The Role of Trans Oral Robotic Surgery in the Carcinoma of Unknown Primary: A New Evidence in the Horizon?

The detection of the primary site in Carcinoma of Unknown Primary (CUP) is a challenging task which can significantly alter the course of management and also prognosis. Various modalities have been assessed with varying sensitivity and specificity. Imaging and cytological diagnosis have formed a key part of the diagnostic algorithm of CUP. Trans Oral Robotic Surgery offers the advantage of being both diagnostic as well as therapeutic with promising sensitivity and specificity and can form an integral part in the management of CUP. A prospective study was carried out at a tertiary care centre over a period of one year. Patients with unilateral neck swelling which was histopathologically proven squamous cell carcinoma neck metastasis were included in the study. They were evaluated with endoscopy and radiology according to the standard algorithm. When these failed to detect the primary, the patients underwent ipsilateral radical tonsillectomy and tongue base mucosal wedge biopsy via TORS. Post-operative histopathological examination was done on the resected specimens to detect the primary site. Transoral Robotic Surgery was able to localise primary in 50% of the patients enrolled in the study. Out of the primary site identified by TORS; 55.56% were located in the tonsil and 44.4% in the tongue base. TORS can offer promising detection rates of the occult primary in CUP and should form an integral part of the diagnostic algorithm.

Pilot Evaluation of Perioperative High Dose Rate Brachytherapy in Head Neck Cancers.

Perioperative high dose rate brachytherapy involves insertion of brachytherapy catheter over the tumor bed during surgical removal of disease followed by radiation in the postoperative period. It has applications in radiotherapy dose escalation or reirradiation and for extending the surgical margins. We report here initial results of treatment in five cases of locally advanced head and neck cancers.

Survival Analysis of Oral Squamous Cell Carcinoma Patients Attending Tertiary Care Centre of North India.

The cumulative survival for all stages in oral squamous cell cancers (OSCC) in the world remains poor despite the advances in management; hence, we conducted this study to evaluate the survival outcomes. This is a retrospective review and analysis of treatment, follow-up and survival records of 249 OSCC patients treated in our department from April 2010 to April 2014. Telephonic interviews were conducted for survival details for some patients who had not reported. Survival analysis was done using the Kaplan-Meier analysis, comparisons were done using log-rank test and multivariate analysis was conducted using the Cox proportional hazard model to find different variables (site, age, sex, stage and treatment) affecting overall survival (OS)/disease-free survival (DFS). Two-year and 5-year DFS for OSCC were observed to be 72.3% and 58.3% with mean survival of 63.17 months (95% CI: 58.342-68.002). Similarly, OS at 2 years and 5 years were 84.3% and 55.9% with mean survival of 65.143 months (95% CI: 60.143-69.601). Tumour site, patient age, stage of disease and treatment modality had a statistically significant hazardous effect on the overall and disease-free survival rates. The significant influence of age, site of tumour, stage of disease and modality of treatment required based on the clinic-pathologic risk factors on prognosis emphasizes the importance of early diagnosis through regular screening and early treatment which can be ensured with early referral, high clinical suspicion and awareness at the point of primary/secondary care.

Intra-operative intaoral ultrasonograpy ensures free deep resection margins in carcinoma tongue: A pilot study.

ABSTRACT: Resection of primary in carcinoma tongue is challenging as the tumor often spreads submucosal and deep in muscles. There are various Intraoperative tools available to guide tumor resection margins. We studied the use of intraoperative ultrasound-guided resection for obtaining free deep resection margins in cases of oral carcinoma tongue. To assess the feasibility of resection of tongue tumor using intraoral ultrasound intraoperatively. 5 patients of oral tongue squamous cell carcinoma were included in this prospective pilot study. Intraoral ultrasound-guided resection of the primary tongue tumor was done. The surgeon moved the probe over the tumor and focussed on the point of maximum invasion by the tumor. A 26 G needle was passed in the tongue at a point that was 10 mm away from the deepest point of infiltration. It marked the deepest plane of resection. Following the above marking, a resection of tumor was done. Deep surgical resection margin was found to be >5 mm (free) in all the USG-guided surgically resected primary tongue tumors on histopathological examination. We have found intraoperative ultrasonography a useful tool for the surgical resection of primary tongue tumours.

Perioperative high dose rate brachytherapy in head and neck cancers: case report and review of clinical application.

Perioperative high dose rate brachytherapy is a radiotherapy treatment technique which involves intraoperative insertions of brachytherapy catheters into the tumor bed during the surgical resection followed by treatment in the post-operative period. We report here two cases to highlight its use in the primary treatment and reirradiation of head and neck cancers.

Feasibility of Using Posterior Auricular Artery as Landmark for Identification of Facial Nerve Trunk in Parotid Surgery: A Cadaver Study.

INTRODUCTION: Despite good surgical knowledge of the anatomy of parotid gland and meticulous surgical technique, the incidence of facial palsy in parotid surgeries is up to 26.7% transient and 1.7% complete facial palsy(1). The risk of facial palsy increases further in malignant and revision cases. METHOD: Superficial parotidectomy was done in 14 cadaveric hemi faces in 10 cadavers. Posterior auricular artery and its stylomastoid branch was dissected and facial nerve trunk was identified in all cases. The relationship of posterior auricular artery along with its stylomastoid branch with the facial nerve trunk was studied and recorded. RESULT: Posterior auricular artery was found running inferior to the facial nerve trunk in 12 cadaveric dissection while the posterior auricular artery was found crossing below the main trunk of facial in 2 cadaver dissection. The average distance between PAA and facial nerve trunk was 7 mm (2-14 mm) Stylomastoid artery was found arising from Posterior auricular artery in 12 of 14 and it was found running medial to the facial nerve trunk in all the 8 cadavers. CONCLUSION: Post auricular artery can be used as another landmark for identification of the main trunk of facial nerve in parotid surgeries.

Malignant peripheral nerve sheath tumor of the parapharyngeal space arising from cervical sympathetic chain: A rare entity.

Malignant peripheral nerve sheath tumors (MPNSTs) of parapharyngeal space are rare and if present are most often in association with neurofibromatosis type 1 (NF-1). Only a few cases of MPNST have been reported in the literature without coexisting NF. We report one such case of an MPNST of parapharyngeal space tumor in a 35-year-old female with no associated features of NF-1. She presented with right-sided neck swelling and ptosis. Magnetic resonance imaging showed a 7 cm × 8 cm × 11 cm irregular swelling in the right parapharyngeal space with invasion of surrounding muscles. The mass was excised using a transcervical approach. Postoperative histopathological examination of the specimen revealed MPNST possibly arising from the cervical sympathetic chain.

Quality of Life in Patients with Reconstructions After Resections for Oral Cavity Cancers.

To determine effects of reconstruction in advanced oral cavity cancers in achieving a quality of life (QOL), which can help patients to cope with their routine day to day activity. A Cross sectional analysis involving 32 patients of stage III and IV oral cavity cancers already operated in the department of otolaryngology and head and neck surgery was carried out. All these patients had resection of their tumors along with reconstruction. Patients who consented for QOL assessment and follow up through personal visit and telephonic interviews were included in the study. Voice related quality of life; Swallowing related QOL; overall Quality of life (WHO QOL BREF II) and disability assessment scale (WHO DAS II) were used for assessing the various QOL parameters during post-operative period. Patients with stage T3 tumors had better QOL compared to patients with T4 stage tumors. Patients who had reconstruction with free flaps had better QOL compared to those with Pectoralis Major myocutaneous (PMMC) flaps or those reconstructed with combinations of flaps involving delto-pectoral flaps or local flaps along with a free flap or PMMC. Patients with lower stage tumors have better QOL even after reconstruction. If available, free flaps should be preferred over local flaps. Delto-pectoral flaps should be a less preferred option in terms of QOL. Every patient should be counseled accordingly while any reconstruction plan is included in the management of cancers of oral cavity.

Does preoperative bacterial culture have bearing on healing of mastoid cavity: A prospective study.

OBJECTIVE: To study the bacteriological profile in a healing mastoid cavity. METHODS: This study was a single centre prospective study. Culture swabs from granulations in the mastoid cavity were sent in 40 consecutive patients with squamosal chronic otitis media undergoing mastoidectomy. Cultures were processed for both aerobic and anaerobic bacteria. RESULTS: Preoperatively: specimens from 26 out of 40 (60.5%) had growth on culture, with 22 (55%) showing only one organism while 4 showing multiple organisms. The commonest organism isolated was pseudomonas aeruginosa (n = 15).At 1 month after mastoidctomy, 11 patients had sterile culture while 29 had growth, of which 26 had aerobic growth and 3 had anaerobic growth. Pseudomonas was seen in 22 patients and staphylococcus aureus in 2 patients. The mean Merchant score was 2.At 3 months: 29 patients (72.5%) had sterile culture from mastoid cavity while 11 patients (27.5%) had growth on culture. All positive cultures were aerobic, including pseudomonas (n = 9) and proteus (n = 2). The mean Merchant score was 1.03. Of the 40 patients, 16 (40%) had a different organism cultured postoperatively compared to preoperative swabs. CONCLUSION: Pseudomonas and proteus seem to be the most common organisms responsible for persistent otorrhea after mastoidectomy. Persistent sterile otorrhea was seen in 4 patients (10%) in this group at the end of 3 months. Sterile cultures of preoperative swab are more likely to remain sterile in the postoperative period.

Secondary encephalocele in infant following subdural empyema repaired endoscopically-A case report.

Subdural empyema (SDE) is an uncommon entity, mostly associated with meningitis and can be life threatening in infants. Rarely, a subdural empyema can lead to nasal encephalocele which can be challenging situation to manage especially in infant. We present a case of 7 month old infant who presented with subdural empyema that led to formation of nasal encaphalocele after 4 months which was managed endoscopic route.

Epithelio- Myoepithelial Carcinoma of Masseteric Space: a Case Report.

Epithelio-myoepithelial carcinoma (EMEC) is a very rare malignancy of the salivary gland which comprises less than 1 % of salivary gland tumors. In the parapharyngeal space they can either arise from the deep lobe of parotid gland or de novo from minor salivary glands. We present a case of epithelio-myoepithelial carcinoma of parapharyngeal and masseteric space. The case is important for its rarity of presentation and we discuss the surgical difficulties and morbidities.

Role of preoperative versus postoperative itraconazole in allergic fungal rhinosinusitis.

Antifungals used as adjuvant to surgery in AFRS (Allergic Fungal Rhinosinusitis) have shown varying success in delaying recurrences. Itraconazole has been used both as preoperative and postoperative adjuvant. This study investigates the role of itraconazole in AFRS and compares its role between preoperative and postoperative administration of the drug. Patients were randomly divided into groups as: Group 1 (n = 25), received 4 weeks itraconazole in the preoperative period and operated subsequently, Group 2 (n = 25), received 4 weeks itraconazole in the postoperative period, Group 3 (n = 50), matched patients of AFRS, who didn't receive itraconazole. All the groups received oral steroids in tapering doses staring from 1 mg/kg for 6 weeks in the postoperative period. Symptomatic (SNOT 20), radiologic (Lund Mackay, LM) scores and endoscopic (Kupferberg's NE Grades) were noted. Primary postoperative follow-up was for 24 weeks with routine CT scans and nasal endoscopies, followed by which all the patients were followed with nasal endoscopies only with CT scans when required. Both preoperative and postoperative itraconazole showed significant improvement in the SNOT, LM, and Kupferberg's grades in the follow-up period. Preoperative itraconazole therapy showed significantly better results compared to postoperative itraconazole therapy though the recurrence rates were similar in both groups. Itraconazole is a better preoperative adjunct in AFRS than postoperative.

Neck dissection with harmonic scalpel and electrocautery? A randomised study.

OBJECTIVE: Is the use of harmonic scalpel for neck dissection useful? Literature search did not show a single, prospective, randomised control trial. We intended to study the role of harmonic scalpel in neck dissection and compare it with conventional electrocautery technique for oral cavity carcinoma. METHODS: 40 patients undergoing selective neck dissection for primary oral cavity malignancy were enrolled in this study. The harmonic scalpel (HS) group consisted of 20 patients, and the electrocautery technique (ET) group comprised of 20 patients. The following variables were examined: intraoperative blood loss, operative time, number of ligatures used, postoperative drain, and postoperative hospital stay. RESULTS: Intraoperative blood loss was found to be significantly reduced in harmonic scalpel group as compared to electrocautery group. However, we found no difference in other parameters like operative time, postop drain, postoperative hospital stay and number of ligatures used between both groups. CONCLUSION: Harmonic scalpel for neck dissection is associated with significantly lesser intraoperative blood loss as compared to electrocautery. There is no effect on operative time and postoperative hospital stay in both groups.

Comparison of spinal accessory dysfunction following neck dissection with harmonic scalpel and electrocautery - A randomized study.

INTRODUCTION: Harmonic scalpel is being increasingly used in neck dissection as alternative to conventional electro-cautery for achieving haemostasis. Use of harmonic scalpel has been shown to significantly reduce intra operative blood loss and intra operative time in neck dissection. But how safe is it with regards to nerve injury (spinal accessory nerve and other nerves) during neck dissection. We intended to study the spinal accessory nerve injury during neck dissection by both harmonic scalpel and electro cautery technique and compared postoperative recovery of shoulder function after neck dissection. METHODS: 40 patients undergoing selective neck dissection for primary oral malignancy were enrolled in this study. The Harmonic scalpel (HS) group consisted of 20 patients, and the electo cautery technique (ET) group had 20 patients. The following variables were examined: shoulder pain by visual analog scoring and shoulder function by means of degree of abduction and graded was grade I-0-90°; grade II-90-135°; grade III-135-180°. They assessment was done at the time of discharge, 1month and 3month and six month after surgery. RESULTS: Though shoulder pain was almost similar at 1st week and 1month, however at 2nd and 6th month shoulder pain was found to be significantly lesser in harmonic scalpel group as compared to electro cautery. At 1week more no of patients had restricted shoulder mobility in HS as compared to EC group. But at 6months the shoulder function was found to be significantly better in HS group as compared to EC group (p value<0.05). CONCLUSION: Spinal accessory nerve function recovery after selective neck dissection is better in HS group as compared to the electro cautery group.

Congenital bilateral adult choanal atresia undiagnosed until the second decade: How we did it.

BACKGROUND: Bilateral congenital choanal atresia that presents in adulthood is rare. There are only eight reported cases in the literature. METHOD: We present a ninth case of adult bilateral choanal atresia diagnosed at the age of 20 years. Can a bilateral choanal atresia present so late in life when such a condition is considered incompatible with life? RESULTS AND CONCLUSION: Clinical details, diagnosis, and surgical steps with a clear depiction of photographs and comparison with all other previously reported cases, which can help novel otolaryngologists in their clinical practice are discussed.

Oropharyngeal exercises in the treatment of obstructive sleep apnoea: our experience.

INTRODUCTION: Oropharyngeal exercises are new, non-invasive, cost effective treatment modality for the treatment of mild to moderate obstructive sleep apnoea. It acts by increasing the tone of pharyngeal muscles, is more physiological, and effects are long lasting. AIM OF THE STUDY: The aim of our present study was to evaluate the effect of oropharyngeal exercises in the treatment of mild to moderate obstructive sleep apnoea. METHOD: Twenty patients of mild to moderate obstructive sleep apnoea syndrome (OSAS) were given oropharyngeal exercise therapy for 3 months divided into three phases in graded level of difficulty. Each exercise had to be repeated 10 times, 5 sets per day at their home. Oropharyngeal exercises were derived from speech-language pathology and included soft palate, tongue, and facial muscle exercises. Anthropometric measurements, snoring frequency, intensity, Epworth daytime sleepiness and Berlin sleep questionnaire, and full polysomnography were performed at baseline and at study conclusion. RESULTS: Body mass index (25.6 ± 3.1) did not change significantly at the end of the study period. There was significant reduction in the neck circumference (38.4 ± 1.3 to 37.8 ± 1.6) at the end of the study. Significant improvement was seen in symptoms of daytime sleepiness, witnessed apnoea, and snoring intensity. Significant improvement was also seen in sleep indices like minimum oxygen saturation, time duration of Sao2 < 90 %, sleep efficiency, arousal index, and total sleep time N3 stage of sleep at the end of study. CONCLUSION: Graded oropharyngeal exercise therapy increases the compliance and also reduces the severity of mild to moderate OSAS.

Understanding paediatric allergic fungal sinusitis: Is it more aggressive?

OBJECTIVE: To study and characterize the features of AFRS in children as compared to adults. METHODS: 50 consecutive patients of AFRS attending our outpatient department were included in the study from July 2011 to December 2013. They were divided into two groups (A and B) according to age being ≤14 years and >14 years. Clinical history and examination included anterior rhinoscopy, SNOT 20 scores, CT of Nose and PNS (para nasal sinuses) (Lund Mackay scores), diagnostic nasal endoscopy (Kupferberg's grades), punch biopsy from nasal polyp, serum IgE, absolute eosinophil counts (AEC) and Aspergillus skin hypersensitivity test was done in all patients for conformation of AFRS. Bent and Kuhn's criteria were used for diagnosis. Sweat chloride levels were done in all patients of group A. RESULTS: Group A had 12 patients and group B had 38. Mean duration of symptoms was significantly less in children as compared to adults (p<0.05). All patients of both groups had nasal polyposis at presentation. Unilateral disease and multisinus involvement was more common in children (6/12) as compared to adults. Proptosis (2/12) and telecanthus (4/12) was more common in children (group A) as compared to adults (group B). LM (Lund Mackay) scores and serum IgE were significantly high in children as compared to adults. Follow up CT scans showed early evidence of recurrence in children as compared to adults (p<0.05). CONCLUSION: AFRS was seen to be more aggressive in children with increased fungal load when compared with adults. Typically, AFRS in children was less responsive to treatment with increased recurrence rates.

Efficacy of preoperative itraconazole in allergic fungal rhinosinusitis.

INTRODUCTION: Criterion standard treatment of allergic fungal sinusitis (AFS) is primary surgery followed by adjuvant therapy. Even after good surgery, recurrence rates vary from 10 to 79%. Antifungals, e.g., itraconazole, and steroids have shown varying success rates in delaying recurrences given after surgery. Itraconazole decreases the need for steroids given as a primary treatment in allergic bronchopulmonary aspergillosis. This study investigated the efficacy of itraconazole given preoperatively for allergic fungal rhinosinusitis. METHODOLOGY: A prospective study was carried out from July 2011 to November 2013 with 27 patients with histologically proven AFS, who were given itraconazole for 1 month in the preoperative period and operated after completion of the course of itraconazole. They were compared with 25 matched controls of patients with AFS who were operated on directly without preoperative itraconazole. Both groups were given oral steroids in tapering doses for 6 weeks during the postoperative period and followed up at regular intervals. Evaluations were done by using symptomatic (Sino-Nasal Outcome Test [SNOT-20]), radiologic (Lund Mackay scores), and endoscopic (Kupferberg nasal endoscopic grades) parameters. RESULTS: Symptomatology scores (SNOT-20) decreased significantly (p = 0.000) with itraconazole. There was a decrease (p = 0.007) in the Lund Mackay scores that reached up to 0. There was complete resolution of disease in 15% of the patients. Reductions in hyperdensities were noted on computed tomography in all the patients after preoperative itraconazole. Polyp sizes decreased and nasal endoscopic grades improved after itraconazole. Postoperative fungal cultures were positive in 60% of the patients in the preoperative itraconazole group compared with 76% of the patients in the control group, which indicated a decreased fungal burden. CONCLUSION: We found improvements in clinical, radiologic, and endoscopic parameters in AFS after preoperative itraconazole administration, which decreased the disease load significantly and also reduced the extent of surgery in the short-term follow-up. It may prove to be a good preoperative adjunct that needs further research.

Metastasis to submandibular glands in oral cavity cancers: Can we preserve the gland safely?

OBJECTIVE: To analyze submandibular gland (SMG) involvement in cases of oral cavity cancers and decide whether to remove submandibular glands while performing neck dissections for oral cavity cancers to decrease the incidence of xerostomia, a common issue post-operatively. METHODS: Retrospective analysis of 157 neck dissections out of 204 neck dissections performed for oral cavity carcinomas in the Department of Otolaryngology and Head and Neck Surgery from 2008 to 2013 was done. SMG was bilaterally removed in 6 dissections, hence a total of 163 glands were analyzed. Those involved by tumor in histopathology were further studied for the pattern of involvement. RESULTS: 3.68% (6/163) glands showed involvement by the tumor. 9.20% (15/163) showed chronic sialo-adenitic changes. Four of the six involved glands showed direct contiguous spread from primary lesion, one showed extra-capsular spread from level IB lymph nodes and evidence of both modes of spread was seen in one. Evidence of metastasis was not seen in any of the glands (0%). Literature review showed a metastasis rate of 0.096% (2/2074). CONCLUSION: Metastatic involvement of submandibular gland is extremely rare. Submandibular gland preservation, in the absence of evidence of gross contiguous involvement, does not affect survival. Hence, SMG can be safely spared during neck dissections for oral cavity squamous cell cancers except in certain situations such as close proximity of the primary lesion to gland, presence of intra-capsular lymph nodes in radiology, gross intraoperative evidence of invasion of the SMG and in salvage surgeries performed in post-irradiated and recurrent cases.