RESUMO
Dendritic cells (DC) are professional antigen-presenting cells whose primary function is the initiation of immune response. Based on the finding that the immune system usually fails to identify and kill cancer cells, DC have been recently used as vaccines for stimulation of tumour-specific immunity. This review focuses on pitfalls related to DC-based vaccination against solid tumours and on improvement of this immunotherapeutic approach for routine treatment of cancer disease.
Assuntos
Antígenos de Neoplasias/imunologia , Vacinas Anticâncer , Células Dendríticas , Neoplasias/imunologia , Neoplasias/terapia , Adjuvantes Imunológicos , Formação de Anticorpos , Ensaios Clínicos como Assunto , Humanos , Imunidade Celular , Metástase Neoplásica , Estadiamento de NeoplasiasRESUMO
The combination of radiation and chemotherapy administered for patients undergoing therapy for advanced head and neck neoplasms leads to a significant rise in toxic side-effects. Oral mucositis remains one of the most distressing factors leading to pain, impairment of oral nutrition, local and systemic infection and often cessation of the oncological treatment. The local and systemic administration of recombinant growth factors has revealed a potential benefit in the treatment of oral mucositis. Clinical data concerning the topical use of granulocyte-macrophage colony-stimulating-factor (GM-CSF) in the prevention and therapy of mucositis in patients undergoing radiochemotherapy for advanced cancer of the head and neck are presented in this paper. A prospective, randomised, open parallel-grouped, single centre study at a university hospital was performed. 35 patients with stage III and IV carcinomas of the head and neck were included. Statistical analysis concerning the degree of oral mucositis, the perception of pain, the incidence of secondary infections and the change in haematological parameters revealed no superiority of GM-CSF in comparison to conventional mouthwash between the two groups of patients. As a result, and faced with the tremendous costs of the regular use of a recombinant cytokine, we ended the clinical trial after 35 patients. The topical administration of GM-CSF to treat oral mucositis as a result of radiochemotherapy in patients suffering from head and neck cancer cannot be recommended.
Assuntos
Fator Estimulador de Colônias de Granulócitos e Macrófagos/uso terapêutico , Neoplasias de Cabeça e Pescoço/terapia , Substâncias Protetoras/uso terapêutico , Lesões por Radiação/tratamento farmacológico , Proteínas Recombinantes/uso terapêutico , Estomatite/tratamento farmacológico , Adulto , Idoso , Idoso de 80 Anos ou mais , Protocolos de Quimioterapia Combinada Antineoplásica/efeitos adversos , Terapia Combinada , Feminino , Neoplasias de Cabeça e Pescoço/tratamento farmacológico , Neoplasias de Cabeça e Pescoço/radioterapia , Humanos , Masculino , Pessoa de Meia-Idade , Mucosa Bucal , Antissépticos Bucais , Estudos Prospectivos , Lesões por Radiação/etiologia , Radioterapia/efeitos adversos , Estomatite/induzido quimicamente , Estomatite/etiologiaRESUMO
Acetylcholine (ACh) has long been considered a neurotransmitter candidate in the efferent vestibular system of mammals. Recently, choline acetyltransferase (ChAT), the synthesizing enzyme for ACh, was immunocytochemically localized in all five end-organs of the rat vestibule (Kong et al. (1994) Hear. Res. 75, 192-200). However, there is little information in the literature concerning the cholinergic innervation in the vestibular periphery of man. In the present study the ultrastructural localization of the ChAT-like immunoreactivity in the human vestibular periphery was investigated in order to reveal the cholinergic innervation in the human vestibular end-organs. A modified method of pre-embedding immunoelectron microscopy was applied. It was found that the ChAT-like immunoreactivity was located in the bouton-type vesiculated nerve terminals in the vestibular neurosensory epithelia of man. These ChAT-like immunostained nerve terminals make synaptic contacts either with afferent chalices surrounding type I vestibular sensory hair cells, or with type II vestibular sensory hair cells. These results show that the ChAT-like immunoreactivity in the human vestibular periphery is confined to the efferent vestibular system. The ChAT-containing efferents innervate both type I hair cells and type II hair cells, making postsynaptic and presynaptic contacts, respectively. This study presents evidence that ACh is a neurotransmitter candidate in the efferent vestibular system of man.
Assuntos
Máculas Acústicas/inervação , Colina O-Acetiltransferase/metabolismo , Osso Temporal/inervação , Máculas Acústicas/ultraestrutura , Autopsia , Colina O-Acetiltransferase/análise , Células Epiteliais/enzimologia , Células Epiteliais/ultraestrutura , Humanos , Imuno-Histoquímica , Microscopia Imunoeletrônica , Neurônios Aferentes/enzimologia , Neurônios Aferentes/ultraestrutura , Neurônios Eferentes/enzimologia , Neurônios Eferentes/ultraestrutura , Perfusão , Perilinfa , Osso Temporal/ultraestruturaRESUMO
In the vertebrate vestibular periphery, gamma-aminobutyric acid (GABA) has long been presumed to be a neurotransmitter candidate. However, experimental reports about the localization and function of GABA in the vestibular systems of vertebrates are contradictory. In addition, there is no information in the literature concerning the localization of GABA in the human vestibular periphery. The present study investigates the ultrastructural localization of GABA-like immunoreactivity in the human utricular macula. A modified pre-embedding immunostaining electron microscopy technique was applied using two different commercially available polyclonal antibodies to GABA. GABA-like immunoreactivity is confined to the vesiculated nerve fibers and terminals of the human vestibular neurosensory epithelia. The GABA-containing nerve terminals make asymmetrical axo-dendritic synapses with the afferent chalices surrounding the type I sensory hair cells. Type I and type II hair cells as well as afferent chalices are devoid of GABA-like immunoreactive staining. The present study demonstrates that GABA exists in the human vestibular periphery, and that GABA is a neurotransmitter candidate of the human efferent vestibular system.
Assuntos
Máculas Acústicas/inervação , Fibras Nervosas/metabolismo , Neurônios Aferentes/metabolismo , Ácido gama-Aminobutírico/metabolismo , Máculas Acústicas/ultraestrutura , Autopsia , Células Epiteliais/metabolismo , Células Epiteliais/ultraestrutura , Humanos , Imuno-Histoquímica , Microscopia Imunoeletrônica , Fibras Nervosas/ultraestrutura , Neurônios Aferentes/ultraestrutura , Osso Temporal/inervação , Osso Temporal/ultraestrutura , Ácido gama-Aminobutírico/análiseRESUMO
We report the intraoperative use of bent probes for 3-dimensional computer-assisted navigation in ENT surgery with the ISG Viewing Wand. Probe calibration is standardized and the new probes comply with the overall application accuracy of the navigation system. The bent probes permit an easy access to the remotest locations of the maxillary and the frontal sinus and are beneficial for application in paranasal sinus surgery. We present our clinical experiences with these probes.
Assuntos
Endoscópios , Seio Frontal/cirurgia , Seio Maxilar/cirurgia , Terapia Assistida por Computador , Calibragem , Desenho de Equipamento , Seio Frontal/diagnóstico por imagem , Seio Frontal/patologia , Humanos , Processamento de Imagem Assistida por Computador , Imageamento por Ressonância Magnética , Seio Maxilar/diagnóstico por imagem , Seio Maxilar/patologia , Tomografia Computadorizada por Raios XRESUMO
OBJECTIVE: To conduct a review of contemporary approaches on the diagnostic-preoperative, operative, and postoperative methods in the management of juvenile nasopharyngeal angiofibroma (JNA). STUDY DESIGN: Retrospective study of 14 cases of JNA resection at the Department of Otorhinolaryngology, University of Innsbruck (Innsbruck, Austria) between 1987 and 1998. METHODS: Data was obtained for each patient regarding age, presenting symptoms, duration of symptoms, biopsy findings, tumor location, administration of preoperative angiography and embolization, and surgical approach. The follow-up period ranged from 1 to 13 years. RESULTS: Based on the histological evaluation by the preoperative biopsy and the tumor location, several surgical approaches were applied. A transnasal endoscopic procedure was employed in seven cases. The preoperative embolization and the intranasal approach with the potassium titanyl phosphate laser minimized blood loss. The recurrence rate was at a low of 15%. CONCLUSION: The surgical approach should be determined by tumor location, tumor size, and effectiveness of tumor embolization. For patients with JNA with tumor extension involving the nasopharynx, the nasal cavity, the paranasal sinuses, and the pterygopalatine fossa, the transnasal endoscopic technique offers a minimally invasive resection of the entire tumor mass with minimal morphological disturbance.
Assuntos
Angiofibroma/cirurgia , Endoscopia/métodos , Neoplasias Nasofaríngeas/cirurgia , Adolescente , Angiofibroma/diagnóstico , Perda Sanguínea Cirúrgica/prevenção & controle , Embolização Terapêutica , Humanos , Terapia a Laser , Masculino , Neoplasias Nasofaríngeas/diagnóstico , Cuidados Pós-Operatórios , Cuidados Pré-OperatóriosRESUMO
OBJECTIVE/HYPOTHESIS: Although anatomic data regarding the gross anatomy of the paranasal sinuses are available, severe complications of endonasal sinus surgery (ESS) are frequently reported. To understand and to avoid these complications, density of bony walls of the paranasal sinuses were studied in this report. Special attention was given to the analysis of the bone density in regions where minor and major complications occur in ESS. METHODS: Thirty cadaver heads were embedded in epoxy resin. The plastic blocks were sectioned with a diamond-coated wire saw into 1.0-mm thick, parallel slices in axial, coronal, and sagittal planes for 10 specimens each. The slices were x-rayed and scanned with a computerized image analyzing system. For each specimen the bone density in 12 regions of interest was measured. RESULTS: Besides the macroscopic examination of the plastinated specimens, a bone density analysis based on x-ray films is presented. Lowest bone density was found at the lateral wall of the sphenoid sinus (3.31 +/- 0.99 mm aluminum [Al]); highest density was measured at the roof of the sphenoid sinus (12.91 +/- 1.75 mm Al). Overall bone density in female specimens was 0.41 mm Al (mean) lower than in male specimens. CONCLUSIONS: This study is the first to use plastinated whole-organ serial sections and bone density images for the analysis of potential complications in ESS. The illustration of regions with minor and major bone density of the paranasal sinuses and the ethmoid floor as presented in this study may help the novice sinus surgeon to minimize the risks of ESS and to avoid severe complications.
Assuntos
Densidade Óssea/fisiologia , Endoscopia , Complicações Intraoperatórias/patologia , Seios Paranasais/patologia , Absorciometria de Fóton , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Inclusão em Plástico , Valores de Referência , Fatores de Risco , Fatores SexuaisRESUMO
OBJECTIVE: We demonstrate that computer-assisted frameless stereotactic navigation with the ISG/ELEKTA Viewing Wand system in the petrous bone is routinely possible with sufficient application accuracy. METHODS: High-resolution computed tomography imaging is done with a dedicated structure attached to the mouthpiece of the Vogele-Bale-Hohner (VBH) head holder, an integral part of our intraoperative patient fixation. The patient image registration can be reliably performed before surgery in an unsterile environment with the registration structure of the mouthpiece. For intraoperative navigation either the position-sensitive articulated arm or the optical three-dimensional digitizer of the ISG/ELEKTA system is used. RESULTS: In the operations of the petrous bone performed so far, i.e., mastoidectomy, cholesteatoma surgery, and lateral skull base revision surgery, the clinical value of three-dimensional navigation was clearly demonstrated with an application accuracy, constant throughout surgery, mostly limited only by the resolution of the computed tomography.
Assuntos
Colesteatoma da Orelha Média/cirurgia , Osso Petroso/cirurgia , Terapia Assistida por Computador , Fístula/cirurgia , Humanos , Período Intraoperatório , Base do Crânio/cirurgia , Software , Terapia Assistida por Computador/instrumentação , Terapia Assistida por Computador/métodos , Doenças Vestibulares/cirurgiaRESUMO
OBJECTIVES: Hyperplastic lesions of the laryngeal mucosa can eventually develop into squamous cell carcinoma The relationship between dendritic cell infiltration of head and neck cancers and prognosis is well known. Surprisingly, data regarding dendritic cell infiltration in precancerous lesions are not available today. It was the purpose of our study to extend these observations and to investigate in more detail the density and distribution of dendritic cells in pre-cancerous lesions. STUDY DESIGN: Retrospective survey by immunohistochemistry. METHODS: For this study we investigated paraffin-embedded tissue sections of 41 specimens. Histological diagnosis disclosed precancerous lesions of the larynx in 34 cases and in 7 cases, squamous cell carcinoma Immunohistochemical study was performed using antibodies against the cell surface markers S-100, HLA-DR, CD20, CD45 RO, CD45 RA, and Lag. Typical dendritic cell distributions of the immunostained specimens were photographed and measured on a quantitative basis. The medical histories of the patients were then analyzed retrospectively. RESULTS: HLA-DR+ cells could be detected in 14 of 16 cases in mild dysplastic lesions. The infiltration of the dysplastic lesions was sparse compared to cases with higher-graded dysplastic lesions. The distribution patterns of the dendritic cells in specimens with severe dysplastic lesions, but squamous cell carcinoma were extremely similar and markedly different from those in grades I and II specimens. Memory T lymphocytes (CD45 RO+) were detected more often in the group with severe dysplastic lesions (8 of 9 cases) than in the group with squamous cell carcinoma (3 of 8 cases). The inverse became evident for CD20 and CD45 RA immunolabeling. CONCLUSIONS: Few dendritic cells were found in the precancerous lesions. This may suggest that these early lesions (grades I and H) are not efficiently monitored by the immune system. Therefore they may develop into carcinomas unimpaired by cytotoxic T cells. As the degree of malignancy rises (grade III), more dendritic cells infiltrate the tumor.
Assuntos
Carcinoma de Células Escamosas/imunologia , Células Dendríticas/imunologia , Neoplasias Laríngeas/imunologia , Lesões Pré-Cancerosas/imunologia , Idoso , Carcinoma de Células Escamosas/classificação , Feminino , Antígenos HLA-DR/imunologia , Humanos , Imunidade Celular , Imuno-Histoquímica , Memória Imunológica/imunologia , Neoplasias Laríngeas/classificação , Masculino , Pessoa de Meia-Idade , Lesões Pré-Cancerosas/classificação , Prognóstico , Estudos Retrospectivos , Linfócitos T/imunologiaRESUMO
We report the first intraoperative use of a microdebrider as a stereotactic three-dimensional (3D) navigation instrument in paranasal and frontobasal surgery. The microdebrider uses rotating blades and an integrated suction device for controlled removal of tissue under video-endoscopic view. The ISG Viewing Wand uses the patient's computed tomography/magnetic resonance (CT/MR) data and a 3D reconstruction thereof and a high-precision position-sensitive mechanical arm for intraoperative three-dimensional navigation. We have linked the microdebrider to the Viewing Wand to transform it into a continuously available intraoperative stereotactic localizing device. We discuss the problems related to this extension of the Viewing Wand and demonstrate the practical use in an exemplary polypectomy.
Assuntos
Desbridamento/instrumentação , Processamento de Imagem Assistida por Computador/instrumentação , Seios Paranasais/cirurgia , Técnicas Estereotáxicas/instrumentação , Desenho de Equipamento , Humanos , Imageamento por Ressonância Magnética , Otolaringologia/instrumentação , Tomografia Computadorizada por Raios XRESUMO
Frameless stereotactic procedures crucially depend on the firmness of immobilization. Once registered, shifting of the patient leads to inaccuracy, and the patient registration has to be realigned. To overcome the drawbacks of conventional invasive fixation for neurosurgery and the widely accepted fixation with surgical tape in ENT, the Vogele-Bale-Hohner (VBH) head holder has been developed. It permits rigid, noninvasive fixation of the head by using an individualized dental cast attached to the upper jaw by vacuum. Oral intubation is uncomplicated. In addition, a special registration device providing well defined reference points can be mounted to the mouthpiece. We report the first promising clinical applications of this device.
Assuntos
Otolaringologia/instrumentação , Técnicas Estereotáxicas/instrumentação , Adenocarcinoma/cirurgia , Desenho de Equipamento , Humanos , Processamento de Imagem Assistida por Computador , Imobilização , Cuidados Intraoperatórios , Intubação Intratraqueal/instrumentação , Maxila , Procedimentos Cirúrgicos Minimamente Invasivos/instrumentação , Boca , Protetores Bucais , Neurocirurgia/instrumentação , Neoplasias dos Seios Paranasais/cirurgia , Pólipos/cirurgia , Cuidados Pré-Operatórios , Reprodutibilidade dos Testes , Tomografia Computadorizada por Raios X , VácuoRESUMO
OBJECTIVE: To evaluate the benefits and difficulties encountered when using various 3-dimensional (3-D) navigation systems in head and neck procedures. DESIGN: Five different navigation systems were used for preoperative planning and intraoperative 3-D navigation in procedures at the paranasal sinuses, the frontal and lateral skull bases, and the petrous bone. INTERVENTION: Intraoperative 3-D localizing systems (position-sensitive mechanical arms, infrared cameras, etc) demand reliable patient fixation on the operating table. We achieved this by developing a noninvasive head holder. Other systems allow patient movements by using magnetic digitizing technology (ARTMA System) and sophisticated programming. RESULT: Having surpassed an initial learning curve, we now achieve an accuracy of 1 to 2 mm regularly. Especially in paranasal and frontal basal surgery, all navigation systems used provide valuable positioning information during surgery. In particular for revision or tumor surgery, decisive benefits resulted from use of these systems: shorter overall operation time; safer manipulation near delicate structures; and reliable identification of the skull base even in patients with bleeding, scarring, or missing anatomical landmarks. CONCLUSIONS: We performed approximately 250 operations with different systems and introduced navigation at the lateral skull base and the petrous bone with mechanical, optic, and magnetic digitizers. In these anatomical areas, navigation was used successfully; the technical challenge is greatest at the lateral skull base, however.
Assuntos
Endoscópios , Neoplasias de Cabeça e Pescoço/cirurgia , Processamento de Imagem Assistida por Computador/instrumentação , Imageamento por Ressonância Magnética/instrumentação , Tomografia Computadorizada por Raios X/instrumentação , Gravação em Vídeo/instrumentação , Desenho de Equipamento , Neoplasias de Cabeça e Pescoço/patologia , Humanos , Microcirurgia/instrumentação , Robótica , Interface Usuário-ComputadorRESUMO
OBJECTIVE: To analyze the value of electromyography in predicting recovery from acute neurogenic vocal fold paralysis. STUDY DESIGN: Prospective case series. SETTING: University-based hospital of otorhinolaryngology-head and neck surgery. PATIENTS: Ninety-eight patients (56 women, with a mean age of 62.2 years; 42 men, with a mean age of 39.8 years) with 111 paralyzed vocal folds. The causes were varied, with thyroid surgery (53 cases) and idiopathic palsy (18 cases) being the predominant factors. INTERVENTION: Prognostication was based on electromyography performed no earlier than 14 days after onset of palsy. Findings were classified as neurapraxy, axonotmesis, and neurotmesis. Prognosis is inherent in this classification, since neurapraxy is presumed to resolve completely within 8 to 12 weeks, whereas axonotmesis is most likely to be followed by impaired vocal fold mobility. MAIN OUTCOME MEASURES: Vocal fold mobility after 6 months. RESULTS: In 102 vocal folds, some palsy of various degree persisted after 6 months. Free mobility of the paralyzed vocal fold was restored in 9 cases. By means of laryngeal electromyography, defective recovery, defined as absence of completely free vocal fold mobility, was predicted correctly in 94.4% of cases (68/72). For complete recovery, prognosis was accurate in only 12.8% of cases (5/39). CONCLUSIONS: The detection of neural degeneration by laryngeal electromyography allows the prediction of poor functional outcome with sufficient reliability in an early phase of the disease process. Conversely, the absence of signs of degeneration does not imply that complete recovery is to be expected.
Assuntos
Eletromiografia , Paralisia das Pregas Vocais/fisiopatologia , Adulto , Feminino , Humanos , Masculino , Prognóstico , Estudos Prospectivos , Paralisia das Pregas Vocais/etiologiaRESUMO
BACKGROUND: The Iceman is a prehistoric, completely preserved, 5300-year-old male human mummy. OBJECTIVE: To obtain the first biopsy specimens from inside the Iceman while meeting an extended standard of hygiene and following precise intraoperative guidance to the site of biopsy and keeping tissue damage to a minimum. DESIGN: Biopsy specimens from the nose, the maxillary sinus, and the larynx of the Iceman were obtained. Special caution had to be taken while performing the biopsies to not contaminate the Iceman with heavy metals or remnants of microorganisms. SUBJECT: The Iceman, a cadaver kept frozen in a glacier for 5300 years. The Iceman is in an excellent state of preservation and will allow fundamental histological, morphological, and molecular genetic insights into early man. INTERVENTION: The biopsies were planned and executed with the aid of Interventional Video Tomography, a system that guides the surgeon to the target area by combining live video with existing imaging modalities. The system does not need mechanical fixation of the subject (the Iceman) and is barely in physical contact with the subject; thus, it was the ideal tool for guiding the surgeon to the site of the biopsy samplings through a tiny canal into the nose, the maxillary sinus, and the larynx of the Iceman. RESULTS: We have obtained a number of tissue samples by precisely guided 3-dimensional navigation. Unnecessary tissue damage was avoided. CONCLUSIONS: Visual inspection of the extracted mucosa showed typical human cadaver tissue, despite its age, without clinical abnormalities. Currently, the samples are being investigated by various international scientific groups.
Assuntos
Hominidae/fisiologia , Laringe/patologia , Seio Maxilar/patologia , Múmias/patologia , Nariz/patologia , Animais , Biópsia/métodos , Congelamento , História Antiga , Humanos , Masculino , Manejo de Espécimes/métodos , Tomografia Computadorizada por Raios X , Gravação em VídeoRESUMO
Although photodynamic therapy (PDT) for the treatment of head and neck cancer has proved useful in other departments (J. Feyh, A. Goetz and W. Muller, Photodynamic therapy in head and neck surgery, J. Photochem. Photobiol. B: Biol., 7 (1990) 353-358; V.G. Schweitzer, Photodynamic therapy for treatment of head and neck cancer, Arch. Otolaryngol. Head Neck Surg., 102 (1990) 225-232; B.L. Wenig, D.M. Kurtzmann and L.I. Grossweiner, Photodynamic therapy in the treatment of squamous cell carcinomas of the head and neck, Arch. Otolaryngol. Head Neck Surg., 116 (1990) 1267-1270), it is not a standard therapy at the ENT Department of the University Clinic Innsbruck. PDT has only been applied in a few selected cases. Photosan 3 (dihaematoporphyrin either, DHE) was used as photosensitizer at a dose of 2.5 mg (kg body weight)-1 administered intravenously 24-48 h prior to photoirradiation. In one case, Photosan 3 was applied topically in a solution with 40% dimethylsulphoxide (DMSO). The light source was an argon dye laser with a wavelength of 630 nm and a power of 100 mW cm-2, coupled with a cylindrical or spherical applicator and a lens fibre tip. Patients suffering from cancer of the palatine arch, tonsil, nasal septum and glottis are reported. These selected cases had previous treatment (e.g. chemotherapy, percutaneous irradiation and surgery), and PDT was either performed as a palliative treatment for recurrence or in elderly patients to avoid inappropriate extensive and mutilating surgery.
Assuntos
Neoplasias de Cabeça e Pescoço/tratamento farmacológico , Fotoquimioterapia , Idoso , Idoso de 80 Anos ou mais , Feminino , Hematoporfirinas , Humanos , Neoplasias Laríngeas/tratamento farmacológico , Masculino , Neoplasias Nasais/tratamento farmacológico , Neoplasias Orofaríngeas/tratamento farmacológico , Fármacos Fotossensibilizantes/uso terapêutico , Neoplasias da Língua/tratamento farmacológicoRESUMO
The function of the tensor and levator veli palatini muscles was examined electromyographically in 26 patients with cleft palate, before and after Le Fort I-osteotomy. Hearing ability was determined audiometrically and via tympanometry and the maxillary advancement determined three dimensionally on the basis of model operation and lateral teleradiography. Due to the operative oedema, temporary functional impairment in palatal muscle tissue and sound transmission ability in the middle ear can occur. In several cases, maxillary osteotomy produced an improvement in ventilation of the middle ear and also improved the muscular activity of the palate in cleft patients.
Assuntos
Fissura Palatina/cirurgia , Orelha Média/fisiologia , Audição , Maxila/cirurgia , Músculos/fisiologia , Osteotomia/métodos , Músculos Palatinos/fisiologia , Palato Mole/fisiologia , Testes de Impedância Acústica , Audiometria , Cefalometria , Eletromiografia , Humanos , PressãoRESUMO
The authors have developed four different types of endolaryngeal laser resections for the treatment of larynx carcinomas. These new techniques are based on traditional concepts employed in partial larynx resections. From 1986 onward, 110 patients with laryngeal cancers were treated by endoscopic laser surgery. One hundred six patients were operated on for cure and 4 for palliation. In 9 cases of T3 tumor, complete removal of the tumor was not possible, requiring total laryngectomy. In all T2 cancers of the glottis and subglottis (n = 36), a total resection was possible. Additional staged neck dissection was performed in 16 cases, and postoperative radiotherapy in 10 cases. Follow-up investigations of the patients treated for cure (n = 106) cover a period of 3 to 42 months (mean, 22 months). These revealed 6 recurrences in the larynx, which were treated by laryngectomy. Recurrences in the cervical nodes were seen in 2 patients following resection of a supraglottic tumor and a subglottic tumor, respectively. Seven patients could not be followed up, 4 patients died of intercurrent disease, and 87 patients are alive and free of tumor. At present the number of recurrences and the rate of survival show no significant difference from those previously reported after conventional surgery. The phonatory function is not always predictable and still remains to be investigated. The authors believe that laser surgery may obviate the need for total laryngectomies in selected cases of laryngeal cancer, especially in T2 tumors. However, T3 tumors should not be treated by endolaryngeal laser surgery.
Assuntos
Carcinoma/cirurgia , Neoplasias Laríngeas/cirurgia , Laringectomia/métodos , Terapia a Laser/métodos , Carcinoma/patologia , Feminino , Seguimentos , Glote/cirurgia , Humanos , Neoplasias Laríngeas/patologia , Laringectomia/instrumentação , Terapia a Laser/instrumentação , Metástase Linfática , Masculino , Recidiva Local de Neoplasia/epidemiologia , Estadiamento de Neoplasias , Complicações Pós-Operatórias/epidemiologia , Prega Vocal/cirurgiaRESUMO
Zoom endoscopic electromyography of the larynx, as introduced in 1979, has contributed greatly to the diagnosis of lower cranial nerve palsies, but in the early stage of a vagus nerve disorder one cannot investigate the nerve conduction from the brain stem to the laryngeal muscles with electrical stimulation. As with the early diagnosis of facial nerve palsies, up to now the intracranial part of the motoric brain nerves could not be stimulated directly. With a new magnetic coil device (Novametrix, Magstim 200) this intracranial stimulation is easily possible in the awake patient with painless magnetic stimuli that induce a muscle action potential into the laryngeal muscles. Hence, an immediate diagnosis is possible. Two coils with mean diameters of 8.5 or 3 cm were used. The stimulator delivered current pulses of peak amplitude up to 5,000 A with rise times of 140 microseconds and 65 microseconds, respectively, that generated peak fields of up to 2 T. In a healthy population, cisternal stimulation of the vagus nerve leads to a muscular response in the vocal muscle after 4 to 6.6 milliseconds (mean 5 milliseconds). Cortical stimulation leads to such a response after 9.5 to 12 milliseconds. Potentials in healthy individuals have been shown to be very uniform. Stimulation in recurrent nerve palsies may show prolongation of these latencies up to 30 milliseconds. The method is limited by the fact that complete neural blocks cannot be overcome by proximal stimulation. We have applied magnetic stimulation to 190 patients with different disorders of the vagus nerve.(ABSTRACT TRUNCATED AT 250 WORDS)
Assuntos
Eletromiografia , Nervos Laríngeos , Magnetismo , Nervo Vago , Potenciais de Ação/fisiologia , Adulto , Doenças dos Nervos Cranianos/diagnóstico , Doenças dos Nervos Cranianos/fisiopatologia , Nervo Facial/fisiologia , Nervo Facial/fisiopatologia , Feminino , Humanos , Recém-Nascido , Nervos Laríngeos/fisiopatologia , Pessoa de Meia-Idade , Condução Nervosa/fisiologia , Tempo de Reação/fisiologia , Valores de Referência , Nervo Vago/fisiopatologia , Paralisia das Pregas Vocais/congênito , Paralisia das Pregas Vocais/fisiopatologiaRESUMO
Radiotherapy is widely accepted as primary treatment in the T1 stage of glottic cancer, but controversy surrounds the proper approach to T2 lesions of the glottis. A retrospective review of 90 patients addresses treatment results for T1 and T2 lesions of glottic carcinoma managed by primary radiotherapy with 60 to 64 Gy from 1977 to 1989. Seventy-nine patients met the criteria for local control analysis with a minimum follow-up of 5 years. Radiotherapy alone controlled disease in 93% (43 of 46) of patients with T1 lesion and 18% (6 of 33) of those with T2 tumors (including 10 patients in whom radiotherapy was terminated at 40 Gy because of persistent tumor). Ultimate control of disease for T1 and T2 lesions, including surgical salvage, was 100% and 82%, respectively. Larynx preservation was achieved in 100% of T1 and in 45% of T2 lesions. Extension of tumor and impaired vocal cord mobility showed statistical significance for adverse prognosis (p < .001). This paper discusses how these results affect treatment of glottic carcinoma, particularly in the T2 stage.
Assuntos
Carcinoma de Células Escamosas/radioterapia , Glote , Neoplasias Laríngeas/radioterapia , Análise Atuarial , Carcinoma de Células Escamosas/mortalidade , Carcinoma de Células Escamosas/cirurgia , Radioisótopos de Cobalto/uso terapêutico , Feminino , Humanos , Neoplasias Laríngeas/mortalidade , Neoplasias Laríngeas/cirurgia , Masculino , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Segunda Neoplasia Primária/epidemiologia , Teleterapia por Radioisótopo , Dosagem Radioterapêutica , Radioterapia de Alta Energia , Estudos Retrospectivos , Terapia de Salvação , Resultado do TratamentoRESUMO
Botulinum toxin is known as a relatively safe and efficacious agent for the treatment of various neurologic and ophthalmologic disorders. Since dysphagia and deglutition problems combined with aspiration are often caused by spasticity, hypertonus, or delayed relaxation of the upper esophageal sphincter (UES), conventional treatment including lateral cricopharyngotomy was replaced by localized injections of botulinum toxin into the cricopharyngeal muscle (CM) in a series of 7 patients. The study comprised patients with slight dysphagia caused by isolated hypertonus of the UES, as well as patients with severe deglutition disorders, complete inability to swallow, and aspiration problems. Preoperative diagnostic evaluation included careful history-taking, physical examination, cineradiography, and esophageal manometry to exclude other causes of dysphagia. For precise localization, injections were performed under general anesthesia after location of the CM by direct esophagoscopy and electromyographic guidance. Injections were administered into the dorsomedial part and on both sides into the ventrolateral parts of the muscle. Depending on the severity of symptoms and the intraluminal pressure of the UES, the dose varied between 80 and 120 units (botulinum toxin A from Dysport). The treatment outcome was evaluated by a disability rating score: patients' complaints were scored by subjective and objective parameters before and after injection. All but 2 patients experienced complete relief or marked improvement of their complaints. There were no severe side effects or postoperative complications. Local botulinum toxin injection proved to be an effective alternative treatment to invasive procedures for patients with isolated dysfunction of the UES, and also for patients with more complex deglutition problems combined with aspiration.