Surgery of thyroid cancer: twelve years' personal experience.

Diagnosis and treatment of thyroid carcinoma require a multidisciplinary approach. The close and long-standing collaboration between the Otorhinolaryngology, Pathological Anatomy and Nuclear Medicine Departments of Legnano Hospital has led to a precise diagnostic and therapeutic protocol in thyroid patients. In the 1990-2002 period, 131 patients underwent total thyroidectomy after diagnosis of thyroid cancer at the Otorhinolaryngology--Head and Neck Surgery Department. Patients submitted to lobectomy for differentiated thyroid cancer were excluded from the present study. The patient population is composed of 96 females (73%) and 36 males (27%) aged between 22 and 85 years. Of the 131 patients, 115 (87%) presented papillary carcinoma, 13 (10%) follicular carcinoma, 2 (2%) medullary carcinoma and one (1%) undifferentiated carcinoma. Two patients (2%) suffered from a preoperative monolateral recurrent nerve palsy. Total thyroidectomy was performed in all 131 patients. Selective neck dissection was performed only in patients with positive lymph nodes for papillary (37/115, 32%) and follicular carcinoma histotype (2/13, 15%) and, in both patients with medullary carcinoma (100%). Of the 131 patients, 15 (11%) did not undergo routine follow-up and were, therefore, excluded from the study, the remainder completed a mean follow-up of 47 months. During follow-up, the incidence of the two most frequent complications of thyroid surgery were evaluated: recurrent nerve paralysis and permanent hypoparathyroidism (exceeding the postoperative 6 months). Results of treatment have been evaluated considering the incidence of local and/or distant recurrences and patient survival rate. As far as concerns papillary and follicular histotype, we have considered as healed (absence of signs suggesting loco regional and distant recurrence) only those patients presenting both negligible levels of plasma thyroglobulin and a negative total-body 131I scintigraphy. Briefly, in 3 cases (3%), all papillary carcinomas, local recurrence occurred; 9 (8%), all with papillary carcinoma, developed lateral neck recurrence; 6 (5%), 5 with papillary carcinoma and one with follicular carcinoma, developed distant metastases, of which 3 pulmonary, 2 bone and 1 hepatic. Serum thyroglobulin values were considered during the last control visit in 95/113 patients (84%). Of these, 86 (91%) with negligible thyroglobulin levels and negative 131I scintigraphy, were considered healed. All 113 patients with differentiated thyroid carcinoma were alive at the last control visit. Both patients with medullary carcinoma are alive with no sign of illness at the last follow-up control. The patient presenting undifferentiated carcinoma died 2 months after surgery. In conclusion, at the last follow-up control, 1 (1%) patient has died, 5 patients (4%) are alive with disease (2 of whom suffered from multiple recurrences) and the remaining 110 (95%) patients are alive without evidence of disease. As far as concerns complications of surgery, iatrogenic recurrent palsy and permanent hypoparathyroidism are present in 2 (2%) and 10 patients (8%), respectively.

Posterior fossa vestibular neurotomy as primary surgical treatment of Menière's disease: a re-evaluation.

Fifty-eight patients underwent vestibular neurotomy via the posterior fossa approach between September 1992 and December 1998 at the ENT department of Legnano. All patients presented a history of disabling unilateral Menière's disease and underwent complete neuro-otologic evaluation following the 1985 American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) guidelines. All patients underwent MRI imaging, ABR and electronystagmographic testing before surgery. Objective analysis of results is reported using the criteria published by the Committee on Hearing and Equilibrium of the AAO-HNS in 1985. According to the AAO formula, 52 patients obtained a score of 0, indicating complete control of major vertigo spells, while four were classified within the 'substantial control' group. Immediate hearing results indicated that 93 per cent of the patients maintained a level within 10 dB from the pre-operative level. Only one patient experienced a subtotal hearing loss yet retained measurable hearing. No major complications were reported. We conclude that a retrosigmoid approach to vestibular neurotomy can be considered a safe and effective procedure in relieving medically refractory vertigo in Menière's disease while preserving the hearing. Tinnitus and long-term hearing deterioration are not influenced by the procedure.

[Trans-labyrinthine approach for the resection large and giant acoustic nerve neuromas]. / Abordaje translaberíntico para resección de neurinomas de gran tamaño y gigantes del nervio acústico.

The standard translabyrinthine approach for acoustic neuromas removal was introduced by W. House in 1964. After several years of experience the original translabyrinthine approach has been progressively modified into the current "enlarged" approach by extending the area of bone removal. This increased surgical field has made the translabyrinthine approach suitable for the removal of tumours of all sizes. We present our serie of 71 large (52) and giant (19) neuromas of the VIIIth nerve removed through a translabyrinthine approach between 1993 and 1998 at the ENT Department of Legnano.

Abordaje translaberíntico para resección de neurinomas de gran tamaño y gigantes del nervio acústico / Translabyrinthine approach for the resection large and giant acoustic nerve neuromas

El abordaje translaberíntico clásico para la exéresis de neurinomas del acústico fue introducido por William House en 1964. En el curso de los años el abordaje translaberíntico original ha sido progresivamente modificado hacia el actual abordaje "ampliado", extendiendo el área de resección ósea. Esta modificación permite la exéresis de tumores prácticamente de cualquier tamaño del ángulo pontocerebeloso. Se presentan los resultados de 71 neurinomas del nervio acústico grandes (52) o gigantes (19) operados entre los años 1993-1998 por abordaje translaberíntico en el Servicio de Otorrinolaringología del Hospital de Legnano. (AU)

The standard translabyrinthine approach for acoustic neuromas removal was introduced by W. House in 1964. After several years of experience the original translabyrinthine approach has been progressively modified into the current «enlarged» approach by extending the area of bone removal. This increased surgical field has made the translabyrinthine approach suitable for the removal of tumours of all sizes. We present our serie of 71 large (52) and giant (19) neuromas of the VIIIth nerve removed through a translabyrinthine approach between 1993 and 1998 at the ENT Department of Legnano (AU)

[Petrous bone cholesteatoma: surgical strategy]. / I colesteatomi della rocca: strategia chirurgica.

Petrous bone cholesteatoma is a rare pathology which grows slowly and is often asymptomatic. This work presents a series of 25 cases of Petrous bone cholesteatoma and discusses the diagnostic impact, the surgical approach, the results and the complications. Currently our surgical orientation favors translabyrinthine and transcochlear approaches which, better than other ones, allow both radical excision of the lesion and preservation of the main neuro-vascular structures. Out of the 25 patients undergoing surgery, 22 were treated with the translabyrinthine (6 cases) or transcochlear (16 cases) approaches, in 1 case an infratemporal type A approach was used while the remaining 2 were treated with a median cranial fossa approach. Paralysis of the facial nerve is the most dreaded complication, particularly when a deficit is already present prior to surgery. In just a few cases did the hearing justify an attempt at preservation but in no case should this compromise radical removal of the cholesteatoma.

Occult sporadic medullary microcarcinoma with lymph node metastases.

A sporadic form of medullary occult microcarcinoma was cytologically diagnosed, by fine-needle aspiration biopsy (FNAB), on metastatic cervical lymph nodes. The cytologic specimens were partially smeared and partially zinc-formalin-fixed, so that a microinclusion clot for immunohistochemical studies would be possible. The reactivity to calcitonin of neoplastic cells obtained from metastatic cervical lymph nodes supported the search for a thyroid tumor, which only a careful echographic study revealed. Under sonographic guidance, FNAB on a 0.5-cm hypoechoid nodule was performed. The smears were diagnostic of medullary carcinoma. A total thyroidectomy with node dissection was made. Diagn. Cytopathol. 1999;21:203-206.

Parasitic nodule of the right carotid triangle.

We present the case of a woman in whom intraoperatory examination of a laterocervical mass in the right carotid triangle (thought to be a glomus tumor) disclosed thyroid tissue. Although the overwhelming majority of cases of "thyroid parenchyma in the laterocervical region" represent a lymph node metastasis from a primary occult thyroid carcinoma, the rare occurrence of a parasitic nodule, as in our case, must be considered.

Primary malignant melanoma of the oral cavity.

Primary mucosal melanomas of the upper aero-digestive tract are uncommon and represent only 1.7 to 3 per cent of all primary melanomas. The most frequent localizations are the nasal fossae, the paranasal sinuses and the oral cavity where melanomas most often arise from the palate and alveolar ridge, buccal mucosa, lips, tongue and floor of mouth. The authors describe a case of malignant melanoma of the uvula, review the literature and discuss the aetiology, pathology and diagnostic and therapeutic problems.

[Surgery of the base of the skull]. / La chirurgia della base del cranio.

This is a review of the current status of the surgery of the skull base with special reference to the otolaryngological districts. The main topics are as follow: classification of pathology review of the clinical and surgical anatomy clinical and neuroradiological diagnosis surgical management of the pathology in the occipito-temporal area and in the rhinobase principles of management and operative approaches to the skull base in Neurosurgery principles of management and operative approaches to the skull base in Maxillo-Facial Surgery.

Intratemporal vascular tumours.

Hemangiomas of the temporal bone are uncommon benign tumours, occurring most frequently at two sites: the internal auditory meatus (IAM) and the geniculate ganglion. In this paper the authors discuss the pathology, clinical onset and features, and the therapeutic management of two of these lesions. A review of the literature is also presented, paying attention to the controversy regarding the origin, pathogenesis and histologic classification of this rare lesion of the temporal bone.

Hearing preservation in acoustic neuroma surgery. Middle fossa versus suboccipital approach.

Over the past few years there have been reports discussing the preservation of hearing after the removal of acoustic neuromas through the middle cranial fossa or the suboccipital approaches. This is a complex issue with many facets and controversies. In an attempt to answer at least some of these controversies, this article reviews the experience of our group. Preservation of hearing was attempted in thirty-four cases out of 220 acoustic neuromas. In twenty cases the middle fossa approach was used: All tumors were less than 2 cm from the fundus, and in four patients the tumor was bilateral. In sixteen of the twenty (80%) the cochlear nerve was spared; in ten of twenty (50%) measurable hearing was retained, but in only four (20%) was the postoperative hearing serviceable according to the 50/50 rule. In fourteen cases the suboccipital approach was used: All but two of the tumors were smaller than 2 cm. In three patients the tumor was bilateral. The cochlear nerve was preserved in ten of the fourteen cases (71.4%). Measurable hearing was present in four of fourteen cases postoperatively (28.6%); none had serviceable hearing according to the 50/50 rule. Hearing was not preserved in any bilateral tumor case. The middle fossa and the suboccipital approaches are discussed as well as the relative merits of each procedure in preservation of hearing.