[Topical liquid nasal gel, its anatomical distribution and transport]. / Distribución anatómica y transporte de un gel líquido tópico nasal.

The objectives of this study are: 1) to assess the anatomical distribution of a topical liquid nasal gel in patients with and without rhinitis using a metered dose nasal pump, and 2) to determine whether the distribution pattern is influenced by dosage and delivery technique. Thirty-nine volunteers were evaluated, 26 without nasal inflammation and 13 with rhinitis. Patients self-administered the nasal spray according to the specifications in one fossa and incorrectly in the other one (sniffing and double doses). The findings showed that the nasal gel delivered by spray did not penetrate beyond the inferior part of the middle turbinate, regardless of delivery technique (double dose with sniffing or single dose without sniffing) and the presence or absence of inflammation.

Results of near-total laryngectomy.

The clinical records of 225 patients undergoing primary or salvage near-total laryngectomy (NTL) for laryngeal and pyriform cancer were analyzed for local control and morbidity. If the primary cancer was laryngeal in origin, patients underwent a simple NTL; if it was pyriform, a minor modification called near-total laryngopharyngectomy (NTLP) was used. When NTLP was extended to include necessary portions of the tongue base or posterior pharyngeal wall, pharyngeal reconstructions were added. The principal outcomes studied were 1) 5-year local control of the primary cancer, 2) achievement of lung-powered shunt speech, and 3) incidence of aspiration. The local control of cancer was similar to that expected with total laryngectomy or laryngopharyngectomy. Conversational voice was achieved in 85% of patients surviving beyond 1 year. Some patients required additional surgery for voice -- usually endoscopic dilation. Aspiration was absent if primary healing was achieved. It was troublesome in wound breakdown if the shunt was directly affected. Secondary anti-aspiration procedures were required in 9% of our patients -- usually preserving shunt speech.

"Early" cancer of the larynx: the concept as defined by clinicians, pathologists, and biologists.

Since a great deal of confusion surrounds the different uses made by clinicians, pathologists, and biologists of the term, this paper clarifies the concept of "early" cancer of the larynx. Clinically, this is usually a glottic neoplasm in which full cordal mobility is still present; early supraglottic cancer is infrequent, and usually a chance finding. Whatever the site, early laryngeal cancer is a minimally invasive neoplastic lesion that does not invade the muscle or cartilage, but is still capable of metastasis. Being confined to the lamina propria, it is more than a carcinoma in situ but less than a deeply infiltrating carcinoma. Superficial extending carcinoma is therefore an early cancer. Biologically, early cancer belongs to stage II.

Quality of life after surgical treatment of cancer of the larynx.

The purpose of the study was to assess the quality of life of patients after surgical treatment for cancer of the larynx. Three groups of patients were identified according to surgical treatment: total laryngectomy, 111 patients; near-total laryngectomy, 38 patients; and partial laryngectomy, 23 patients. The impact of successful surgical treatment on their life roles was analyzed in terms of work, activities, familial and spousal relationships, sexuality, and psychologic features such as stress and anxiety. Two questionnaires were used; the Psychosocial Adjustment to Illness Scale (PAIS) and the Mayo Clinic Postlaryngectomy Questionnaire. With the PAIS questionnaire, no difference was found in role adjustment between the total laryngectomy and near-total laryngectomy groups, with one exception. In the work domain, the total laryngectomy patients who were working had better adjustment than the near-total laryngectomy patients. The overall adjustment of both groups was less favorable than that of a comparison group of patients with nonlaryngeal cancer. The patients who had the classic conservation operations adjusted in all domains more favorably than the patients with permanent tracheostomas. The partial operation patients adjusted better than the nonlaryngeal cancer patients. We conclude that the stoma has a negative impact on adjustment postoperatively and that it may have a more serious impact on life adjustment than voice alteration. Further investigation and standardization of measurement tools are needed.

Are clinical classifications for laryngeal cancer satisfactory?

All clinical classifications for laryngeal cancer are compromises based on clinical and imaging evaluations, with no concern for important elements such as phenotype, host-tumor relationship, and any concomitant nonneoplastic disease. The various staging systems are critically examined along with a report on the outcome of an international survey on the applicability of the TNM system in relation to laryngeal neoplasms, promoted by The Laryngeal Cancer Association.

Primary head and neck cancer. Histopathologic predictors of recurrence after neck dissection in patients with lymph node involvement.

OBJECTIVE: Retrospectively analyze several histopathologic variables that may predict neck recurrence after neck dissection. DESIGN: From 1970 through 1980, 284 patients with pathologically confirmed metastatic squamous cell carcinoma underwent neck dissection and received no adjuvant therapy. Kaplan-Meier evaluation estimated a 74% 2-year neck recurrence-free rate. After adjusting for the standard covariates of age, gender, neck stage, and tumor grade, we also controlled for the time-dependent covariates of primary recurrence, occurrence in the side of the neck not operated on, or development of new head and neck primary disease. SETTING: A large referral-based practice. RESULTS: The number of lymph nodes involved, invasion of vascular/lymphatic space, invasion of soft tissue, and desmoplastic lymph node pattern adversely affect neck recurrence. A desmoplastic stromal pattern was associated with almost a sevenfold increased risk of neck recurrence. To our knowledge, this finding has not been reported previously. CONCLUSION: Histopathologic evaluation of metastatically involved cervical nodes can identify patients with head and neck cancer who are at high risk for recurrence.

Recurrences after endoscopic management of early (T1) glottic carcinoma.

From 1976 to 1986, 106 patients with early glottic carcinoma were managed endoscopically at our institution. Twenty-four (23%) patients required retreatment of the larynx for local recurrences or new primary lesions after initial endoscopic management. The probability of remaining free of local recurrence 3 years after primary surgery was estimated to be 0.87 and, after 5 years, it was 0.81. Of the 24 patients who required re-treatment of their larynx, 10 did so beyond 3 years, indicating a new second primary. In 1 patient who required retreatment within 3 years, a new primary developed on the opposite cord. Therefore, true local recurrences developed in 13 patients (12.3%); 3 of these patients (2.8%) ultimately required laryngectomy and 3 are dead (2.8%) with disease.

Graves ophthalmopathy. Results of transantral orbital decompression performed primarily for cosmetic indications.

PURPOSE: Transantral orbital decompression is effective treatment for excessive proptosis and optic neuropathy due to Graves ophthalmopathy. In these sight-threatening circumstances, patients willingly accept the side effects of orbital decompression. When transantral orbital decompression is performed for cosmetic indications, patients' acceptance of side effects may be different. This study reports detailed results of transantral decompression for 34 patients in whom the indications were primarily cosmetic. METHODS: The medical records of 34 patients with Graves ophthalmopathy who had transantral orbital decompression primarily for cosmetic indications were reviewed. Preoperative and postoperative physical features of the eyes were compared. Long-term assessment was formulated from follow-up examination and a follow-up questionnaire. RESULTS: The most notable improvement was in the reduction of proptosis (mean decrease, 5.2 mm). The frequency of asymmetry of proptosis, however, did not improve. Asymmetry was more than 1 mm in 44% of patients preoperatively and in 54% postoperatively. Although the palpebral fissure was decreased by an average of 2.7 mm, upper lid retraction became worse in 12 (43%) of 28 eyes. Of 15 patients who had no diplopia preoperatively, continuous diplopia developed postoperatively in 73%. The patients underwent a total of 37 eye muscle operations and 31 eyelid operations after decompression. Of 29 patients who responded to a long-term follow-up questionnaire, 69% were satisfied with the appearance of the eyes and 31% found it acceptable. No patient was dissatisfied. Symptomatic diplopia was present in 6.9% of patients at the time of the follow-up questionnaire. CONCLUSION: Transantral orbital decompression performed for cosmetic indications in Graves ophthalmopathy may need to be followed by eye muscle and lid operations. These procedures result in a high degree of patient satisfaction. However, a small percentage of patients experience persistent diplopia, despite multiple eye muscle procedures.

Carcinoma of the oral cavity in a young woman.

Although tobacco and alcohol abuse are known factors in the genesis of many head and neck cancers, none of the consultants believe that the cause and effect is established in younger patients. No one is willing to make a connection between her carcinoma and her connective tissue disease. With regard to panendoscopy, the consultants would perform a rigid bronchoscopy and an esophagoscopy (Dr. Donald), laryngoscopy and esophagoscopy (Dr. Eibling), and esophagoscopy (Dr. DeSanto). (Editor's note: Bronchoscopy and/or esophagoscopy have been considered standard in the evaluation of patients with head and neck malignancies, but the editor believes there is little or no justification for endoscopy in nonsmoking young adults.) There is consensus as to how to treat this woman. The consultants concur that excision followed by radiotherapy offers the best chance for cure. On expert (Dr. Eibling) suggests that postoperative chemotherapy should also be given. Radiotherapy or chemotherapy alone are not options that anyone believes in as curative. Cure rate estimates center around 40% to 50% five-year survival (Dr. Donald) or 30% to 50% (Dr. Eibling). One physician believes it is useless to estimate the patient's odds (Dr. DeSanto). When this patient refuses surgery and stops her radiotherapy, one expert suggests waiting until the mucositis resides and proceeding with a resection (Dr. Donald). Another encourages completing the course (Dr. Eibling) and another believes there are no guidelines in such an ad-hoc program (Dr. DeSanto).(ABSTRACT TRUNCATED AT 250 WORDS)

Early glottic carcinoma treated with open laryngeal procedures.

OBJECTIVE: The purpose of this study was to determine the recurrence rate and long-term survival of patients treated with open cervical procedures. DESIGN: The study is a retrospective analysis of a cohort of patients who underwent an open laryngeal procedure between 1976 and 1986. The median follow-up was 6.6 years. PATIENTS/PARTICIPANTS: The sample was a consecutive series of 159 patients with early glottic carcinoma without impaired vocal cord mobility. Patients with a history of radiation therapy or surgical treatment elsewhere were excluded. INTERVENTION: Surgical treatment in this group of 159 patients included 82 frontolateral partial vertical laryngectomies, 61 laryngofissures with cordectomy, 12 hemilaryngectomies, and four anterior commissure procedures. OUTCOME MEASURE: Estimates of survival time beyond the day of surgery, time to first recurrence (local, regional, and distant), and time to first local recurrence were obtained with the Kaplan-Meier product-limit method. RESULTS: Eleven patients experienced recurrent laryngeal cancer. Ten patients underwent laryngectomy for recurrence. One patient underwent an anterior commissure procedure. Three of the 11 patients who underwent re-treatment of the larynx were ultimately salvaged. The probability of survival at 3 and 5 years was 91% and 84%, respectively. The probability of remaining free of local recurrence 3 and 5 years after surgery was 94% and 93%, respectively. CONCLUSION: In our experience, open laryngeal procedures continue to be excellent treatment for select cases of early glottic carcinoma. They are versatile and efficacious for managing the wide spectrum of larger T1 glottic carcinomas.

Results of transantral orbital decompression in 428 patients with severe Graves' ophthalmopathy.

We reviewed records from 428 consecutive patients with severe Graves' ophthalmopathy to determine early and late results after transantral orbital decompression. Optic neuropathy was present in 217 (50.7%) patients. Post-operatively, 402 (89%) of 453 eyes with preoperative visual acuity worse than 20/20 improved or remained the same. Visual field scotomas improved or resolved in 245 (91%) of 269 eyes tested pre- and postoperatively. Preoperative papilledema resolved or improved in 99 (94%) of 105 eyes, and preoperative exposure keratitis improved or resolved in 178 (92%) of 195 eyes. Average proptosis reduction was 4.7 mm. Postoperatively, new diplopia developed in 74 (64%) of 116 patients who had no diplopia before orbital decompression, although 300 patients ultimately had strabismus surgery. At late follow-up (N = 293 patients), 226 (77%) had single vision and 44 (15%) had correction with prism. Complications included sinusitis (18 patients), lower eyelid entropion (38 patients), numb lip (23 patients), cerebrospinal fluid leaks (15 patients), and one frontal lobe hematoma (one patient). The average duration of follow-up was 8.7 years. Transantral orbital decompression effectively reduces proptosis and usually corrects optic neuropathy. In other circumstances, the benefits achieved and the side effects incurred must be carefully balanced for each patient before transantral orbital decompression is considered.

Base of tongue carcinoma: patterns of failure and predictors of recurrence after surgery alone.

Between January 1971 and December 1986, 55 patients with squamous cell carcinoma of the tongue base underwent complete surgical resection with curative intent. No preoperative or postoperative adjuvant therapy was administered. The study group consisted of 41 men and 14 women (median age 61 years). All patients were followed until death (39 patients) or for a median of 9.4 years. Local control at 5 years was 74%. No predictors of local recurrence were discovered. Control in the dissected neck at 5 years was 68%. Control of cancer above the clavicles at 5 years was 48%. Distant metastases developed in 14% of the patients by 5 years. Cause-specific survival at 5 years was 65%. A Cox multivariate regression analysis revealed that pathologic N stage was the only significant independent predictor of recurrence in the dissected neck, recurrence above the clavicles, and cause-specific survival. The 5-year overall survival was 55%. Surgical mortality was 4%.

Indications and results of cordectomy for early glottic carcinoma.

Select early glottic carcinomas in patients with normal vocal cord mobility can be successfully treated with cordectomy, performed either endoscopically or by means of an open operation (laryngofissure-cordectomy). From 1976 to 1986, 95 patients underwent cordectomy at our institution. There were 88 men and 7 women, with an age range at the time of surgery of 27 to 84 years. A laryngofissure was used to perform a cordectomy in 61 patients and an endoscopic approach was used in 34. The median number of days in the hospital for the endoscopic group was 2, and for the laryngofissure group it was 6. The Kaplan-Meier product-limit method showed the probability of no recurrence in the first 3 years after an endoscopic cordectomy was 0.9099, and in the laryngofissure-cordectomy group it was 0.9502. To date, there have been four recurrences (11.8%) in the endoscopic group and three (4.9%) in the laryngofissure group. Only one patient with recurrent tumor is known to have died of the cancer. Laryngectomy was necessary for ultimate control in three patients. The Kaplan-Meier survival curve for the 95 patients was the same as that for a sex- and age-matched control group. Cordectomy is an effective treatment option that results in minimal morbidity for select early glottic carcinomas.

Cervical nodal metastasis of squamous cell carcinoma of unknown origin: indications for withholding radiation therapy.

The records of patients with pathologically confirmed metastatic squamous cell carcinoma involving cervical lymph nodes who were treated at the Mayo Clinic between January 1965 and December 1987 were reviewed. In 117 patients a primary tumor could not be discovered. Of these, 24 patients underwent curative resection of all gross disease by neck dissection or excisional biopsy. All 24 patients presented with unilateral adenopathy. Their median age was 63 years. Eighteen patients were men. Fourteen patients were in clinical stage N1; six, N2a; three, N2b; and one, N3. Six patients had grade 1 or 2 nodal metastases; 14, grade 3; and 4, grade 4. Gross or microscopic evidence of extracapsular tumor extension was noted in eight patients. All patients were followed until death or for a median of 8.5 years (range, 3.3-20.4 years). A squamous cell carcinoma of the upper aerodigestive tract subsequently developed in only one patient (4%) within 5 years of operation. In six patients (25%), a recurrence developed in the dissected neck a median of 3 months (2.4 months-6.6 years) after operation. Five of these patients had extracapsular extension, and four had pathologic Stage N2a or higher neck disease. Both patients with pathologic Stage N1 disease who had recurrences in the dissected neck had extracapsular extension. Delayed, contralateral neck metastases in an undissected neck developed in two patients. The 5-year overall and cause-specific survivals for all 24 patients were 66% and 74%, respectively. Extracapsular extension was a predictor of neck recurrence, control of disease above the clavicles, cause-specific survival, and overall survival. Patients with pathologic Stage N1 neck disease with no extracapsular extension can be managed by surgery alone. Patients with pathologic Stage N2 or higher neck disease or extracapsular extension should be considered for postoperative, adjuvant radiation therapy.

Early supraglottic cancer.

Early supraglottic cancers (T1 and T2) are treated today with several dissimilar programs. Operation or irradiation alone, combined irradiation and operation, and irradiation with operation for salvage are the options. This study analyzed the effectiveness of operation alone in a group of 94 patients with early lesions. There were no local failures in the group. The only cause of failure was recurrence in the neck and distant metastasis in 15% of patients. Comparisons were made of effectiveness of treatment with regard to local and neck failure, voices retained, frequency of retreatment, and determinate survival to the alternate treatment programs. No differences were found in regard to survival with any of the contemporary programs. There are differences in terms of retreatment frequency, voice preservation, and cause of failure between programs. Conservation surgery is preserving voices today. Combined therapy seems of little value in the early cancers.

Use of anticytoplasmic autoantibodies in the diagnosis of Wegener's granulomatosis with subglottic stenosis.

Subglottic stenosis is one of the lesser known manifestations of Wegener's granulomatosis and poses great difficulty in confirming the diagnosis. We present the use of the anticytoplasmic autoantibodies (ACPA) blood test, which has been shown to be highly specific for Wegener's granulomatosis, for corroboration of Wegener's granulomatosis in a patient with subglottic stenosis for whom tissue biopsies were nondiagnostic. The ACPA test and the presentation, diagnosis, and management of subglottic stenosis due to Wegener's granulomatosis are discussed. Otolaryngologists must be aware of the varied manifestations of Wegener's granulomatosis and the availability of the ACPA blood test as an aid in confirming the diagnosis.