Application of enhanced recovery after surgery in laryngeal cancer surgery with multi-disciplinary team / 中华耳鼻咽喉头颈外科杂志

Objective: To explore the application value of enhanced recovery after surgery (ERAS) with the multidisciplinary team (MDT) model in laryngeal cancer surgery. Methods: Eighty patients with laryngeal cancer treated in Department of Otorhinolaryngology Head and Neck Surgery of Yantai Yuhuangding Hospital from May 2016 to June 2017 were selected, including 76 males and 4 females, aged 45 to 75 years old. By random number table method, they were divided into ERAS group (40 cases) and control group (40 cases). Visual analogue scale (VAS), general comfort questionnaire (GCQ) and self-rating Anxiety Scale (SAS) were used to evaluate the symptoms and signs and psychological state of the two groups before and after operation. Mann Whitney U test was used for non-normal distribution data, and chi square test, Fisher exact probability method and covariance analysis were used for classification data. Repeated measures analysis of variance was used for the comparison of each group at different time points. Results: Two cases in the ERAS group and six cases in the control group withdrew from the study for some reason. Finally, 38 cases in the ERAS group and 34 cases in the control group were enrolled in this study. The postoperative pain scores of the two groups were the highest at 6 h after operation, and then gradually decreased. At different time points after operation, the pain scores of ERAS group were lower than those of the control group. At 24 h after operation, the pain relief degree of ERAS group was significantly higher than that of the control group, with a statistically significant difference (P<0.05). Compared to control group, ERAS group had lower preoperative thirst score [(0.15±0.36) vs. (4.29±1.17), Z=-7.695, P<0.001] and hunger score [(0.38±0.49) vs. (3.44±1.13), Z=-7.426, P<0.001]. The total number of postoperative adverse reactions (8 vs.16), oral feeding time [(4.06±4.42) d vs. (9.06±2.42) d] and postoperative hospital stay [(5.91±0.97) d vs. (11.03±2.11)d] in ERAS group were lower than those in control group (statistics 5.461, -4.558, -7.347, P<0.05), but there was no significant difference in postoperative catheter indwelling time and neck drainage tube indwelling time between the two groups (P>0.05). Before discharge, the comfort of ERAS group was significantly higher than that of control group [(60.37±8.78) vs. (50.38±8.08), Z=-4.370, P<0.001]. Before discharge, the anxiety level of ERAS group decreased, while that of the control group increased significantly, which was higher than that of ERAS Group [(59.12±6.43) vs. (52.62±6.25), Z=-4.179, P<0.001]. Conclusion: The application of multidisciplinary ERAS in laryngeal cancer surgery can improve preoperative hunger and thirst, postoperative pain and mental state, shorten the length of hospital stay and reduce postoperative adverse reactions.

Surgery and function reconstruction of laryngeal cancer involved supraglottic and glottis area / 中华耳鼻咽喉头颈外科杂志

<p><b>OBJECTIVE</b>To investigate the surgery preserving epiglottis, the repair and the postoperative functions in laryngeal carcinoma involving supraglottic and glottic areas.</p><p><b>METHODS</b>A total of 97 cases with laryngeal cancer involving both supraglottic and glottic areas with normal epiglottis underwent surgery between June 2005 and December 2010 was reviewed. Of them 37 cases were stage II, 41 cases were stage III, and 19 cases were stage IV. Vertical partial laryngectomy (VPL) or extended VPL with the repair and functional reconstruction was carried out in 86 cases and cricohyoidoepiglottopexy (CHEP) in 11 cases. Postoperative survival rate, laryngeal functions and quality of life were evaluated.</p><p><b>RESULTS</b>The 3-year and 5-year total cumulative survival rate (Kaplan-Meire survival analysis) were 87.1% and 69.6% in the 97 cases; 86.6% and 68.3% in VPL/EVPL group; 90.0% and 78.8% in CHEP group, respectively, with no significant difference between VPL/EVPL and CHEP groups (P > 0.05). Of 97 cases, 86(88.7%) cases were decannulated postoperatively. The rates of decannulation were 87.2% (75/86) in VPL/EVPL group and 100% (11/11) in CHEP group, with no significant difference (P > 0.05). Average oral diet recovery time of VPL/EVPL group and CHEP group was (5.2 ± 1.3) and (15.7 ± 5.2) days, respectively, with a significant difference (P < 0.01). Voice evaluation showed the mean maximum phonation time of VPL/EVPL group was shorter than that of CHEP group (P < 0.01) and the S/Z ratio of VPL/EVPL group was higher than that of CHEP group (P < 0.01). Perceptual voice evaluation GRBAS ratings showed patients in VPL/EVPL group had higher G and B ratings compared to patients in CHEP group (P < 0.01), but no significant difference in R-rating between two groups (P > 0.05). Voice handicap index-10 (VHI-10) scores of VPL/EVPL and CHEP groups were 29.5 ± 4.7 and 31.6 ± 6.3, respectively, no significant difference (P > 0.05).</p><p><b>CONCLUSIONS</b>For patients with the laryngeal carcinoma involving both supraglottic and glottic areas, VPL has better anatomical and functional outcomes than CHEP. The preservation of at least 2/3 of the lamina of thyroid cartilage on one side and shift-down of epiglottis were key to successful VPL and postoperative decannulation.</p>

Treatment of pyriform sinus carcinoma involving the lateral wall / 中华耳鼻咽喉头颈外科杂志

<p><b>OBJECTIVE</b>To present and discuss the clinical features, treatment, and efficacy of pyriform sinus carcinoma involving the lateral wall.</p><p><b>METHODS</b>Seventy-seven patients with pyriform sinus cancer involving the lateral wall (stage I 8, stage II 10, stage III 32, stage IV 27, according to UICC 2002 staging) were treated from Jun 1997 to Jun 2009 in the department of otorhinolaryngology head and neck surgery, Yuhuangding Hospital. The patients were divided into two groups: Group one 17 cases, simply underwent radiation therapy (R group); Group two 60 cases underwent surgery plus postoperative radiation (SR group). All patients underwent radiotherapy 50-75 Gy. In SR group, hyoid area and lateral pharyngeal approaches were taken according to the lesions for resection. To repair the defects and reconstruct the functions of larynx and pharynx, regional roping in suture, fascial flap/muscular- fascial of strap muscles, glosso-flap, musculocutaneous flap of major pectoral muscle, joint split graft or heterologous (bovine) acellular dermal matrix were used respectively.</p><p><b>RESULTS</b>In group R, the primary tumor and neck lymph node metastasis disappeared at the end of radiotherapy in 15 cases. For one case, the N3 cervical lymph nodes shrank, but failed in local control and died of systemic metastases after 7 months. For another case, the N2 neck lymph nodes significantly reduced after the full course of radiation, PET-CT and biopsy did not find the cancer, but the tumor grew again after 6 months, and died of a neck bleeding 11 months later. All repairing materials used were alive in SR group. Two cases developed postoperative wound infection, and 2 cases suffered from pharyngeal fistula. All patients retained laryngeal functions, and all patients in SR group recovered diet 12 - 30 days, the mean time was 15.6 days. Three and 5 year survival rates for all 77 patients were 59.1% and 41.4%. For stage I + stage II cases in SR group and R group, 3 and 5 year survival rates were 63.6%, 53.0% and 66.7%, 50.0% respectively. There was no significant difference between the two groups (χ(2) = 0.021, P = 0.884). For cases of stage III + stage IV of the SR group and R group, 3 and 5 year survival rates were 63.9%, 43.7%, 16.4%, and 0. There was a very significant difference (χ(2) = 20.496, P = 0.000); all cases in SR group and in R group for 3, 5-year survival rates were 63.6%, 45.8%, 41.5%, and 24.9% respectively. There was also a significant stastical difference (χ(2) = 4.644, P = 0.031).</p><p><b>CONCLUSIONS</b>Pyriform sinus carcinoma involving the lateral wall is characterized with scattered growth on the surface of mucous or submucously, tending to invade lamina cartilaginis thyroidea. Simple radiotherapy can get better therapeutic effect for early stage cases. The comprehensive therapy measures should be taken in advanced cases, especially those with surgical indications should be taken to surgery plus radiotherapy. For the purpose of excising the tumor thoroughly and preserving good laryngeal functions, proper operative approaches and ways of repairing should be selected.</p>

Resection and one-stage repair of basal cell carcinoma of external nose / 中华耳鼻咽喉头颈外科杂志

<p><b>OBJECTIVE</b>To present the method of resection and one-stage repair of basal cell carcinoma of external nose.</p><p><b>METHODS</b>Sixty-two patients with basal cell carcinoma of external nose were hospitalized and underwent surgeries from January 2002 to June 2010. The defects after resection were as follows: 1 partial defect of soft tissue of lateral ala nasi, associated defect of ala nasi margin, total defect of ala nasi, defect of soft tissue of apex nasi, defect of apex nasi and ala nasi, defect of the bridge of the nose. Various flaps were applied according to the degree of defects. With nasal parabolic sulci and nasolabial sulcus as the center, different flaps were used, including advanced skin flap, pedicle tunnel island flap of nasolabial sulcus, and flip flap of nasolabial sulcus, forehead axial flap, dissociated auricle compound soft tissue flap for one-stage repair respectively.</p><p><b>RESULTS</b>Two flaps failed because of thanatosis after the surgeries. One flap mostly was a necrosis with the upper small part survived. A marginal partial necrosis of the flap appeared in 2 patients. Two fixing nasal apex and nasal wing suffered a partial circum exfoliation. All other 55 flaps were successfully implanted with satisfying looks and breathing functions with the exception of 1 complaining about obvious nasal obstruction. The rest were followed up for 6 months to 8 years with no relapse.</p><p><b>CONCLUSIONS</b>Most of the tumors of external nose are basaloma, and the margin of safety should be secured during the operation with Mohn's surgery, and once thoroughly resected, there are barely relapses, and radiotherapy or chemotherapy is unnecessary. Pedicled skin flaps can be used as in one-stage repairing of the defect of external nose, with high rate of success and close color shade and good outcome.</p>

Endoscopic maxillary sinus surgery through anterior or posterior nasolacrimal duct approach / 中华耳鼻咽喉头颈外科杂志

<p><b>OBJECTIVE</b>To explore the feasibility and effectiveness of the approaches and methodology of the endoscopic surgery for maxillary sinus lesions through the medial wall of the maxillary sinus.</p><p><b>METHODS</b>From Jun. 2003 to Aug. 2010, endoscopic surgery through anterior or posterior nasolacrimal duct approaches to remove maxillary sinus lesions were conducted in 139 patients. Among them there were 43 cases with inverted papilloma, 63 cases with fungal maxillary sinusitis, 28 cases with maxillary sinus cyst, 3 cases with hemorrhagic necrotic polyps, and 2 cases with osteomas. All patients underwent preoperative CT scans, and patients with inverted papillomas also had MRI tests. Anterior-nasolacrimal canal paths included 3 ways: pyriform aperture, lacrimal bone recess (dissecting nasolacrimal duct or not were 2 subtypes), pyriform aperture-nasolacrimal duct approaches, and 97 patients were treated. Posterior-nasal lacrimal duct paths were also divided into 3 subtypes: the inferior turbinate flip flap, double pedicle inferior turbinate, single pedicle inferior turbinate, and 42 patients were treated. The postoperative effects were observed.</p><p><b>RESULTS</b>All lesions were completely removed under endoscope, the nasolacrimal ducts and inferior turbinates were protected, no nasal lacrimal duct injury and inferior turbinate necrosis were found. Postoperative nasal congestion, headache, swelling discomfort, strange odor, dental pain and numbness and other symptoms gradually disappeared. Nine patients felt nasal dryness, and after nasal washing for about 1 month, the symptom gradually disappeared. Patients were followed up for 6 months to 79 months. In case of osteoma, and hemorrhagic and necrotic polyps, no recurrences were found. Apparent edema, hypertrophy of sinus mucosa could be seen during the surgery in all patients with fungal maxillary sinusitis, and the edema gradually disappeared after 3 months or so, with no relapse. Two cases of maxillary sinus cysts were found in other parts of the maxillary sinus 10 months and 18 months after the surgery, but the cysts were small and asymptomatic, so no further management needed, and they were still under follow-up. Three patients, recurred. In 1 case with inverted papilloma, a local lump on the opening were found 17 months after the surgery, and was removed in out-patient department and pathology showed papillary tumor recurrence, no relapse was found 1 year later; 1 patient had recurrence in anterior ethmoid sinus 15 months after operation, total ethmoidectomy was done and no relapse was found in 3 years. One patient had local recurrence in the posterolateral wall of the maxillary sinus 26 months after operation, and the secondary surgery was done via single pedicle inferior turbinate. The papilloma relapsed again after 1 year, an endoscopic Denker surgery was performed, with no recurrence after 18 months of follow-up. Three months after surgery, the maxillary sinus was scar-covered in all cases. Inferior turbinate maintained good shape, compared to those with inferior nasal meatus windowing surgery. Scars were significantly smaller, but no latch or obstruction of drainage were found.</p><p><b>CONCLUSIONS</b>Endoscopic maxillary sinus surgery through anterior or posterior nasolacrimal duct approach can reduce the trauma, fully expose the sinuses, and facilitate postoperative treatment and review with a window. Retained inferior nasal turbinate is helpful to avoid dryness, crusting, headache and other complications due to too much removal of nasal exteral walls.</p>

Effect of hyoid suspension with uvulopalatopharyngoplasty in the treatment of obstructive sleep apnea hypopnea syndrome / 中华耳鼻咽喉头颈外科杂志

<p><b>OBJECTIVE</b>To discuss the methodology and therapeutic effect of hyoid suspension in association with uvulopalatopharyngoplasty (UPPP) in the treatment of severe obstructive sleep apnea hypopnea syndrome (OSAHS).</p><p><b>METHODS</b>Sixty-nine patients with severe OSAHS (apnea hyponea index, AHI > 30) were treated with hyoid suspension and UPPP. Sixty-one patients were followed for 6 months (48 of them for 12 months). Polysomnogram (PSG) tests were performed and an Epworth sleepiness scale (ESS) was recorded preoperatively and postoperatively in these patients.</p><p><b>RESULTS</b>After the surgery,the snoring of the patients disappeared or was alleviated to varing degrees. Eighteen patients underwent fiberoptic nasopharyngolaryngoscopic examination. Twelve of them showed palatopharyngeal and glossopharyngeal stenosis was improved 6 months after surgery. Six patients showed no change, but had no glossoptosis. Fourteen patients underwent fiberoptic nasopharyngolaryngoscopic examination 1 year after surgery, with no recurrence of the stenosis being found. A decrease of 50% in the AHI was considered effective, and in patients the effective rate was 78.7% (48/61) 6 months after the operation and 75.0% (36/48) 1 year after the operation. The average AHI decreased from 44.8 to 15.1 and 17.2, and the minimum arterial oxygen saturation average increased from 0.512 to 0.880 and 0.730. Matching t tests were utilized and the results of follow-up indicated that there was a significant improvement in the indexes in those cases which could be followed up (P < 0.01). The average of the ESS was 6.7 six months after operation and 7.2 one year after operation, with a significant decrease compared to the preoperative (16.6) data (P < 0.01).</p><p><b>CONCLUSIONS</b>Modified hyoid suspension in association with UPPP has the advantage of a simple operation, short hospitalization and less expense, and the effect of the operation was significant. Patients with palatopharyngeal and glossopharyngeal stenosis should be chosen for this operation.</p>