[Surgical therapy of lung metastases from head and neck cancer]. / Chirurgische Therapie pulmonaler Metastasen von Kopf-Hals-Tumoren.

Pulmonary metastasectomy is an established procedure in oncological therapeutic concepts. A systematic literature search and an analysis of all studies published since 01.01.2000 should evaluate the advantage of pulmonary metastasectomy for patients with primary head and neck cancer. Lung metastases develop in 1.9-13% of head and neck cancer patients. Following metastasectomy, patients reach a median survival of 9.5-78 months and 5-year survival rates of up to 58% are achieved. Intrathoracic recurrence occurs in 18.4-81.8% of patients, selected instances of which can be successfully treated by remetastasectomy. Patients with squamous cell carcinoma have the worst prognosis, but could also become long-term survivors (≥ 60 months). Pulmonary metastasectomy is frequently the only potentially curative therapeutic approach and offers a better long-term survival than nonsurgical therapies. Lung metastasectomy is thus the treatment of choice in selected patients with pulmonary metastases from primary head and neck cancer.

Endoscopic laser-assisted diverticulotomy without versus with wound closure in the treatment of Zenker's diverticulum.

The aim of the present study was to compare the modifications of endoscopic laser-assisted diverticulotomy regarding closure of mucosal wound at the cricopharyngeal bridge. The results of 62 cases after endoscopic laser-assisted diverticulotomy without and with wound closure were retrospectively compared. After laser-assisted transection of the cricopharyngeal bridge, the mucosa wound was left open (OW) in 35 cases (56%), whereas a closure of the mucosa wound (CW) with sutures and fibrin glue was performed in 27 patients (44%). Duration of hospitalization, residual diverticular sac rate and occurrence of complications did not differ significantly between the two groups. Mean surgical time was significantly less in the OW cases. According to these results, it can be assumed that readapting and sealing the wound after transecting the cricopharyngeal bridge does not significantly reduce the complication rate. It does, however, extend the length of surgery and increases the cost of the procedure.

Influence of formalin fixation on tissue dimensions in palatal tonsils.

AIM: To investigate the change of tissue dimensions after formalin fixation, and to determine the optimal time of fixation. HYPOTHESIS: Formalin fixation may lead to shrinkage in tissue dimensions and may thus alter tumor stages. BACKGROUND: It is often observed in tumor surgery that the dimensions in vivo seem larger than after resection, and tissue appears to shrink further after formalin fixation. This might alter dimensions and assessment of spread of the tumor and thus lead to a lesser tumor classification and stage. In cases where the decision for adjuvant chemoradiation is based upon the stage, it may thus be of relevance for the patient to evaluate the pathologic and not the in vivo dimensions of the tumor. MATERIAL AND METHODS: In order to obtain comparable tissues, we investigated 100 palatal tonsils after cold steel dissection tonsillectomy for chronic tonsillitis. There were four time points investigated: directly after excision in the operating room and after four, 24 and 72 h of fixation in formaldehyde (4% Formaldehyde in phosphate buffer pH 7.4). The tissue was measured in the following dimensions: volume (ml), weight (g) and length, broadness and width (mm). RESULTS: The tissue size did not change significantly in dimensions except for an increase in length. The time of fixation did not influence the size. DISCUSSION: Formalin fixation does not significantly influence the tissue dimensions of palatal tonsils in comparison to direct ex vivo measurements. A minimal time of fixation of 20 h is required in order to stop all degenerative processes; however, longer fixation does not change the dimensions of the specimen. CONCLUSION: The null hypothesis has to be withdrawn that tissue dimensions are altered by formalin fixation. Thus, the histopathological measurements do not influence TNM staging.

[Update on HPV-induced oropharyngeal cancer]. / Aktuelles zu HPV-induzierten Oropharynxkarzinomen.

Oropharyngeal squamous cell carcinoma (OSCC) is associated with oncogenic human papillomavirus (HPV) infection in 30-40% of all cases in Germany. The use of PCR and / or in situ hybridisation to detect HPV in tumour tissue is used in combination with p16 immunohistochemistry to reliably distinguish HPV-related and HPV-unrelated OSCC. The distinct biological behaviour of the HPV-related subset of OSCC results in a more favourable prognosis. This might be the result of a greater response to chemotherapy and radiotherapy as seen in recent studies. Ongoing and future clinical trials will stratify for HPV status. If the results of these prospective, randomized trials are consistent with the preliminary results of recent studies, HPV status will be of enormous clinical relevance in the future.

[A review of indications for primary surgical care of patients with advanced head and neck cancer]. / Ist die primäre Chirurgie bei fortgeschrittenen Kopf-Hals-Karzinomen noch aktuell?

Organ preservation protocols for advanced head and neck carcinoma have proven to be successful in controlled clinical trials. This has led to an increase in the use of primary chemoradiation for these tumors. However, the intensification of nonoperative treatment protocols has been associated with a dramatic increase in acute treatment-related toxicity and mortality. In this paper, the role of primary surgical care is reviewed. Recent publications in the field and current treatment concepts are discussed.

[Human papillomavirus and cancer of the oropharynx. Molecular interaction and clinical implications]. / Humane Papillomviren und Oropharynxkarzinome. Molekulare Interaktion und klinische Auswirkung.

One-third of the cases of oropharyngeal squamous cell carcinoma (OSCC) contain oncogenic human papillomavirus (HR-HPV). Epidemiologic and molecular evidence underlines the causal role of HR-HPV in these tumors, which can be defined as HPV-related OSCC. These tumors differ from chemical/toxin-induced OSCC in several biological aspects, including specific molecular and genetic alterations. This leads to a characteristic clinical profile of HPV-related OSCC. Sexual risk factors play a role; however, the knowledge about natural infection and the rate of persistence of HR-HPV in the oropharynx is marginal. It is shown that the distinct biological behavior of the HPV-related subset of oropharyngeal tumors results in a more favorable prognosis. This might be the result of a better response to chemotherapy and radiotherapy. However, further studies are needed to show whether it will be possible to reliably select patients for individualized therapy depended on the HPV status of their tumors. Therefore, we think it will be mandatory to consider and stratify HPV status in the design of prospective clinical trials in the future.

Transoral laser surgery for laryngeal cancer: outcome, complications and prognostic factors in 275 patients.

AIM: Curative treatment options for laryngeal carcinoma include primary radiation therapy, open surgical techniques and transoral laser surgery (TLS). In the last decade, TLS has become an important tool in the treatment of laryngeal cancer and has become the standard approach in many institutions. The aim of this study was to review the experience of a single center institution with TLS for early and advanced laryngeal cancer. METHODS: We retrospectively analyzed 275 patients who underwent TLS in regard to the survival outcome and surgical complications. RESULTS: The 5-year disease-free survival estimate was 90.3% and the 10-year disease-free survival estimate was 88.2%. The 5-year larynx preservation rate estimate was 88.2% and the 10-year larynx preservation rate estimate was 87.3%. The disease-free survival was significantly worsened by the variables T and N (p=0.0003; p<0.001, respectively). Two percent of all patients required intraoperative tracheostomy and the rate of minor postoperative complications was 17%. There were no fatal complications. CONCLUSIONS: We conclude that TLS is a valid treatment method for early laryngeal carcinoma. Selected cases of advanced carcinomas may also benefit from TLS.

[Perforation of the hypopharynx after endotracheal intubation]. / Hypopharynxperforation nach endotrachealer Intubation.

A case of perforating injury to the hypopharynx following uneventful intubation is reported. As symptoms are relatively unspecific, perforating trauma of the pharynx, larynx, esophagus or trachea may temporarily remain undetected. Consecutive development of an abscess or mediastinitis can cause a potential vital threat to the patient. Depending on the defect size and the overall situation a conservative or surgical management should be followed. Persistent complaints of neck or thorax pain after endotracheal intubation should always raise suspicion of injury to the upper aerodigestive tract, even after uncomplicated intubation.

Accessory parotid gland lesions: case report and review of literature.

There are numerous causes for chronic cheek swelling, including masseteric hypertrophy, lymphadenopathy, diffuse inflammatory changes and neoplasia. We report an unusual case of a recurrent swelling as the result of sialolithiasis of an accessory parotid gland, which lay isolated from the main parotid gland along the Stensen's duct. The calculi developed in the accessory salivary tissue whereas all major salivary glands presented without sialolithiasis. Clinical findings as well as imaging results are shown and surgical management and histopathology are discussed. Hereby, for the first time we report a case with multiple calculi in an accessory parotid gland removed via a standard parotid incision. Further to this, we give a comprehensive review of literature on accessory parotid gland lesions.

Postoperative fulminant varicella zoster virus hepatitis with fatal outcome: a case report.

INTRODUCTION: Fulminant hepatitis due to varicella zoster virus (VZV) infection has a poor prognosis although an effective treatment is available. CASE REPORT: We present a case of fulminant hepatic failure (FHF) as a result of disseminated VZV infection in a long-term alcoholic patient who underwent laryngectomy and radical neck dissection due to squamous cell carcinoma of the larynx. Post-mortem examination revealed the diagnosis of fulminant hepatitis and infection with VZV. Viral inclusion bodies were found in the hypopharyngeal mucosa as well as in the liver tissue. In these tissues VZV was detected by PCR. The clinical presentation is suggestive for a reactivation of VZV without cutaneous signs of herpes zoster during a state of immunosuppression. DISCUSSION: Differential diagnosis comprises hepatitis by other Herpes group viruses and toxic hepatic injury.

Nuclear survivin expression is associated with HPV-independent carcinogenesis and is an indicator of poor prognosis in oropharyngeal cancer.

The relationship between expression of the inhibitor of apoptosis protein survivin and the presence of high-risk human papillomavirus (HPV) in oropharyngeal squamous cell carcinoma (OSCC) remains unclear. This also accounts for its role as a predictor of survival. Therefore, we conducted a multicentre retrospective study on 106 consecutive oropharyngeal cancer patients. Human papillomavirus sequences were detected by nested PCR protocols. Survivin and p16 expression as a surrogate marker for HPV status were analysed by immunohistochemistry. Sequences of high-risk HPV were detected in 29% of cases. Prominent cytoplasmatic expression of survivin was found in 58% of cases and nuclear expression of survivin was found in 19% of the survivin-positive tumours. Nuclear expression of survivin was significantly correlated with HPV-negative tumours (P=0.023) and with a poor disease-free survival rate with an estimated 3-year disease-free survival probability of 35% for tumours with nuclear expression of survivin vs 78% for tumours with non-nuclear expression of survivin (hazard ratio=8.264; 95% confidence interval (95% CI)=2.510-27.210; P<0.001). In multivariate analysis, p16 expression status as well as nuclear expression of survivin were strong independent and opposing prognostic indicators of disease-free survival (hazard ratio=0.068; 95% CI=0.005-0.892; P=0.041 and hazard ratio=15.975; 95% CI=2.377-107.360; P=0.004, respectively). Our data show that nuclear accumulation of survivin correlates with HPV-independent carcinogenesis and is an independent predictor of poor survival in patients with OSCC.

[Impact of TORP diameter on fracture of the footplate]. / Zur Gefahr einer Fraktur der Fussplatte durch unterschiedlich grosse TORP-Prothesenfüsse.

BACKGROUND: A columella-prosthesis is the typical reconstruction procedure of the ossicular chain in cases with a destroyed stapedial arch. Lightweight titanium prostheses are commonly used for this type of surgery. The smaller the prosthesis foot the lower the risk of dislocation and friction of the prosthesis with the bony rim of the oval niche. However, using a smaller prosthesis foot, fracture of the footplate and penetration of the prosthesis into the inner ear are conceivable. METHODS: Using fresh temporal bone preparations, lacking the stapedial arch, in conjunction with a load cell, the force needed to fracture the footplate was measured. Different prostheses with different foot diameters (0.2 - 0.8 mm) were used in these experiments. Furthermore, a human stapes was evaluated morphologically by scanning electron microscopy. RESULTS: The forces leading to fracture of the footplate were measured to be between 250 mN and 980 mN. Statistical analysis showed no significant difference between 0.2 mm and 0.8 mm prosthesis foots. Moreover, different forces were attributed to varying thickness of the stapes footplate. In scanning electron microscopy the rough and uneven bony surface of the footplate could be demonstrated. CONCLUSION: Due to the uneven footplate, only punctual contact of the prosthesis foot can be achieved. Hence, the risk of footplate fracture is not considerably higher by using smaller diameters. However, the use of smaller feet in upcoming generations of TORPs seems to be appropriate.

Long-term results of the combined modality therapy for advanced cervical metastatic head and neck squamous cell carcinoma.

AIM: A consensus treatment strategy for advanced cervical metastatic head and neck squamous cell carcinoma has not been established. The aim of this retrospective study was to investigate the outcome of these patients uniformely using a strategy which consists of surgery for the primary tumor and the neck metastases followed by postoperative radio(chemo)therapy. METHODS: We included a selected series of 518 patients with previously untreated head and neck squamous cell carcinoma. The overall survival (OS), the disease specific survival (DSS), the disease free survival (DFS), the local control (LC) and regional control (RC) estimates were calculated. The statistical relationship of various clinical and histopathological variables on the above mentioned estimates were analyzed. RESULTS: The overall survival probability was 73.2% for pN0 stage, 43% for pN>1 stages and 31% for pN2c/pN3 stages. The pN stage significantly influenced the survival probabilities in oropharyngeal (p=0.0001) and laryngeal tumors (p<0.0001) in univariate analyses. In multivariate analysis, age, pT stage, pN stage, M stage, and extranodal spreading were independent risk factors for decreased disease-specific survival. CONCLUSIONS: We could show that pN stage is an important independent prognostic factor in head and neck cancer. The presented multimodal treatment protocol provides excellent oncological outcomes and should therefore be standard of care for patients with operable advanced cervical metastatic head and neck squamous cell carcinoma.

[Vallecular cyst as a rare cause of progressive inspiratory stridor]. / Progredienter inspiratorischer Stridor durch eine gestielte Valleculazyste.

BACKGROUND: Vallecular cysts are frequently observed, benign masses of the upper aerodigestiv tract. Usually they appear as harmless and asymptomatic and go unnoticed by the patient. In rare cases, obstructions of the upper airway due to monstrous vallecular cysts may become life threatening. CASE: We report on a 69-year-old otherwise healthy woman with a rapidly progressive history of dyspnea caused by a pedicled vallecular cyst. Increasing stridor prompted emergency surgical resection. CONCLUSION: Vallecular cysts that increase in size can cause dyspnea due to obstruction of the aditus of the larynx. This case demonstrates the need for surgical treatment at an early stage of pedicled vallecular cysts.

[On the diagnosis and treatment of parotid gland tumors. Results of a nationwide survey of ENT hospitals in Germany]. / Zur Diagnostik und Behandlung von Parotistumoren. Ergebnisse einer Umfrage an deutschen HNO-Kliniken.

BACKGROUND: It seems that the choice of the treatment modalities for parotid gland tumors frequently depends on personal experience more than on evidence-based criteria. A nationwide survey was conducted to obtain an overview of current practice in German ENT hospitals. METHODS: A standardised questionnaire comprising 19 questions on the treatment and diagnostic methods for parotid gland tumors was sent to all ENT hospitals in Germany. RESULTS: The overall return rate of the questionnaires was 128 of 170 (75%). The results confirmed highly variable strategies for the treatment of parotid gland tumors in Germany. CONCLUSION: On the basis of our survey and the upcoming establishment of a German database for salivary gland cancer in Erlangen, Germany, we hope to be able to clarify controversial topics on the treatment of parotid gland tumors in the near future.

[An accessory retropharyngeal bone as a rare cause of dysphagia]. / Akzessorischer retropharyngealer Knochen. Seltene Ursache einer Dysphagie.

A 77-year-old woman had a history of several-years of dysphagia. On presentation, a submucosal mass impinging on the left oropharynx was present. CT-scans showed a bony structure isolated from the cervical column. The patient underwent complete surgical resection using a transoral approach. Histological examination confirmed the radiological finding; a new formation of bone surrounded by cartilage with hematopoieses in the bone marrow. Recovery was complete within 2 weeks. Dysphagia due to cervical spine osteophytes, Forestier's disease or progressive ossifying fibrodysplasia is well known. This case adds an isolated retropharyngeal bone formation as a rare cause of dysphagia to the literature.