Thirty-eight-year evaluation of a surgical technique to protect the external branch of the superior laryngeal nerve during thyroidectomy.

The purpose of this study is to evaluate a surgical technique for the preservation of the function of the external branch of the superior laryngeal nerve (EBSLN) during total thyroid lobectomy and total thyroidectomy. Permanent injury to this nerve can be a disaster, especially in singers and professional speakers who depend on control of pitch, and a clear and forceful voice. Voice changes may be either obvious or subtle. For better voice analysis, a detailed questionnaire is necessary. Thus, the evaluation in this study is based on laryngoscopy of 934 nerves in 675 patients and detailed subjective voice evaluation of 66 patients during the last 2 years of the study. There are 2 surgical principles. First, the EBSLN is not routinely exposed; the distal 1.5 to 2.0 cm (critical area) of the superior thyroid vessels are carefully dissected, exposed, and ligated, preferably independently. Careful observation ensures that the EBSLN is not included in the ligature. Second, the ultimate evaluation of the surgical technique is the effect of voice changes on the patient's lifestyle. Laryngoscopy of 934 nerves found bowing, temporary in 4 patients and permanent in 1 patient (limited follow-up). Of the 66 patients with voice evaluations, 14 had changes: 9 had temporary changes, while 5 had permanent changes. In these 14 patients, voice changes had no effect on lifestyle in 13, and the effects were indeterminate in 1 (unavailable for follow-up). The estimated deleterious effect of voice changes on lifestyle is no greater than 1.5% of the 66 patient responders.

Improved survival with preoperative chemotherapy followed by resection uncompromised by tumor response for advanced squamous cell carcinoma of the head and neck.

BACKGROUND: A total of 93 patients were treated with one of two preoperative chemotherapy regimens over a 15-year period. The study supports the importance of strict adherence to guidelines for ablative surgery. METHODS: A single surgeon performed the surgery and evaluated each patient prior to treatment. The extent of the planned operation was documented. RESULTS: The 5-year absolute survival of 88 patients who completed the protocol was estimated at 55%. The 40 cisplatin/5-fluorouracil-treated patients exhibited a significantly better outcome than the 48 cisplatin/bleomycin-treated patients (76% versus 43%, respectively). Comparison of a subset of 37 patients with a matched group from the standard control arm of the Head and Neck Contracts Program demonstrated a statistically significant improvement in overall survival over standard treatment. CONCLUSIONS: These data suggest that strict adherence to preoperative chemotherapy planning of ablative uncompromised surgery contribute to improved survival. Selective rather than routine postoperative radiotherapy may be advantageous.

Access to the superior mediastinum.

Surgical access for diseases that involve the superior mediastinum can be achieved without thoracotomy by utilizing the suprasternal approach with extension of the head and neck and transection of the interclavicular ligament, median sternotomy, resection of the medial third to one half of the clavicle, or resection of the manubrium sterni. There has been minimal morbidity and no operative or postoperative mortality in a review of 53 consecutive patients. There has been no significant disability. Combined with exposure at the base of the neck, the access to the superior mediastinum is good to excellent.

Long-term follow-up of chemotherapy in advanced head and neck cancer.

We treated 94 patients with advanced head and neck cancer with a combined-modality protocol that included induction chemotherapy followed by surgery with and without radiotherapy. With a minimum follow-up of 3 1/2 years, 33 (35%) of the patients were alive and disease free. Thirty (32%) of the patients died of recurrent head and neck cancer. Complete response to chemotherapy and initial tumor bulk correlated with prolonged disease-free survival. Site of disease had no effect. There appeared to be no advantage to the use of routine postoperative radiotherapy in these advanced tumors.

Preoperative adjuvant chemotherapy for advanced head and neck cancer: a surgical evaluation.

This presentation consists of two parts: 1) a brief account of the results of treating 94 patients with stage III (n = 24) and stage IV (n = 70) advanced head and neck cancer, primarily with two courses of preoperative adjuvant chemotherapy; and 2) an evaluation of 42 of the 94 patients consecutively treated by surgery by the senior author. It is our conclusion that preoperative chemotherapy using cisplatin, vincristine, and bleomycin can improve the compromised airway and deglutition without producing deleterious effects relative to surgical complications. Moreover, overall survival is promising and justifies continued study using organized protocols.

Induction therapy in head and neck cancer. A comparison of two regimens.

Seventy-two patients with advanced resectable head and cancer received two courses of induction chemotherapy before definitive therapy. Forty-six patients were treated with platinol, Oncovin (vincristine), and bleomycin. Twenty-six received Platinol (cisplatin), Velban (vinblastine), and 5-fluorouracil (5-FU). Although both regimens had an overall response rate of 80% or more, the bleomycin-containing regimen had a higher complete response rate and better long-term disease control, with greater than 60% probability of remaining disease-free (36 month minimum follow-up). As given in this regimen, the 5-FU regimen was well tolerated but had a higher incidence of stomatitis and a low rate of complete responses. When the two regimens were compared to a historical control, the regimen with Platinol, Oncovin, and bleomycin was significantly better.

A nontoxic adjuvant treatment for advanced head and neck cancer.

A variety of adjuvant chemotherapy programs have been described for advanced head and neck cancer. The protocol described herein is nontoxic and particularly appropriate for patients with advanced tumors who cannot, because of severe pulmonary disease, tolerate bleomycin sulfate. Eighty percent of patients treated with this combination responded with more than 50% tumor shrinkage. Chemotherapy was followed by either surgery, radiation therapy, or both. Long-term control with this combined modality therapy was better in oral cavity and oropharyngeal lesions than in tumors from the hypopharynx.

Preoperative chemotherapy for hypopharyngeal carcinoma.

Twenty patients with advanced squamous cell carcinoma of the hypopharynx received two courses of chemotherapy with cisplatinum, vincristine and bleomycin before undergoing surgery. The chemotherapy was well tolerated, with minimal toxicity and no intra or postoperative complications attributable to it. The response to the chemotherapy was dramatic with all but 2 patients exhibiting a greater than 50% tumor shrinkage. Only 3 patients, all with positive surgical margins, received postoperative radiation therapy. Surgical salvage of recurrent lesions was performed on 2 patients who are now free of disease. With a median follow-up of 20 months, 1 patient has died of recurrent disease, 3 have died of other causes, all others remain free of disease.