[Salivary gland drainage into the thyroglossal duct]. / Spyttkjerteldrenasje til ductus thyreoglossus.

BACKGROUND: Failure in regression of the thyroglossal duct is one of the most common reasons for midline swellings in the neck. Several authors have described recurrent thyroglossal duct remnants with persisting draining sinuses. However, few have described accessory salivary glands that drain into the thyroglossal duct. MATERIAL AND METHODS: In this article we report two such cases with midline salivary glands in the floor of the mouth. RESULTS: These two patients were subsequently successfully treated with radical tissue resection in the area between the hyoid bone and foramen cecum. INTERPRETATION: Preoperative fistulography or sinography was useful to demonstrate the ductal ramification of the salivary glands, and use of methylene blue during surgery proved of significant value for the result.

Survival of patients with squamous cell carcinoma of the supraglottic larynx--thirty-five-year experience with radiotherapy.

A retrospective comparison of treatment policies in two institutions revealed a change in the reliance on radiotherapy. Since 1978, high-energy, high-dosage radiotherapy has played a prominent role in the primary therapy of squamous cell carcinoma of the supraglottic larynx. Statistically, the overall determinate survival rate has improved compared with results during the preceding period, but the death rate from intercurrent disease and second primary cancers has remained unchanged. Improved cancer control and patient survival were restricted to clinical tumor stages III, T4N0, and T4N1. The choice of primary therapy and the radiation dose and fractionation pattern were important variables influencing the survival. A description of the data is followed by a critical analysis of the significance of the findings, in view of the fact that the treatments were performed in two different institutions at different time periods.

Recurrence after different primary treatment for cancer of the supraglottic larynx.

Retrospective analysis of patient records at two hospitals was performed with the principal goal of clarifying the role of primary radiotherapy ill patients with squamous cell carcinoma of the supraglottic larynx. Primary surgery was frequently performed during the first period from 1958 to 1978. Primary radiotherapy with surgery in reserve was the prevailing therapy during the second period from 1978 to 1993. Fewer recurrences were observed during the second period. The improved results were apparent mainly in patients with the more advanced stages (III, T4N0 and T4N1). Analysis of many factors suggest that the more frequent choice of primary radiotherapy with surgery in reserve, or applied as preoperative treatment, with optimal dosage and technique, might have contributed to the improved results.

[Laser surgery of laryngeal cancer (T1 glottis). New therapeutic alternative]. / Laserkirurgi ved larynxcancer (T1a glottis). Nytt behandlingsalternativ.

The standard treatment for patients with T1a vocal cord cancer has been radiotherapy. From October 1995 selected patients have undergone laser surgery and up until March 1997 we had treated 16 patients. The results so far have been satisfactory with only one recurrence. Some of the patients have experienced a slight to moderate degree of hoarseness postoperatively. Laser treatment is more cost-effective than radiotherapy and in larger series the incidence of residual disease and recurrence seems to be equal to or even better than when following radiotherapy. The procedure demands considerable skill with laser surgery of the larynx and should be limited to 1-2 surgeons at two hospitals in this country where the annual incidence of T1a glottic cancers is approximately 30.

[Free vascular grafts in reconstructions in the head and neck region]. / Frie vaskulariserte transplantater ved rekonstruksjoner i hode- og halsregionen.

Since 1989, 40 free-tissue grafts were used in 39 patients to repair defects following major head and neck ablative surgery (n = 32) and for reconstruction of the mandible because of osteoradionecrosis or trauma (n = 7). The radial forearm flap was used in 17 patients (five including a segment of radius), the lateral arm flap in seven, fibula in five and a segment of ileum for restoration of the hypopharynx in 11 cases. Three radial forearm flaps and the bone in one lateral arm flap failed. Better functional and cosmetic results seem to be obtained with free flaps than with other reconstructive techniques.

Relationship of intraoperative rupture of pleomorphic adenomas to recurrence: an 11-25 year follow-up study.

BACKGROUND: Intraoperative rupture of the capsule of a pleomorphic adenoma is reported to be associated with an increased recurrence rate. For many years, we have noted few recurrences among patients who experienced rupture of the capsule during surgery. Therefore, we asked "How often has surgical rupture of the capsule of a mixed parotid tumor resulted in recurrence among our patients?" This study is a summary of our clinical observations and not a methodologic one. METHODS: The medical records of 346 patients operated on between 1965 and 1981 were reviewed. The surgical notes and histopathologic descriptions were examined with special reference to the relationship between surgical margins and tumor capsule. Satisfactory follow-up was obtained from 238 patients primarily operated on in our department. The average observation time was 18 years. None of our patients received postoperative irradiation. RESULTS: Six (2.5%) patients had a recurrence 7 to 18 years postoperatively (mean 11.8 years). This recurrence rate is of the same order of magnitude as other reports. Rupture of the capsule with macroscopic spillage of tumor cells occurred in 26 patients and two (8%) of them developed recurrent tumors. Surgical dissection close to the capsule was performed in 87 cases, with one recurrence. In the remaining 121 patients the surgical dissections were done without visualizing the tumor capsule. Three (2.5%) of these cases developed recurrent tumor. The 8% recurrence rate after capsule rupture is not statistically different from the 2% for the other patients. There was also no difference in recurrence rate between patients with microscopic positive or negative surgical resection margins. CONCLUSIONS: We question whether spillage of tumor cells from a pleomorphic adenoma plays such an important role in the development of recurrent tumors as has been previously postulated. We also question the justification and benefit of postoperative radiotherapy for patients with this benign disease.

Fistulae following laryngectomy in patients treated with irradiation.

The development of fistulae following 197 consecutive laryngectomies performed from 1980 to 1987 have been examined. Fistulae were present in 28 patients (14 per cent). Age, T-classification, daily level of radiation dose and the time lapse between diagnosis and operation did not seem to influence the rate of fistula development. The study indicates that there is a two to three per cent risk of fistula development when a primary laryngectomy is performed. Fistula formation increased to about 10 to 12 per cent following radiotherapy, with an additional increase whenever previous operations on the neck had been done and/or if the disease demanded more extensive surgery. The study also indicates that the risk for fistula development is less when an experienced surgeon performs the operation.

Combined radiotherapy and surgery in the treatment of neck node metastases from squamous cell carcinoma of the head and neck.

A prospectively recorded series of 107 patients with clinical neck node metastases from head and neck squamous cell carcinomas, treated in 1983-1988, and with initial local control, is evaluated. Eighty-eight patients received preoperative, and were operated 4-6 weeks after radiotherapy, and 19 received postoperative radiotherapy. Forty-four of the neck specimens in the preoperatively treated patients showed vital tumor tissue, 7 with positive and 37 with negative resection margins. Nine of the latter 37 patients died due to regional recurrence. Twenty-three of the preoperatively treated patients had no palpable residual tumor following radiotherapy, but histological examination showed vital tumor tissue in five, of whom two had N1 neck disease. The overall regional failure rate was 19%. Eleven patients (10%) died from local recurrence and 11 from distant metastases. Forty-one patients (38%) are alive without evidence of disease and three (3%) alive with disease (mean observation time 30 months). Combined treatment is recommended for all cases of neck node metastases.

Computed tomography in T1 carcinoma of the larynx.

The findings at computed tomography (CT) were reviewed in 33 patients with laryngeal carcinoma classified as T1 at clinical examination. CT revealed extralaryngeal growth and thus changed the classification to T4 in 6 of the 20 patients with a supraglottic primary tumor, but in none of the 13 patients with a glottic tumor.

Experience with reconstructive surgery in 137 cases of head and neck cancer.

A retrospective analysis of 137 patients treated with reconstruction of defects following head and neck cancer surgery is presented. From 1976 through 1984, 151 regional flaps were used: 43 pectoralis myocutaneous, 29 deltopectoral, 19 forehead, 17 nasolabial, 14 combinations of the aforementioned and 15 other types. The minimum follow-up was two years. Of 62 patients (51 stage III and IV) operated as part of the primary treatment, 20 (32%) died due to relapse, of which 14 (23%) occurred within the region reconstructed. The corresponding figures for 64 patients receiving salvage surgery for recurrences were 53% and 39% respectively. Eleven patients had repair of wounds following surgery or irradiation. Major flap necrosis necessitating reoperation occurred in 11%. The average duration of hospitalization was 35 days. We feel that these results justify these resource-demanding operations.

Value of routine follow-up in patients treated for squamous cell carcinoma of the head and neck.

The records of 214 consecutively registered, previously untreated patients with squamous cell carcinoma of the head and neck region were reviewed. Among the 157 patients considered "free of disease" following the primary treatment 54 developed recurrences - all but three within three years. Only in patients with carcinoma of the larynx treated with radiation alone did follow-up disclose recurrences for which further treatment resulted in a significant number of cures. For these patients the cure rate was one in 79 routine appointments compared to only one cure in 325 appointments for patients with carcinoma in other localizations. It seems that our routine follow-up procedure for most types of carcinoma is too extensive and that follow-up beyond three years mainly will be of value for the possible detection of second primary malignancies.

Pre-operative embolization of juvenile nasopharyngeal angiofibromas with gelfoam.

Two patients with juvenile nasopharyngeal angiofibromas are presented. Different haemorrhage-reducing operative methods were used. The cases illustrate the hazards of permanent ligation of the external carotid artery and the advantage of pre-operative embolization with absorbable Gelfoam.

Laryngectomees in Norway. Study no. 5: Problems of everyday life.

In a country-wide investigation, 20-30% of the laryngectomees were offered insufficient postoperative counselling/training about practical/somatic matters. Psychic stimulation and support was also sometimes deficient. A laryngectomy necessitates a structured rehabilitation program which should be provided by different counsellors at times when the patient is receptive to this kind of counselling. A proposal for a rehabilitation program is presented, which the otolaryngologist is in the natural position to organize and coordinate. He is also in the best position to adjust the program according to the patient's individual desires and needs.

Influence of different climates on the peak expiratory flow in laryngectomees.

Peak expiratory flow (PEF) has been measured in 61 laryngectomees before and after a fortnight's stay on the Canary Islands during the Norwegian winter season. A statistically highly significant increase in the PEF-values has been shown. The warmer climate with a higher degree of humidity in the air on the Canary Islands is the most probable cause.

Study No. 4: Social, occupational and personal factors related to vocational rehabilitation.

Sixty-nine of 110 laryngectomees (63%) in Norway resumed work after operation. Re-employment was established for most of the patients before active rehabilitation was initiated. The best situational and social guidelines for successful re-employment were residence, education, and social group. Abuse of alcohol gave a poor outlook for re-employment. A thorough pre-operative history comprising social factors, life story, and previous occupation may give valuable information about prospects of postoperative re-employment. Patients with an assumed low vulnerability to stressful events and those with good adjustment proven or indicated in earlier life, resumed work significantly more often than patients with other personal and behavioral characteristics.

Laryngectomees in Norway. Study No. 3: Pre- and postoperative factors of significance to esophageal speech acquisition.

The acquisition and acceptability of esophageal speech were evaluated relative to a number of variables in 188 laryngectomees. Of the population studied, 63% were rated as having socially acceptable esophageal speech (SAES) according to a rating scale developed by the author. Advanced age, persistent swallowing difficulties, and small stomas or dependency on a cannula resulted in reduced capability for acquiring SAES. As well, the ratings of premorbid adjustment patterns and personality traits were found to predict success in esophageal speech acquisition better than any social or situational factor.

Laryngectomees in Norway. Study No. 2: pre-operative counselling and postoperative training evaluated by the patients and their spouses.

Twenty-six per cent of 189 Norwegian laryngectomees considered pre-operative counselling to be nonsatisfactory. Similarly, postoperative self-care training was rated nonsatisfactory by 55%. The quality of the pre-operative counselling had a significant influence on the patients' ability to perceive postoperative training which subsequently correlated with mastery of the laryngectomy event. Seventy per cent of the spouses felt that they had not been offered adequate counselling. The problems endured at home for 60% of them could have been amenable to relief by improved counselling. It is questionable if the teams in the different treatment and rehabilitation institutions were aware of all the requirements for the total treatment and rehabilitation of patients facing a laryngectomy.

Study No. 1: Social, personal, and behavioral factors related to present mastery of the laryngectomy event.

Premorbid adjustment patterns and personality traits characterizing assumed vulnerability to stressful events have been shown, in a retrospective study, to provide valuable prognostic profiles which are highly correlated with the laryngectomees' mastery of the operation. Patients with assumed low vulnerability and/or who previously had proven or given indication of being well adjusted, mastered the laryngectomy significantly better than patients with other characteristics. Personality traits and premorbid adjustment patterns predict present mastery abilities better than any of the situational and social factors analyzed. This type of diagnostic exploration may be of great help in planning the rehabilitation program needed by the individual patient.

Tracheal changes in relation to different tracheostomy techniques. (An experimental study on rabbits).

An experimental study on rabbits was undertaken to evaluate the effect of the tracheostomy technique on the development of tracheal stenosis. An operation model was made for the purpose of excluding all pathogenetic factors in the formation of tracheal stenosis, except the surgical procedure. Five different operative methods were used: A. vertical incision, B. anterior wall flap, C. H-type incision, D. window-type excision, and E. subperichondreal enucleation of cartilage. The "cannulation" period was 7 days, and the animals were kept alive for another 140 days before postmortem examinations were undertaken. Minor macroscopical and microscopical changes were noted. The pathological findings were somewhat more pronounced in groups B, C and E than in the other groups. The tracheostomy technique apparently plays a minor role in the formation of tracheal stenosis.