[Agranulocytosis after use of metamizole - an underestimated risk?] / Agranulozytose nach Metamizol-Einnahme ­ ein unterschätztes Risiko?

OBJECTIVE: Metamizole was the second most common drug prescribed in Germany in 2018 despite the known risk of agranulocytosis and the strict indication. According to Stammschulte et al. up to 25 % of all prescriptions are off-label use. Although mandatory according to the prescribing information of metamizole, regular blood cell counts are not performed in up to 50 % of the patients with long-term use of this drug. MATERIAL AND METHODS: Retrospective analysis of eight cases metamizole-induced agranulocytosis over a period of five years (2016-2020) in the university ENT department in Erlangen. Five patients were men and three women. Mean age of diagnosis was 52,4 years (±â€Š25,6). RESULTS: Agranulocytosis after use of metamizole is a serious adverse drug reaction that may affect patients of all ages. Frequently, only distinct clinical symptoms such as temperature of unknown origin, dysphagia and tonsillitis in combination with abscesses in the head and neck area result in the detection of a metamizole-induced agranulocytosis. An agranulocytosis provokes partially radical surgery and/ or intensive-care measures and could lead to sepsis with organ failure or even to death. CONCLUSIONS: These patient cases show that agranulocytosis is a dangerous or even deadly adverse drug reaction after use of metamizole. Although the risk of agranulocytosis appears to increase with duration of use, we would recommend patient education as well as documentation of even a single administration of metamizole. This may facilitate early diagnosis of metamizole-induced agranulocytosis and thus prevent the onset of severe complications with possible lethal outcome.

Clinical practice guideline: tonsillitis II. Surgical management.

In 2013, a total of 84,332 patients had undergone extracapsular tonsillectomies (TE) and 11,493 a tonsillotomy (TT) procedure in Germany. While the latter is increasingly performed, the number of the former is continually decreasing. However, a constant number of approximately 12,000 surgical procedures in terms of abscess-tonsillectomies or incision and drainage are annually performed in Germany to treat patients with a peritonsillar abscess. The purpose of this part of the clinical guideline is to provide clinicians in any setting with a clinically focused multi-disciplinary guidance through the surgical treatment options to reduce inappropriate variation in clinical care, improve clinical outcome and reduce harm. Surgical treatment options encompass intracapsular as well as extracapsular tonsil surgery and are related to three distinct entities: recurrent episodes of (1) acute tonsillitis, (2) peritonsillar abscess and (3) infectious mononucleosis. Conservative management of these entities is subject of part I of this guideline. (1) The quality of evidence for TE to resolve recurrent episodes of tonsillitis is moderate for children and low for adults. Conclusions concerning the efficacy of TE on the number of sore throat episodes per year are limited to 12 postoperative months in children and 5-6 months in adults. The impact of TE on the number of sore throat episodes per year in children is modest. Due to the heterogeneity of data, no firm conclusions on the effectiveness of TE in adults can be drawn. There is still an urgent need for further research to reliably estimate the value of TE compared to non-surgical therapy of tonsillitis/tonsillo-pharyngitis. The impact of TE on quality of life is considered as being positive, but further research is mandatory to establish appropriate inventories and standardized evaluation procedures, especially in children. In contrast to TE, TT or comparable procedures are characterized by a substantially lower postoperative morbidity in terms of pain and bleeding. Although tonsillar tissue remains along the capsule, the outcome appears not to differ from TE, at least in the pediatric population and young adults. Age and a history of tonsillitis are not a contraindication, abscess formation in the tonsillar remnants is an extremely rare finding. The volume of the tonsils should be graded according to Brodsky and a grade >1 is considered to be eligible for TT. The number of episodes during 12 months prior to presentation is crucial to indicate either TE or TT. While surgery is not indicated in patients with less than three episodes, a wait-and-see policy for 6 months is justified to include the potential of a spontaneous healing before surgery is considered. Six or more episodes appear to justify tonsil surgery. (2) Needle aspiration, incision and drainage, and abscess tonsillectomy are effective methods to treat patients with peritonsillar abscess. Compliance and ability of the patient to cooperate must be taken into account when choosing the surgical method. Simultaneous antibiotic therapy is recommended but still subject of scientific research. Abscess tonsillectomy should be preferred, if complications have occurred or if alternative therapeutic procedures had failed. Simultaneous TE of the contralateral side should only be performed when criteria for elective TE are matched or in cases of bilateral peritonsillar abscess. Needle aspiration or incision and drainage should be preferred if co-morbidities exist or an increased surgical risk or coagulation disorders are present. Recurrences of peritonsillar abscesses after needle aspiration or incision and drainage are rare. Interval TE should not be performed, the approach is not supported by contemporary clinical studies. (3) In patients with infectious mononucleosis TE should not be performed as a routine procedure for symptom control. TE is indicated in cases with clinically significant upper airway obstruction resulting from inflammatory tonsillar hyperplasia. If signs of a concomitant bacterial infection are not present, antibiotics should not be applied. Steroids may be administered for symptom relief.

Clinical practice guideline: tonsillitis I. Diagnostics and nonsurgical management.

More than 120,000 patients are treated annually in Germany to resolve repeated episodes of acute tonsillitis. Therapy is aiming at symptom regression, avoidance of complications, reduction in the number of disease-related absences in school or at work, increased cost-effectiveness and improved quality of life. The purpose of this part of the guideline is to provide clinicians in any setting with a clinically focused multi-disciplinary guidance through different conservative treatment options in order to reduce inappropriate variation in clinical care, improve clinical outcome and reduce harm. Surgical management in terms of intracapsular as well as extracapsular tonsillectomy (i.e. tonsillotomy) is the subject of part II of this guideline. To estimate the probability of tonsillitis caused by ß-hemolytic streptococci, a diagnostic scoring system according to Centor or McIsaac is suggested. If therapy is considered, a positive score of ≥3 should lead to pharyngeal swab or rapid test or culture in order to identify ß-hemolytic streptococci. Routinely performed blood tests for acute tonsillitis are not indicated. After acute streptococcal tonsillitis, there is no need to repeat a pharyngeal swab or any other routine blood tests, urine examinations or cardiological diagnostics such as ECG. The determination of the antistreptolysin O-titer (ASLO titer) and other antistreptococcal antibody titers do not have any value in relation to acute tonsillitis with or without pharyngitis and should not be performed. First-line therapy of ß-hemolytic streptococci consists of oral penicillin. Instead of phenoxymethylpenicillin-potassium (penicillin V potassium), also phenoxymethlpenicillin-benzathine with a clearly longer half-life can be used. Oral intake for 7 days of one of both the drugs is recommended. Alternative treatment with oral cephalosporins (e.g. cefadroxil, cefalexin) is indicated only in cases of penicillin failure, frequent recurrences, and whenever a more reliable eradication of ß-hemolytic streptococci is desirable. In cases of allergy or incompatibility of penicillin, cephalosporins or macrolides (e.g. Erythromycin-estolate) are valuable alternatives.

Single-cycle induction chemotherapy followed by chemoradiotherapy or surgery in patients with head and neck cancer: what are the best predictors of remission and prognosis?

BACKGROUND: There is controversy over the concept of function and organ preservation by chemotherapy/chemoradiation instead of surgery in locally advanced cancer of the larynx or pharynx. Tumor response to induction chemotherapy (ICT) can help in choosing between conservative and surgical treatment. This study compared 3 methods of assessing response to ICT: endoscopy, computed tomography, and (18) F-FDG-PET/CT. METHODS: Primary response to 1 cycle of ICT with docetaxel plus platinum was assessed by the aforementioned methods in 62 laryngopharyngeal cancer patients. Endoscopic response was the deciding factor for selecting further treatment: surgery for endoscopic nonresponders (<30% tumor response) versus chemoradiotherapy for endoscopic responders. RESULTS: ICT achieved endoscopic response in 48 of 62 patients (77%). Individual relative residual tumor activity of standardized uptake value (resSUV(max)) in (18)F-FDG-PET/CT was a median 0.38 of baseline (0.09-1.71), whereas residual tumor extent in CT (resCT) was 0.75 of baseline (0.32-1.20). Endoscopic responders and nonresponders differed significantly in SUV(max) after ICT (postSUVmax , 6.0 vs 14.5; P < .001), resSUV(max) (0.34 vs 0.81, P < .001), and resCT (0.71 vs 0.87, P = .004), but not in maximum tumor diameter after ICT (14 vs 20 mm, P = .11). resSUV(max) <0.8 and absolute postSUV(max) <10 provided the best discriminatory power for long-term success criteria (tumor-free survival, overall survival). CONCLUSIONS: Metabolic tumor response showed very good correlation with clinical tumor response to ICT. The value of metabolic response detected by (18)F-FDG-PET/CT should be explored in a prospective clinical trial.

Lymph node ratio as a predictor of outcome in patients with oropharyngeal cancer.

To evaluate the utility of lymph node ratio (LNR) as a potential prognostic predictor and to test whether LNR may be useful as a potential selection criterion for adjuvant treatment in patients with oropharyngeal squamous cell carcinoma (OPSSC). This retrospective study included 384 patients with regionally metastasized OPSCC who underwent primary surgery with or without adjuvant therapy from 1980 to 2010. LNR was calculated as the ratio of positive lymph nodes to the total number of lymph nodes removed during neck dissection. Statistical analysis using a Cox regression model was carried out. The 5-year disease-specific survival (DSS) was 73%. An individual LNR peak at 0.1 was closest to the median of 0.0909, and both were set as cut-off values. Patients in the group greater than median had a hazard ratio (HR) of 2.472 for a DSS event; this was close to an HR of 2.513 for LNR >0.1. In multivariate analysis, LNR showed a markedly stronger HR with regard to survival in comparison with the grouped pN classification. The covariate treatment modality did not meet the assumption of the Cox regression, and it was therefore not possible to comment reasonably on the issue of whether LNR could be a potential selection criterion for adjuvant treatment. Lymph node ratio is in itself a valuable additional prognostic factor for risk stratification. According to the current results, the most valuable LNR for OPSSC is expected to be located in the range from 0.09 to 0.1. Further investigations in large prospective trials will be required to allow evidence-based recommendations for treatment decisions based on the LNR.

Primary surgical treatment of T2 oropharyngeal carcinoma.

BACKGROUND: The optimal management of oropharyngeal carcinoma (OPC) is not yet proven. The aim of this study is to analyze the outcome of primary surgical management of T2 cancers of the oropharynx. METHODS: All patients treated with primary surgery for pT2 OPCs between 1984 and 2005 were evaluated retrospectively. Two hundred and twenty eight cases were assessed for disease-specific survival (DSS) as well as local control (LC) estimates, with respect to tumor location, surgical technique, status of surgical margins, N classification, and adjuvant therapy. Cases were also evaluated for major complications and functional results. RESULTS: DSS was 73.2% and LC 88.9%. Carcinoma of the tonsils showed a significantly better DSS than lesions of the base of the tongue (DSS = 76.3 vs. 60.2%, P = 0.02). DSS estimates in patients with pN0-1 classification were significantly better in comparison with pN2-3 (83.6 vs. 64.5%, P = 0.018). Patients who were given adjuvant treatment had a better prognosis. The incidence of occult neck metastases was 17% and complications rate 12.7%. CONCLUSIONS: Primary surgical treatment of T2 OPC proved to be an effective treatment modality with a low rate of complications and satisfactory functional results. Complete tumor excision is essential and a neck dissection is justified. Most patients need adjuvant radiotherapy.

Management of advanced carcinoma of the base of tongue.

BACKGROUND AND OBJECTIVE: Base-of-tongue carcinoma is a relatively rare disease with aggressive behavior and poor prognosis. Up to date no consensus exists regarding the ideal management strategy for each stage of the disease. This study aims to evaluate the experience of a single head and neck oncology center in the management of advanced stage base-of-tongue cancer. METHODS: A retrospective evaluation of cases primarily treated for stage III/IV(A-B) base-of-tongue carcinoma, between 1980 and 2007, at a tertiary referral center. RESULTS: A total of 366 cases were studied. Five-year disease specific survival (DSS) was 42% and local control (LC) 80%. Regional and distal control estimates were 91.3 and 84%, respectively. Prognosis was significantly superior for cases receiving surgery plus adjuvant treatment compared to cases solely managed with non-surgical modalities. Positive surgical margins and regional disease significantly worsened prognosis. Satisfactory retention of pharyngeal function and no fatal complications were noted in surgical cases. CONCLUSION: Although no consensus exists regarding ideal therapy for advanced base-of-tongue carcinoma, combined strategies with the use of surgery and adjuvant chemoradiotherapy (CRT) seem to offer the best possibility for a positive outcome.

Efficacy and Safety of a Fixed-Dose Combination of Cinnarizine 20 mg and Dimenhydrinate 40 mg in the Treatment of Patients with Vestibular Vertigo: An Individual Patient Data Meta-Analysis of Randomised, Double-Blind, Controlled Clinical Trials.

BACKGROUND AND OBJECTIVE: The source data of four individual randomised, double-blind, reference- and/or placebo-controlled clinical trials with virtually identical study design were pooled for the present meta-analysis. The main objective was to further evaluate the efficacy and safety of the fixed combination of cinnarizine 20 mg and dimenhydrinate 40 mg in comparison to various other antivertigo treatments in patients suffering from central and/or peripheral vestibular vertigo. METHODS: Adult male and female outpatients were subjected to a 4-week treatment with the fixed combination of cinnarizine 20 mg and dimenhydrinate 40 mg, cinnarizine (20 mg, 50 mg), dimenhydrinate (40 mg, 100 mg), betahistine dimesylate (12 mg), betahistine dihydrochloride (16 mg) and placebo, respectively. The primary efficacy endpoint was the reduction of a validated mean vertigo score (MVS), a composite score of 12 individual vertigo symptoms, the intensities of which were each evaluated by the patients on a 5-point visual analogue scale. For analysis of primary and further secondary efficacy endpoints, baseline-adjusted analysis of covariance (ANCOVA) was used to calculate adjusted least squares means (LSM) with associated two-sided 95% confidence intervals (CIs) for the difference in MVS reductions between treatment groups. Moreover, various sensitivity analyses, responder and subgroup analyses as well as descriptive analyses with respect to safety/tolerability of the treatments were conducted. RESULTS: Of 795 randomised patients, 779 belonged to the intent-to treat (ITT) and 723 to the per-protocol (PP) population. The main efficacy analysis was based on the ITT population (mean age 52.1 years, 61% female). The mean decrease of the MVS from baseline to Week 4 in the cinnarizine/dimenhydrinate group (-1.10) proved to be significantly larger than in any of the comparator groups. LSM differences for comparators versus the fixed combination ranged between 0.16 (95% confidence interval (CI) 0.03; 0.30, p = 0.017) for cinnarizine 20 mg and 0.60 (95% CI 0.42; 0.78; p < 0.001) for betahistine dimesylate 12 mg in favour of the fixed combination. Furthermore, after 4 weeks of treatment, 74 patients (24.7%) in the cinnarizine/dimenhydrinate group were completely symptom free (MVS = 0), a significantly greater proportion than in any of the comparator groups. Sensitivity analyses showed that baseline characteristics such as age, sex, duration of vertigo and antivertigo pretreatment had only a very minor and clinically non-relevant impact on the efficacy results regarding the primary efficacy outcome. Subgroup analyses with respect to age groups (< 65 years/≥ 65 years) and sex showed no significant differences in efficacy within any of the treatment groups. All treatments were well tolerated. A total of 55 patients (6.9%) reported 75 non-serious adverse events (AEs), and 19 patients (2.4%) discontinued the study prematurely because of AEs. Nearly 95% of the patients (cinnarizine/dimenhydrinate group: 97.9%) rated the tolerability of the study medications as either "good" or "very good". CONCLUSION: The findings of the present meta-analysis indicate that the fixed combination of cinnarizine and dimenhydrinate is a safe and potentially superior treatment option for patients suffering from central and/or peripheral vestibular vertigo, as compared to current standard treatments such as cinnarizine, dimenhydrinate or betahistine given alone in monotherapy.

Pain management after tonsillectomy-by demand or by-the-clock-is there a difference?

PURPOSE: To improve pain management after tonsillectomy (TE) by comparing individual analgesic management by demand versus a fixed-scheduled analgesic treatment protocol in a prospective trial. PATIENTS AND METHODS: Forty consecutive patients received individual pain treatment by demand (control group) followed by 40 patients who were treated by a fixed-scheduled four-staged escalating analgesic protocol (intervention group) after TE. Minimum and maximum pain as well as pain on ambulation (NRS 0-10) on the first postoperative day were defined as primary objectives. Secondary endpoints comprised the analgesic score, treatment-related side effects/pain-associated impairments, wish for more pain medication, and patient satisfaction. Patients were surveyed using the standardized and validated "Quality Improvement in Postoperative Pain Treatment" (QUIPS) questionnaire. RESULTS: Patients of the control group reported comparable minimum (2.03 ± 1.42 vs 2.38 ± 1.79, P = 0.337, r = 0.110) and maximum pain (6.65 ± 2.10 vs 6.93 ± 1.86, P = 0.536, r = 0.07) and pain on ambulation (4.73 ± 2.26 vs 5.18 ± 2.19, P = 0.370, r = 0.10) compared to the intervention group. Patients in both groups were comparably well satisfied with the pain treatment (7.53 ± 2.40 vs 7.73 ± 2.30, P = 0.704, r = 0.04), experienced similar side effects and functional impairments (P > 0.050, Φ < 0.3), and did not ask for much more analgesic medication (P = 0.152, Φ = 0.160). CONCLUSION: Pain control following TE was not distinctly affected by applying a fixed-scheduled analgesic treatment protocol compared to individual analgesic therapy. In conclusion, analgesic treatment after TE remains unsatisfying. Consequently, further efforts are needed to achieve a standardized and effective approach to the underlying pathophysiological causes of pain following TE.

Feasibility, toxicity, and efficacy of short induction chemotherapy of docetaxel plus cisplatin or carboplatin (TP) followed by concurrent chemoradio-therapy for organ preservation in advanced cancer of the hypopharynx, larynx, and base of tongue. Early results.

PURPOSE: Concurrent chemoradiotherapy (CRT) is standard treatment for advanced head and neck cancer. Whether short induction chemotherapy (ICT) provides additional benefit or, in particular, predictive benefit for the response to chemoradiotherapy is an open question. The present study aimed to assess the feasibility, toxicity, and efficacy of induction with docetaxel and platinum salt (TP) and subsequent CRT. PATIENTS AND METHODS: A total of 25 patients with functionally inoperable cancer of the base of the tongue, hypopharynx, or larynx received 1 cycle of docetaxel (75 mg/m², day 1) combined with either cisplatin (30 mg/m², days 1-3; n = 23) or carboplatin (AUC 1.5 days 1-3; n = 2). Responders (n = 22, >30% tumor reduction, graded by endoscopy) and 1 non-responder received CRT (target dose: 69-72 Gy) with cisplatin/paclitaxel, carboplatin/paclitaxel, or cisplatin/docetaxel. RESULTS: All patients completed ICT with acceptable toxicity (leukocytopenia grade 4: 8%). The remission rate of the primary tumor was 88% (22/25 patients). There was no need to delay CRT due to toxicity in any case. Each patient received the full radiation dose. Of the patients, 56% received >80% of the chemotherapy. The acute toxicity of CRT was moderate, no grade 4 toxicities occurred, while grade 3 toxicities included the following: infection (39%), dermatitis (13%), leukocytopenia (30%), and thrombocytopenia (4%). The local control rate was 84.6% ± 8.5% and the survival rate was 89.6% ± 7.2% at 12 months. Organ preservation was possible in 22/23 (95%) cases. CONCLUSION: Short induction with a TP regimen and subsequent CRT with a taxan is feasible and associated with an encouraging local control rate.

Resection margins and other prognostic factors regarding surgically treated glottic carcinomas.

BACKGROUND AND OBJECTIVES: This study aims to assess the prognostic significance of free histopathologic margins in the surgical treatment of glottic cancer. Furthermore, it evaluates other prognostic factors regarding cases that receive surgical management for glottic lesions. METHODS: A retrospective case-series study was conducted at an academic tertiary referral center. The files of 1,314 cases that underwent primary surgical treatment for glottic cancer were studied. Various prognostic factors, including age, surgical procedure, T classification, N classification, histological grade, and status of margins were assessed in univariate and multivariate analyses. All variables were investigated for their association with local and regional disease control as well as disease specific and overall survival. RESULTS: Status of margins significantly affected disease specific survival and local control regardless of tumor stage in this series. All other variables assessed in the univariate analysis for their association with survival were also found to be significant. However, status of surgical margins and N classification were the only significant variables in multivariate analysis. CONCLUSION: The prognostic value of negative surgical margins for the treatment of glottic cancer cannot be overestimated. Responsibility of the surgeon during primary surgical treatment of glottic carcinomas is emphasized.

T1 and T2 hypopharyngeal cancer treatment with laser microsurgery.

BACKGROUND AND OBJECTIVE: To assess the oncologic results and functional outcomes of CO(2) laser microsurgery in T1 and T2 hypopharyngeal cancer. METHODS: The files of 119 T1 and T2 hypopharyngeal carcinoma cases primarily managed with laser surgery were reviewed. Cases were assessed for 5-year disease-specific survival (DSS) as well as local control (LC) rates, with respect to T and N classification, status of surgical margins, and decision on neck management and adjuvant therapy. Cases were additionally evaluated for incidence of major complications and retention of laryngeal and pharyngeal function. RESULTS: DSS and LC rates of 72.6% and 85.4%, respectively, were noted overall in this series. Survival rates were found to be significantly better for cases with negative surgical margins. The presence of regional metastases was also found to significantly affect prognosis. Satisfactory retention of function and a low rate of major complications were noted. CONCLUSION: Laser surgery appears to be very effective for T1 and T2 hypopharyngeal cancer treatment as long as clear surgical margins can be achieved. Oncologic results are acceptable with low incidence of complications and satisfactory retention of function. The neck must always be included in the primary treatment plan of hypopharyngeal lesions.

Characterization of initial clinical symptoms and risk factors for sinonasal adenocarcinomas: results of a case-control study.

PURPOSE: Sinonasal adenocarcinoma is a rare cancer, frequently associated with occupational exposure to inhalable wood dust. Among the EU member States, Germany was reported to have the highest number of exposed workers. Location and long latency make early diagnosis difficult. This case-control study was aimed at assessing potential risk factors and at characterizing initial clinical symptoms, both serving as matrix to identify persons at increased risk and to improve management of this cancer. METHODS: Of 58 patients, 31 diagnosed with sinonasal adenocarcinoma (cases) between 1973 and 2007 were identified and underwent standardized interview on clinical data. A total of 85 patients diagnosed over the same period with carcinoma of the oral cavity served as controls. RESULTS: The ethmoid was confirmed as the predominant site of adenocarcinoma associated with wood dust exposure, whereas the nasal cavity was most commonly affected in patients denying any exposure to wood dust. Cases were significantly engaged in mainly woodworking occupations compared to controls. The main initial clinical symptoms were nasal obstruction 6 months (71%) and epistaxis 4 years (41.9%) prior to diagnosis. Hardwood dust from beech and oak proved to be the most common occupational exposure, with a mean exposure period of 32.3 years and a latency of 43.5 (34-58) years. CONCLUSIONS: Our investigation confirms the importance of regular screenings for persons exposed to wood dust even years after the end of occupational or private exposure. Banal clinical symptoms such as epistaxis and nasal obstruction might be predictive, requiring early and thorough investigation.

Implementation of study results in guidelines and adherence to guidelines in clinical practice.

Guidelines were introduced in hospital- and practice-based otorhinolaryngology in the 1990ies, and have been undergoing further development ever since. There are currently 20 guidelines on file at the German Society of Oto-Rhino-Laryngology, Head & Neck Surgery. The society has cooperated in further 34 guidelines. The quality of the guidelines has been continuously improved by concrete specifications put forward by the Association of the Scientific Medical Societies in Germany (Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e.V., AWMF). Since increasing digitalization has made access to scientific publications quicker and simpler, relevant study results can be incorporated in guidelines more easily today than in the analog world. S2e and S3 guidelines must be based on a formal literature search with subsequent evaluation of the evidence. The consensus procedure for S2k guidelines is also regulated. However, the implementation of guidelines in routine medical practice must still be considered inadequate, and there is still a considerable need for improvement in adherence to these guidelines.

Management of locally advanced laryngeal cancer.

BACKGROUND: Management of advanced laryngeal cancer is complex and ideal strategy is yet to be defined. This study evaluates the experience of a single head and neck oncologic centre in the management of T4 laryngeal cancer. METHODS: Retrospective assessment of cases primarily treated for T4a squamous cell carcinoma of the larynx, between 1980 and 2007, at a tertiary referral center. RESULTS: A total of 384 cases were studied. Five-year disease specific survival was 56.2% and local control 87.4%. Regional and distal control estimates were 90.3% and 88.3% respectively. Prognosis was significantly superior for cases treated with primary surgery compared to cases solely managed with non-surgical modalities. Positive surgical margins and regional disease worsened prognosis. CONCLUSION: This study suggests that primary surgery remains a key element in the treatment of advanced laryngeal cancer. The need for well-designed, prospective, randomised studies in order to further evaluate the remaining role of primary surgery in the modern management of locally advanced laryngeal lesions is emphasized.

Primary surgical therapy for locally limited oral tongue cancer.

OBJECTIVES: The aim of this study was to assess the efficacy of primary surgical treatment in the management of locally limited oral tongue carcinoma. METHODS: A retrospective evaluation was carried out for all patients treated with primary surgery for pT1-pT2 oral tongue carcinomas at a tertiary referral center between 1980 and 2005. All cases were assessed for disease-specific survival and local control rates in relation to T classification, N classification, infiltration depth of the primary tumor, and decision making on neck management and adjuvant therapy. The cases were additionally evaluated for the incidence of major complications and tracheotomies. RESULTS: 263 cases were assessed. The 5-year disease-specific survival rate was 75.2%. Positive neck disease was shown to be a significant negative prognostic factor. The occult metastasis rate was 20.2%. CONCLUSIONS: Primary surgical treatment is a very effective modality against T1-T2 oral tongue carcinoma, and a low rate of complications can be anticipated.

Management of patients with risk factors.

This review addresses concomitant diseases and risk factors in patients treated for diseases of the ears, nose and throat in outpatient and hospital services. Besides heart disease, lung disease, liver disease and kidney disease, this article also covers disorders of coagulation (including therapy with new oral anticoagulants) and electrolyte imbalance. Special attention is paid to the prophylaxis, diagnosis and treatment of perioperative delirium. It is also intended to help optimise the preparation for surgical procedures and pharmacotherapy during the hospital stay.

Prognostic factors in limited (T1-2, N0-1) oropharyngeal carcinoma treated with surgery ± adjuvant therapy.

BACKGROUND: Surgical therapy for early oropharyngeal carcinoma leads to excellent oncologic results but often requires adjuvant radiotherapy. The purpose of this study was to identify prognostic factors that worsen the outcome of limited oropharyngeal carcinoma treated with surgery ± adjuvant therapy. METHODS: Two hundred sixty-six patients were retrospectively evaluated between 1980 and 2007. RESULTS: Overall 5-year disease-specific survival (DSS) was 88.7% and local control (LC) was 93.3%. The univariate analysis showed a significant difference in DSS between pT1 and pT2 oropharyngeal carcinoma (DSS, 94.0% vs 81.2%; p = .008) and patients with tumor depth greater than 5 mm (DSS, 94.5% vs 78.9%; p = .031). No difference could be found as to N classification, marginal status, p16 human papillomavirus (HPV) status, type of treatment, and adjuvant radiotherapy. CONCLUSION: Primary surgical treatment is an effective therapy of limited oropharyngeal carcinoma. Patients with pT2 status and tumor depth of more than 5 mm show a significantly worse survival rate and should be further investigated in future clinical trials.

Results of chemoselection with short induction chemotherapy followed by chemoradiation or surgery in the treatment of functionally inoperable carcinomas of the pharynx and larynx.

OBJECTIVES: Chemoradiation is the treatment of choice for carcinomas of the pharynx and larynx with imminent loss of organ or function. However, the prognosis after CRT decreases when salvage surgery becomes necessary. Single-cycle induction chemotherapy is therefore performed to identify patients who would benefit more from S than from CRT. The present study aims to evaluate the feasibility and effectiveness of this approach. MATERIALS AND METHODS: Forty-seven patients received Induction Chemotherapy (IC) with docetaxel plus cisplatin or carboplatin and were subsequently assessed for tumor response. Responders achieving a ≥30% decrease in endoscopic tumor size and a ≥20% decrease in 18F-fluorodeoxyglucose uptake proceeded to primary Chemoradiation (CRT) and non-responders received surgery (S). Six weeks after CRT patients with residual tumors underwent secondary surgery (S). RESULTS: Thirty eight patients were elected for CRT and 9 received S. A local control rate of 86.1% and disease-free survival of 80.4% was achieved at 2 years. Overall treatment time in CRT-patients >80 days was associated with inferior disease-free survival (p = 0.05), cause-specific survival (p = 0.02), overall survival (p = 0.01) and a trend to inferior local control (p = 0.07) at 2 years. CONCLUSION: The strategy of selecting patients for CRT vs. S based on the response to IC achieves encouraging rates of disease control by surgery and CRT.