Secondary tracheoesophageal puncture and myotomy--A novel outpatient technique.

BACKGROUND: The purpose of this study was to show a novel technique for secondary tracheoesophageal puncture (TEP) and myotomy in patients who previously underwent total laryngectomy. METHODS: Fifteen patients underwent secondary TEP and 3 patients underwent myotomy. In 1 patient, both myotomy and TEP were done concurrently. A Foley catheter is nasally inserted into the esophagus with the patient under local anesthesia and the catheter balloon is inflated at the site of the planned procedure. The myotomy is performed over the inflated balloon for esophageal posterior wall protection and a voice prosthesis is inserted in a small incision made by the physician. When only myotomy is performed, the muscles over the mucosa are incised. A voice test is performed immediately. RESULTS: All patients exhibited good voice rehabilitation. One patient who had a myotomy had a penetration of the pharyngeal mucosa with immediate closure and no sequelae. CONCLUSION: Outpatient Foley catheter-guided myotomy and secondary TEP are simple, safe, time saving, and cost-effective procedures.

Exclusive endoscopic ear surgery for acquired cholesteatoma: preliminary results.

OBJECTIVE: To present preliminary results in transmeatal exclusive endoscopic ear surgery. STUDY DESIGN: Retrospective. INTERVENTION: Rigid endoscopes were used for all procedures. A wide posterior tympanomeatal flap was elevated transmeatally, and the scutum was removed with a bone curette or was drilled until visualization of cholesteatoma extension and the mastoid antrum. The malleus and incus were removed when they were involved in the cholesteatoma or restricted access to it. When present, the stapes was left intact. Endoscopic accessibility was defined by no extension of the cholesteatoma beyond the level of the lateral semicircular canal. Scutumplasty was by with tragal cartilage, and tympanic membrane defects were reconstructed with the palisade technique and perichondrium. RESULTS: Thirty patients, aged 9 to 75 years, underwent the exclusive endoscopic transmeatal cholesteatoma eradication between July 2008 and May 2010. There were no incidents of iatrogenic injuries to the facial nerve or ossicles. Closure of the tympanic membrane and good hygienic status (water tolerance and absence of inflammation) were achieved in all operated ears. Two patients had significant postoperative worsening of their sensorineural hearing loss: the cholesteatoma of one of them involved all 3 ossicles and oval window and the other patient experienced postoperative labyrinthitis. There was no residual disease in 18 patients who were followed for more than 1 year, and the non-echo-planar base diffusion-weighted sequence magnetic resonance imaging was negative in 3 patients. CONCLUSION: Our preliminary results indicate that the minimally invasive endoscopic ear surgery allowed complete eradication of cholesteatoma from the middle ear and its extensions, with minimal morbidity and good functional results.

Recombinant activated factor VII and tranexamic acid are haemostatically effective during major surgery in factor XI-deficient patients with inhibitor antibodies.

One-third of patients with severe factor XI (FXI) deficiency caused by homozygosity for null alleles develop inhibitor antibodies following exposure to plasma. Haemostasis during surgery is achievable in such patients by recombinant activated factor VII (rFVIIa) at doses used in haemophilia A patients with an inhibitor to FVIII. However, thrombosis has occurred in three of 12 such patients. In this study we discerned whether low-dose rFVIIa would secure haemostasis and cause no thrombosis in patients with severe FXI deficiency and an inhibitor during surgery. In vitro, a very low concentration of rFVIIa (0.24 microg/ml) induced thrombin generation in FXI-deficient plasma quite similarly to 1.9 microg/ml (a concentration that is achieved in patients with haemophilia A and inhibitor after infusion of 80 microg/kg). Based on this finding, a protocol was designed for four patients with severe FXI deficiency and an inhibitor or immunoglobulin A deficiency who underwent five major surgical procedures. This included administration of tranexamic acid from two hours before surgery until seven to 14 days after, and single infusion of low-dose rFVIIa. No excessive bleeding or thrombosis were observed. In conclusion, a single low dose of rFVIIa and tranexamic acid secure normal haemostasis in patients with severe FXI deficiency who can not receive blood products.

[Recurrent pleomorphic adenomas of the parotid gland--treatment and outcome].

Epithelial tumors of the parotid gland comprise 3% of head and neck tumors, and 70%-80% of those are benign. Pleomorphic adenoma is the most common tumor of the parotid gland. Recurrence rate of pleomorphic adenomas (RPAs) following superficial parotidectomy was reported to be as high as 4%, sometimes associated with inadequate surgical treatment of the primary tumor. These tumors have a very slow growth rate, and a ten-year follow-up period is mandatory. RPAs are usually located in the superficial lobe (75%) and are often multinodular. Treatment of RPAs is challenging due to a high risk of facial nerve paresis (7%-50%) and of re-recurrence. Occasionally, post-operative radiotherapy is indicated, but this treatment must be balanced with potential long term risks of secondary malignancy. Medical records of 16 patients with first recurrence and 4 patients with more than one recurrence who were treated in our institution during the past 5 years were reviewed. Five patients were treated by post-operative radiotherapy. Residual or recurrence rate following a second procedure was 15%. Two patients (10%) had permanent paresis of a single branch of the facial nerve. Seventeen out of 20 patients (85%) treated were disease-free after a follow-up period of 5 years. In conclusion, surgical treatment of RPAs is a complex procedure which should be managed by a trained surgical team and can be performed with success and minimal morbidity.

25-year experience of using a linear stapler in laryngectomy.

BACKGROUND: Stapler application for pharyngeal closure after total laryngectomy allows for rapid watertight closure without field contamination and for potentially reduced fistula rate. METHODS: One thousand four hundred fifteen patients underwent laryngectomy with linear stapler closure. In 98.6%, laryngectomy was performed after radiation failure. RESULTS: A relatively high incidence of pharyngeal fistulae (12%) was seen, although these rates were reduced to 5.5% during the recent decade. Simultaneous creation of tracheoesophageal fistula and myotomy by a novel technique was introduced. Swallowing problems were observed in 11 patients and local recurrences in nine patients (0.6%). CONCLUSION: The advantages of mechanical sutures with the closed stapling technique are simple and rapid application, watertight closure with good hemostasis, prevention of field contamination, good speech and deglutition, no increase in fistula rate, and low local recurrence rates. Operating room expenses may also be significantly reduced, rendering this method cost-effective as well.

Limited use of complementary and alternative medicine in Israeli head and neck cancer patients.

HYPOTHESIS/OBJECTIVE: The use of complementary or alternative medicine (CAM) is growing among cancer patients. A Medline search failed to reveal any dedicated report of CAM use specifically in patients with head and neck cancer (HNC). STUDY DESIGN: Use of CAM was evaluated in a cohort of treated HNC patients. METHODS: Patients treated for HNC were asked if they had used CAM since their diagnosis. Demographic data and data pertaining to mode of CAM, duration of treatment and effects were obtained. RESULTS: One hundred forty-three patients (mean age 61 years) were included. Only nine patients (6.3%) reported using disease related CAM. This included acupuncture (4), Reiki (2), naturopathy (2), hypnosis (1), shiatsu (1), chiropractic treatment (1), homeopathy (1), and selenium (1). CONCLUSION: Contrary to the reported use, few of our HNC patients used CAM. Although this could be related to good caregiver-patient relationship, further studies in comparable populations are warranted to evaluate if this is a local or a pervading finding in head and neck cancer patients.

Quality of life following parotidectomy for malignant and benign disease.

Parotidectomy is performed for benign or malignant tumors and for selected benign inflammatory and autoimmune conditions. Possible associated complications include facial nerve paralysis, pain, loss of sensation, gustatory sweating, and facial scarring. Global quality of life in patients undergoing parotidectomy has not been reported. The implications of facial surgery with the catastrophic potential of facial nerve paralysis may severely affect quality of life. A quality-of-life study was conducted in patients undergoing parotidectomy for benign and malignant diseases to define the significance of associated morbidity and its impact on quality of life. A quality-of-life instrument was specifically created, based on the principles of the University of Washington Quality of Life questionnaire, and mailed to the patients. Questions addressed recognized complications of parotidectomy. Patient group results were compared for age above and below 45 years, sex, benign versus malignant disease, presence or absence of Frey syndrome, and presence or absence of benign pleomorphic adenoma. Forty-six percent of 125 patients meeting the study criteria fully replied to the questionnaire. The global health score was 3.5, corresponding with "good" to "very good." Except for local sensation, which had a score of 50, all other domains scored above 76. Change in appearance, gustatory sweating, and pain were reported by 70 percent, 57 percent, and 30 percent, respectively. Importance attributed to all domains except facial function was low. Pain was encountered significantly less in patients younger than 45 years of age, and scores for appearance were also highly significant in this age group. Postoperative sequelae were noted in the majority of patients. The dominant sequelae were altered sensation, change in appearance, Frey syndrome, and pain. A degree of permanent postoperative facial nerve impairment was reported by 10 patients. Nevertheless, overall, parotidectomy does not seem to severely affect quality of life.

Quality of life of well-differentiated thyroid carcinoma patients.

The thyroid gland is the second most common site for malignancy in the head and neck region. Quality of life (QOL) of thyroid cancer patients has not been studied directly. The QOL of long-term thyroid carcinoma patients was investigated. A standardized set of questions based on the University of Washington QOL questionnaire for head and neck cancer with specific domains associated with thyroid disease was created. This questionnaire was mailed to patients who underwent total thyroidectomy for well-differentiated cancer in the department of Otolaryngology--Head and Neck surgery at the Chaim Sheba Medical Centre in Israel between the years 1994-2000. Seventy-eight patients undergoing total thyroidectomy were identified. Forty-eight patients were excluded and 20 out of the 30 remaining patients responded to the questionnaires. Six were male and 14 female, 12 were under the age of 45 (these 12 patients were staged as stage 1). Eleven patients underwent neck dissection. General health and QOL were significantly better for the younger age group and so was the calcium balance score. General health and QOL were significantly better for patients undergoing neck dissection. The overall QOL score was 3.8 conforming with 'good' in the questionnaire. Surgery and initial radioiodine treatment scored 6.75 and 6.9 respectively in the distressing scale (0-10 range: 10 = most distressing). The highest distress was encountered during withdrawal from thyroid hormone. Women rated the importance of proper replacement therapy significantly higher than men. Global low scores were found for employment and for effective L-thyroxine replacement therapy. Overall, QOL in these patients was good although lower than expected when compared with other forms of cancer. Age and gender-related differences were noted. Better QOL in neck dissection patients is probably associated with age under 45 years. High distress scores for hormone withdrawal during periodical imaging correspond with former reports and supports use of Thyrogen. Better hormone balance is warranted for this group.

Primary non-Hodgkin's lymphoma of the sinonasal tract.

OBJECTIVES: We sought to review the records of patients seen at the Chaim Sheba Medical Center (Tel Hashomer, Israel) during a 10-year period with respect to the presenting features, management, and outcome of extranodal non-Hodgkin's lymphoma (NHL) of the sinonasal region. STUDY DESIGN: Eight patients were diagnosed with NHL of the paranasal sinuses from 1993 to 2003. The data were reviewed, and we noted the patient's age, sex, the presenting signs and symptoms, staging, histology, treatment, and outcome of NHL. RESULTS: The mean age was 61.75 years (range, 24-83 years), with a 1:1 male-to-female ratio. All cases involved the paranasal sinuses, and the most common symptom was nasal obstruction (6 patients). All the patients had large B-cell lymphoma, and all were treated with combined chemotherapy and radiation. Three patients died from the disease, 3 were free of disease after 12 to 36 months of follow-up, and 1 had a recurrence after 60 months. CONCLUSIONS: NHLs of the paranasal sinuses are uncommon. Early diagnosis and combined treatment are essential for achieving an optimal outcome.

Coronoidectomy in maxillary swing for reducing the incidence and severity of trismus--a reminder.

PURPOSE: The maxillary swing approach is a proven method for access to the nasopharynx. However, often, trismus is incurred postoperatively, hampering adequate oral care and follow-up and affecting patients' quality of life. CASE REPORTS: Coronoidectomy was performed in four patients undergoing maxillary swing. Minimal trismus was seen in one patient undergoing repeat irradiation and chemotherapy. After a 1-month period no trismus was observed in the other three patients. CONCLUSION: Coronoidectomy, usually performed in maxillectomy for reducing trismus is a useful adjunct in the maxillary swing procedure.

Preservation of the facial artery in excision of the submandibular salivary gland.

BACKGROUND: The accepted method for submandibular gland excision traditionally includes ligation of the facial artery (FA) as suggested by a host of surgical atlases. Preservation of the FA may be significant in reconstructive procedures of the head and neck and its ligation may altogether be obviated. OBJECTIVE: Prospective feasibility study of FA preservation in submandibular gland excision. MATERIALS AND METHODS: Patients undergoing excision of the submandibular salivary glands from September 1999 through August 2001 were prospectively included. The FA was dissected and only its glandular branches ligated. Exclusion criteria were primary benign or malignant tumors of the submandibular salivary gland or metastatic disease involving the gland or level I of the neck. In cases where the primary tumor involved the floor of mouth, anterior tongue or mandible, resection of level I contents included the FA even in N0 necks. RESULTS AND CONCLUSIONS: 104 patients (116 procedures) were included in the study. 81 patients underwent resection of the gland with preservation of the FA. The vessel was sacrificed in 35 necks because of metastases or primary tumor and in two cases of chronic sialadenitis. One patient had a postoperative hematoma following neck dissection requiring re-exploration. The source of bleeding was not found to be related to the FA. Contrary to accepted methodology, the FA may readily be preserved in surgery of the submandibular salivary glands. We suggest preservation of the FA in all cases of procedures for benign disease and in selected cases of malignancy.

Amputation neuromas after neck dissection.

OBJECTIVE: We sought to define the incidence of neuroma formation after neck dissection in a large series of patients. METHODS: One hundred fifty-three patients who were seen during a 2-year period (followed for 3 months to 10 years; mean, 52 months) were evaluated for neuroma formation after neck dissection (185 procedures). Cut nerve edges were not routinely ligated or cauterized. RESULTS: Operative records indicated that except for 4 cases, the stumps of the great auricular nerve and cervical branches were left intact after resection. No cases of palpable neuromas were found. In one case of a revised neck, a small macroscopically indiscernible nodule was histologically defined as neuroma. CONCLUSION: No neuromas were discovered in our series of neck dissection cases. If found, it is imperative these lesions be differentiated from recurrent cancer. Our results do not support any interference with cut nerve edges.

Syndrome of inappropriate antidiuretic hormone or arginine vasopressin secretion in patients following neck dissection.

OBJECTIVES/HYPOTHESIS: The syndrome of inappropriate antidiuretic hormone or arginine vasopressin secretion (SIADH) is a disorder in which release of antidiuretic hormone is independent of plasma osmolarity, resulting in fluid retention and development of dilutional hyponatremia. The incidence of SIADH following neck dissection was found to be 18% to 30% in two separate reports. The incidence of SIADH in a cohort of patients who underwent neck dissection was prospectively studied. METHODS: Eighty-six patients were included in the study, along with a control group of 19 patients who underwent other neck procedures. Patient gender, age, physical condition (American Society of Anesthesiologists score), type of neck dissection, prior treatment, and smoking history were noted. Blood and urine osmolarity and sodium levels were sampled before surgery and during the first 24 hours after the surgery. These were recorded daily in cases with SIADH until the syndrome resolved. RESULTS: The incidence of SIADH was only 1.15% in patients before surgery. The syndrome developed in seven patients following neck dissection (8.14%) and in none of the patients in the control group. SIADH resolved within 72 hours at the latest. No association was found with patient gender, age, physical condition, or type or laterality of neck dissection. A statistically significant connection between the syndrome and history of smoking was noted (P <.05), and it was more commonly seen in patients with node-positive necks (P =.1231). CONCLUSIONS: SIADH following neck dissection may be less common than formerly reported. Previous studies have presented contradicting data concerning the influence of tumor recurrence or prior radiation therapy on its incidence. Our results indicate no such association. A statistically significant connection between smoking and the syndrome was found. No clinical symptoms developed in the patients with SIADH, but it seems prudent to suggest limiting fluid intake in the first postoperative 24 hours for patients following neck dissection.

Pulmonary function after pectoralis major myocutaneous flap harvest.

OBJECTIVE: The pectoralis major myocutaneous flap is widely used in the reconstruction of surgical defects in the head and neck region. Pulmonary atelectasis has been reported in patients undergoing these procedures, and many of these patients are heavy smokers and drinkers and have associated cardiopulmonary disorders. Flap harvest and donor site closure may lead to impairment of pulmonary function before and after the use of pectoralis major myocutaneous (PMC) in surgical reconstruction in patients with cancer of the head and neck. METHODS: Patients undergoing extirpation of head and neck tumors with PMC reconstruction were prospectively evaluated. Patient age, smoking history (pack-years), anesthesia duration, percentage predicted pre- and postoperative FEV1, percentage-predicted pre- and postoperative FVC (forced vital capacity), and preoperative SaO2 (oxygen saturation) were evaluated. Preoperative FEV1/FVC ratio was calculated. Chest x-rays were reviewed. RESULTS: Only 11 patients, 5 of whom smoked, could be evaluated postoperatively. Preoperative FEV1/FVC was more than 70 and FEV1 more than 75% predicted in all patients. A decrease in FVC was observed in 7 of the 11 patients, which ranged between 2% and 27% without any clinically obvious respiratory manifestations. A baseline SaO2 of more than 96% was noted in all patients. Four of 9 postoperative chest x-rays demonstrated atelectasis. CONCLUSIONS: PMC harvest and donor site closure may lead to the recorded decrease in FVC measurements. These changes did not manifest clinically. Nevertheless, alternative methods of surgical defect closure should be considered in patients with severe preexisting pulmonary disorders.

Rhino-orbital and rhino-orbito-cerebral mucormycosis.

BACKGROUND: Rhino-orbito-cerebral mucormycosis (ROCM) is a devastating infection of immunocompromised hosts. We present our experience with 19 ROCM cases and attempt to define preferred diagnostic and treatment protocols. METHODS: All had tissue biopsies obtained studied by direct smear, histologic studies, and cultures. Imaging was obtained in 14 cases. RESULTS: Sixteen patients presented between August and November. Six had mixed fungal infections. Seven patients had end-stage underlying disease or infection and did not undergo surgery and 4 had an indolent form of disease. Patients were treated by surgery and by amphotericin B. The overall survival was 47%. CONCLUSIONS: ROCM may have seasonal incidence peaking in the fall and early winter. The therapeutic approach should be unchanged in cases of mixed fungal infections. Amphotericin B with aggressive debridement remains the mainstay of treatment. Early recognition and treatment are essential. A presentation and survival-dependent classification of ROCM are offered.

Quality of life of nasopharyngeal carcinoma patients.

BACKGROUND: Quality of life (QOL) issues in patients with head and neck carcinoma are of importance beyond the incidence of these tumors because of the impact of the disease and its treatment on external appearance and function of the upper aerodigestive tract. Nasopharyngeal carcinoma (NPC) patients comprise a unique subgroup in whom, to our knowledge, QOL has not been studied directly. METHODS: Adult patients with NPC treated during the past 15 years at the Chaim Sheba Medical Center with a minimum follow-up of 6 months were included in the current study. Patients were mailed the revised University of Washington quality of life (UW-QOL) questionnaire and data pertaining to their disease were recorded. Patients with recurrent disease or another malignancy or those whose present status could not be ascertained were excluded from the study. QOL scores were analyzed based on treatment, disease stage, and patient age. RESULTS: Twenty-eight patients of 35 disease-free patients (80%) responded to the questionnaire sent to patients meeting the study criteria. The mean score for general health was 3.1 (range, 1-5). Pain was not a significant factor. Other domains without noteworthy problems were speech and shoulder disability. The majority of patients described their appearance as normal or with minor changes, and questions concerning activity, recreation/entertainment, employment, and swallowing all scored > 70 (range, 0-100). Dry mouth, chewing, and ear problems were of major concern with the majority of patients and affected the QOL indices. Nevertheless, the overall mean QOL score of these patients was rated as "good" (4.2 on a scale of 1-6). CONCLUSIONS: In the current study, patients with NPC reported ear problems, difficulties in chewing, and dry mouth but their overall QOL appeared to be good. Ear problems such as secretory otitis media should be recognized at the time of presentation and treated. Conformal radiotherapy techniques sparing the salivary glands and temporal bone most likely will be useful in reducing the morbidity associated with treatment.

Smoking-induced squamous-cell cancer of the nose.

Squamous-cell cancer (SCC) isolated to the anterior nose is uncommon. Numerous industrial and environmental contaminants have been implicated as causative factors in nasal carcinoma. The association between nasal cancer and smoking was recognized in the 1980s, but results have not been consistent and no possible mechanisms have been suggested. The case histories of 11 patients with SCC limited to the anterior nasal cavity were reviewed. The authors found no relationship with exposures to chemicals previously implicated in nasal cancer. Nine patients with SCC were exposed to cigarette smoke (mean = 103 pack-years). Cigarette smoke may induce cancer directly, thus affecting the mucosa, or by inducing genetic alterations. The authors favor the former mechanism.