A comparison between endoscopic CO2 laser cauterization and open neck surgery in the treatment of congenital piriform fistula / 中华耳鼻咽喉头颈外科杂志

Objective: To compare the efficacy, advantages and disadvantages of endoscopic CO2 laser cauterization (ECLC) and open neck surgery in the treatment of congenital pyriform sinus fistula (CPSF). Methods: From September 2014 to March 2017, 80 cases with confirmed diagnosis of CPSF received initial treatment at Guangdong Provincial People's Hospital were prospectively analyzed, including 34 males and 46 females, aged 18 to 672 (194.17±141.18) months. They were consecutively divided into endoscopic group and open-surgery group, with 40 cases in each group. Both groups of patients received surgical treatment under general anesthesia. The endoscopic group was treated by endoscopic CO2 laser cauterization, and the open-surgery group underwent the following surgery: first, we performed suspension laryngoscopy examination to confirm the presence of fistula in the bottom of the piriform fossa, then open-neck resection of congenital piriform sinus fistula with recurrent laryngeal nerve and/or lateral branch of superior laryngeal nerve anatomy plus partial thyroidectomy were performed. The data between the two groups were compared, including the operative time, intraoperative blood loss, postoperative pain, average length of stay, neck cosmetic scores, complications and cure rates. All patients were followed up in outpatient clinics. Statistical analysis was performed using SPSS 20.0 software. P<0.05 indicates that the difference is statistically significant. Results: All patients were successfully completed the operation. The operative time, intraoperative blood loss, postoperative pain and average length of hospital stay in the endoscopic group were significantly less than those in the open group [(27.4±5.5) min to (105.8±52.5) min, (0.6±0.5) ml to (33.6±41.5) ml, (1.7±0.9) points to (4.6±0.7) points, (5.9±2.9)d to(8.9±3.3)d, t values were-9.400, -5.031, -16.199, -4.293, P values were all<0.01]; The neck cosmetic score in the endoscopy group was significantly greater than that of the open group [(9.9±0.4) against (5.8±0.9) points, t=25.847, P<0.01]. Compared with the open group (15.0%, 6/40), the complication rate of the endoscopic group (7.5%, 3/40) was not statistically significant (χ²=0.50, P>0.05). Three months after the first treatment, the cure rate in the endoscopic group (82.5%, 33/40) was significantly lower than that in the open-neck group (100.0%, 40/40), χ²=5.64, P<0.05. The follow-up time was 12 months after the last treatment. Eighty cases were followed up and none was lost to follow-up. During the follow-up period, the cure rate of the endoscopy group (97.5%, 39/40) was compared with that of the open group (100.0%, 40/40), and the difference was not statistically significant. Conclusions: In the treatment of CPSF, the two-surgical method each has their advantages. Compared with open-neck surgery, ECLC is simpler, repeatable. ECLC has shorter time in operation and hospital stay, less complications, and less postoperative pain and more precise cosmetic results. It could be preferred for the initial treatment of CPSF and relapsed cases after cauterization. But subject to relatively low cure rate of one-time cauterization and uncertain long-term efficacy, it cannot completely replace the open-neck surgery at present.

Evaluation of pre- and post-pyriform plasty nasal airflow / Avaliação do fluxo aéreo nasal pré e pós-piriformeplastia

Abstract Introduction: Nasal obstruction is a frequent complaint in otorhinolaryngology outpatient clinics, and nasal valve incompetence is the cause in most cases. Scientific publications describing surgical techniques on the upper and lower lateral cartilages to improve the nasal valve are also quite frequent. Relatively few authors currently describe surgical procedures in the piriform aperture for nasal valve augmentation. We describe the surgical technique called pyriform plasty and evaluate its effectiveness subjectively through the NOSE questionnaire and objectively through the rhinomanometry evaluation. Objective: To compare pre- and post-pyriform plasty nasal airflow variations using rhinomanometry and the NOSE questionnaire. Methods: Eight patients submitted to pyriform surgery were studied. These patients were screened in the otorhinolaryngology outpatient clinic among those who complained of nasal obstruction, and who had a positive response to Cottle maneuver. They answered the NOSE questionnaire and were submitted to preoperative rhinomanometry. After 90 days, they were reassessed through the NOSE questionnaire and the postoperative rhinomanometry. The results of these two parameters were compared pre- and postoperatively. Results: Regarding the subjective measure, the NOSE questionnaire, seven patients reported improvement, of which two reported marked improvement, and one patient reported an unchanged obstructive condition. Regarding the rhinomanometry assessment, of 96 comparative measurements between the preoperative and postoperative periods, we obtained 68 measurements with an increase in nasal airflow in the postoperative period, 26 negative results, and two cases that remained unaltered between the preoperative and postoperative periods. Conclusion: When analyzing the results obtained in this study, we can conclude that the piriform plasty surgical procedure resulted in nasal airflow improvement in most of the obtained measurements.

Resumo Introdução: A obstrução nasal é queixa frequente nos ambulatórios de otorrinolaringologia, e a incompetência da válvula nasal é responsável em grande parte dos casos. São bastante frequente também as publicações de trabalhos científicos descrevendo técnicas cirúrgicas sobre as cartilagens laterais superiores e inferiores para melhorar a válvula nasal. Relativamente poucos autores descrevem atualmente procedimentos cirúrgicos na abertura piriforme para incremento da válvula nasal. Descrevemos a técnica cirúrgica chamada piriformeplastia e avaliamos a sua eficácia de forma subjetiva através do questionário NOSE e de forma objetiva através do exame rinomanometria. Objetivo: Comparar as variações do fluxo aéreo nasal pré e pós-piriformeplastia através da rinomanometria e do questionário NOSE. Método: Foram estudados 8 pacientes submetidos à piriformeplastia. Estes pacientes foram triados no ambulatório de otorrinolaringologia, pacientes estes que se queixavam de obstrução nasal, e que apresentavam resposta positiva a manobra de Cottle. Responderam ao questionário NOSE e foram submetidos a rinomanometria no pré-operatório. Após 90 dias foram reavaliados pelo questionário NOSE e pela rinomanometria pós-operatória. Os resultados desses dois parâmetros foram comparados pré e pós-operatoriamente. Resultados: Em relação a medida subjetiva, questionário NOSE, sete pacientes referiram melhora, sendo que dois deles referiram melhora acentuada, e um paciente referiu quadro obstrutivo inalterado. Em relação ao exame rinomanometria, de 96 medidas comparativas entre o pré e o pós-operatório, obtivemos 68 medidas com incremento ao fluxo aéreo nasal no pós-operatório, 26 resultados negativos, e dois casos inalterados entre pré e pós-operatório. Conclusão: O procedimento cirúrgico piriformeplastia conferiu melhoria do fluxo aéreo nasal na maioria das medidas obtidas.

Piriformeplastia associada à rinoplastia aberta / Pyriform plasty associated with open rhinoplasty

Introdução: A respiração bucal ou mista desde a infância, por fatores alérgicos que causam hipertrofia de cornetos e adenoides ou desvio septal traumático no parto ou por traumas na primeira infância, provoca incorreto desenvolvimento da face com o palato ogival, crescimento excessivo da crista maxilar, alterações na arcada dentária e hipomaxilismo, por falta de aeração dos seios paranasais. O septo com limitado espaço para de crescer empurra o arcabouço osteocartilaginoso cranialmente, originando a giba nasal com desvios do septo, comprometendo a respiração nasal. Método: A piriformeplastia mediante incisão no sulco gengivolabial permite amplo acesso à crista maxilar e ao palato ogival. A crista maxilar é desgastada com broca e o palato é modelado ou pode ter sua cúpula removida subperiostealmente. Resultados: A rinoplastia aberta facilita a abordagem e a fixação dos enxertos alargadores para tratar as alterações da válvula interna e prevenir retrações cicatriciais ao nível da gaiola cartilaginosa, além dos enxertos estruturais na columela para projeção e evitar retração cicatricial neste nível. A abordagem aberta permite também a simetrização das estruturas nasais, que possibilita o tratamento das laterorrinias num tempo único e a correção da válvula nasal externa por meio dos enxertos específicos. A piriformeplastia permite ainda a abordagem mais abrangente das alterações nasais estéticas e funcionais. Conclusão: A rinoplastia aberta é por nós preferida dada a facilidade de fixação dos enxertos, bem como dos enxertos alargadores para tratamento das alterações da válvula interna com o objetivo de prevenir futuros problemas respiratórios.

Introduction: Mouth or mixed breathing since childhood that is due to allergy factors causing turbinate hypertrophy and adenoids, or traumatic septal deviation at childbirth or first trauma in childhood leads to the impairment of facial development, including ogival palate, excessive growth of the maxillary crest, changes in the dental arch, and small jawbone. Mouth or mixed breathing may be due to the lack of aeration of the paranasal sinuses. A septum with limited space for growing pushes the osteocartilaginous framework cranially, originating from the nasal hump with septal deviations and gibbus. Consequently, this hampers nasal breathing. Method: Pyriform plasty by incision in the gingivolabial sulcus allows broad access to the maxillary crest and ogival palate. The maxillary crest is worn out with a drill, and the palate is modeled or may have its dome subperiosteally removed. Results: Open rhinoplasty facilitates the approach and fixation of graft reamers to treat changes in the internal valve and prevents scar reactions at the level of the cage cartilage grafts and structure of the columella to project and prevent a cartilaginous scar retraction at this level. The open approach also enables the symmetrization of nasal structures, which allows the treatment of bent nose at a single time, and correction of nasal valve by using external grafts. Moreover, pyriform plasty is a more comprehensive approach to nasal aesthetic and functional nasal alterations. Conclusion: Our preferred techniques are open rhinoplasty, given the ease of graft fixation, and use of reamer grafts to treat changes in the internal valve to prevent future respiratory problems.

Early stage squamous cell carcinoma of the pyriform sinus: A review of treatment options.

The purpose of this review of the literature was to present treatment options for early stage pyriform sinus cancer. Squamous cell carcinoma of the pyriform sinus, as the most frequent cancer arising from the hypopharynx, is rarely diagnosed in its early stage. Based on evidence from retrospective studies, conservation surgery and definitive radiotherapy are considered the available treatment modalities for patients presenting with stage T1 and T2 pyriform sinus carcinomas without clinical evidence of neck lymph node metastases, offering similar results with respect to disease control and functional organ preservation. Also, the high risk of occult metastatic nodal disease even in the earliest stage of pyriform sinus cancer entails elective neck dissection or elective neck irradiation to be considered mandatory. However, for patients with early stage pyriform sinus cancer, no level 1 study exists in which conservation surgery is compared with radiotherapy alone for the evaluation of local control or survival. Randomized multicenter controlled trials evaluating efficacy of conservation surgery and definitive radiotherapy, and correctly interpreting functional outcome for each of the treatment procedures examined are necessary to obtain sufficient evidence to influence the decision in the choice of the most effective treatment for early pyriform sinus cancer.