Transoral laser microsurgery for glottic cancer in the elderly: Efficacy and safety.

BACKGROUND: Data about the results of transoral laser microsurgery (TLM) in elderly patients are limited. METHODS: A retrospective study of 72 consecutive cases of glottic carcinoma (63 pT1 and 9 pT2 cases) in elderly patients (≥70 years old, mean 76 years) treated with TLM was made. A systematic review of the literature was performed. RESULTS: Six patients (8%) had postoperative complications, but no treatment-related deaths were observed. Local recurrences occurred in 12 patients (16.5%): nine with pT1 (14%) and three with pT2 (33%) tumors. Five-year disease-specific survival (DSS), overall survival, and laryngectomy-free survival were 95%, 68%, and 88%, respectively. The literature review indicated that TLM is safe and effective treatment for these patients, with few complications and good local control (>85%) and DSS (>90%) rates. CONCLUSIONS: Our results and the information from the literature show that TLM for glottic cancer in elderly patients can lead to satisfactory treatment results.

Themistocles Gluck: biographic remarks emphasising his contributions to laryngectomy.

Themistocles Gluck was one of the most imaginative representatives of early modern surgery. During his life he developed landmark innovations in many different areas of surgery. His ideas were often far ahead of his time, a circumstance, which exposed him to severe criticism by his peers. In an era before surgical specialization, he contributed to several fields of surgery. He performed the first total joint replacement in Berlin, in 1890 with a hinged ivory prosthetic knee, and developed models for replacement of shoulder, elbow, and wrist. These efforts had remarkable short term success, but invariably failed in the long term because of infection. A long standing conflict with the powerful Ernst von Bergmann, seriously damaged Gluck's reputation, which he eventually regained, mostly because of his contributions to surgery of the head and neck; in particular, total laryngectomy. The results of laryngectomy in the decade after Billroth's first successful operation were dismal. Through Glucks refinements, developed in cooperation with his coworkers Johannes Soerensen, the results of laryngectomy improved slowly but inexorably, and mortality rates were reduced from 56 to 2%. In his lifetime, Gluck made significant contributions to head and neck surgery, some of which are still currently valid. This publication gives an outline of Gluck's remarkable biography.

The history of horizontal glottectomy.

The history of horizontal glottectomy (HG) for the treatment of bilateral vocal cord lesions is not entirely clear. The present investigation analyzes the history of HG on the basis of cross-referenced database searches in general and professional medical literature databases. Books, original historical articles and medical history reviews were evaluated. The initial work was done by Moser in years from 1959 to 1965, and in 1961 he published the first paper on HG. Follow-up publications were reported in 1977 by Gramowski and in 1984 by Wilke. In 1970, Romanian laryngologists headed by Calarasu described a HG via excision of a rhomboid-shaped portion of the thyroid cartilage, but the authors had neither sufficient numbers of patients nor a sufficiently long follow-up for the procedure to gain widespread acceptance. In 1978, Calearo and Teatini described HG similar to Calarasu's method, but slightly more extended by the eventual inclusion of an arytenoid cartilage in the operative specimen. Theses authors have often been credited as the originators of the procedure, but actually were the first to publish in an English language journal. The procedure, while quite effective for treatment of bilateral and anterior commissure lesions, has never gained general acceptance in the United States, and in current practice, has been supplanted by endoscopic and non-surgical treatments.

Cancer of the oro- and hypopharynx - when to expect recurrences?

CONCLUSION: Relapse-free survival (RFS) of patients suffering from cancers located in the oro- and hypopharynx (COH) is strongly related to the localization and initial tumor stage; 25% of relapses remain undetected by the patients themselves. To detect relapse at an early stage oncologic follow-up should be performed at close intervals during the first 3 years. For confirmation imaging procedures should be indicated generously as well as control endoscopy under general anesthesia. OBJECTIVES: COH are often characterized by a rapid progression of disease in case of relapse. Most of these relapses are already incurable at the time of diagnosis. The aim of the present study was the assessment of time intervals between initial diagnosis of the primary tumor and its relapse. PATIENTS AND METHODS: The course of disease of 280 patients was analyzed. RFS was evaluated statistically. RESULTS: RFS was strongly related to the location of the primary tumor. The median RFS of patients suffering from oropharyngeal cancer was longer (86 months) than that of patients with hypopharyngeal carcinomas (45 months). Patients with COH revealed an accumulation of recurrent disease within the first 33 months after initial diagnosis. Within the first 2 years more than 60% of COH recurred. After 3 years 80% had developed a relapse.

Pathogenesis of lymphangiomas.

Based on various hypotheses concerning lymphangiogenesis published in the literature, different putative mechanisms of lymphangioma development are discussed including failure of the lymphatic system to connect with or separate from the venous system, abnormal budding of the lymphatic system from the cardinal vein, or acquired processes such as traumata, infections, chronic inflammations, and obstructions. Increasingly, the possible influence of lymphangiogenic growth factors on the development of lymphangiomas is discussed. The proved expression of different growth factors in the endothelium of lymphangiomas leads to new hypotheses regarding the pathogenesis of lymphangiomas. Thus, further studies on the lymphangiogenesis and the development of lymphangiomas will have to clarify as to whether lymphangiomas are true malformations or neoplastic in nature.

End-of-life care for terminal head and neck cancer patients.

The objective of this study was to describe end-stage disease in patients suffering from advanced head and neck cancer (hnc). It is one of the most unpleasant and agonizing way a person may die and is a challenging problem for all involved with its treatment. Until today, only few detailed information about the final phase of life of hnc patients in a hospice setting are available. The design of this study was a cohort sample. The course of disease until death was thoroughly analyzed. In addition, hospice staff was interviewed. The study was conducted in a hospice setting (University Hospital). The charts of 16 patients suffering from end-stage hnc were evaluated. The median survival time in the hospice was 19.5 days. There, a more or less rapid deterioration of disease was evident. Several nurses sometimes felt extremely distressed after confrontation with the advanced disease stages. Partially, the situations for the nursing staff were unbearable because of visible, odorous, and fungating tumors or metastasis. The final days were characterized by restlessness followed by somnolence and resulting in an irreversible coma. The goal of palliative treatment of terminal hnc patients is offering the most convenient way to "live" the final days of their lives in dignity. The short survival time in hospice indicates that incurable patients may be referred to terminal care institutions too late in their dying trajectory. Physicians should be encouraged to talk to their terminally ill patients about the status and incurability of the disease as early as possible to facilitate patient and family decision making on how to prepare for the impending end of life.

Analysis of cytokine levels in human lymphangiomas.

BACKGROUND: Different theories concerning the origin of lymphangiomas have been formulated but their precise pathogenesis is still unknown. This study aimed to analyze the levels of different cytokines in lymphangioma cyst fluids. MATERIALS AND METHODS: Fluid aspirates from lymphangioma cysts of five patients were obtained. The intracystic levels of interleukin (IL)-6, IL-8, IL-2R and tumor necrosis factor alpha (TNFalpha) were determined in four cases before and one case after OK-432 administration using an immunometric assay. RESULTS: Increased IL-6 levels were observed in all cases. Moreover, elevated IL-2R and TNFalpha levels were observed in three out of four and elevated IL-8 levels in two out of four untreated cases. There was a 25-fold increase in IL-6 after repeated OK-432 injections while IL-8, IL-2R and TNFalpha levels did not change significantly. CONCLUSION: These findings suggest that cytokines may be involved in the pathogenesis of lymphangiomas.

Incidence of sinunasal disease in laryngectomized patients.

OBJECTIVES: Patients having a total laryngectomy for cancer of the larynx or the hypopharynx are faced with tremendous physical and emotional challenges. Nasal airflow, which transports potentially pathogenic substances into the nose, is almost completely interrupted after laryngectomy. Postlaryngectomy patients are estimated to suffer less frequently from sinunasal diseases. The aim of this study was to evaluate and compare the incidence of sinunasal disorders in patients before and after laryngectomy retrospectively. PATIENTS AND METHODS: A questionnaire was designed comprising items addressing specific symptoms of sinunasal disease. RESULTS: The questionnaire was answered by 104 laryngectomized patients. Common colds occurred less frequently (p < 0.0001) as well as acute and chronic sinusitis (p = 0.0168) after laryngectomy. In comparison, the incidence of rhinorrhea increased significantly (p < 0.0001). Medical interventions for sinunasal disorders were rarely necessary and surgical interventions remained reserved for exceptional cases. CONCLUSION: Sinunasal diseases seem to affect laryngectomized individuals less frequently than before laryngectomy.

History of voice rehabilitation following laryngectomy.

INTRODUCTION: The history of voice rehabilitation following laryngectomy is as long as the history of laryngectomy itself. The multitude of methods which have been employed to reduce the disability associated with the loss of the larynx, illustrate the difficulty of finding an optimal method of reestablishing verbal communication while preserving the ability to breathe and swallow. MATERIAL AND METHODS: The world literature was reviewed using various Internet and medical search engines and library facilities. Landmark articles were identified and summarized. RESULTS: A coherent history of voice rehabilitation following laryngectomy was constructed. DISCUSSION: The methods employed to reestablish voice after extirpation of the larynx may be grouped into the categories of: esophageal speech, surgical methods of creating competent tracheo-pharyngeal shunts to create lung powered voice with and without the use of prosthetic devices to prevent aspiration, "near-total" resection of the larynx with dynamic phonatory shunt, and the use of external pneumatic or electrical devices to create sound which is then transmitted through the oral cavity and pharynx. CONCLUSION: For the past two decades, simple shunt devices inserted either primarily, at the time of laryngectomy, or later as a secondary procedure, have mainly supplanted the other methods of voice rehabilitation, with the exception of an occasional patient who has acquired good esophageal speech, or for whom external devices may be the only practical method of voice production.

An outline of the history of head and neck oncology.

This review analyzes the development of head and neck oncology as outlined in medical history articles. A systematic literature survey was conducted with the search engines "Google Scholar" and "PubMed" and the retrieved publications were cross-referenced. In addition, books and, when possible, original sources were consulted. While most of the material was obtained from publications from the modern era reviewing historical data, some of the information was derived from original source material. The obtained articles on the history of cancer were then analyzed for details on head and neck oncology. The cradle of oncology was located in ancient Egypt and Greece. The search showed that the first tumors treated in the head and neck were either cutaneous malignancies or cancers on the mucosal surfaces of the oral cavity. The origin, diagnosis and treatment of more deeply situated tumors of the larynx and hypopharynx remained obscure for many centuries. The medieval age brought little progress to medicine in general, and in head and neck oncology in particular, due to religious concerns. Renaissance medicine was characterized by advances in medicine and oncology made by systematic dissection studies of normal and pathologic anatomy. The 19th and 20th century reflect the development of head and neck oncology in the era of science based medicine. Almost all of our current understanding of head and neck oncology, our diagnostic methods and treatment strategies have been developed in these two centuries. The analysis showed that many oncologic problems, which occupy our minds today, were also concerns of our medical ancestors.

European surgeons were the first to perform neck dissection.

The history of the surgical treatment of cervical lymph node metastases began in the 19th century, and, unfortunately, the initial attempts at surgical treatment of neck metastases were disastrous. Although some European surgeons reported few cases of radical en bloc dissection, the first successful surgical procedure was performed and described in detail by Franciszek Jawdynski, a Polish surgeon, in 1888. George Washington Crile popularized and illustrated radical en bloc neck dissection in the early 20th century.

In-vitro investigations evaluating the detection spectrum of cervical lymph nodes via handheld gamma probe.

BACKGROUND: Currently the significance of the sentinel node (SN) biopsy also for head and neck cancer is discussed intensively. Based on the complex anatomic structures of this region with a low distance between primary and sentinel node as well as approximately 300 lymph nodes an intensive discussion of the methodical basis of sentinel node detection seems to be essential. Thus it was the aim of the present study to examine the detection spectrum of a gamma probe for identification of cervical lymph nodes using an in vitro model to describe and objectify the particularities of measurement existing in the head and neck region. MATERIAL/METHODS: In an in vitro model the detection spectrum of a gamma probe is examined in 29 different series of measurements (variation of the specimen filled with 99m pertechnetat regarding activity, position, collimator distance, tissue sheath). RESULTS: The presented in vitro model reflects the clinical problem of narrow intranodal activity of neighbouring lymph nodes and reveals a direct relation between the number of radiation sources and their isolated evidence. Using muscle tissue with a thickness of 0.4 cm, two two-rowed radiation sources, the more powerful is placed 1.5 cm behind the other specimen, with a lateral difference of 3 cm, can be resolved only with a maximal detector distance of 1 cm. Not the difference of the tissue but the thickness of the tissue is decisive for detection. CONCLUSION: Especially for pharyngeal and laryngeal lymph nodes a transcutaneous measurement reflecting the exact localisation of hot nodes in the area of the deep jugular lymph nodes is not possible with increasing tissue thickness. The described results require a critical discussion of the different detection techniques varying among the different working groups of this field.

Treatment of HNSCC cell lines with the EGFR-specific inhibitor cetuximab (Erbitux) results in paradox phosphorylation of tyrosine 1173 in the receptor.

Overexpression of the epidermal growth factor receptor (EGFR, ErbB1, HER1) is frequent in head and neck squamous cell carcinomas (HNSCCs) and correlates with disease progression. Inhibition of EGFR with the kinase inhibitor AG1478 abolished receptor phosphorylation and reduced cell proliferation. However, treatment of HNSCC cells with cetuximab (Erbitux), a monoclonal antibody designed to block the EGFR ligand binding site, led to paradox EGFR activation due to hyperphosphorylation of tyrosine 1173, however, with a concomitant reduction in Erk1/2 phosphorylation levels. No pronounced influence on cell proliferation levels could be observed after treatment with this antibody. Since cetuximab appears able to activate EGFR in HNSCC cell lines, it is necessary to rethink the exact mechanisms by which cetuximab that recently was approved for the treatment of advanced head and neck cancer, inhibits tumor growth.

Manifestations of hereditary hemorrhagic telangiectasia in children and adolescents.

The medical literature provides little information on manifestations of hereditary hemorrhagic telangiectasia (HHT) in children. The presented investigation was initiated to analyze early presenting symptoms in HHT, which should help to make the diagnosis at a young age and thus prevent potential complications from occult visceral arteriovenous malformations (AVM), which have commonly been described in HHT. A series of 15 children and adolescents with a suspicious diagnosis of HHT were examined clinically for typical signs and symptoms of the disorder. If the diagnosis of HHT seemed to be likely, recommendations for non-invasive screening procedures were given. Screening was directed at the detection of occult visceral AVMs. Main outcome measures were the definition of principal signs of HHT in children and adolescents. Family history was positive for HHT in 13 persons. The principal sign of recurrent epistaxis was present in 10/15 individuals and the earliest age of onset with regard to epistaxis was 4 years. Cutaneous vascular lesions were present in 5/15 patients. Screening for AVMs was performed in six individuals and revealed vascular lesions of the brain in two patients and vascular lesions of the lung in two patients. Gastrointestinal hemorrhages were present in one infant. Based on these findings, diagnosis of HHT seemed likely in ten individuals and unlikely in five individuals. Signs and symptoms of HHT in children and adolescents may be discrete, but are detectable at an earlier age than previously thought. Clinical examinations in children from HHT families may help identify candidates who will benefit from molecular genetic testing or screening imaging studies.

Natural history and control of epistaxis in a group of German patients with Rendu-Osler-Weber disease.

INTRODUCTION: Epistaxis is the most common symptom of a complex, genetically determined vasculopathy, which is known under the notion hereditary hemorrhagic telangiectasia (HHT, Rendu-Osler-Weber-syndrome). This study was initiated to gain more knowledge about the natural history of epistaxis in a German HHT-population. PATIENTS AND METHODS: Data of 49 HHT patients were ascertained by interviewing these patients with a standardized disease specific questionnaire. Patients' files were retrospectively reviewed for data concerning age, gender, past medical history, laboratory parameters, number of hospital admissions for epistaxis, conservative and operative types of therapy, treatment results and follow-up. MAIN RESULT: Epistaxis was the first and most prominent symptom in 93% of the patients and could be triggered most frequently by stress. Half of the patients had experienced first episodes of epistaxis in childhood, but usually epistaxis did not become troublesome before the age of 35 years. The effects of hormonal changes or therapies with systemic hormones were inconclusive with regard to impact on epistaxis. Patients with septal perforations had to be admitted for inpatient epistaxis treatment more frequently than patients with an intact nasal septum. An overall reduction of frequency and intensity of epistaxis could be achieved in 89% of the patients through the daily use of nasal lubricants and a minimum of two treatment sessions with the Nd:YAG laser. However in none of the cases the treatment results were permanent. More than 50% of the patients, who had been screened for visceral arteriovenous malformations, were positive for pathologic vascular lesions. PRINCIPAL CONCLUSION: The natural history of epistaxis in German HHT patients is similar to previously described entities from other parts of the world. First clinical signs of HHT may be present at an earlier age than previously thought.