Surgical margins in head and neck squamous cell carcinoma: what is 'close'?

The aim of this systematic review is to evaluate the definition of close margin in head and neck squamous cell carcinoma (HNSCC), and its possible prognostic significance. An appropriate string was run on PubMed to retrieve articles discussing the 'close' surgical margin issue in HNSCC. A double cross-check was performed on citations and full-text articles retrieved. In total, 348 articles were identified. Further references were included by using the option "Titles in your search terms" option in PubMed. 15 papers were finally included for qualitative synthesis. In vocal cord surgery of HNSCC, a close margin could be considered to be ≤1 mm, in the larynx ≤5 mm, in the oral cavity ≤4 mm, and in the oropharynx ≤5 mm. In each patient, the choice of extent of close margin should be balanced against general condition, tumor stage, and functional issues to indicate appropriate adjuvant therapy.

Endoscopic open technique in patients with middle ear cholesteatoma.

UNLABELLED: The objective of this study was to describe an endoscopic open "centrifugal" technique used to treat middle ear cholesteatoma with antral and periantral extension, using a retrospective chart and video review of a case series performed in a university tertiary referral center. Charts and videos of patients who underwent middle ear endoscopic surgery from January 2007 to September 2009 were reviewed. Patients who were treated with endoscopic "centrifuge" open techniques were included in the study. Surgical indications were collected and the surgical technique described. The final study group consisted of 12/150 subjects (9 males and 3 females with a mean age of 40 years). All 12 patients who underwent endoscopic open tympanoplasty had antral, periantral or mastoid involvement of cholesteatoma with or without posterior canal wall erosion. They had sclerotic mastoids with the presence of the antrum and, in some cases, small periantral mastoid cells. In 9/12 patients, external auditory canal reconstruction was performed with a cartilage graft. In 3/12 patients, canal reconstruction was not performed. No subjects required a meatoplasty of the external auditory canal. Endoscopic "centrifugal" open techniques can be an option in the surgical management of middle ear cholesteatoma involving antral and periantral mastoid cells, in the case of sclerotic mastoids. Further study will be necessary to examine the long-term consequences of the endoscopic "centrifugal" open technique. LEVEL OF EVIDENCE: 2C.

Atypical neoglottis after supracricoid laryngectomy: a morphological and functional analysis.

The objective of this study was to analyze atypical neoglottis after supracricoid subtotal laryngectomy (SSL) from a morphological and functional point-of-view using retrospective case series reviewin a Tertiary university referral center setting. From May 2003 until January 2010, 106 patients underwent SSL (CHEP, CHP, THEP, THP) for laryngeal cancer, in the Otolaryngology Department of the University Hospital of Modena. We performed a retrospective analysis of recorded videos in our database of patients who underwent SSL. Patients with atypical neoglottis were included in the study. Six patients with atypical neoglottis were identified and morphologically evaluated. The functional outcomes were collected and analyzed. Atypical neoglottis may form after SSL, in particular in the case of CHEP. In most cases, these atypical conformations are due to anomalous positioning of the epiglottis, or involvement of the lateral pharyngeal wall in the sphincteric and vibratory function of the neoglottis. Atypical neoglottis formation seems to guarantee adequate functional outcomes in terms of vocal and swallowing performance.

Forestier disease: single-center surgical experience and brief literature review.

OBJECTIVES: We describe the experience of our otolaryngology department in the treatment of Forestier disease, particularly regarding the diagnostic process, surgical treatment, and postoperative outcomes. METHODS: The charts of 12 patients who underwent surgical treatment of Forestier disease between January 1, 2003, and January 1, 2009, were analyzed. All patients were subjected to clinical, radiologic, and endoscopic evaluation that confirmed the presence of cervical osteophytes. All patients were treated by a right-sided prevascular transcervical approach to remove cervical osteophytes. A literature review on Forestier disease was also carried out. RESULTS: One case of immediate postoperative hemorrhage was reported. During the postoperative follow-up, ranging from 1 to 5 years, all patients underwent cervical radiography and fiberoptic laryngoscopy that confirmed no evidence of recurrence, and all patients remained asymptomatic. CONCLUSIONS: A prevascular transcervical right-sided approach seems to be an effective treatment for surgical removal of hyperostosis in Forestier disease, with an acceptable rate of complications and recurrence.

Prognostic factors in stage IV oropharyngeal squamous cell carcinoma: the "punto" experience.

PURPOSE: Squamous Cell Carcinoma (SCC) of Oropharynx is often diagnosed in advanced stages. Treatment options have improved during recent years, however the choice of most appropriate treatment is still controversial. Prognostic factors can help to optimize the care. This study investigate the role of 9 potential prognostic factors, including HPV status, in Oropharyngeal SCC. MATERIALS AND METHODS: Nine prognostic factors were investigated in a retrospective chart of 98 patients treated for stage IV SCC of Oropharynx from january 2006 to january 2012, including  age (<60 or >60), gender, tumor subsite , histological grading, T stage, N stage, AJCC stage, BMI pre-treatment and HPV status. Moreover treatment modalities were compared  and the data regarding the treatment factors, like radiotherapy technique and kind of chemotherapy  were collected and compared.Primary endpoint was the impact of the prognostic factors on OS, DFS and DSS.Seconrdary endopoint were the impact of these factors on QOL and Toxicity. RESULTS: On univariate analisys significant improved OS was associated with age < 60 (p= 0,004), grading G3 (p=0.003), BMI > 25 (p= 0.03), radiotherapy with IMRT/SIB IMRT  technique (p=0,01) and AJCC stage IVa (p=0,01).No prognostic factor was associated to DFS improvement.Instead a significant improved DSS was associated with age <60 (p=0,01) , Grading G3 (p=0,04), T stage (p=0,02), AJCC stage IVa (p=0,03) and tonsil subsite (p=0.04). in the analysis of hazards ratios for OS age (HR 2.22; 95% CI 1.00-4.93; p=0.019), grading (HR 0.17; 95% CI 0.047-0.64 ; p= 0.008), AJCC stage (HR 4.81; 95% CI 1.34-17.2; p=0.016) and radiotherapy technique (HR 0.2; 95% CI 0.08-0.87; p=0.02) maintained significance, whereas BMI (HR 0.45; 95% CI 0.09- 2.2; p=0.3) did not. In the analysis for DSS only age (HR 2.22; 95% CI 1.22-7.81; p= 0.017) and grading (HR 0.11; 95% CI  0.02- 0.59; p=0.009) maintained significance. CONCLUSION: improved outcomes were significantly associated with lower age and tumor stage, grading G3, tonsil subsite, radiotherapy performed with IMRT technique, and BMI > 25.

FDG-PET/CT appearance of injected silicone particles (VOX Implants®) in head and neck tissues.

OBJETIVES: In head and neck surgery, Positron Emission Tomography/Computed Tomography imaging (FDG-PET/CT) is often used to identify primary tumor site in patients with unknown primary carcinoma, to predict response after chemoradiotherapy and in some cases, to detect recurrence. To rehabilitate swallowing after surgery in patients with persistent dysphagia, an injectable suspension of silicone (VOX® Implants) can be used to reduce the gaps in the neoglottis. The purpose of this report is to document the PET appearance of PDMS in a series of 3 patients who underwent partial laryngectomy with subsequent VOX® Implants injection. MATERIAL AND METHODS: a retrospective chart and imaging review was performed at our institution. Three patients were identified and included in the study. Appearance of PDMS at PET was described and discussed. RESULTS: An increased uptake of 2-fluoro-2-deoxy-d-glucose (FDG) was noticed at PET in all patients. CONCLUSIONS: the increased uptake was possibly due to active inflammatory reactions that are necessary for tissue integration of textured silicone particles.

Cochlear implantation in children with cochlear nerve deficiency.

OBJECTIVE: The aim of this study was to report on auditory performance after cochlear implantation in children with cochlear nerve deficiency. METHODS: A retrospective case review was performed. Five patients with pre-lingual profound sensorineural hearing loss implanted in an ear with cochlear nerve deficiency participated in the study. Postoperative auditory and speech performance was assessed using warble tone average threshold with cochlear implant, speech perception categories, and speech intelligibility ratings. All patients underwent high resolution computed tomography and magnetic resonance imaging. RESULTS: According to Govaerts classification, three children had a type IIb and two a type IIa cochlear nerve deficiency. Preoperatively, four patients were placed into speech perception category 1 and one into category 2. All patients had an improvement in hearing threshold with the cochlear implant. Despite this, at the last follow-up (range 18-81 months, average 45 months), only one girl benefited from cochlear implantation; she moved from speech perception category 2 to 6 and developed spoken language. Another child developed closed set speech perception and had connected speech that was unintelligible. The other 3 children showed little benefit from the cochlear implant and obtained only an improved access to environmental sounds and improved lipreading skills. None of these 4 children developed a spoken language, but they were all full-time users of their implants. CONCLUSIONS: The outcomes of cochlear implantation in these five children with cochlear nerve deficiency are extremely variable, ranging from sporadic cases in which open set speech perception and acquisition of a spoken language are achieved, to most cases in which only an improved access to environmental sound develops. Regardless of these limited outcomes, all patients in our series use their device on a daily basis and derive benefits in everyday life. In our opinion, cochlear implantation can be a viable option in children with cochlear nerve deficiency, but careful counseling to the family on possible restricted benefit is needed.

Endoscopic anatomy and ventilation of the epitympanum.

The use of an endoscope with varied angulations has allowed the surgeon to explore areas that were often not visualized using standard microscopic procedures. The endoscope has improved knowledge of the complex anatomy of mucosal fold and improved functional interventions in middle ear inflammatory disorders during middle ear surgery; intraoperative evaluation of middle ear anatomy during endoscopic surgery for inflammatory disorders helps surgeon visualize anatomic blockages of the middle ear ventilation trajectories. This article discusses the anatomy of the epitympanum and the ventilation patterns and pathophysiology of epitympanic retraction.

Endoscopic management of attic cholesteatoma: a single-institution experience.

At present, the main application of endoscopic surgery is in the surgical treatment of middle ear cholesteatoma; however, for definitive validation and acceptance by scientific community, results are needed regarding recurrent and residual rates of the condition. This article analyzes the single-institution experience from results of surgical treatment of attic cholesteatoma.

Voice and swallowing after partial laryngectomy: factors influencing outcome.

BACKGROUND: The purpose of this study was to assess the factors influencing swallowing and phonatory results after partial laryngectomy. METHODS: We carried out a medical chart review of patients who underwent partial laryngectomies between June 2003 and November 2010, focusing on functional outcomes. RESULTS: Thirty-two patients were enrolled. No statistically significant difference was found in the comparison of phonatory outcomes of patients with preservation of both arytenoids; the results of the Yanagihara classification were significantly different (p = .015) in patients with an atypical neoglottis; radiotherapy statistically significantly influenced only the mean fundamental frequency (p = .035). The type of partial laryngectomy does not seem to affect the deglutition results; radiotherapy statistically significantly affected the dysphagia score (DS; p = .03), penetration aspiration (p = .02), and MD Anderson Dysphagia Inventory (MDADI; p = .02). CONCLUSION: Horizontal supraglottic laryngectomy and supracricoid partial laryngectomy give the same swallowing results. The presence of both arytenoids does not influence the final outcome compared to patients in whom only 1 arytenoid is preserved. Postoperative radiotherapy only influences the swallowing function.

A step backward: the 'Rough' facial nerve grading system.

OBJECTIVES: Several modalities currently exist to rate the degree of facial function clinically but even though it has significant limitations, the most widely used scale is the House-Brackmann grading system (HBGS). A simplified scale is introduced here, the 'Rough' Grading System (RGS - Grade I: normal movement; Grade II: slight paralysis; Grade III: frank paralysis with eye closure; Grade IV: frank paralysis without eye closure; Grade V: almost complete paralysis with only slight movements; Grade VI: total paralysis). The aim of the present study was to verify the interrater reliability and the interscale validity of this simplified grading system. STUDY DESIGN: Scale validation study based on a prospective cohort. METHODS: Fifty patients with facial palsy, consecutively referred to our department were filmed while performing some codified facial movements. Then two independent groups (one rating using the HBGS, the other rating using the RGS) assigned a grade after reviewing the videos. The time required for the rating was also noted. RESULTS: The HBGS showed a mean value of interrater agreement of 0.46 while the RGS showed a mean value of 0.59. The concurrent validity between HBGS and RGS ranged from 0.86 to 0.90 (p < 0.001 for every comparison). There was no statistically significant difference between HBGS and RGS in the mean time taken for rating (p = 0.15). CONCLUSIONS: The RGS reached an adequate level of interrater reliability, higher than the HBGS. The correlation between the two scales is high and the times required for rating are similar. The present results may justify the use of the RGS in routine clinical practice. LEVEL OF EVIDENCE: N/A.

Surgical anatomy of transcanal endoscopic approach to the tympanic facial nerve.

OBJECTIVES/HYPOTHESIS: Until recently, tympanic facial nerve surgery had been performed using microscopic approaches, but in recent years, exclusive endoscopic approaches to the middle ear have increasingly been used, particularly in cholesteatoma surgery. The aim of this report was to illustrate the surgical anatomy of the facial nerve during an exclusive endoscopic transcanal approach. STUDY DESIGN: Retrospective video review of cadaveric dissections and operations on living patients in a tertiary university referral center. METHODS: Between November 2008 and July 2010, a total of 12 endoscopic cadaveric dissections were performed by an exclusive endoscopic transcanal approach. All dissections were recorded and stored in a database. In July 2010, video recordings from those dissections were reviewed, and the anatomic variations and accessibility of the tympanic facial nerve were studied and noted. Two further video recordings from living patients affected by middle ear chronic disease were also included in our study. RESULTS: In all 14 subjects, the transcanal endoscopic approach guaranteed direct access to the entire tympanic segment of the facial nerve after ossicular chain removal, allowing decompression of the nerve from the geniculate ganglion and the greater petrosal nerve to the second genu of the facial nerve. As in microscopic techniques, the cochleariform process and transverse crest (cog) may represent useful landmarks. CONCLUSIONS: The tympanic facial nerve can be thoroughly visualized by an exclusive endoscopic transcanal approach, even in poorly accessible regions such as the second genu and geniculate ganglion. Further clinically based reports may strengthen our preliminary results.

Inferior retrotympanum revisited: an endoscopic anatomic study.

OBJECTIVES/HYPOTHESIS: To describe the inferior retrotympanic anatomy from an endoscopic perspective. STUDY DESIGN: This was an anatomic study on a retrospective case series. METHODS: During November 2009 and December 2009, videos from endoscopic middle ear procedures carried out between June 2007 and November 2009 and stored in our database were retrospectively reviewed. Surgeries in which the inferior retrotympanic region was visualized were included in the study. Accurate descriptions of the anatomic findings were made for each ear included in the study group. RESULTS: The final study group consisted of 25 videos from 25 ear procedures. In 14/25 subjects, a bony ridge connecting the inferior portion of the styloid prominence to the anterior and inferior lip of the round window niche (Proctor's sustentaculum promontory) was identified and renamed the finiculus (from the Latin finis, -is: borderline), representing the ideal limit between the inferior retrotympanum and hypotympanum. In 14/25 patients, a complete sinus subtympanicus could be identified, lying between the subiculum and finiculus. CONCLUSIONS: Endoscopic exploration of the middle ear might guarantee a very good exposure of the inferior retrotympanum, allowing detailed anatomic descriptions of this hidden area. Improvement in our knowledge of its anatomy might decrease the possibility of residual disease during cholesteatoma surgery.