misdiagnosed as arytenoid subluxation after laryngeal blunt trauma. Stroboscopy and electromyography permitted the correct diagnosis.

[Cricohyoidopexy (CHP) and Cricohyoidoepiglottopexy (CHEP). Indication, complications, functional und oncological results]. / Krikohyoidopexie (CHP) und Krikohyoidoepiglottopexie (CHEP). Indikationen, Komplikationen, funktionelle und onkologische Ergebnisse.

BACKGROUND: Subtotal laryngectomy with Cricohyoido(epiglotto)pexy (CHEP and CHP) is a commonly used surgical procedure in France, Italy and North America, but it is rarely carried out in Germany,where most laryngeal carcinomas staged T1-T3 are resected endoscopically or with total laryngectomy. OBJECTIVE: To identify indications for the CHEP and CHP in a setting that uses endolaryngeal procedures as a standard approach to organ preserving surgery in laryngeal cancer patients. PATIENTS: Nineteen patients with primary (n=15) or recurrent (n=4), supra- or transglottic carcinoma or carcinoma of the anterior commissure staged (r)T1b-4N0-2cM0 were treated with subtotal laryngectomy with CHEP (with or without neck dissection/radiotherapy) between October 1997 and June 1999. RESULTS: Undisturbed deglutition without aspiration and respiration without tracheotomy was achieved in 17/19 patients. Three patients showed temporary pneumonia from aspiration and two patients needed further treatment for endolaryngeal synechia. Three patients died of unrelated causes. Four patients were diagnosed with local recurrence: Two of them died from tumor, two patients had curative total laryngectomy as salvage surgery. Fourteen patients are living free of disease 24-40 months after therapy. CONCLUSION: CHEP is a subtotal laryngectomy with increased postoperative morbidity, but good functional results. Assuming a scrupulous indication for the extended tumors the oncological results of the CHEP are satisfying, too.

[Cricohyoidopexy (CHP) and Cricohyoidoepiglottopexy (CHEP). Indication, complications, functional und oncological results]. / Krikohyoidopexie (CHP) und Krikohyoidoepiglottopexie (CHEP) : Indikationen,Komplikationen, funktionelle und onkologische Ergebnisse.

BACKGROUND: Subtotal laryngectomy with Cricohyoido(epiglotto)pexy (CHEP and CHP) is a commonly used surgical procedure in France, Italy and North America, but it is rarely carried out in Germany,where most laryngeal carcinomas staged T1-T3 are resected endoscopically or with total laryngectomy. OBJECTIVE: To identify indications for the CHEP and CHP in a setting that uses endolaryngeal procedures as a standard approach to organ preserving surgery in laryngeal cancer patients. PATIENTS: Nineteen patients with primary (n=15) or recurrent (n=4), supra- or transglottic carcinoma or carcinoma of the anterior commissure staged (r)T1b-4N0-2cM0 were treated with subtotal laryngectomy with CHEP (with or without neck dissection/radiotherapy) between October 1997 and June 1999. RESULTS: Undisturbed deglutition without aspiration and respiration without tracheotomy was achieved in 17/19 patients.Three patients showed temporary pneumonia from aspiration and two patients needed further treatment for endolaryngeal synechia. Three patients died of unrelated causes. Four patients were diagnosed with local recurrence: Two of them died from tumor, two patients had curative total laryngectomy as salvage surgery.Fourteen patients are living free of disease 24-40 months after therapy. CONCLUSION: CHEP is a subtotal laryngectomy with increased postoperative morbidity, but good functional results.Assuming a scrupulous indication for the extended tumors the oncological results of the CHEP are satisfying, too.

Indications, complications, and surgical techniques for pediatric tracheostomies--an update.

BACKGROUND: With the decrease of life-threatening obstructive upper airway infections and the ongoing improvement of intensive care medicine, the role of tracheostomy in children has been changing considerably, until now. The aim of this study was to establish data regarding indications, complications, and techniques of pediatric tracheostomy, which would reflect the current state of science. METHODS: The authors analyzed the international literature as well as their own experience with 25 children less than 6 years of age who were operated on between 1980 and 1996. RESULTS: Literature proved to be very heterogeneous in terms of terminology, patient groups, operation techniques, indications, and complications. Within the past decades, long-term intubation and congenital anomalies of the upper respiratory tract have become increasingly prevalent, whereas inflammatory diseases were less and less an indication for tracheostomy. Endotracheal intubation as an alternative has resulted in less frequent tracheostomies in general. Today, children can be ventilated for months without considerable complications. However, individual, clinical, and fiberoptical controls are necessary. Tracheostomy-related complications have not changed significantly. Fatalities are mostly caused by the underlying disease. The most frequent causes of tracheostomy-related death are cannula obstruction and accidental decannulation. The most frequent early complications are pneumomediastinum, pneumothorax, wound complications, and bleedings. Subsequent complications most often are granulations and tracheal stenosis. CONCLUSIONS: The authors' research agreed widely with that in the literature. However, no tracheostomy-related death occurred. Possibly, this was because of their operative technique. In the opinion of the authors, establishing a cartilage window facilitates cannula exchange and reduces the risk of a fatal accidental decannulation.

[Perioperative mortality in otorhinolaryngology tumor surgery]. / Perioperative Mortalität in der HNO-Tumorchirurgie.

BACKGROUND: Perioperative mortality is an important factor for quality assurance in surgery. For ENT-surgery only sparse data has been published. PATIENTS AND METHODS: A retrospective analysis of 1054 interventions performed on 775 consecutive patients treated surgically for benign and malignant tumors of the head and neck was conducted during a 3-year period in 1995-1998. RESULTS: Of these patients, 34.1% were female and 65.9% male. Age ranged from 4-88 years with a mean age of 54.8 years. 489 patients (63.1%) were treated for malignoma and 286 for benign tumors (36.9%). 0.9% (n = 7) of our patients (n = 775) died during the first 30 days after surgery. That means 0.66% of all surgical interventions (n = 1054) were followed by post-operative mortality. DISCUSSION: In otorhinolaryngological surgery, post-operative mortality seems to be acceptable and low compared to other medical disciplines. The challenge for surgery must be to reach and preserve low perioperative mortality rates in the future. Finding the individually correct indication for surgical treatment must be guaranteed in order to reach this aim.

[Quality assurance indicators in an ENT practice]. / Qualitätsbewertende Indikatoren in einer HNO-Klinik.

BACKGROUND: According to German legislature, hospitals have to implement quality assurance (QA) programs, which are of particular importance in times of ongoing structural changes in healthcare. Amongst other internal methods of QA, indicators measuring the quality of total hospital performance can reflect medical outcome and the activities of physicians, nurses, and administrators. METHODS: Five indicators for measuring total hospital performance and for controlling total medical outcome were used in this study. RESULTS: Evaluation was time consuming, and some indicators showed a wide range, which could be explained by external reasons independent from internal quality. Valid values could be ascertained in the field of administrative quality, whereas in contrast the assessment of medical quality seemed to be more difficult. CONCLUSION: Due to current developments in German healthcare, the application of quality assurance methods such as the presented system of indicators is recommended.

Prevalence, distribution, and viral load of human papillomavirus 16 DNA in tonsillar carcinomas.

BACKGROUND: Oncogenic human papillomaviruses (HPV) DNA have repeatedly been observed in many head and neck carcinomas (HNSCCs), and HPV infections are currently considered a possible factor in the etiology of these tumors. However, the reported prevalences of HPV-DNA in HNSCC are variable. In the current study the authors used highly sensitive polymerase chain reactions (PCRs) to analyze the occurrence of viral sequences in 98 carefully stratified HNSCCs. The authors determined the load and localization of HPV DNA in a subset of tonsillar carcinomas and their metastases. METHODS: Nested PCR and an HPV16 specific single step PCR were used to screen 98 HNSCCs for HPV DNA for genital- and Epidermodysplasia verruciformis (EV)-associated HPVs. Typing was performed by direct sequencing and/or sequencing of cloned amplimers. In two patients HPV16 subtypes in tonsillar carcinomas and their metastases were compared by amplification and sequencing of the long control region of the virus. In a subset of HPV16 positive tonsillar carcinomas and their metastases, localization and viral load were determined using laser assisted microdissection and real time fluorescent PCR, respectively. RESULTS: Altogether 25 HNSCCs (26%) were found to be HPV positive. Stratified according to the tumor localization, the frequency of HPV positive lesions was 18% in the oral cavity, 45% for oropharynx, 25% for hypopharynx, 8% for nasopharynx, and 7% for larynx. The highest HPV DNA prevalence (58%) was found in tonsillar carcinomas. The high risk HPV type 16 was found in 84% of positive HNSCCs, in 14% of which EV-associated HPVs were detected. Human papillomavirus sequences were detected in 64% of biopsies with normal mucosa from 11 patients with positive carcinomas. As a control group, 14 tumor free tonsils were analyzed. In none of these specimens were HPV sequences detected. Viral long transcriptional control region sequences in homologous metastases were identical with those in primary tumors and the load values in both locations were roughly comparable. Viral loads differed substantially in different areas of one tumor. Statistical evaluation of data related to clinicopathologic parameters showed a significant linkage of HPV with tonsillar carcinomas compared to other locations. Furthermore, a significant correlation of HPV status of tonsillar carcinomas with tumor grading and alcohol consumption was found. CONCLUSIONS: Our study shows a preferential association of HPV-DNA with tonsillar carcinomas. The data support the view of HPV negative and positive tonsillar carcinomas being different tumor entities and conventional cancer risk factors being of less importance in HPV-infected individuals. The HPV genome is located in the cancer cells, whereas the infection of normal mucosa is a rare event. Data on quantification of HPV16 in tonsillar tumors and their metastases showed mean viral loads comparable to other HPV associated malignancies.

[Unilateral and bilateral recurrence of inferior laryngeal nerve paralysis]. / Die uni- und bilaterale Lähmung des Nervus laryngeus inferior (recurrens).

Unilateral recurrent nerve paralysis leads to glottic insufficiency, causing a significant lack of vocal ability. In contrast, bilateral palsies present with stridor on inspiration due to glottic stenosis. Most of the underlying lesions are iatrogenic, with thyroid surgery being the single most important causative factor. However, a variety of different reasons can lead to such a condition. Whenever aetiology is uncertain a complete diagnostic work-up is mandatory. Indirect laryngoscopy confirms the diagnosis. Laryngeal electromyography is of great value because it differentiates between paralysis and ankylosis of the cricoarytaenoid joint. Moreover, in many cases laryngeal electromyography provides a reliable prognosis of clinical outcome. While unfavorable results can be predicted with high accuracy, correct prognosis of complete recovery is more difficult. Speech therapy is the treatment of choice in case of unilateral recurrent nerve palsy. Only if a significant glottal gap persists medialization procedures may become useful for voice improvement. Endoscopic as well as open approaches are available for this purpose. Bilateral recurrent nerve palsies need to be addressed surgically in the vast majority of cases. Today, a variety of endoscopic techniques for widening the glottic airway are available. Compared to permanent tracheostomy these procedures have much less impact on the patient's quality of life and should be preferred whenever possible. Inevitably, voice quality is traded for airway normalisation. However, modern surgical techniques accomplish very tolerable phonatory results.