Chondrosarcoma of the larynx: a case report.

Chondrosarcomas of the larynx are rare cancers and are more frequently located at cricoid cartilage level. They are characterised by a low tendency to metastatic diffusion (low grade). The treatment of choice is surgery, which may be endoscopic or "open partial surgery", if extension of the cancer is limited. Prognosis is generally good. In this report, a case of low malignancy chondrosarcoma of the larynx is presented, which was treated surgically with a glottic-hypoglottic laryngectomy according to Serafini-Bartual. Chondrosarcoma of the larynx shows a slow and painless growth, the first symptom is often an ingravescent dysphonia. Laryngoscopy reveals tumefaction of the larynx, covered by intact mucosa. Computerized tomography imaging with contrast and magnetic resonance imaging defines not only coarse calcifications, pathognomonic of chondromatous neo-formations but also the relationship of the neoformation with the surrounding tissues. However, histology remains the gold standard for diagnostic purposes. Treatment is essentially surgical; it must allow eradication of the cancer between specific safety margins and, it must, at the same time, be functional, if the lesion does not extend beyond half of the cricoid circle and if histological grade is low.

Oncological and functional results of CO2 laser cordectomy.

Laser surgery represents the evolution of endoscopic surgery and, as far as concerns treatment of laryngeal tumours, CO2 laser cordectomy is considered a valid alternative to conventional surgery (laryngofissure cordectomy) and to exclusive radiotherapy for glottic carcinomas, classified as T1a, T1b and T2. The present report focuses on personal experience with CO2 laser cordectomy over the last 11 years, evaluating oncological and functional results. Between October 1990 and December 2001, micro-laryngoscopy has been performed with CO, laser, in 606 cases (benign and malignant lesions), of which 150 laser cordectomies, at the ORL Department, Eastern Piedmont University of Novara. An analysis is made of 63 patients (mean age 64.3 years) who underwent laser cordectomy for glottic carcinoma, observed at follow-up for at least 3 years. Vocal function has been studied on a sample of 20 patients. Of those who underwent CO2 laser cordectomy for T1a and T1s, 95.8% were disease free after a minimum of 3 years follow-up. Video-larynx-stroboscopic test highlighted the presence of a "satisfying" fibrous neocord in cases treated with Type III cordectomy. The speech compensation was of the "cord-neocordal" type (35%), false cordal (40%) and with arytenoideus hyperadduction (25%). The electro-acoustical analysis of the voice highlighted a "serious dysphonia" compatible with Type IV cases according to Yanagihara (70%) and moderate-severe dysphonia (30%). Mean values of vocal parameters were 5.8% for Jitter, 12.2% for Shimmer, 0.34 for NHR. CO2 laser cordectomy is first choice treatment for T1a glottic carcinoma, offering intra- and post-operative advantages: reduced traumatism, lack of tracheostomy, low bleeding, fast functional recovery (deglutition and speech), brief hospital stay, and low management costs. Dysphonia resulting from treatment, characterised by breathed voice, allows the patient to lead a normal life.

Centripetal approach to the facial nerve in parotid surgery: personal experience.

There is particular interest in parotid surgery on account of the close relationship between the gland and the extrapetrous facial nerve. The seventh cranial nerve is generally located by means of an anterograde or proximal surgical identification technique aimed at identifying the facial nerve at its point of exit from the stylomastoid canal. There are very few reports in the literature on retrograde or centripetal identification techniques, which may be adapted to the morphology of the neoformation limiting surgical access, in order to isolate the nerve from its peripheral rami. The present report deals with personal clinical experience, describing a technique for retrograde detection of the facial nerve. Between 1990 and 2001, 313 parotid surgery procedures were performed at the ORL Clinic of the Università del Piemonte Orientale in Novara. In 308/313 cases, corresponding to 98% of the operations, the technique chosen for the identification of the extrapetrous facial nerve was anterograde, proximal or centrifugal; in 5 cases alone, retrograde or centripetal exploration of the orbicular branch was undertaken, on account of difficulty in locating the main trunk, due to the presence of a post-inflammatory fibrosis in three patients and a stylomastoid emergency, arising from a malignant neoformation, in the other two. The decision to resort to the identification of the orbicular nerve of the eye is supported by the regular course and adequate size of this facial branch in its peripheral area, which enable it to be easily located.

[Merkel cell carcinoma]. / Tumore a cellule di Merkel.

The authors present 2 cases of Merkel cell carcinoma in the head and neck district, evaluating the characteristics and evolution. Merkel cell carcinoma is a rare, highly aggressive neuroendocrine cutaneous neoplasm which is often located in the head and neck district. This carcinoma has the same characteristics as small cell tumors and tends to significant metastatization both through the lymph nodes and through the blood. It is also prone to frequent recurrence. Today diagnosis is facilitated by electron microscopy and immunohistochemistry to search for neurofilaments and cytocheratin 20. The treatment of choice is radical surgery ensuring a tumor-free edge of at least 3 cm, associated with supplementary local radiotherapy. Recurrence is quite frequent despite the treatment strategies applied.

Post-thyroidectomy superior laryngeal nerve injury.

Voice dysfunction after thyroidectomy may be caused by damage to laryngeal nerves or lesions to strap muscles with laryngo-tracheal movement impairment. Injury to an external branch of the superior laryngeal nerve (EBSLN) is sometimes difficult to recognize clinically and its electromyographic incidence ranges from 0% to 58%. In this study we evaluated, 12-18 months postoperatively, 45 patients who had undergone thyroid surgery (6 total lobectomy, 5 subtotal thyroidectomy, and 34 total thyroidectomy), using a subjective interview, laryngeal videostroboscopy and spectrographic analysis with a multidimensional voice program. Vocal parameters included fundamental frequency, jitter, shimmer, noise-to-harmonic-ratio (NHR) and degree of sub-harmonics. Laryngeal electromyography (LEMG) of the cricothyroid (CT) muscles was performed in 21 subjects with voice problems (35 EBSLNs) using a modified method for the CT recording. In 3 patients of this group (14%) LEMG documented a unilateral EBSLN injury. Easy voice fatigue and decreased pitch range were the most common symptoms after surgery. Average values of vocal parameters pre- and postoperatively in patients without neural damage (n = 42) were: jitter 0.64% and 0.78%, shimmer 3.25% and 3.54%, and NHR 0.12% and 0.13%, respectively (P > 0.05). Acoustic analysis revealed altered patterns in some patients with no objective evidence of damage to EBSLNs, suggesting an extralaryngeal cause of vocal dysfunction, such as laryngo-tracheal fixation or lesions to strap muscles. We conclude that laryngeal videostroboscopy and spectrographic analysis are very useful to assess voice problems after thyroidectomy, including in patients without LEMG-proven neural lesions, in order to suggest early speech rehabilitation, especially in professional voice users.

[Complications in thyroid surgery]. / Le complicanze della chirurgia tiroidea.

Today, when performed applying stringent technique, thyroid surgery can be considered a procedure with low risk of post-surgical complications. Post-surgical hypoparathyroidism is frequent (1.6-53.6% of the cases) although most of these cases are temporary, linked to functional stupor of the parathyroid glands and/or other reversible factors. Analysis of the literature has shown that preservation of 3 or more parathyroid glands is a highly positive (95%) predictive factor for normal post-operative calcemia. The incidence of recurrent definitive paralysis ranges around 0.3-2% of the nerves at risk of iatrogeneous lesions and is usually correlated with thyroid histology and with the extension and type of ablative treatment performed. The authors retrospectively consider a 10-year case study of 218 patients (222 surgical procedures, of which 17 undergoing surgery twice) analyzing endocrinological, hemorrhagic and neurological complications and paying particular attention to any vocal dysfunctions arising at a later date, even in the absence of an ascertained neurological deficit. Considering 116 total and subtotal thyroidectomies, the percentages of acute hypoparathyroidism (AH) and definitive hypoparathyroidism (DH) were, respectively, 43.9% and 6%. Four of the 7 cases of DH presented one of the factors known to increate the risk of complications: malignant thyroid histology, second surgery and/or lymph node dissection. As regards neurological sequele, the authors report an incidence of recurrent definitive paralysis of 1.8% (3 out of 35 nerves at risk examined using EMG of the cricothyroid muscle). Spectroacoustic analysis of samples from 42 subjects showed an alteration in the vocal parameters considered (jitter, shimmer, NHR and DSH) in 14-27% of the cases, even in the absence of any laryngeal nerve deficit. It may be that iatrogeneous lesions and/or scarring of prethyroid strap muscles, known to play a role in phonation mechanisms, are implicated in determining post-thyroidectomy vocal dysfunctions, seen even in patients with anatomfunctionally intact laryngeal nerves.

[Malformations of the first branchial cleft: a case report]. / Le malformazioni del i solco branchiale: case report.

First branchial cleft anomalies are extremely rare and account for less than 8% of all branchial anomalies. They are generally found in infancy although they arise during the embryonal period because of an incomplete closure of the first branchial cleft. In 1972 Work classified first branchial cleft anomalies into two types: Type I, ectodermal cysts, is a duplication of the external auditory duct; Type II, originate in both ectodermal and endodermal components and contain cartilage. The present case report describes a Type II branchial malformation. G.M., a 2-year-old male, presented painful tumefaction in the left parotid area with cutaneous fistulization between the sternocleidomastoid muscle and the mandibular angle. Cranial CT permitted diagnosis and made it possible to stage surgery. The difficulties encountered in recognizing and diagnosing first branchial cleft anomalies are often responsible for application of the wrong surgical approach and the resulting frequency in recurrences.

Drought tolerance of clonal Malus determined from measurements of stomatal conductance and leaf water potential.

We examined tolerance to soil drying in clonally propagated apple (Malus domestica Borkh.) rootstocks used to control shoot growth of grafted scions. We measured leaf conductance to water vapor (g(L)) and leaf water potential (Psi(L)) in a range of potted, greenhouse-grown rootstocks (M9, M26, M27, MM111, AR69-7, AR295-6, AR360-19, AR486-1 and AR628-2) as the water supply was gradually reduced. Irrespective of the amount of available water, rootstocks that promoted scion shoot growth (M26 and MM111) generally had higher g(L) and more negative Psi(L) than rootstocks that restricted scion shoot growth (M27 and M9). After about 37 days of reduced water supply, there were significant decreases in g(L) and Psi(L) in all rootstocks compared with well-watered controls. In all treatments, the slope of the relationship between log (g(L)) and Psi(L) was positive, except for rootstocks AR295-6, AR628-2 and AR486-1 in the severe-drought treatment, where the drought-induced change in the relationship suggests that rapid stomatal closure occurred when leaf water potentials fell below -2.0 MPa. This drought response was associated with increased root biomass production. Rootstock M26 showed little stomatal closure even when its water potential fell below -2.0 MPa, and there was no effect of drought on root biomass production. We conclude that differences among rootstocks in the way that g(L) and Psi(L) respond to drought reflect differences in the mechanisms whereby they tolerate soil drying. We suggest that these differences are related to differences among the rootstocks in their ability to control shoot growth.

[Non-Hodgkin's lymphoma of the larynx: clinical cases]. / Linfoma non Hodgkin della laringe: casi clinici.

Non-Hodgkin Lymphoma (NHL) is a relatively frequent lymphatic system tumor in the head and neck region with both nodal and extranodal localizations. The larynx is one of the least frequent extranodal sites. The present study reports three cases of NHL with extranodal laryngeal localization that had recently come under observation. In these cases, the symptoms reported by the patients were aspecific and not particularly significant. Indirect macroscopic laryngoscopy and direct microlaryngoscopy did not prove pathognomonic while definitive histology clearly diagnosed lymphoma. The treatment of choice for primary laryngeal lymphoma is radiotherapy; combined chemo-radiotherapy is indicated in cases of high malignancy and in multifocal cases.

[CO2 laser treatment in laryngeal papillomatosis]. / Il trattamento laser CO2 della papillomatosi laringea.

Laryngeal papillomatosis is a rare, unpredictable pathology which often recurs. Although several forms of surgery have been suggested for this pathology, CO2 laser surgery is the treatment of choice. This paper presents 30 cases of laryngeal papillomatosis, 12 of which arose in infancy, all treated by dissection and/or CO2 laser vaporization. The treatments were performed in one or more stages depending on the site and appearance of the lesions. Special care must be taken to preserve the anatomical integrity when a papillomatosis must be removed from the glottic area. The average number of surgical procedures per patient proved greater in multifocal vs. unifocal forms (4.7 vs. 1.6) and in children vs. adults (4.9 vs. 3.7). In four patients the pathology followed a neoplastic evolution. Today 57% of the subjects treated (17) are in clinical remission after an average 17 month follow-up. CO2 laser endoscopic microsurgery is presently the most suitable method for treating laryngeal papillomatosis although the biological features of this diseases often make treatment difficult.

[Indications and methods for rhino-pharyngo-laryngeal fibroscopy in children]. / Indicazioni e metodiche della fibroscopia rinofaringolaringea in età pediatrica.

Flexible rhinopharyngolaryngoscopy (RFL) has now definitively replaced rigid endoscopy in the diagnosis of VADS in children owing to its ease of use and handling, also in the case of patients who are not wholly cooperative. RFL also enables the morphology and laryngeal function to be evaluated in children without risks for the patient provided the operator complies with a few simple precautions during diagnosis. During elective diagnosis, the patient must be in a fasting state and must not present uncompensated coagulopathies. The main indications for RFL are dyspnea, dysphonia and stridor, given that the VADS regions can be easily displayed. The current limits of this method are the impossibility of allowing therapeutic interventions and the impossibility of passing beyond the glottic level without local anesthesia.