Open partial horizontal laryngectomies: a proposal for classification by the working committee on nomenclature of the European Laryngological Society.

We present herein the proposal of the European Laryngological Society working committee on nomenclature for a systematic classification of open partial horizontal laryngectomies (OPHL). This is based on the cranio-caudal extent of laryngeal structures resected, instead of a number of different and heterogeneous variables present in existing nomenclatures, usually referring to eponyms, types of pexy, or inferior limit of resection. According to the proposed classification system, we have defined three types of OPHLs: Type I (formerly defined horizontal supraglottic laryngectomy), Type II (previously called supracricoid laryngectomy), and Type III (also named supratracheal laryngectomy). Use of suffixes "a" and "b" in Type II and III OPHLs reflects sparing or not of the suprahyoid epiglottis. Various extensions to one arytenoid, base of tongue, piriform sinus, and crico-arytenoid unit are indicated by abbreviations (ARY, BOT, PIR, and CAU, respectively). Our proposal is not intended to give a comprehensive algorithm of application of different OPHLs to specific clinical situations, but to serve as the basis for obtaining a common language among the head and neck surgical community. We therefore intend to present this classification system as a simple and intuitive teaching instrument, and a tool to be able to compare surgical series with each other and with non-surgical data.

[Management of lymph node metastases in well-differentiated and medullary thyroid cancer: retrospective study on 52 cases]. / Il trattamento delle metastasi linfonodali nel carcinoma ben differenziato e midollare della tiroide: analisi retrospettiva di 52 casi.

OBJECTIVE: To define the surgical principles of neck dissections as applied to the head and neck squamous cell carcinomas, extending their rationale to treatment of lymph nodes metastases from thyroid carcinomas. MATERIALS AND METHODS: Between January 1994 and June 2002, 52 patients affected by well-differentiated thyroid cancers (1 follicular, 9 medullary, and 42 papillary cancers) underwent uni- or bilateral neck dissections at our Department, for a total of 73 neck dissections. Patients were subdivided into 2 groups: 37 simultaneously treated on the thyroid and the neck (Group A), and 15 operated elsewhere on the thyroid and for a neck recurrence and/or persistence at our Department (Group B). RESULTS: 48 patients underwent a regular follow-up (range: 3-86 months, mean: 38). Among patients alive with disease, 5 in Group A and 4 in Group B had a local-regional recurrence. In particular, 2 patients for each group (2 medullary and 2 papillary cancers) had a regional recurrence on the N site, at the level of one or more lymph nodes "in field" as regards the neck dissection previously performed. Moreover, in all these patients a local recurrence on the T site has been observed. DISCUSSION: Lymph nodes metastases have a minor prognostic impact in well-differentiated thyroid cancers in respect of the rest of head and neck cancers. Nonetheless, when performing a curative or elective neck dissection, the gold standard surgical principles must be the same. As a matter of fact, a 20% incidence of lymph nodes metastases at the V level, often not specifically addressed in neck dissections for thyroid cancers, it is noteworthy. Aim of such an aggressive surgical approach of the neck is to obtain a low incidence of "in field" regional recurrences, which become no more amenable of a subsequent surgical salvage. CONCLUSION: Surgical techniques as lymphadenectomy or "pick-berry procedure" must be abandoned because they do not respect the basic anatomic, physiopathologic, and oncologic principles of neck dissections along cervical fasciae and spaces.

Improvement of vestibular compensation by Levo-sulpiride in acute unilateral labyrinthine dysfunction.

L-sulpiride is the levorotatory enantiomer of sulpiride, a neuroleptic of the family of benzamide derivatives; it has a characteristic antagonist effect on central DA2 dopaminergic receptors and dopamine DA1 "autoreceptors". Its efficacy in the symptomatic control of acute vertigo spells has been recognized, apart from its well-known antiemetic, antidyspeptic and anti-depressant properties, at high dosages. To establish objective parameters of the results of its clinical application, a randomized prospective study was started comparing the effects of the drug in a group of 87 patients with vertigo of peripheral origin, with those in a control group treated with other vestibular suppressants. The drug was administered via the intravenous route, 25 mg t.i.d., for the first 3 days, then by oral administration, with the same schedule and dosage, for a further 7 days. After clinical evaluation of vestibular signs and symptoms, electronystagmographic recordings of rotatory tests were obtained, at admission and were then controlled after 6 months. A subjective Visual Analogue Scale was also delivered daily to the patients in order to monitor symptomatic improvements. When compared to conventional treatments, L-sulpiride appeared to induce a statistically significant faster recovery in unilateral vestibular lesions. An unexpected favourable outcome of treatment was the facilitation of spontaneous vestibular compensation, in terms of lesser residual labyrinthine dysfunction and reduction of recurrent vertigo attacks during the 6 months follow-up. The mechanisms of action of the drug and its interaction with the vestibular system are discussed.

Atypical carcinoid tumour of the larynx treated with CO2 laser excision: case report.

A case of atypical laryngeal carcinoid tumour of the right aryepiglottic fold is described in a 56-year-old female. The patient presented a 4-year history of dysphagia, occasional dyspnoea and pain originating in the right tonsillar fossa and radiating to the ear. A sessile, submucosal neoplasm of about 1 cm in diameter and apparently benign appearance was detected endoscopically in the supraglottic region. An excisional biopsy was collected by CO2 laser during direct microlaryngoscopy from which a diagnosis of atypical carcinoid tumour of the larynx was made, and later confirmed by histochemical and immunohistochemical staining. Post-operative course was uneventful, with return to a normal diet per os on the first post-operative day. Histopathological evaluation of the excised specimen revealed the presence of a neoplasm in proximity of the surgical margins, which were not, however, directly involved by the tumour. The close endoscopic follow-up was, nonetheless, implemented in order to promptly detect any evidence of relapse of the disease. After 18 months, a lesion, suspected of being a recurrence, was found, in the site of the original tumour. CO2 laser excision was again carried out, this time allowing for wider margins on the surgical resection. The post-operative diagnosis confirmed the clinical hypothesis of recurrence of atypical carcinoid tumour. The patient is presently alive and free from disease 7 years after the second endoscopic procedure. The difficult aspects of clinical and histopathological diagnoses, the surgical treatment as well as endoscopic and instrumental follow-up of this rare condition are discussed.

[Salvage surgery in squamous cell carcinoma of the oral cavity]. / Chirurgia di salvataggio nel carcinoma squamocellulare del cavo orale.

The objective of this work was to evaluate the results of salvage surgery in squamous cell carcinoma of the oral cavity. In the period 1983-1998, 127 patients consecutively underwent surgical treatment. Of these, 80 cases had not been treated previously (Group I), while 47 patients had come under our observation after radiotherapy alone or other treatment had failed (Group II). Local recurrence was observed in 29 cases, local/regional in 10 cases, and exclusively regional in eight cases. In both groups, the surgical T-approach was prevalently transoral (55 cases in Group I and 24 in Group II). A transmandibular approach was taken in most of the remaining patients (22 cases in Group I and 16 in Group II). One hundred patients (65 in Group I and 35 in Group II) underwent laterocervical neck dissection. The neoplasms in group I were staged as follows: pT1, 29%; pT2, 37.5%; pT3, 12.5%; pT4, 21%. In group II, the neoplasms were stages as: pT0, 17%; pT1, 21%; pT2, 38%; pT3, 13%; pT4, 11% (Group II). The overall 5-year survival rate was 38% and the overall determinate 5-year survival rate was 45%, distributed as follows in the two groups: 51% of the patients in Group I, 36% of the patients in Group II (p = 0.01). Restricting the analysis to Group II, the difference in the three year survival rate was 54% among the patients at stages I-II and 25% among the patients suffering from a recurrence at stages III-IV (p = 0.04). In patients whose recurrence was limited to the primary tumor, survival at 3 years was 49%; in those whose recurrence also had nodal involvement, survival was 27% (p = 0.05). Lastly, the 5-year survival rate was 45% in the patients whose recurrence had been diagnosed late and only 24% in the 24 patients whose recurrence had been diagnosed within a year of prior treatment (p = 0.09). In conclusion, the life expectancy of patients undergoing salvage surgery for squamous cell carcinoma of the oral cavity is significantly less with respect to patients undergoing first round treatment. This difference appears significant only in patients with a recurrence that was diagnosed at an advanced stage. In accordance with the previously published data, an early recurrence (within a year) and the presence of a recurrence in the neck are unfavorable prognostic factors.

Surgical repair of bone defects of the ear canal wall with flexible hydroxylapatite sheets: a pilot study.

OBJECTIVE: Evaluation of suitability of flexible composite sheets (hydroxylapatite and polymer) for outer ear canal (OEC) wall reconstruction in tympanoplasty. STUDY DESIGN: Prospective, open label pilot study. SETTING: University and regional hospital. PATIENTS: Forty-two randomly selected patients with chronic otitis media (n = 20) and cholesteatoma (n = 22) among 356 patients admitted between 1996 and 1997. INTERVENTIONS: Eradication of disease through a partial or total canal wall down mastoidectomy; immediate reconstruction of canal wall with flexible composite sheet (hydroxylapatite and polymer) and connective tissue graft. OUTCOME MEASURES: Anatomic integrity of the OEC and neotympanum, extrusion rate, complications. RESULTS: At minimum follow-up of 24 months: recurrent cholesteatoma (n = 0), residual cholesteatoma (n = 3/22) (13.6%) in the mesotympanum (none behind the hydroxylapatite sheet or in the attic or antrum). The neotympanum was intact in 38 ears (90.4%), reperforated in 2, and severely retracted and lateralized in 1, respectively. Anatomic integrity of the OEC was obtained in 37 (88%) of 42 patients; stenosis or membranous synechiae were observed in 5 ears and treated in the office. Extrusion of the hydroxylapatite sheet occurred in 7 patients (16.6%) because of purulent otorrhea and granulation tissue formation. Surgical revision achieved complete epithelialization of the rebuilt canal wall in 33 ears (78.6%). CONCLUSIONS: A dry, disease-free ear and normal anatomy may be expected 2 years postoperatively in more than three-fourths of the patients treated using the described surgical technique. Complete protection with a connective tissue graft is essential to avoid extrusion of the implant. The failure rate is significantly higher if otorrhea is present at the time of the operation.

[Functional results after type I thyroplasty with the Montgomery's prosthesis]. / Risultati funzionali dopo tiroplastica tipo I con protesi di Montgomery.

Between January 1999 and October 2000, 16 patients with glottic insufficiency of varying etiologies underwent Montgomery type I thyroplasty at the E.N.T. Department of the University of Brescia, Italy. In 2 cases revision surgery was required for the onset of delayed complication (cutaneous and endolaryngeal exposure of the prosthesis). All subjects underwent a battery of clinical-instrumental tests pre- and postoperatively as well as 2, 6 and 12 months after surgery. These tests included videolaryngostroboscopy, subjective perception analysis using the GRBAS scale proposed by Hirano on vowels, statements and songs, and, using the Multi-Dimensional Voice Program (MDVP), acoustic measurement of the following parameters: jitter (J), shimmer (S), noise to harmonic ratio (NHR) and maximum phonation time (MPT). The patients also filled out a self-evaluation questionnaire to judge the postoperative voice and this was used to calculate the "voice handicap index" (VHI). In order to make the study sample as homogeneous as possible, detailed pre- and postoperative functional data were studied only for the 11 patients with glottic insufficiency subsequent to monolateral vagal or recurrent paralysis. Analysis of these data revealed that, in these patients, postoperative perceptive and subjective evaluation was similar to that found in normal subjects. Videolaryngostroboscopy showed that the glottis closed completely in most cases and objective acoustic analysis parameters were significantly improved after surgery. Despite the small sample, our functional results confirm the validity of the cord medialization technique through an external approach in laryngeal hemiplegia. In cases of glottic insufficiency of various etiologies (trauma, scarring subsequent to external and/or endoscopic surgery and radiotherapy), more accurate selection of the patients is required to reduce the incidence of complications and to improve vocal results.

Oncological results of endoscopic resections of Tis and T1 glottic carcinomas by carbon dioxide laser.

A cohort of 88 patients with glottic cancer (13 Tis, 75 T1) who underwent endoscopic CO2 laser excision between January 1995 and June 1997 was prospectively studied. The mean follow-up was 43 months (range, 30 to 60 months). The depth and extent of the excision (graded according to the European Laryngological Society Classification, which includes 5 types of resection) were based on the results of a preoperative and intraoperative diagnostic test battery. Five patients died of other diseases, and none of glottic cancer. Of the 12 patients who developed a local recurrence, 5 underwent a second endoscopic procedure, 5 a total laryngectomy, and 1 a supracricoid laryngectomy, and 1 was treated with radiotherapy. The 5-year local control rate with endoscopic surgery alone, according to the Kaplan-Meier method, was 91%. None of the variables (8 related to the tumor and 2 to the treatment) tested in a univariate analysis by the log-rank test was found to have a significant impact on disease-free survival rates. The present study confirmed that endoscopic partial cordectomy for Tis and T1 glottic cancers can be regarded as a valid alternative to radiotherapy in terms of oncological results.

[Laryngeal-tracheal resection in the treatment of thyroid malignancies: description of a case and review of literature]. / Ruolo della resezione laringo-tracheale nella patologia maligna tiroidea: descrizione di un caso e revisione della letteratura.

Well-differentiated thyroid carcinomas infiltrate into the respiratory tract in between 0.9 and 7% of the cases. Laryngeal-tracheal involvement--most often discovered intra-operatively--can substantially modify the surgical approach. It should be evaluated pre-operatively through laryngo-tracheoscopy with a flexible fibroscope and, in some selected cases, using CT or NMR. Thyroidectomy, associated with laryngeal-tracheal resection and termino-terminal anastomosis, ensures good oncological results without any negative effect on the incidence of post-operative complications. The present work reports the case of a 64-year-old patient who, for 5 months, had presented a swelling of increasing consistency in the left hemithyroid, fixed on the deep planes. Echography showed a 5 cm mass in the left lobe and thyroid isthmus, without suspected lymphadenopathy for metastasis. Fine needle cytology was compatible with papillary carcinoma. CT using a contrast medium revealed an infiltration into the left antero-lateral wall of the I and II tracheal ring, with submucosal extension with no significant signs of stenosis of the airway. Esophagogastroscopy was normal while tracheobroncoscopy confirmed the radiological picture and made it possible to perform a tracheal biopsy which proved positive for papillary carcinoma. The patient underwent total thyroidectomy associated with anterior compartment lymphadenectomy and crico-tracheal resection of the cricoid arch and the first 5 tracheal rings. When surgery was completed, the patient was extubated without complications. Post-operative recovery was uneventful and the patient was discharged on the 9th day after surgery. Histopathological examination confirmed the pre-operative diagnosis and made it possible to stage the lesion as pT4N1bM0 because of the presence of one prelaryngeal lymph node metastasis and another one at the right paratracheal space. Complementary I131 therapy was scheduled along with periodic laryngo-tracheoscopic controls. 16 months after surgery the anastomotic line is perfectly healed and the patient is clinically disease free. A review of the literature on the surgical treatment of well-differentiated malignant thyroid neoplasms with respiratory tract involvement through resection and laryngo-tracheal anastomosis has made it possible to trace the indications, limits and results of this type of therapeutic approach.

[Surgical treatment of neck lymph nodes in squamous cell carcinoma of the pyriform sinus]. / Il trattamento chirurgico dei linfonodi del collo nel carcinoma squamocellulare del seno piriforme.

The present study reports the results of 66 patients surgically treated for squamous cell carcinoma of the pyriform sinus between 1984 and 1996. Twenty eight patients underwent mono!ateral neck dissection and bilateral neck dissection was performed in 38 cases, for a total of 104 radical neck dissections. Of these, 73 (71%) were modified type III dissections, 17 (16%) were classical, and 14 (13%) were modified type I and II dissections. The primary lesion was strictly lateralized in 47 cases (71%), while median structures were involved in 19 patients. The primary tumor was staged pT1 in 2 patients, pT2 in 29, pT3 in 19, and pT4 in 16. The overall incidence of lymph node metastases was 79% (9 pN1, 3 pN2a, 33 pN2b, 7 pN2c) which was not correlated with T stage (50% pT1, 72% pT2, 89% pT3, 81% pT4). Occult nodal metastases were present in 42% of cases (8/19) with an incidence that increased from 11% (1/9) for pT1-2 to 70% for pT3-4 (7/10). The bilateral metastases (11%) were uniformly distributed between strictly lateral neoplasms and those tumors involving the midline. The incidence of bilateral metastases reached 19% only in patients with T4 cancers. Occult controlateral metastases were found in 12% of patients not having clinical evidence of metastases on the contro-lateral side of neck dissection (4/33). Nodal metastases never involved the I and V levels. Our data did not permit an assessment of the incidence of retropharyngeal lymph node metastases. In view of these results and considering current knowledge of the anatomy of lymphatic drainage, a selective II-IV dissection extending to the level VI on the side of the tumor appears justified in cases clinically staged as NO. In our view, when the lesion involves the posterior wall of the pharynx, neck dissection should be extended to the lateral retropharyngeal lymph nodes. Selective dissection of the controlateral side of the neck should be performed in patients having either locally advanced primary lesions or with lesions approaching the midline. In the presence of metastases which are either clinically or intraoperatively evident, neck dissection should be extended to additional lymph node levels.

[Pulsating tinnitus associated with high homolateral jugular bulb and aplasia of the contralateral transverse and sigmoid sinuses]. / Acufene pulsante associato a bulbo della giugulare alto omolaterale ed aplasia dei seni trasverso e sigmoide controlaterali.

Pulsating tinnitus is uncommon in the general population. This clinical manifestation can be associated with severe intracranial pathologies and is particularly characterized by a rhythm and synchronism reflecting the heart beat. This work presents a clinical case of pulsating, subjective tinnitus associated with a high homolateral jugular bulb and marked hypoplasia of the contralateral transverse and sigmoid sinuses and the clinical-radiological examinations that made diagnosis possible (particular reference going to CT, MRI and angio-MRI). The intracranial venous drainage pattern varies and is nearly always asymmetrical. The jugular bulb is defined as "high" when its upper edge extends nearly to the level of the tympanic anulus, a condition found in 6-20% of the general population. In many cases it is found by chance as often this condition is asymptomatic. However, the pathological picture associated with pulsating tinnitus is highly complex and requires a detailed diagnostic process which some Authors have arranged in specific "flow charts". Imaging methods are essential and must be identified according to the clinical-audiological findings. The radiologist can avail himself of CT, MRI (in association with angio-MRI), Doppler ultrasound of the supraortic and transcranial branches, and digital imaging subtraction angiography. The therapeutic approach to the patient manifesting a "high" jugular bulb is surgical and makes use of such procedures as: ligature of the internal jugular vein, extracranial transposition of the bulb and, in cases of dehiscence of the limiting bone, hypotympanum repair using an autologous or homologous graft of cartilage or bone. Whichever the case, an accurate cost-benefit evaluation must be made, particularly in regard to the risks of endocranial hypertension from the reduced venous drainage, a condition which is significantly increased when concomitant abnormalities of the dural sinuses are present. In the present case, this risk was quite high because of the particular venous morphology described and the patient refused surgery. Currently the patient is under clinical-radiological observation.

[Pleomorphic adenoma: a case treated by laryngotracheal resection and reconstruction]. / Un caso di adenoma pleomorfo trattato con resezione e ricostruzione laringo-tracheale.

Benign Pleomorphic Adenoma (PA) is a tumor rarely found in tracheal and laryngotracheal sites. A review of the literature published since 1922 has revealed only 30 certain cases of which 3 presented simultaneous involvement of both larynx and trachea. The present work describes the thirty-first case (the fourth with a laryngotracheal localization), diagnosed in a white, 40-year-old male who had been complaining of acute dyspnea for the last three years. Initially these symptoms had been interpreted as asthmatic crises. During one of these episodes, the patient underwent emergency tracheotomy and a laryngotracheoscopy revealed a rounded cricotracheal lesion with smooth surface and approximately 4 cm in cranio-caudal diameter. The mass occupied 90% of the air space and originated from the posterolateral right portion of the cricoid, and from the first 3 tracheal rings. CT and esophagoscopy ruled out its transmural invasion into the esophagus. Under rigid bronchoscopy, assisted NdYAG laser debulking was performed for biopsy purposes. The histological diagnosis was benign AP. For this reason a Grillo cricotracheal resection was performed with exeresis of the cricoid arch, mucosa of the cricoid plate and the first 4 tracheal rings. Reconstruction of the respiratory tract was achieved through termino-terminal cricothyrotracheal anastomosis. The initial diagnosis was confirmed and the resection edges were without evidence of neoplasm. Post-operative recovery proceeded without complications and the patient was discharged 7 days after surgery. Endoscopic and radiological follow-up after 30 months is still negative for any neoplastic recurrences. The laryngo-tracheal lumen is within the norm and cord motility has been preserved. The authors then describe the clinical, anatomopathological and radiological elements which prove useful in evaluating tracheal neoplasms and they underline the problems of differential diagnosis between benign AP and adenoid-cystic carcinoma. In addition, the various therapeutic options are discussed with special attention being focused on surgery through external approaches. Given the location of the AP described, the Grillo procedure-most commonly used in cases of inflammatory cricotracheal stenoses-proved well suited to the loco-regional control of the neoplasm. Stringent respect for some parts of this surgical technique make it possible to reduce post-operative complications to a minimum.

Endoscopic CO2 laser excision for tis, T1, and T2 glottic carcinomas: cure rate and prognostic factors.

We present the results of a retrospective study based on a cohort of 140 patients who underwent endoscopic CO(2) laser excision for previously untreated early glottic cancer (21 Tis, 96 T1, and 23 T2). This study used univariate analysis to review the impact on disease-free survival of 15 factors related to the host, the tumor, and the treatment. Recurrent cancer developed in 28 patients with an average interval to recurrence of 37.5 months. Retreatment consisted of different procedures, including laser excision, partial or total laryngectomy, and/or radiotherapy. The larynx was definitively preserved in 96% of patients. By the end of the study, 14 patients had died, but only 2 of them had died of the disease. Five-year overall survival and determinate survival were 93% and 98%, respectively. Ultimate local control at 5 years with CO(2) laser excision alone was 95% for Tis, 87% for T1, and 91% for T2 lesions. Only involvement of the anterior third of the vocal cord (P = 0.02), involvement of the false vocal cord (P = 0.02), and infiltration of the vocalis muscle (P = 0.004) showed a significant negative impact on disease-free survival.

[Indications for elective neck dissection in malignant epithelial parotid tumors]. / Indicazioni allo svuotamento linfonodale latero-cervicale elettivo nelle neoplasie maligne epiteliali della parotide.

The purpose of the present study was to define the indications and extension for the treatment of lymph nodes in clinically NO patients with primary malignant epithelial parotid tumors. A retrospective analysis was performed on 46 cases with such tumor out of 307 parotid neoplasms (246 benign, 61 malignant) consecutively treated from 1985 to 1994. Lymph node metastases were present only in the histotypes with a high degree of malignancy (overall incidence, 24%). Two patients (5%) showed occult metastases. No correlation was found between the size of the neoplasm and the incidence of lymph node metastases. However, the latter were significantly more common in locally highly aggressive neoplasms (class "a"), 8%; class "b" 43%; P = 0.006). Due to the small number of cases, it was not possible to correlate the incidence of occult metastases with neoplasm size or local extension. As regards topographic distribution of lymph node metastases, level II was always involved, level V was never involved, and level i.v was involved only when metastases were found in the upper levels. Occult metastases were found only at level II. Over a follow-up period of 2 to 10 years, no cases were seen with cervical recurrences. Although drawn from a limited series, the results are similar to the data generally reported in the literature, showing that lymph node metastases are rare in neoplasms with a low grade of malignancy whereas there is a significant increase in the incidence of metastatic lymph nodes and occult metastases when the grade of malignancy is high. In conclusion, in clinically NO patients, a suprahomohyoid neck dissection (levels I-II-III) is indicated only when the neoplasm shows a high grade of malignancy or when it is a class "b" malignancy. In the other cases, neck dissection is determined by the clinical evidence of metastasis and can be extended to the lower levels. Neck dissection can be avoided in NO patients whenever ultrasound and fine needle biopsy are both routinely used in the preoperative evaluation of the cervical lymph nodes.

[Endoscopic treatment of sphenoid aspergilloma]. / Il trattamento endoscopico dell'aspergilloma sfenoidale.

In recent years there has been an increase in fungal infections of the nose and paranasal sinuses, even though it is difficult to ascertain the incidence and prevalence of such disorders. The only information which can be drawn from the literature is that such infections are diagnosed in 6% to 13% of surgically treated chronic sinusitis. Aspergillus is the etiologic agent in approximately 80% of cases. Fungal infections are classified into two groups: non-invasive and invasive. The former includes mycetoma and allergic fungal sinusitis. The latter comprises the chronic indolent form, which presents slowly progressive bone erosion, and the fulminant form, which almost invariably carries a dismal prognosis. The maxillary sinus is involved in 80% of mycetomas, followed, in order of frequency, by the ethmoid and frontal sinus. Localization in the sphenoid sinus is exceedingly rare, with only 71 cases reported in the literature. Diagnosis of mycetoma is based on fungal cultures of nasal secretion (which are indeed of limited sensitivity, around 40%) and histological examination of the material removed from the sinus, which identifies the fungus in 80% of cases. CT and MR are highly sensitive diagnostic tools because of their ability to detect the presence of ferromagnetic substances (i.e. iron, magnesium and manganese) and calcium deposits in the diseased sinus. Four new cases of sphenoid mycetoma, treated with endoscopic surgery, are described. The advantages of the endoscopic approach compared to traditional techniques and the role of anti mycotic agents are also discussed.

Prognostic determinants in supraglottic carcinoma: univariate and Cox regression analysis.

BACKGROUND: A series of 281 consecutive patients affected by supraglottic cancer and treated with surgery alone or with surgery followed by radiotherapy between 1983 and 1989 was reviewed to identify significant prognostic determinants. METHODS: Fifty-one variables (related to host, tumor, and treatment) were tested by univariate and multivariate analysis performed on absolute and determinate survival. RESULTS: The final model of the multivariate analysis for absolute survival included the following covariates listed in order of higher relative risk of death: extracapsular spread, involvement of the medial wall of the pyriform sinus, thyroid cartilage invasion, metachronous tumor, anesthesiologic risk according to the American Society of Anesthesiologists classification (chi 2 = 71.28 with 6 d.f., p < .00001). The definitive model for determinate survival included: extracapsular spread, involvement of the medial wall of the pyriform sinus, extralaryngeal soft tissue invasion, and thyroid cartilage invasion (chi 2 = 82.74 with 5 d.f., p < .0001). CONCLUSIONS: Extracapsular spread was the most important factor affecting the prognosis of patients with supraglottic carcinoma. A second important finding was that T and N category did not emerge as a significant independent prognostic predictor at multivariate analysis. The negative impact on absolute survival of physical status and metachronous tumor could be the expression of the influence of concomitant diseases on survival. These observations concur to reinforce the concept that the current TNM classification is rather inadequate in predicting the prognosis of patients with supraglottic carcinoma when the aforementioned variables are considered.