Open partial horizontal laryngectomies: a proposal for classification by the working committee on nomenclature of the European Laryngological Society.

We present herein the proposal of the European Laryngological Society working committee on nomenclature for a systematic classification of open partial horizontal laryngectomies (OPHL). This is based on the cranio-caudal extent of laryngeal structures resected, instead of a number of different and heterogeneous variables present in existing nomenclatures, usually referring to eponyms, types of pexy, or inferior limit of resection. According to the proposed classification system, we have defined three types of OPHLs: Type I (formerly defined horizontal supraglottic laryngectomy), Type II (previously called supracricoid laryngectomy), and Type III (also named supratracheal laryngectomy). Use of suffixes "a" and "b" in Type II and III OPHLs reflects sparing or not of the suprahyoid epiglottis. Various extensions to one arytenoid, base of tongue, piriform sinus, and crico-arytenoid unit are indicated by abbreviations (ARY, BOT, PIR, and CAU, respectively). Our proposal is not intended to give a comprehensive algorithm of application of different OPHLs to specific clinical situations, but to serve as the basis for obtaining a common language among the head and neck surgical community. We therefore intend to present this classification system as a simple and intuitive teaching instrument, and a tool to be able to compare surgical series with each other and with non-surgical data.

Endoscopic laser excisional biopsy for selected glottic carcinomas.

From January 1988 to December 1990, 44 previously untreated patients with squamous cell carcinomas (SCCs) of the true vocal cord (33 T1a, 11 Tis) underwent carbon dioxide laser excision. The mean follow-up was 28 months (range, 12 to 44 months). Endoscopic excisional biopsy was the primary treatment in 38 of the 44 patients, whereas postoperative radiotherapy was added in 6 cases in which the pathology report showed positive margins. Recurrent vocal cord SCC developed in 8 (18%) of the cases, with an average interval of 17.8 months. Re-treatment consisted of a second laser excision in 4 cases, radiotherapy in 1, hemilaryngectomy in 1, and total laryngectomy in 2. The definitive cure rate with endoscopic excisional biopsy for the patients originally treated with laser excision alone was 94.7% (36/38). Endoscopic laser treatment for selected glottic SCC proves to be an excellent alternative to radiotherapy or open neck surgery.

Metastatic neoplasms to the larynx: report of three cases.

Metastatic involvement of the larynx by distant malignancies is a rare event that can occur by hematogenous or lymphogenous spread through a retrograde or anterograde route. Only 143 cases of secondary laryngeal tumors have been reported in the literature. Metastases from cutaneous melanoma and renal carcinoma are the most common, whereas only sporadic cases stemming from lung and colon adenocarcinoma have been documented. The authors report a case of lung adenocarcinoma and two cases of colonic adenocarcinoma metastatic to the larynx and discuss the problems related to the pathogenesis, diagnosis, and management of secondary laryngeal neoplasms.

Diagnosis, staging, and treatment of juvenile nasopharyngeal angiofibroma (JNA).

Nineteen patients with juvenile nasopharyngeal angiofibroma (JNA) were surgically treated with different techniques from January 1968 through December 1985. Two patients had undergone a previous operation at another hospital; all patients were males (mean age 15.4), and the most common symptom was nasal obstruction (84.2%). Lateral extension into the pterygomaxillary fossa occurred in 14 patients (73.6%), and 2 also had intracranial invasion (10.5%). In five cases, the tumor's cytosol was analyzed for hormonal receptors. Negative values for estrogen and progesterone receptors were obtained, although the content of dehydrotestosterone receptors was highly positive. These results tend to support the hypothesis of JNA's androgen-dependence. The authors emphasize the need of a preoperative staging classification based on clinicoradiological data in selecting the most adequate surgical approach. Tumors with lateral extension into the pterygomaxillary fossa can be easily removed through a midface degloving; large involvement of the infratemporal fossa requires, also, a transzygomatic dissection. In JNAs with intracranial extension a combined intracranial-extracranial approach is advisable.

Nasopharyngeal cysts. Report of seven cases with review of the literature.

A series of seven patients with nasopharyngeal cysts is presented. A review of the pertinent literature and a description of the clinical, radiologic, and pathologic features of these lesions are also included. The role of computed tomography in differentiating nasopharyngeal cysts from other pathologic entities, as well as the importance of surgery as an elective method of treatment, is specifically emphasized.

Surgical repair of bone defects of the ear canal wall with flexible hydroxylapatite sheets: a pilot study.

OBJECTIVE: Evaluation of suitability of flexible composite sheets (hydroxylapatite and polymer) for outer ear canal (OEC) wall reconstruction in tympanoplasty. STUDY DESIGN: Prospective, open label pilot study. SETTING: University and regional hospital. PATIENTS: Forty-two randomly selected patients with chronic otitis media (n = 20) and cholesteatoma (n = 22) among 356 patients admitted between 1996 and 1997. INTERVENTIONS: Eradication of disease through a partial or total canal wall down mastoidectomy; immediate reconstruction of canal wall with flexible composite sheet (hydroxylapatite and polymer) and connective tissue graft. OUTCOME MEASURES: Anatomic integrity of the OEC and neotympanum, extrusion rate, complications. RESULTS: At minimum follow-up of 24 months: recurrent cholesteatoma (n = 0), residual cholesteatoma (n = 3/22) (13.6%) in the mesotympanum (none behind the hydroxylapatite sheet or in the attic or antrum). The neotympanum was intact in 38 ears (90.4%), reperforated in 2, and severely retracted and lateralized in 1, respectively. Anatomic integrity of the OEC was obtained in 37 (88%) of 42 patients; stenosis or membranous synechiae were observed in 5 ears and treated in the office. Extrusion of the hydroxylapatite sheet occurred in 7 patients (16.6%) because of purulent otorrhea and granulation tissue formation. Surgical revision achieved complete epithelialization of the rebuilt canal wall in 33 ears (78.6%). CONCLUSIONS: A dry, disease-free ear and normal anatomy may be expected 2 years postoperatively in more than three-fourths of the patients treated using the described surgical technique. Complete protection with a connective tissue graft is essential to avoid extrusion of the implant. The failure rate is significantly higher if otorrhea is present at the time of the operation.

Endoscopic CO2 laser excision for tis, T1, and T2 glottic carcinomas: cure rate and prognostic factors.

We present the results of a retrospective study based on a cohort of 140 patients who underwent endoscopic CO(2) laser excision for previously untreated early glottic cancer (21 Tis, 96 T1, and 23 T2). This study used univariate analysis to review the impact on disease-free survival of 15 factors related to the host, the tumor, and the treatment. Recurrent cancer developed in 28 patients with an average interval to recurrence of 37.5 months. Retreatment consisted of different procedures, including laser excision, partial or total laryngectomy, and/or radiotherapy. The larynx was definitively preserved in 96% of patients. By the end of the study, 14 patients had died, but only 2 of them had died of the disease. Five-year overall survival and determinate survival were 93% and 98%, respectively. Ultimate local control at 5 years with CO(2) laser excision alone was 95% for Tis, 87% for T1, and 91% for T2 lesions. Only involvement of the anterior third of the vocal cord (P = 0.02), involvement of the false vocal cord (P = 0.02), and infiltration of the vocalis muscle (P = 0.004) showed a significant negative impact on disease-free survival.

Oncological results of endoscopic resections of Tis and T1 glottic carcinomas by carbon dioxide laser.

A cohort of 88 patients with glottic cancer (13 Tis, 75 T1) who underwent endoscopic CO2 laser excision between January 1995 and June 1997 was prospectively studied. The mean follow-up was 43 months (range, 30 to 60 months). The depth and extent of the excision (graded according to the European Laryngological Society Classification, which includes 5 types of resection) were based on the results of a preoperative and intraoperative diagnostic test battery. Five patients died of other diseases, and none of glottic cancer. Of the 12 patients who developed a local recurrence, 5 underwent a second endoscopic procedure, 5 a total laryngectomy, and 1 a supracricoid laryngectomy, and 1 was treated with radiotherapy. The 5-year local control rate with endoscopic surgery alone, according to the Kaplan-Meier method, was 91%. None of the variables (8 related to the tumor and 2 to the treatment) tested in a univariate analysis by the log-rank test was found to have a significant impact on disease-free survival rates. The present study confirmed that endoscopic partial cordectomy for Tis and T1 glottic cancers can be regarded as a valid alternative to radiotherapy in terms of oncological results.

The relationship of head and brainstem size to main parameters of ABR in the developmental age and in adults.

In a previous investigation the relationship between head size and main parameters of ABR, i.e. waves absolute latencies and interwave delays, was studied in 55 subjects (1). Significant and positive correlation coefficients were found between I-V I.P.I. and the sum of head circumference, nasion-inion, and intertragal distances in the age range 7 to 11 years only and not in adult age. The purpose of the present study was to verify whether in 11 adults a correlation could be demonstrated between ABR parameters and two axial measures of brainstem length, calculated on MRI views. A positive and significant coefficient was found to exist between these measures and I-V I.P.I. and wave V absolute latency.

Basement membrane components in normal, dysplastic, neoplastic laryngeal tissue and metastatic lymph nodes.

The immunohistochemical localization of the basement membrane (BM) components laminin, type IV collagen and fibronectin was analyzed in normal, dysplastic and neoplastic laryngeal specimens. The distribution of these macromolecules was also investigated in metastatic lymph nodes. A regular and continuous staining for laminin and type IV collagen was present in normal and mild dysplastic epithelium (LIN I); interruptions and reduplications were more evident in severe dysplasia (LIN III), together with an increased positivity for fibronectin in the subepithelial connective tissue. In squamous cell carcinomas the distribution of BM components was related to the degree of cellular differentiation, with a decreased immunostaining being evident in moderately and poorly differentiated carcinomas. Furthermore, the positivity for laminin and type IV collagen was influenced by the pattern of neoplastic growth, being continuous around the "pushing" border and discontinuous where the neoplastic front had an "invading" appearance. Similar changes were present in cervical metastatic lymph nodes. These observations tend to support the theory that the neoplastic growth is a cyclic process, with BM component synthesis and reabsorbtion related to the shifts of cellular metabolism.

[Pulsating tinnitus associated with high homolateral jugular bulb and aplasia of the contralateral transverse and sigmoid sinuses]. / Acufene pulsante associato a bulbo della giugulare alto omolaterale ed aplasia dei seni trasverso e sigmoide controlaterali.

Pulsating tinnitus is uncommon in the general population. This clinical manifestation can be associated with severe intracranial pathologies and is particularly characterized by a rhythm and synchronism reflecting the heart beat. This work presents a clinical case of pulsating, subjective tinnitus associated with a high homolateral jugular bulb and marked hypoplasia of the contralateral transverse and sigmoid sinuses and the clinical-radiological examinations that made diagnosis possible (particular reference going to CT, MRI and angio-MRI). The intracranial venous drainage pattern varies and is nearly always asymmetrical. The jugular bulb is defined as "high" when its upper edge extends nearly to the level of the tympanic anulus, a condition found in 6-20% of the general population. In many cases it is found by chance as often this condition is asymptomatic. However, the pathological picture associated with pulsating tinnitus is highly complex and requires a detailed diagnostic process which some Authors have arranged in specific "flow charts". Imaging methods are essential and must be identified according to the clinical-audiological findings. The radiologist can avail himself of CT, MRI (in association with angio-MRI), Doppler ultrasound of the supraortic and transcranial branches, and digital imaging subtraction angiography. The therapeutic approach to the patient manifesting a "high" jugular bulb is surgical and makes use of such procedures as: ligature of the internal jugular vein, extracranial transposition of the bulb and, in cases of dehiscence of the limiting bone, hypotympanum repair using an autologous or homologous graft of cartilage or bone. Whichever the case, an accurate cost-benefit evaluation must be made, particularly in regard to the risks of endocranial hypertension from the reduced venous drainage, a condition which is significantly increased when concomitant abnormalities of the dural sinuses are present. In the present case, this risk was quite high because of the particular venous morphology described and the patient refused surgery. Currently the patient is under clinical-radiological observation.

[Functional results after type I thyroplasty with the Montgomery's prosthesis]. / Risultati funzionali dopo tiroplastica tipo I con protesi di Montgomery.

Between January 1999 and October 2000, 16 patients with glottic insufficiency of varying etiologies underwent Montgomery type I thyroplasty at the E.N.T. Department of the University of Brescia, Italy. In 2 cases revision surgery was required for the onset of delayed complication (cutaneous and endolaryngeal exposure of the prosthesis). All subjects underwent a battery of clinical-instrumental tests pre- and postoperatively as well as 2, 6 and 12 months after surgery. These tests included videolaryngostroboscopy, subjective perception analysis using the GRBAS scale proposed by Hirano on vowels, statements and songs, and, using the Multi-Dimensional Voice Program (MDVP), acoustic measurement of the following parameters: jitter (J), shimmer (S), noise to harmonic ratio (NHR) and maximum phonation time (MPT). The patients also filled out a self-evaluation questionnaire to judge the postoperative voice and this was used to calculate the "voice handicap index" (VHI). In order to make the study sample as homogeneous as possible, detailed pre- and postoperative functional data were studied only for the 11 patients with glottic insufficiency subsequent to monolateral vagal or recurrent paralysis. Analysis of these data revealed that, in these patients, postoperative perceptive and subjective evaluation was similar to that found in normal subjects. Videolaryngostroboscopy showed that the glottis closed completely in most cases and objective acoustic analysis parameters were significantly improved after surgery. Despite the small sample, our functional results confirm the validity of the cord medialization technique through an external approach in laryngeal hemiplegia. In cases of glottic insufficiency of various etiologies (trauma, scarring subsequent to external and/or endoscopic surgery and radiotherapy), more accurate selection of the patients is required to reduce the incidence of complications and to improve vocal results.

Improvement of vestibular compensation by Levo-sulpiride in acute unilateral labyrinthine dysfunction.

L-sulpiride is the levorotatory enantiomer of sulpiride, a neuroleptic of the family of benzamide derivatives; it has a characteristic antagonist effect on central DA2 dopaminergic receptors and dopamine DA1 "autoreceptors". Its efficacy in the symptomatic control of acute vertigo spells has been recognized, apart from its well-known antiemetic, antidyspeptic and anti-depressant properties, at high dosages. To establish objective parameters of the results of its clinical application, a randomized prospective study was started comparing the effects of the drug in a group of 87 patients with vertigo of peripheral origin, with those in a control group treated with other vestibular suppressants. The drug was administered via the intravenous route, 25 mg t.i.d., for the first 3 days, then by oral administration, with the same schedule and dosage, for a further 7 days. After clinical evaluation of vestibular signs and symptoms, electronystagmographic recordings of rotatory tests were obtained, at admission and were then controlled after 6 months. A subjective Visual Analogue Scale was also delivered daily to the patients in order to monitor symptomatic improvements. When compared to conventional treatments, L-sulpiride appeared to induce a statistically significant faster recovery in unilateral vestibular lesions. An unexpected favourable outcome of treatment was the facilitation of spontaneous vestibular compensation, in terms of lesser residual labyrinthine dysfunction and reduction of recurrent vertigo attacks during the 6 months follow-up. The mechanisms of action of the drug and its interaction with the vestibular system are discussed.

[Intra-parotid lymph node metastasis of malignant skin neoplasms of the head]. / Metastasi linfonodali intra-parotidee da neoplasie maligne cutanee della testa.

More than 75% of parotid metastases represent a secondary localization in the parotid region lymph nodes of malignancies arising from the skin of the head. Among 94 parotidectomies performed at the Otolaryngologic Clinic of the University of Brescia in the years 1980-1987, 21 were primary malignant growths and of these 5 (23.8%) proved to be intraparotid lymph node metastases of previously resected cutaneous tumors of the face (1 melanoma and 4 squamous cell carcinomas). Parotid metastases were treated by lateral (3 cases) or total parotidectomy (2 cases) with preservation of the facial nerve; in 4 cases a homolateral neck dissection of the functional type was performed in the same session (N+ in 1 case only). Three out of four patients with squamous cell carcinoma were subsequently submitted to Co60 radiation therapy. Four patients died 1 to 22 months after the treatment: in three, death was due to a local recurrence or a distant metastasis; in 1 case to osteoradionecrosis with no signs of relapse of the tumor. One patient only treated with total parotidectomy, functional neck dissection (N-) and postoperative radiation therapy is still alive and free of disease 18 months after surgery.

[Laryngocele: analysis of 18 cases and review of the literature]. / Il laringocele: analisi di 18 casi e revisione della letteratura.

18 cases of laryngocele (8 combined, 6 external, 4 internal) treated at the E.N.T. Clinic from January 1968 to December 1989 are reported. The review of the literature is specifically focussed on some controversial issues (i.e. nomenclature, association with laryngeal cancer, pre-operative work-up, surgical procedures). The main symptoms at presentation have proved to be airway obstruction (44.4%), hoarseness (44.4%) and a cervical mass (44.4%). In 12 cases (66.6%) surgical excision was performed by means of an extralaryngeal approach, median thyrotomy was used in 2 cases (11.1%). In 4 cases (22.2%) in which the laryngocele was associated with a laryngeal cancer, a total laryngectomy proved necessary, four patients required a second operation for a recurrence of the laryngocele. Major complications included pyocele (33.3%) and acute airway obstruction (22.2%). CT scan proved to be the most accurate radiological method for defining the spatial relationship between the laryngocele and the laryngeal structures and extralaryngeal soft tissues, in differentiating the laryngoceles from other cystic formations and in identifying the co-existence of a laryngeal cancer. Surgery is the treatment of choice. An extralaryngeal approach, according to Stell and Maran (1975) provides the most adequate exposure of the laryngocele, preserving the integrity of the laryngeal framework. Only in cases of small internal laryngoceles can endoscopic CO2 laser excision be considered a valid alternative. Tracheotomy is usually not indicated.

[Laryngeal-tracheal resection in the treatment of thyroid malignancies: description of a case and review of literature]. / Ruolo della resezione laringo-tracheale nella patologia maligna tiroidea: descrizione di un caso e revisione della letteratura.

Well-differentiated thyroid carcinomas infiltrate into the respiratory tract in between 0.9 and 7% of the cases. Laryngeal-tracheal involvement--most often discovered intra-operatively--can substantially modify the surgical approach. It should be evaluated pre-operatively through laryngo-tracheoscopy with a flexible fibroscope and, in some selected cases, using CT or NMR. Thyroidectomy, associated with laryngeal-tracheal resection and termino-terminal anastomosis, ensures good oncological results without any negative effect on the incidence of post-operative complications. The present work reports the case of a 64-year-old patient who, for 5 months, had presented a swelling of increasing consistency in the left hemithyroid, fixed on the deep planes. Echography showed a 5 cm mass in the left lobe and thyroid isthmus, without suspected lymphadenopathy for metastasis. Fine needle cytology was compatible with papillary carcinoma. CT using a contrast medium revealed an infiltration into the left antero-lateral wall of the I and II tracheal ring, with submucosal extension with no significant signs of stenosis of the airway. Esophagogastroscopy was normal while tracheobroncoscopy confirmed the radiological picture and made it possible to perform a tracheal biopsy which proved positive for papillary carcinoma. The patient underwent total thyroidectomy associated with anterior compartment lymphadenectomy and crico-tracheal resection of the cricoid arch and the first 5 tracheal rings. When surgery was completed, the patient was extubated without complications. Post-operative recovery was uneventful and the patient was discharged on the 9th day after surgery. Histopathological examination confirmed the pre-operative diagnosis and made it possible to stage the lesion as pT4N1bM0 because of the presence of one prelaryngeal lymph node metastasis and another one at the right paratracheal space. Complementary I131 therapy was scheduled along with periodic laryngo-tracheoscopic controls. 16 months after surgery the anastomotic line is perfectly healed and the patient is clinically disease free. A review of the literature on the surgical treatment of well-differentiated malignant thyroid neoplasms with respiratory tract involvement through resection and laryngo-tracheal anastomosis has made it possible to trace the indications, limits and results of this type of therapeutic approach.

Atypical carcinoid tumour of the larynx treated with CO2 laser excision: case report.

A case of atypical laryngeal carcinoid tumour of the right aryepiglottic fold is described in a 56-year-old female. The patient presented a 4-year history of dysphagia, occasional dyspnoea and pain originating in the right tonsillar fossa and radiating to the ear. A sessile, submucosal neoplasm of about 1 cm in diameter and apparently benign appearance was detected endoscopically in the supraglottic region. An excisional biopsy was collected by CO2 laser during direct microlaryngoscopy from which a diagnosis of atypical carcinoid tumour of the larynx was made, and later confirmed by histochemical and immunohistochemical staining. Post-operative course was uneventful, with return to a normal diet per os on the first post-operative day. Histopathological evaluation of the excised specimen revealed the presence of a neoplasm in proximity of the surgical margins, which were not, however, directly involved by the tumour. The close endoscopic follow-up was, nonetheless, implemented in order to promptly detect any evidence of relapse of the disease. After 18 months, a lesion, suspected of being a recurrence, was found, in the site of the original tumour. CO2 laser excision was again carried out, this time allowing for wider margins on the surgical resection. The post-operative diagnosis confirmed the clinical hypothesis of recurrence of atypical carcinoid tumour. The patient is presently alive and free from disease 7 years after the second endoscopic procedure. The difficult aspects of clinical and histopathological diagnoses, the surgical treatment as well as endoscopic and instrumental follow-up of this rare condition are discussed.

[Pleomorphic adenoma: a case treated by laryngotracheal resection and reconstruction]. / Un caso di adenoma pleomorfo trattato con resezione e ricostruzione laringo-tracheale.

Benign Pleomorphic Adenoma (PA) is a tumor rarely found in tracheal and laryngotracheal sites. A review of the literature published since 1922 has revealed only 30 certain cases of which 3 presented simultaneous involvement of both larynx and trachea. The present work describes the thirty-first case (the fourth with a laryngotracheal localization), diagnosed in a white, 40-year-old male who had been complaining of acute dyspnea for the last three years. Initially these symptoms had been interpreted as asthmatic crises. During one of these episodes, the patient underwent emergency tracheotomy and a laryngotracheoscopy revealed a rounded cricotracheal lesion with smooth surface and approximately 4 cm in cranio-caudal diameter. The mass occupied 90% of the air space and originated from the posterolateral right portion of the cricoid, and from the first 3 tracheal rings. CT and esophagoscopy ruled out its transmural invasion into the esophagus. Under rigid bronchoscopy, assisted NdYAG laser debulking was performed for biopsy purposes. The histological diagnosis was benign AP. For this reason a Grillo cricotracheal resection was performed with exeresis of the cricoid arch, mucosa of the cricoid plate and the first 4 tracheal rings. Reconstruction of the respiratory tract was achieved through termino-terminal cricothyrotracheal anastomosis. The initial diagnosis was confirmed and the resection edges were without evidence of neoplasm. Post-operative recovery proceeded without complications and the patient was discharged 7 days after surgery. Endoscopic and radiological follow-up after 30 months is still negative for any neoplastic recurrences. The laryngo-tracheal lumen is within the norm and cord motility has been preserved. The authors then describe the clinical, anatomopathological and radiological elements which prove useful in evaluating tracheal neoplasms and they underline the problems of differential diagnosis between benign AP and adenoid-cystic carcinoma. In addition, the various therapeutic options are discussed with special attention being focused on surgery through external approaches. Given the location of the AP described, the Grillo procedure-most commonly used in cases of inflammatory cricotracheal stenoses-proved well suited to the loco-regional control of the neoplasm. Stringent respect for some parts of this surgical technique make it possible to reduce post-operative complications to a minimum.

[Surgical treatment of neck lymph nodes in squamous cell carcinoma of the pyriform sinus]. / Il trattamento chirurgico dei linfonodi del collo nel carcinoma squamocellulare del seno piriforme.

The present study reports the results of 66 patients surgically treated for squamous cell carcinoma of the pyriform sinus between 1984 and 1996. Twenty eight patients underwent mono!ateral neck dissection and bilateral neck dissection was performed in 38 cases, for a total of 104 radical neck dissections. Of these, 73 (71%) were modified type III dissections, 17 (16%) were classical, and 14 (13%) were modified type I and II dissections. The primary lesion was strictly lateralized in 47 cases (71%), while median structures were involved in 19 patients. The primary tumor was staged pT1 in 2 patients, pT2 in 29, pT3 in 19, and pT4 in 16. The overall incidence of lymph node metastases was 79% (9 pN1, 3 pN2a, 33 pN2b, 7 pN2c) which was not correlated with T stage (50% pT1, 72% pT2, 89% pT3, 81% pT4). Occult nodal metastases were present in 42% of cases (8/19) with an incidence that increased from 11% (1/9) for pT1-2 to 70% for pT3-4 (7/10). The bilateral metastases (11%) were uniformly distributed between strictly lateral neoplasms and those tumors involving the midline. The incidence of bilateral metastases reached 19% only in patients with T4 cancers. Occult controlateral metastases were found in 12% of patients not having clinical evidence of metastases on the contro-lateral side of neck dissection (4/33). Nodal metastases never involved the I and V levels. Our data did not permit an assessment of the incidence of retropharyngeal lymph node metastases. In view of these results and considering current knowledge of the anatomy of lymphatic drainage, a selective II-IV dissection extending to the level VI on the side of the tumor appears justified in cases clinically staged as NO. In our view, when the lesion involves the posterior wall of the pharynx, neck dissection should be extended to the lateral retropharyngeal lymph nodes. Selective dissection of the controlateral side of the neck should be performed in patients having either locally advanced primary lesions or with lesions approaching the midline. In the presence of metastases which are either clinically or intraoperatively evident, neck dissection should be extended to additional lymph node levels.

[Incidence and distribution of lymph node metastases in supraglottic squamous cell carcinoma: therapeutic implications]. / Incidenza e distribuzione delle metastasi linfonodali nel carcinoma laringeo sopraglottico: implicazioni terapeutiche.

This retrospective study was designed to establish some guidelines for the treatment of the neck in the case of supraglottic cancer. The patient population included a series of 264 patients, from 39 to 76 years old (mean age 58.3), who had undergone monolateral (76) or bilateral (188) neck dissection for a total of 452 neck dissections. The distribution of the patients, according to pT category, was the following: 17 T1 (6.4%), 88 T2 (33.3%), 107 T3 (40.5%) and 52 T4 (19.7%). In 121 patients the tumor was central (45.8%), whereas in 143 (54.2%) the neoplasm did not extend beyond the midline and was therefore defined as lateralized. The overall incidence of lymph node metastases was 43.4% (39 N1, 32 N2b, 28 N2c), and the rate of occult metastases was 24.7%. The distribution of metastases according to pT category was as follows: 6.2% T1, 30.7% T2, 38.3% T3 and 57.7% T4 (p < 0.001). Occult metastases distribution was: 0% T1, 19.6% T2, 26.7% T3 and 44.4% T4 (0.001 < p < 0.01). The incidence of bilateral metastases was significantly different (p < 0.001) in central (45.8%) and lateralized tumors (7.8%). The distribution of metastases according to level was 0.8% I, 82.4% II, 35.2% III, 13.6% IV and 0% V (p < 0.001). When level I or IV was involved, lymph node metastases were also present in level II and/or III. These results suggest that contralateral elective neck dissection is not required in lateralized tumors and elective neck dissection is not indicated in T1 lesions. Since no occult metastases were detected in level I or V, the management of choice for the clinically negative neck might well be a selective dissection limited to levels II, III and IV ("lateral neck dissection"). Levels I and V should be dissected only when metastatic nodes are found.