Impact of the COVID-19 Pandemic on Brazilian Head and Neck Surgery Centers

Abstract Objective The outbreak of the COVID-19 pandemic had a considerable impact on the healthcare access, treatment, and follow-up of oncologic patients. The aim of this study was to evaluate how the COVID-19 pandemic has affected consultation and follow-up demand as well as treatment volume at Brazilian Head and Neck Surgery centers. Methods An anonymous online questionnaire was used for collection of data across all Brazilian Head and Neck Surgery Centers across a 3-month period (April‒June 2021). This information included the characteristics of each center, and the perceived self-reported impact of the COVID-19 pandemic on academic activities, residency training, and the diagnosis, treatment, and follow-up of patients with Head and Neck diseases between 2019 and 2020. Results The response rate across the 40 registered Brazilian Head and Neck Surgery Centers was 47.5% (n = 19). The data showed a significant reduction in the total number of consultations (24.8%) and number of attending patients (20.2%) between 2019 and 2020. The total number of diagnostic exams (31.6%) and surgical procedures (13.0%) conducted over this period also decreased significantly. Conclusions The COVID-19 pandemic had a significant national impact on Brazilian Head and Neck Surgery Centers. Future studies should examine the long-term effects of the pandemic on cancer treatment. Level of evidence Evidence from a single descriptive study.

Impact of the COVID-19 Pandemic on Brazilian Head and Neck Surgery Centers.

OBJECTIVE: The outbreak of the COVID-19 pandemic had a considerable impact on the healthcare access, treatment, and follow-up of oncologic patients. The aim of this study was to evaluate how the COVID-19 pandemic has affected consultation and follow-up demand as well as treatment volume at Brazilian Head and Neck Surgery centers. METHODS: An anonymous online questionnaire was used for collection of data across all Brazilian Head and Neck Surgery Centers across a 3-month period (April‒June 2021). This information included the characteristics of each center, and the perceived self-reported impact of the COVID-19 pandemic on academic activities, residency training, and the diagnosis, treatment, and follow-up of patients with Head and Neck diseases between 2019 and 2020. RESULTS: The response rate across the 40 registered Brazilian Head and Neck Surgery Centers was 47.5% (n=19). The data showed a significant reduction in the total number of consultations (24.8%) and number of attending patients (20.2%) between 2019 and 2020. The total number of diagnostic exams (31.6%) and surgical procedures (13.0%) conducted over this period also decreased significantly. CONCLUSIONS: The COVID-19 pandemic had a significant national impact on Brazilian Head and Neck Surgery Centers. Future studies should examine the long-term effects of the pandemic on cancer treatment. LEVEL OF EVIDENCE: Evidence from a single descriptive study.

Early postoperative serum albumin levels as predictors of surgical outcomes in head and neck squamous cell carcinoma.

BACKGROUND: Malnutrition is a common issue in patients with head and neck squamous cell carcinoma and has a negative effect on surgical outcomes. OBJECTIVE: We attempted to determine which malnutrition diagnostic variables can be used as predictors of postoperative complications in patients with head and neck squamous cell carcinoma. METHODS: Forty-one patients undergoing surgery for head and neck squamous cell carcinoma were submitted to a prospective evaluation. Biochemical data, anthropometric measurements and evaluation of body composition were used in the nutritional analysis. RESULTS: Twenty-two patients (53.6%) developed complications. Serum albumin measured on the first postoperative day was the only variable that significantly differed between groups. A cut-off value of 2.8 g/dL distinguished between patients with a complicated and uncomplicated postoperative course. Normalization of albumin levels occurred more frequently and more rapidly in the noncomplicated group. CONCLUSION: Serum albumin measured on the first postoperative day was the only variable that was a predicter of postoperative complications after major head and neck squamous cell carcinoma surgery.

Early postoperative serum albumin levels as predictors of surgical outcomes in head and neck squamous cell carcinoma / Níveis de albumina sérica no pós‐operatório imediato como preditivo de resultados cirúrgicos em carcinoma de células escamosas de cabeça e pescoço

Abstract Background Malnutrition is a common issue in patients with head and neck squamous cell carcinoma and has a negative effect on surgical outcomes. Objective We attempted to determine which malnutrition diagnostic variables can be used as predictors of postoperative complications in patients with head and neck squamous cell carcinoma. Methods Forty-one patients undergoing surgery for head and neck squamous cell carcinoma were submitted to a prospective evaluation. Biochemical data, anthropometric measurements and evaluation of body composition were used in the nutritional analysis. Results Twenty-two patients (53.6%) developed complications. Serum albumin measured on the first postoperative day was the only variable that significantly differed between groups. A cut-off value of 2.8 g/dL distinguished between patients with a complicated and uncomplicated postoperative course. Normalization of albumin levels occurred more frequently and more rapidly in the noncomplicated group. Conclusion Serum albumin measured on the first postoperative day was the only variable that was a predicter of postoperative complications after major head and neck squamous cell carcinoma surgery.

Resumo Introdução A desnutrição é um problema comum em pacientes com carcinoma de células escamosas de cabeça e pescoço e tem um efeito negativo nos resultados cirúrgicos. Objetivo Tentamos determinar quais variáveis diagnósticas de desnutrição podem ser usadas como preditivos de complicações pós‐operatórias em pacientes com carcinoma de células escamosas de cabeça e pescoço. Método Quarenta e um pacientes submetidos à cirurgia de carcinoma de células escamosas de cabeça e pescoço foram submetidos a uma avaliação prospectiva. Dados bioquímicos, medidas antropométricas e avaliação da composição corporal foram usados na análise nutricional. Resultados Vinte e dois pacientes (53,6%) desenvolveram complicações. A dosagem de albumina sérica no primeiro dia pós‐operatório foi a única variável que diferiu significantemente entre os grupos. Um valor de corte de 2,8 g/dL distinguiu os pacientes com uma evolução pós‐operatória complicada e não complicada. A normalização dos níveis de albumina ocorreu mais frequentemente e mais rapidamente no grupo sem complicação pós‐operatória. Conclusão A albumina sérica medida no primeiro dia pós‐operatório foi a única variável capaz de predizer complicações pós‐operatórias após cirurgia de carcinoma de células escamosas de cabeça e pescoço de grande porte.

Incidence of contralateral cervical metastasis in laryngeal tumors

Introduction: Through the knowledge of the metastatic pathways of the Squamous Cell Carcinoma (SCC) of the larynx, the lymph node level with a higher probability of involvement can be predicted. The surgeon uses this knowledge to determine the extension of neck dissection to perform. However, the longer the surgery, the greater the morbidity for the patient. When the metastatic risk is >20%, neck dissection of that cervical level is necessary. In cases of clinically evident (cN+) metastasis, uni or bilaterally, comprehensive neck dissection is determinant for the treatment, however there is no consensus about neck dissection for contralateral clinically negative neck (cN-). Objective: To evaluate if patients with laryngeal SCC homolateral cN+ and contralateral cN- should be submitted to bilateral neck dissection. Methods: The team reviewed medical records from 135 patients with a diagnosis of laryngeal malignancy between March/2009 and September/2017, analyzing gender, age, tobacco and alcohol comsumption, primary tumor site, neck dissection laterality, clinical and pathological contralaterality, staging, tumor recurrence or late metastasis and survival Results: We observed that 40.74% were pN+ on at least one side after neck dissection, which 87.27% performed bilateral neck dissection. Of these, 66.67% did not have contralateral metastasis, 87.5% had no previously clinically evident metastasis. Conclusion: Patients contralateral cN- have a risk <20% for occult metastasis and should not routinely go through bilateral neck dissection.

Predictive factors of occult neck metastasis in patients with oral squamous cell carcinoma / Fatores preditivos de metástases cervicais ocultas em pacientes com carcinoma epidermóide de boca

ABSTRACT INTRODUCTION: It is well established that cervical lymph node metastasis is the most important prognostic factor in patients with oral squamous cell carcinoma of the upper aerodigestive tract. The definition of parameters and classifications that could separate patients in groups of low, intermediate and high-risk is being attempted for several years. OBJECTIVE: The objective of this study was to determine possible predictive factors related to the occurrence of occult cervical lymph node metastasis through the analysis of histopathological reports of surgical specimens obtained after oral squamous cell carcinoma resection and selective neck dissections of patients initially classified as N0. METHODS: This was a primary, retrospective, observational, case-control study. Histopathological reports were reviewed to determine if some findings were related to the occurrence of occult lymph node metastasis. The events analyzed were oral cavity subsites, pT-stage, muscular infiltration, desmoplasia, vascular emboli, perineural infiltration, tumor thickness and compromised margins. RESULTS: Occult cervical metastasis accounted for 19.10 percent of the cases. Desmoplasia, perineural infiltration, tumor thickness and pT4a stage are predictive factors of occult neck metastasis (p-value = 0.0488, 0.0326, 0.0395, 0.0488, respectively). CONCLUSION: The accurate definition of predictive factors of occult cervical metastasis may guide the selection of patients that should be referred to radiotherapy, avoiding the unnecessary exposure of low-risk patients to radiation and allowing a better regional control of the disease in those of moderate or high risk.

Resumo Introdução: Já é bem estabelecido que a metástase oculta em linfonodo cervical é o fator prognóstico mais importante em pacientes com Carcinoma epidermóide de boca (CEB) do trato aerodigestivo superior. Há anos pesquisadores tentam definir parâmetros e classificações que poderiam separar os pacientes em grupos de baixo, médio e alto risco. Objetivo: O objetivo deste estudo foi determinar possíveis fatores preditivos relacionados com a ocorrência de metástase oculta em linfonodo cervical, por meio da análise de laudos histopatológicos de espécimes cirúrgicos obtidos após ressecção de CEB e dissecções seletivas do pescoço em pacientes inicialmente classificados como N0. Método: Este foi um estudo primário, retrospectivo, observacional e de caso-controle. Laudos histopatológicos foram revisados para determinar se alguns resultados estavam relacionados com a ocorrência de metástases em linfonodos oculto. Os eventos analisados foram: subsítios dentro da cavidade oral, estágio-pT, infiltração muscular, desmoplasia, embolia vascular, infiltração perineural, espessura do tumor e margens comprometidas. Resultados: Metástases cervicais ocultas foram responsáveis por 19,10% dos casos. Desmoplasia, infiltração perineural, espessura do tumor e estágio pT4a foram fatores preditivos de metástase cervical oculta (p = 0,0488, 0,0326, 0,0395, 0,0488, respectivamente). Conclusão: A definição precisa dos fatores preditivos de metástase cervical oculta pode orientar a seleção de pacientes que devem ser submetidos a radioterapia, evitando a exposição desnecessária dos pacientes de baixo risco à radiação, e melhorar o controle regional da doença em pessoas de risco moderado ou alto.

Facial paralysis after superficial parotidectomy: analysis of possible predictors of this complication / Paralisia facial após parotidectomia superficial: análise de possíveis preditivos dessa complicação

ABSTRACT INTRODUCTION: Salivary gland tumors represent 3-10% of all head and neck neoplasms. These tumors occur predominantly in major salivary glands. The parotid gland is affected most often, ranging from 36.6% to 83%. The pleomorphic adenoma comprises 45-60% of all salivary gland tumors. Several surgical approaches have been described to treat this tumor. Lesion of the facial nerve is one of the most serious complications that can occur after parotid gland surgery. OBJECTIVES: To determine possible predictive factors related to the occurrence of peripheral facial paralysis (PFP) after superficial parotidectomy in the surgical treatment of the pleomorphic adenomas of the parotid gland. METHODS: This was a primary, observational, case-control study performed through the revision of patients' charts and histopathological reports. Data was obtained from 1995 to 2014. The analyzed events were: tumor's length and depth; duration of the disease referred by the patient (more than 1, 5 or 10 years); primary or secondary surgical approach. RESULTS: The analysis showed that tumor lengths equal or superior to 3.0 cm were a risk factor of PFP with an odds ratio of 3.98 (p = 0.0310). Tumor depths equal or superior to 2.0 cm were also a risk factor with an odds ratio of 9.5556 (p = 0.0049). When the tested event was secondary surgery to recurrent tumors we have found an odds ratio of 6.7778 (p = 0.0029). CONCLUSION: Tumors with 3.0 cm or more in length and/or 2.0 cm or more in depth have a significant higher risk of facial nerve injury. Secondary surgery to recurrent tumors also has a much higher risk of evolving with facial palsy after superficial parotidectomy.

Resumo Introdução: Os tumores de glândulas salivares representam de 3 a 10% de todas as neoplasias de cabeça e pescoço. Esses tumores ocorrem predominantemente nas glândulas salivares maiores. A glândula parótida é afetada na maioria das vezes, variando de 36,6 a 83%. O adenoma pleomórfico abrange 45-60% de todos os tumores de glândulas salivares. Diversas abordagens cirúrgicas foram descritas para o tratamento desse tumor. A lesão do nervo facial é uma das complicações mais graves que podem ocorrer após cirurgia de glândula parótida. Objetivos: Determinar possíveis fatores preditivos relacionados à ocorrência de paralisia facial periférica (PFP) após parotidectomia superficial no tratamento cirúrgico de adenomas pleomórficos de glândula parótida. Método: Estudo preliminar, observacional, de caso-controle, realizado por meio de revisão dos prontuários de pacientes e laudos histopatológicos. Os dados foram obtidos no período de 1995-2014. Os eventos analisados foram o tamanho do tumor no maior diâmetro e a profundidade, o tempo de doença referido pelo paciente (mais de 1, 5 ou 10 anos) e a abordagem cirúrgica primária ou secundária. Resultados: A análise mostrou que o tamanho do tumor igual ou superior a 3,0 cm foi um fator de risco para PFP, com uma razão de chance de 3,98 (p = 0,0310). A profundidade do tumor igual ou superior a 2,0 cm também foi um fator de risco, com uma razão de chance de 9,5556 (p = 0,0049). Quando o evento testado foi cirurgia secundária para tumores recorrentes, encontramos uma razão de chance de 6,7778 (p = 0,0029). Conclusão: Os tumores de 3,0 cm ou mais de comprimento e/ou 2,0 cm ou mais de profundidade apresentam um risco significativamente maior de lesão do nervo facial. A cirurgia secundária para tumores recorrentes também apresenta um risco maior de evoluir com paralisia facial após parotidectomia superficial.

Predictive factors of occult neck metastasis in patients with oral squamous cell carcinoma.

INTRODUCTION: It is well established that cervical lymph node metastasis is the most important prognostic factor in patients with oral squamous cell carcinoma of the upper aerodigestive tract. The definition of parameters and classifications that could separate patients in groups of low, intermediate and high-risk is being attempted for several years. OBJECTIVE: The objective of this study was to determine possible predictive factors related to the occurrence of occult cervical lymph node metastasis through the analysis of histopathological reports of surgical specimens obtained after oral squamous cell carcinoma resection and selective neck dissections of patients initially classified as N0. METHODS: This was a primary, retrospective, observational, case-control study. Histopathological reports were reviewed to determine if some findings were related to the occurrence of occult lymph node metastasis. The events analyzed were oral cavity subsites, pT-stage, muscular infiltration, desmoplasia, vascular emboli, perineural infiltration, tumor thickness and compromised margins. RESULTS: Occult cervical metastasis accounted for 19.10 percent of the cases. Desmoplasia, perineural infiltration, tumor thickness and pT4a stage are predictive factors of occult neck metastasis (p-value=0.0488, 0.0326, 0.0395, 0.0488, respectively). CONCLUSION: The accurate definition of predictive factors of occult cervical metastasis may guide the selection of patients that should be referred to radiotherapy, avoiding the unnecessary exposure of low-risk patients to radiation and allowing a better regional control of the disease in those of moderate or high risk.

Facial paralysis after superficial parotidectomy: analysis of possible predictors of this complication.

INTRODUCTION: Salivary gland tumors represent 3-10% of all head and neck neoplasms. These tumors occur predominantly in major salivary glands. The parotid gland is affected most often, ranging from 36.6% to 83%. The pleomorphic adenoma comprises 45-60% of all salivary gland tumors. Several surgical approaches have been described to treat this tumor. Lesion of the facial nerve is one of the most serious complications that can occur after parotid gland surgery. OBJECTIVES: To determine possible predictive factors related to the occurrence of peripheral facial paralysis (PFP) after superficial parotidectomy in the surgical treatment of the pleomorphic adenomas of the parotid gland. METHODS: This was a primary, observational, case-control study performed through the revision of patients' charts and histopathological reports. Data was obtained from 1995 to 2014. The analyzed events were: tumor's length and depth; duration of the disease referred by the patient (more than 1, 5 or 10 years); primary or secondary surgical approach. RESULTS: The analysis showed that tumor lengths equal or superior to 3.0cm were a risk factor of PFP with an odds ratio of 3.98 (p=0.0310). Tumor depths equal or superior to 2.0cm were also a risk factor with an odds ratio of 9.5556 (p=0.0049). When the tested event was secondary surgery to recurrent tumors we have found an odds ratio of 6.7778 (p=0.0029). CONCLUSION: Tumors with 3.0cm or more in length and/or 2.0cm or more in depth have a significant higher risk of facial nerve injury. Secondary surgery to recurrent tumors also has a much higher risk of evolving with facial palsy after superficial parotidectomy.

Concept of Angiosome Does Not Affect Limb Salvage in Infrapopliteal Angioplasty.

BACKGROUND: The purpose of this study was to evaluate the importance of the "angiosome" concept in patients with critical limb ischemia treated with infrapopliteal angioplasty, analyzing limb salvage, secondary function, and survival rates between those treated with and without reference to the concept of the angiosome (groups 1 and 2, respectively). METHODS: This was a retrospective, consecutive cohort study that evaluated 95 patients with critical limb ischemia who underwent infrapopliteal angioplasty at the Division of Vascular and Endovascular Surgery, São Paulo State Public Servants' Hospital, Brazil, between January 2009 and January 2013. Of the total 92 patients (109 limbs) who underwent angioplasty, 48 (52.2%) patients were in group 1 and 44 (47.8%) patients were in group 2. RESULTS: There was no difference between groups 1 and 2 in terms of the location, lesion severity, or active infection of the infrapopliteal angioplasty. However, groups 1 and 2 differed in their postoperative ankle-brachial indices, which were 0.95 ± 0.18 and 0.85 ± 0.18, respectively (P = 0.001). The estimates of limb salvage were similar in groups 1 and 2 (87% and 92.3%, respectively, at 360 days; P = 0.241). The analysis of secondary function did not differ between the 2 groups (65.1% and 58.3%, respectively, within 360 days; P = 0.92). Operative mortality was 8.3% in group 1 and 8% in group 2 (P = 0.60), and survival at 360 days was 78.5% in group 1 and 78.3% in group 2 (P = 0.86), which were not significantly different. CONCLUSIONS: In this study, we found no evidence to support revascularization based on the concept of the angiosome in preference to revascularization of the artery that is most amenable to endovascular treatment for limb salvage and secondary function.

Total thyroidectomy with ultrasonic scalpel: a multicenter, randomized controlled trial.

BACKGROUND: The ultrasonic scalpel is a recently introduced device in head and neck surgery. Total thyroidectomy is the most common endocrine procedure performed by surgeons. METHODS: This was an open, phase IV, multicenter, randomized controlled trial (RCT) that compared the use of an ultrasonic scalpel with a conventional technique in patients who underwent total thyroidectomy. The outcomes were surgical complication rate, operative time, drainage volume, postoperative pain, and costs. RESULTS: In all, 261 patients were included in 11 centers. There was a mean difference of 17% of operative time in favor of the ultrasonic scalpel group. There were no differences in postoperative complications. There was a difference in costs of 14% in favor of the ultrasonic scalpel group, but it was not statistically significant. CONCLUSIONS: The use of an ultrasonic scalpel was as safe as that of the conventional technique and had the advantage of a shorter operative time and lower postoperative drainage. Costs were not different between groups.

Spinal accessory nerve neuropathy following neck dissection.

UNLABELLED: The most common complication of neck dissection is shoulder dysfunction due to manipulation of spinal accessory nerve, resulting in trapezius muscle atrophy mainly in procedures involving the posterior neck triangle. AIM: This study used electromyography to evaluate the injury to the spinal accessory nerve following neck dissection. MATERIALS AND METHODS: Prospective case series of 51 patients submitted to 60 neck dissections followed by physical therapy evaluation of shoulder dysfunction. Nerve integrity was evaluated before and after the surgery by means of surface EMG registering the electric activity of the trapezius muscle during voluntary contraction. The patients were grouped according to the type of neck dissection, presence of shoulder pain, impairment during abduction movement and hypotrophy/atrophy of the trapezius muscle. RESULTS: Action potential had median values of 54.3 microV before surgery and 11.6 microV after it (p<0.001). There was a mean decrease of 70% comparing to preoperative values. The median was 12.5 microV after dissection including level IIb, and 8.9 microV after dissection including levels IIb and V (p<0.002). CONCLUSION: Surface EMG is a sensitive and painless method for spinal accessory nerve dysfunction evaluation. The results suggest the usefulness of the trapezius muscle electromyography to confirm diagnosis and early physical therapy intervention in neuropathies of the spinal accessory nerve.

[Neck skin collision tumor]. / Tumor de colisão de pele do pescoço.

The collision or mixed tumor is a malignant neoplasm of the skin related to sun exposure and incidence rates of up to 1.5%. It displays a distinctive clinical behavior in relation to other malignancies of the skin and the histological diagnosis, characterized by the collision between a basal cell carcinoma and squamous cell carcinoma, i.e., two malignancies with distinct histologies and sharp interface between them. The case reported was of a male, 73-year-old patient, with two cervical lesions progressively growing in recent months. The chosen treatment was surgery. Histological examination showed the presence of squamous cell carcinoma adjacent to basal cell carcinoma. These tumors preferentially occur in light-skinned men in the fifth or sixth decades of life. Their most common location is in the head and neck, especially in the central part of the face. The differential diagnosis of basal-squamous carcinoma is defined by distinct histological criteria, since both tumors have similar clinical behavior. Local recurrence rates vary from 12% to 45%, whereas regional ones are of approximately 7.5%. The main prognostic factors are gender, surgical margins, perineural infiltration and lymph node status. The treatment of choice is resection, radiotherapy being indicated as adjuvant or to inoperable lesions. Local recurrence is the main limiting factor in disease-free survival, with poor results.

Spinal accessory nerve neuropathy following neck dissection / Neuropatia do nervo acessório espinhal secundária à cirurgia de esvaziamento cervical

Tthe most common complication of neck dissection is shoulder dysfunction due to manipulation of spinal accessory nerve, resulting in trapezius muscle atrophy mainly in procedures involving the posterior neck triangle. AIM: This study used electromyography to evaluate the injury to the spinal accessory nerve following neck dissection. MATERIALS AND METHODS: Prospective case series of 51 patients submitted to 60 neck dissections followed by physical therapy evaluation of shoulder dysfunction. Nerve integrity was evaluated before and after the surgery by means of surface EMG registering the electric activity of the trapezius muscle during voluntary contraction. The patients were grouped according to the type of neck dissection, presence of shoulder pain, impairment during abduction movement and hypotrophy/atrophy of the trapezius muscle. RESULTS: Action potential had median values of 54.3 microV before surgery and 11.6 microV after it (p<0.001). There was a mean decrease of 70 percent comparing to preoperative values. The median was 12.5 microV after dissection including level IIb, and 8.9 microV after dissection including levels IIb and V (p<0.002). CONCLUSION: Surface EMG is a sensitive and painless method for spinal accessory nerve dysfunction evaluation. The results suggest the usefulness of the trapezius muscle electromyography to confirm diagnosis and early physical therapy intervention in neuropathies of the spinal accessory nerve.

Uma das complicações mais comuns do esvaziamento cervical é a disfunção do ombro devido à manipulação do nervo acessório, que resulta na atrofia do músculo trapézio. OBJETIVO: Avaliar com eletromiografia de superfície (EMGs) a lesão do XI par decorrente do esvaziamento cervical. MATERIAL E MÉTODO: Estudo prospectivo com 51 pacientes (60 esvaziamentos cervicais) tratados de câncer de cabeça e pescoço. A função do nervo acessório foi avaliada no período pré e pós-operatório com registro da atividade elétrica das fibras descendentes do músculo trapézio em contração isométrica voluntária máxima. Os pacientes foram agrupados pelo tipo de esvaziamento e movimento de abdução do braço. RESULTADOS: O potencial de ação apresentou mediana de 54,3 microV no pré-operatório e 11,6 microV no pós-operatório (p<0,001). Os valores registrados no pós-operatório apresentaram decréscimo médio de 70 por cento (20 por cento a 94 por cento) em relação aos valores pré-operatórios. Com relação à extensão do EC, foram observadas medianas de 12,5 microV após o esvaziamento do nível iib e 8,9 microV com o esvaziamento dos níveis iib+V (p=0,002). CONCLUSÃO: A eletromiografia de superfície é um método quantitativo, sensível e indolor para complementar o diagnóstico da disfunção do XI par. Os achados sugerem a utilidade da EMGs do músculo trapézio para confirmar o diagnóstico e orientar a intervenção precoce da fisioterapia.

[Association of chronic pulmonary obstructive disease (COPD) and complications in head and neck surgery]. / Associação de doença pulmonar obstrutiva crônica (DPOC) e complicações em cirurgia de cabeça e pescoço.

UNLABELLED: COPD presents in a variety of forms patients with head and neck cancer; it may affect therapeutic decision-making or postoperative outcomes due to its complications. AIM: To correlate the severity of COPD in patients with head and neck SCC treated with surgery, who present postoperative complications. METHOD: A retrospective analysis of 31 patients undergoing en bloc resections, from 2008 to 2009. All cases were evaluated and classified using the GOLD scale. The COPD grade, intubation period, ICU stay and hospital stay were studied. RESULTS: The mean age was 64.8 years; COPD was mild in 24 cases, moderate in 6 and severe in 1 case. ICU stay was 2.7 days and the intubation period was 1,12 days. The mean hospital stay was 24.4 days. There was no relation between COPD grade and brochopneumonia, intubation period, ICU stay and hospital stay. CONCLUSION: Patients with head and neck SCC have a tendency to acquire COPD; its severity was not related with postoperative pulmonary complications, prolonged intubation period, ICU stay and hospital stay.

Tumor de colisão de pele do pescoço / Neck skin collision tumor

O tumor de colisão ou tumor misto é uma neoplasia maligna de pele, relacionada à exposição solar e com índices de incidência de até 1,5 por cento. Apresenta comportamento clínico peculiar, em relação às demais neoplasias malignas de pele e com diagnóstico histológico, caracterizado pela colisão entre um carcinoma basocelular e um carcinoma epidermóide, ou seja, duas neoplasias com histologias distintas e interface nítida entre ambas. O caso relatado foi de paciente do sexo masculino, 73 anos, com duas lesões cervicais de crescimento progressivo nos últimos meses. O tratamento realizado foi cirúrgico, com exame histológico demonstrando a presença de carcinoma de células escamosas contíguo ao carcinoma de células basais. O acometimento preferencial ocorre em homens de pele clara, na quinta ou sexta décadas de vida. Sua localização mais comum é na cabeça e pescoço, principalmente na parte central da face. O carcinoma basoescamoso é diagnóstico diferencial, definido através de critérios histológicos distintos, uma vez que ambas neoplasias apresentam comportamento clínico semelhante. Os índices de recidiva local variam de 12 por cento a 45 por cento, enquanto que é baixo na recidiva regional, de aproximadamente 7,5 por cento. Os principais fatores prognósticos são o gênero do paciente, margens cirúrgicas, infiltração perineural e status linfonodal. O tratamento de escolha é a ressecção, sendo a radioterapia indicada na sua adjuvância e lesões irressecáveis. A recidiva local é o principal fator limitante na sobrevida livre de doença que apresenta resultados pobres.

The collision or mixed tumor is a malignant neoplasm of the skin related to sun exposure and incidence rates of up to 1.5 percent. It displays a distinctive clinical behavior in relation to other malignancies of the skin and the histological diagnosis, characterized by the collision between a basal cell carcinoma and squamous cell carcinoma, i.e., two malignancies with distinct histologies and sharp interface between them. The case reported was of a male, 73-year-old patient, with two cervical lesions progressively growing in recent months. The chosen treatment was surgery. Histological examination showed the presence of squamous cell carcinoma adjacent to basal cell carcinoma. These tumors preferentially occur in light-skinned men in the fifth or sixth decades of life. Their most common location is in the head and neck, especially in the central part of the face. The differential diagnosis of basal-squamous carcinoma is defined by distinct histological criteria, since both tumors have similar clinical behavior. Local recurrence rates vary from 12 percent to 45 percent, whereas regional ones are of approximately 7.5 percent. The main prognostic factors are gender, surgical margins, perineural infiltration and lymph node status. The treatment of choice is resection, radiotherapy being indicated as adjuvant or to inoperable lesions. Local recurrence is the main limiting factor in disease-free survival, with poor results.

Associação de doença pulmonar obstrutiva crônica (DPOC) e complicações em cirurgia de cabeça e pescoço / Association of chronic pulmonary obstructive disease (COPD) and complications in head and neck surgery

A DPOC está presente em graus variados em pacientes portadores de câncer de cabeça e pescoço e pode influenciar na decisão terapêutica ou alterar a evolução no PO por eventuais complicações relacionadas. OBJETIVO: Correlacionar o grau de DPOC em pacientes com de CEC de cabeça e pescoço tratados com cirurgia com complicações no PO. MÉTODO: Estudo retrospectivo de pacientes submetidos a cirurgias em monobloco entre 2008 e 2009. Todos os pacientes foram avaliados e classificados pela escala de GOLD. Foram relacionados o grau de DPOC, tempo de intubação, permanência em UTI e tempo de internação. RESULTADOS: O n foi 31 casos com idade média de 64,8 anos. O grau de DPOC foi leve em 24 casos, moderado em 6 e grave em 1. A permanência em UTI no PO imediato foi 2,7 e o tempo de intubação foi 1,12 dias. A média de internação foi 24,4 dias. Não houve correlação entre grau de DPOC e incidência de broncopneumonia, tempo de IOT, permanência em UTI e permanência hospitalar. CONCLUSÃO: Os pacientes com CEC de vias aerodigestivas superiores têm uma tendência a apresentar DPOC cuja gravidade não teve relação com complicações pulmonares no PO, tempo prolongado de intubação, permanência em UTI ou tempo de internação.

COPD presents in a variety of forms patients with head and neck cancer; it may affect therapeutic decision-making or postoperative outcomes due to its complications. AIM: To correlate the severity of COPD in patients with head and neck SCC treated with surgery, who present postoperative complications. METHOD: A retrospective analysis of 31 patients undergoing en bloc resections, from 2008 to 2009. All cases were evaluated and classified using the GOLD scale. The COPD grade, intubation period, ICU stay and hospital stay were studied. RESULTS: The mean age was 64.8 years; COPD was mild in 24 cases, moderate in 6 and severe in 1 case. ICU stay was 2.7 days and the intubation period was 1,12 days. The mean hospital stay was 24.4 days. There was no relation between COPD grade and brochopneumonia, intubation period, ICU stay and hospital stay. CONCLUSION: Patients with head and neck SCC have a tendency to acquire COPD; its severity was not related with postoperative pulmonary complications, prolonged intubation period, ICU stay and hospital stay.

Assessment of disease-free survival in patients with laryngeal squamous cell carcinoma treated with radiotherapy associated or not with chemotherapy.

UNLABELLED: In early stage (I and II) laryngeal squamous cell carcinoma, both surgery and radiotherapy results in significant local and regional control. In advanced tumors (III and IV), radiotherapy alone has local-regional control rates of 32-43%. AIM: To assess disease-free survival in SCC laryngeal carcinoma patients submitted to radiotherapy alone and/or associated with chemotherapy. MATERIALS AND METHODS: Retrospective study involving 84 cases of laryngeal SCC treated with radiotherapy or chemotherapy together with radiotherapy. Fifty-three cases were treated with intension to cure and 31 because of impossibility to resect the disease. As to clinical stage (CS), 12 were CS I, 15 II, 21 III and 5 IV. In the second group, 11 cases were EC III and 20 IV. RESULTS: Mean age was 60 years, 84.5% were men. Fifty-eight (69.1%) cases had complete response and 26 (30.9%) had persistent or residual disease. Five-year disease-free survival was of 42.5%; 62.5% of the patients with organ preservation indication and 9.75 in the group of irressecable disease. CONCLUSION: Disease-free survival of those patients submitted to radiotherapy because of laryngeal SCC was of 62.5%.

Análise da efetividade de três métodos de imagem -ressonância magnética, ultra-sonografia e cintilografia com 99mTc-MIBI - na localização pré-operatória da paratireoide em pacientes com hiperparatireoidismo primário / Efectivity analysis of three methods of imaging - magnetic ressonance, ultrasound and 99m Tc-MIBI cintilography - in preoperative parathyroid localization in patients with primary hyperparathyroidism

Introdução: No tratamento cirúrgico do hiperparatiroidismo primário a localização pré-operatória da glândula acometida é importante, pois permite uma abordagem menos invasiva. Os exames mais utilizados para localizar adenomas de paratireoide são a cintilografia com 99mTc sestamibi (MIBI), a ultrassonografia (US) e a ressonância magnética (RM). Nos casos de localização atípica do adenoma ou associação com patologias tireoidianas, a US pode perder sua acurácia sendo imprescindível a associação com outros métodos. Objetivo: Identificar a sensibilidade, especificidade, valores preditivos positivo e negativo na localização pré-operatória do adenoma de paratireoide de cada exame de imagem isoladamente. Método: Estudo de coorte retrospectivo analisando 40 prontuários médicos de pacientes com diagnóstico de hiperparatireoidismo primário submetidos a paratireoidectomia. Os pacientes foram submetidos a exames localizatórios (cintilografia com Tc99 sestamibi, ultra-sonografia e ressonância magnética). A análise objetivou identificar a sensibilidade, especificidade, valores preditivos positivo e negativo na localização pré-operatória do adenoma de paratireoide de cada exame de imagem isoladamente. Os achados cirúrgicos e histopatológicos foram o padrão-ouro. Resultados: A US apresentou uma sensibilidade de 63%, especificidade de 98%, valor preditivo positivo de 90% e valor preditivo negativo de 89%. A MIBI apresentou uma sensibilidade de 86%, especificidade de 99%, valor preditivo positivo de 96% e valor preditivo negativo de 95%. A RM apresentou uma sensibilidade de 57%, especificidade de 95%, valor preditivo positivo de 80% e valor preditivo negativo de 87%. Conclusão: A cintilografia com TC99 sestamibi é o exame localizatório com melhor sensibilidade e especificidade para identificar adenomas de paratireoide.

Introduction: It is important to allow a less invasive approach to localize preoperatively the adenoma in surgical management of primary hyperparathyroidism. The most common used methods are radionuclide imaging with 99mTc sestamibi (MIBI), ultrasound (US) an magnetic resonance imaging (MRI). In cases of atypical site adenomas or in association with thyroid diseases US can have less accuracy and it?s necessary the association with other imaging methods. Objective: To identify sensibility, specificity, positive and negative predictive values of each individual imaging method in preoperative location of parathyroid adenoma. Method: Retrospective cohort with 40 patients with primary hyperparathyroidism submitted to surgical treatment. The patients underwent localizatory methods (radionuclide imaging with Tc99 sestamibi, ultrasound and magnetic resonance imaging). The study identified sensibility, specificity, positive and negative predictive values of each individual method in preoperative location of parathyroid adenoma. Surgical and histological findings are the gold standart. Results: US has sensibility of 63%, specificity of 98%, positive predictive value of 905 and negative predictive value of 89%. MIBI has sensibility of 86%, specificity of 99%, positive predictive value of 96% and negative predictive value of 95%. MRI has sensibility of 57%, specificity of 95%, positive predictive value of 80% and negative predictive value of 87%. Conclusion: Radionuclide imaging with Tc99 sestamibi is the most sensible and specific imaging method for location of parathyroid adenomas.

Avaliação da sobrevida livre de doença em pacientes com carcinoma epidermoide de laringe submetidos à tratamento radioterápico exclusivo ou associado à quimioterapia / Assessment of disease-free survival in patients with laryngeal squamous cell carcinoma treated with radiotherapy associated or not with chemotherapy

No carcinoma epidermoide de laringe em estádios clínicos precoces (I e II), tanto a cirurgia quanto a radioterapia resultam em controle loco-regional significativo. Nos tumores avançados (III e IV), a radioterapia exclusiva tem índices de 32-43 por cento de controle loco-regional. OBJETIVO: É avaliar a sobrevida livre de doença dos pacientes com CEC de laringe submetidos à radioterapia exclusiva e/ou associada à quimioterapia. CASUÍSTICA E MÉTODOS: Estudo retrospectivo de 84 casos de CEC de laringe tratados com radioterapia ou quimioterapia concomitante à radioterapia. Cinquenta e três casos foram tratados com intenção curativa e 31 por irressecabilidade da doença. Quanto ao estádio clínico (EC), 12 eram de EC I, 15 II, 21 III e 5 IV. No segundo grupo, 11 casos eram EC III e 20 IV. RESULTADOS: Idade média foi de 60 anos, sendo 84,5 por cento homens. Cinquenta e oito (69,1 por cento) casos tiveram resposta completa e 26 (30,9 por cento) apresentavam doença persistente ou residual. A sobrevida livre de doença há cinco anos foi de 42,5 por cento, sendo de 62,5 por cento nos pacientes com indicação de preservação de órgãos e 9,75 no grupo de doença irressecável. CONCLUSÃO: A sobrevida livre de doença a cinco anos dos pacientes submetidos à radioterapia por CEC de laringe foi de 62,5 por cento.

In early stage (I and II) laryngeal squamous cell carcinoma, both surgery and radiotherapy results in significant local and regional control. In advanced tumors (III and IV), radiotherapy alone has local-regional control rates of 32-43 percent. AIM: To assess disease-free survival in SCC laryngeal carcinoma patients submitted to radiotherapy alone and/or associated with chemotherapy. MATERIALS AND METHODS: Retrospective study involving 84 cases of laryngeal SCC treated with radiotherapy or chemotherapy together with radiotherapy. Fifty-three cases were treated with intension to cure and 31 because of impossibility to resect the disease. As to clinical stage (CS), 12 were CS I, 15 II, 21 III and 5 IV. In the second group, 11 cases were EC III and 20 IV. RESULTS: Mean age was 60 years, 84.5 percent were men. Fifty-eight (69.1 percent) cases had complete response and 26 (30.9 percent) had persistent or residual disease. Five-year disease-free survival was of 42.5 percent; 62.5 percent of the patients with organ preservation indication and 9.75 in the group of irressecable disease. CONCLUSION: disease-free survival of those patients submitted to radiotherapy because of laryngeal SCC was of 62.5 percent