Abstract: The aim of this study was to evaluate the influence of timing of tracheoesophageal puncture (TEP)with indwelling voice prosthesis insertion regarding long-term success rate and postoperative complication. We conducted a Retrospective clinical study at tertiary academic center. There were 75 patients with primary TEP (80.6%) and 18 with secondary TEP (19.3%). Long-term success rate was 81.7%, with 80.0% in primary TEP and 88.9% in secondary TEP. No significant difference in Harrison-Robillard-Schultz Rating Scale success assessment were observed between patients with primary and secondary TEP (P = .596). The use of postoperative radiotherapy did not significantly influence the success rate. The age of patients who were older or younger than 60 years significantly influence the success rate in primary TEP (P = .012). The higher rate of complications in primary TEP was not statistically significant. These findings suggest that primary and secondary TEP are equally safe and effective procedures. Primary TEP should be prefered because of avoiding a second surgical intervention and allowing early voice restoration with a considerable psychological impact.
Abstract: The aim of this study was (1) to analyze the in situ lifetime of indwelling voice prostheses (VPs) and (2) to investigate the role of some variables on device lifetime. We conducted a retrospective clinical study of patients visiting our outpatient clinic for problems related to their VP from August 1998 to March 2006. The mean in situ VP lifetime was 180.9 days (95% CI 162.6-199.2). The mean in situ VP lifetime was 163.3 and 202.9 days in patients irradiated and not irradiated, respectively (P = 0.008). The mean in situ VP lifetime was 126.5 and 215.7 days in patients with and without endoscopic evidence of erosive-ulcerative gastroesophageal reflux disease (GERD), respectively (P < 0.001). Multivariate analysis confirmed that radiotherapy and presence of GERD significantly affected the in situ VP lifetime. This study confirmed the relationship between short VP lifetime and radiation therapy. In addition, a possible association between GERD and limited device lifetime was identified.
Abstract: OBJECTIVE: To compare the quality of life (QoL) of patients who underwent total laryngectomy with voice prosthesis insertion and postoperative radiotherapy (PORT) with those receiving concurrent chemoradiation for laryngeal preservation. STUDY DESIGN: Retrospective, cross-sectional study in a tertiary academic center. METHODS: The European Organization for Research and Treatment of Cancer Quality of Life Questionnaires were used to assess long-term QoL in 67 patients treated for laryngeal cancer. RESULTS: The scores of functional scales for physical (P < .000), social (P = .001), and role functioning (P = .043) were more favorable in the chemoradiation group. The global QoL score was higher in the nonsurgical group (P = .016). Surgical patients reported on sleep disturbance (P < .000), dyspnea (P = .001), and pain (P = .003), with a higher scores and greater difficulties with the senses (P < .000), social contact (P = .002) and speech (P = .010). The chemoradiation group reported greater problems with dry mouth (P < .000) and sticky saliva (P = .005). CONCLUSION: We found better long-term QoL scores in patients undergoing concurrent chemoradiation. This appears to be mainly because of better physical functioning, social functioning, and social contact and smaller problems with pain, respiration, speech, the senses, and sleep disturbances.
Abstract: The objective of this study was to identify, through multivariate analyses, the configuration of factors that most closely impact the development of pharyngocutaneous fistula (PCF). Incidence and treatment of PCF was also revisited. A retrospective longitudinal study of 218 patients who have undergone total laryngectomy (TL) was conducted in a tertiary academic referral center. There were 47 patients (21.6%) developing PCF within 1 month after surgery (median 14 days, range 2-26 days). Non-surgical closure of the PCF was achieved in 36 patients (76.6%) within a median of 16.5 days (range 8-27 days). Eleven patients (23.4%) required a surgical closure of the PCF. In nine patients the surgical approach consisted in resuturing of the pharyngeal mucosa. Major surgery with the use of flaps (pectoralis major myocutaneous flap and free forearm flap) was required in two patients. Multivariate analysis revealed that diabetes mellitus (odd ratio 23.41 [95% CI 8.46-64.78]), preoperative hypoalbuminemia (odd ratio 9.42 [95% CI 3.60-24.61]), chronic pulmonary diseases (odd ratio 6.64 [95% CI 1.97-22.56]) and chronic hepatopathy (odd ratio 3.26 [95% CI 1.19-9.96]) were independent predictors for PCF formation. PCF results in prolonged hospitalization with increased medical costs, delay of adjuvant postoperative therapy and potentially life-threatening complications such as carotid rupture. In order to reduce the risk of PCF and avoid a delayed TL, optimization of comorbidities and correction of nutritional deficiencies with enteral or parenteral nutritional supplements should be achieved as early as possible.
Abstract: BACKGROUND: The aim of this retrospective analysis was to analyze the results of treatment of patients with cervical node metastases from carcinoma of occult primary with a policy including neck dissection and postoperative comprehensive radiotherapy. METHODS: Ninety patients were treated with curative intent from 1990 to 2002. RESULTS: The actuarial rate of neck disease control was 68.8% at 5 years (95% confidence interval [CI], 58.9%-78.7%). On multivariate analysis, the rate of neck disease control was significantly related to lymph nodal metastatic level (P = .006). The actuarial rate of developing head and neck primary tumors at 5 years was 8.9% (95% CI, 2.6%-15.2%). The 5-year actuarial rate of distant metastases was 19.1% (95% CI, 9.4%-28.9%). In multivariate analysis, a statistically significant difference in the rate of distant metastasis was obtained when patients were stratified according to the level of nodal involvement (P = .01) and the presence of extracapsular extension (P = .013). At the time of analysis, 50 of the 90 patients were alive. A total of 32 (35.6%) had died from causes related to their primary disease. Actuarial disease-specific survival at 2 and 5 years was 73.6% (95% CI, 64.3%-82.9%) and 62.8% (95% CI, 51.9%-73.7%), respectively. In multivariate analysis, a statistically significant difference in disease-specific survival was obtained when patients were stratified according to the level of nodal involvement and the presence of extracapsular extension. CONCLUSIONS: Our study seems to support the use of combined-modality therapy in patients with neck metastases from carcinoma of occult primary. However, in the absence of randomized trials, comprehensive irradiation cannot be routinely advised.
Abstract: PURPOSE: The aim of this study was to analyze the prognostic value of some clinical factors and to compare the survival of different treatment plans in patients with cervical lymph node metastases from occult squamous cell carcinoma (SCC). METHODS: A retrospective review was conducted of patients who were diagnosed as having cervical lymph node metastases from occult SCC. Overall cumulative survival was analyzed using the standard Kaplan-Meier method. Tests of significance were based on log-rank statistics. RESULTS: The 82 patients in the study consisted of 69 males (84.2%) and 13 females (15.8%). The average age at diagnosis was 64.7 years. Fifty patients (60.9%) underwent surgical treatment of cervical metastasis. Radiotherapy was performed in 79 patients. Thirty-two patients (40.5%) received primary fractioned external beam radiotherapy; 47 patients (59.5%) received postoperative fractioned external beam radiotherapy. Ipsilateral radiotherapy was performed on 37 patients (46.8%), bilateral neck plus mucosal irradiation was performed in 42 patients (53.2%). Ten patients (12.2%) developed a primary tumor during the follow-up. The actuarial survival rates of all patients 2, 5 and 10 years after diagnosis were 50.9, 25.3 and 18.5%, respectively. Patients with nodal stage N2b, N2c and N3 had a significantly poorer prognosis than those with nodal stage N1 and N2a (p = 0.0239). The survival in patients with metastatic nodes in the supraclavicular region (level IV) was significantly poorer than that of patients with involvement of the upper-middle jugular lymph nodes (p = 0.0003). We observed a statistically significant better survival in patients receiving bilateral neck plus mucosal irradiation (p = 0.0003). CONCLUSIONS: Initial N-category and metastasis localization were the most important prognostic factors and nodal relapse the major cause of treatment failure, thus optimal management of cervical nodes appears crucial for the success of treatment. Patients receiving bilateral neck plus mucosal irradiation had a higher survival rate than those who received ipsilateral irradiation.
Abstract: BACKGROUND: Although the advent of antibiotics and improved dental care decreased the incidence and mortality, deep neck infections (DNIs) are not uncommon and present a challenging problem due to the complex anatomy and potentially lethal complications that may arise. OBJECTIVES: This study reviews our experience with DNIs and tries to identify the predisposing factors of life-threatening complications. METHODS: A retrospective review was conducted of patients who were diagnosed as having DNIs in the Department of Otolaryngology and in the Department of Infectious Diseases at Treviso Regional Hospital from 1995 to 2003. Associations between life-threatening complications and other factors were determined by chi(2) test, Fisher's exact test and Student's t test as appropriate. RESULTS: One hundred sixty-seven charts were recorded; 95 (56.9%) were men, and 72 (43.1%) were women, with a mean age of 49.6 +/- 20.4 years (range: 2-96). There were 39 patients (23.4%) who had associated systemic diseases, with 53.8% (21/39) of those having diabetes mellitus. The lateral pharyngeal and submandibular spaces were the most commonly involved spaces. Upper airway infections and odontogenic infections were the two most common causes of DNIs (47.5 and 27.9% of the known causes, respectively). The pathogenesis remained unknown in 45 patients (26.9%). Coagulase-negative staphylococcus (36.9%) and Streptococcusviridans (28.8%) were the most common organisms, identified through cultures. Of the abscess group (77 patients), 42 patients (54.5%) underwent surgical drainage under general anesthesia. Thirty-one patients (18.6%) developed life-threatening complications: airway obstruction (n = 18), descending mediastinitis (n = 6), jugular vein thrombosis (n = 4), and pneumonia (n = 3). Compared with other patients, the unique features of patients with life-threatening complications were as follows: older age (p = 0.04), a higher white blood cell count (p = 0.01), abscess formation (p = 0.02), associated systemic disease (p < 0.001), diabetes mellitus (p < 0.001), anterior visceral space involvement (p < 0.001), and multiple-space involvement (p < 0.001). CONCLUSIONS: DNIs continue to occur and these are associated with significant morbidity and mortality even in this era of antibiotics. Furthermore, the widespread and inappropriate use of antibiotics may change the clinical presentation and course of these infections, making them more elusive and less predictable also in complicated cases. The clinical assessment of patients who are older, with abscess formation, underlying systemic diseases, diabetes mellitus, visceral anterior space or multiple-space involvement requires careful consideration of potential complications.
Abstract: OBJECTIVES: To review cases of DNAs with special emphasis on contrast-enhanced computed tomography (CECT) findings and their implications for treatment planning. STUDY DESIGN AND SETTINGS: Retrospective evaluation of adult patient records with diagnosis of DNAs on CECT at Treviso Regional Hospital. RESULTS: Eighty patients were identified. In 30.0% of cases, an immediate surgical drainage was performed. In 22.5% of cases, a surgical drainage was necessary because of the lack of clinical response to medical therapy alone. Almost half of the patients were treated with antibiotics alone with complete remission. DM was predictive for lack of response to medical therapy alone (P=0.014). Intraoperative findings confirmed the CECT diagnosis in 88.1%. CONCLUSIONS: Although the mainstay of treatment for deep neck abscesses remains surgical drainage, small abscesses can respond to antibiotics alone. CECT monitoring of DNAs was the essential steps in choosing the more appropriate treatment and, probably, the basis for the good prognosis of patients.
Abstract: In 1986, we initiated a multicenter, randomized trial to compare induction chemotherapy with cisplatin and 5-fluorouracil followed by locoregional treatment (surgery and radiotherapy or radiotherapy alone) with locoregional treatment alone in patients with head and neck squamous cell carcinoma. Here we report the long-term results of the trial. A total of 237 patients with nonmetastatic stage III or IV head and neck carcinoma were randomly assigned to receive four cycles of neoadjuvant chemotherapy followed by locoregional treatment (group A) or locoregional treatment alone (group B). Among all patients, overall survival at 5 and 10 years was 23% (95% confidence interval [CI] = 15.3% to 30.9%) and 19% (95% CI = 11.6% to 26.4%), respectively, for those in group A and 16% (95% CI = 9.6% to 23.4%) and 9% (95% CI = 3.5% to 14.7%), respectively, for those in group B (P = .13). Among operable patients, we observed no difference between group A and group B in overall survival at 5 and 10 years (group A, 31% [95% CI = 14.9% to 47.3%] and 22.7% [95% CI = 7.1% to 38.3%], respectively; group B, 43.3% [95% CI = 25.6% to 61.0%] and 14.2% [95% CI = 0.1% to 28.3%], respectively; P = .73). Among inoperable patients, overall survival at 5 and 10 years was 21% (95% CI = 12.3% to 30.1%) and 16% (95% CI = 7.7% to 23.9%), respectively, for group A and 8% (95% CI = 1.5% to 12.3%) and 6% (95% CI = 0.1% to 9.1%), respectively, for group B (log-rank P = .04). Four cycles of neoadjuvant chemotherapy is a promising approach for treating patients with inoperable advanced head and neck cancer but not for treating patients with operable disease.
Abstract: Acinic cell carcinoma (ACC) is a rare tumor generally involving the parotid gland and infrequently the minor salivary glands with the potential for both local recurrence and metastatic spread when tracked for decades. The biological behavior of ACC cannot be predicted on the basis of histological features, and surgical stage is still the best predictor of clinical outcome. Only 5 cases of ACC of the larynx have been reported in the English literature. The authors present a case of a rare transglottic ACC in a 74-year-old woman. At admission, a submucosal mass involving the left arytenoid and adjacent aryepiglottic fold was noted. A CT scan of the head and neck region showed a mass of the left hemilarynx involving the paraglottic space and extending from the aryepiglottic fold to the sinus piriformis. Definitive histopathological examination showed an ACC with a large amount of clear cells. The patient was treated by radiotherapy alone (66 Gy in 7 weeks) with complete remission.
Abstract: OBJECTIVE: Clinical description of laryngeal tuberculosis. METHODS: Clinical case review. RESULTS: The authors report three cases of laryngeal tuberculosis with lung involvement in HIV-negative patients; symptoms were mostly laryngeal. Diagnosis was made in all cases through laryngeal biopsy and examination of the sputum. Patients fully recovered after being given standard antituberculosis therapy. CONCLUSIONS: Laryngeal tuberculosis almost disappeared after the 1950s, but, concomitant with the increase in pulmonary forms, may still be found and, being uncommon, is often misdiagnosed.
Abstract: The association between dermatomyositis and malignancy of the pharynx is rare among whites but not uncommon among Far Eastern and north African populations. We report two cases of Caucasian Italian patients with dermatomyositis associated, respectively, with nasopharyngeal and tonsillar carcinomas. The relationship between dermatomyositis and malignancy is also discussed.
Abstract: The authors report on 20 immunocompetent patients with brain abscess after 12 cases of middle ear, seven tooth and a single frontal sinus infection.The clinical aspects, hematochemical and microbiological data, the role of imaging diagnostics (CT, MR) and the type of treatment are analysed.Neurosurgery was performed on 17 patients (85%), eight of whom subsequently underwent evacuation of the primary source of infection (four mastoidectomies, two timpanoplasties, two tooth extractions). Mastoidectomy was eventually carried out on one of the three patients who did not undergo neurosurgery. Microbiological diagnosis was possible in nine patients through culture examination: Proteus mirabilis in three cases, Peptostreptococcus sp. in two, Micrococcus varians, Proteus vulgaris, Streptococcus sanguis and Streptococcus viridans not typed in single cases. The pus was sterile in eight patients (47.1% of those operated).An association of two antimicrobial agents was used in 18 patients, while in two cases monotherapy was preferred, based on the isolated bacteria. Treatment lasted on average 38 days. The most frequently used therapy regimen (75%) was the association of a beta-lactam drug with chloramphenicol or metronidazole.Therapy was successful in 19/20 patients; one patient died. There was no significant difference in prognostic terms with regard to sex, age, duration of symptoms prior to diagnosis, clinical picture at onset, number and size of abscesses or type of treatment. Recognising the first clinical signs and symptoms (headache, fever, alterations in consciousness, focal neurological deficit, epileptic seizures) is extremely important for prompt diagnosis of brain abscess.
Abstract: Nasopharyngeal carcinoma has long been reported as the predominant type of cancer associated with dermatomyositis in many several Asian countries, including Hong Kong, Singapore, and Southern-Cina. Dermatomyositis is one of the idiopathic inflammatory myopathies showing characteristic cutaneous manifestations. Reviews from the western literature have demonstrated that certain cancers, such as ovarian and breast carcinoma in women and lung and prostate carcinoma in men, are highly associated with DM relative to the general population. We report the case of a Caucasian Italian patient with nasopharyngeal carcinoma and dermatomyositis. Considering the rarity of nasopharyngeal carcinoma among whites, both the detection and the report of each new case are noteworthy in defining the geographic and ethnic distribution of this tumor.
Abstract: Synovial sarcoma represents a mesenchymal malignancy of unknown histogenesis that most often occurs in the lower limbs of young adults. The head and neck region is a relatively rare location, in which the hypopharynx and larynx are, respectively, the most and least often affected anatomic sites. Histologically, synovial sarcomas are classified into monophasic and biphasic variants. Immunohistochemistry plays a major part in the differential diagnosis, enabling the demonstration of epithelial differentiation. Both monophasic and biphasic synovial sarcomas are characterized cytogenetically by the reciprocal translocation t(X;18)(p11.2;q11.2) between chromosomes X and 18. Two cases of synovial sarcoma arising in the larynx and in the hypopharynx and in which cytogenetic analysis detected a diagnostic t(X;18) chromosome aberration are reported here.
Abstract: A case report of pleomorphic rhabdomyosarcoma of the larynx is presented. It is the first case in which the diagnosis is supported by immunohistochemical investigation. A critical review of the literature follows, evaluating the clinicopathologic features of this rare malignancy.
