Learning curve in diagnostic and interventional sialendoscopy for obstructive salivary diseases.

Sialendoscopy is a new diagnostic and surgical tool for management of salivary gland diseases that offers the opportunity to treat selected pathologies less invasively and with better results compared to previous techniques. As with any new technique, an adequate training programme involving a gradual learning curve is mandatory to quickly obtain results similar to those reported in the literature. This includes an appropriate diagnostic programme, correct patient selection and knowledge of possible pitfalls. In this retrospective study, the outcomes of the first 141 procedures (74 on the parotid gland and 67 on the submandibular gland) performed with this technique in our Department from 2009 to 2013 were compared with those reported in the literature. Patients were divided into three groups: Group A (the first 49 procedures performed), Group B (the next 50 procedures), and Group C (the last 42 procedures). There were no statistically significant differences relative to mean procedure times, recurrence of symptomatology after treatment, need for further treatments and rates of minor complications between groups. No major complications were seen. The increase in experience resulted in an increased number of interventional sialendoscopies performed under local anaesthesia instead of general anaesthesia (51% vs 18% vs 14%). In only three of 130 glands treated (2.3%) was gland resection required. We also evaluated which technique had been used for stone removal and rate of failure, which was similar in all groups (13.6% vs 15% vs 15%). Our results do not substantially differ from those reported in the literature. Initial difficulties in catheterising the papilla could be overcome with practise on fresh human specimens or fresh pig heads. Lack of precision regarding diagnostic imaging techniques was remedied by improving the competence of the surgeon in performing pre- and postoperative ultrasound. The creation of specialised centres capable of treating up to 1 to 2 million people would be desirable in order to better stratify pathologies, validate the investment in equipment and gain the necessary experience in the various surgical techniques.

Unilateral laryngeal and hypoglossal paralysis (Tapia's syndrome) following rhinoplasty in general anaesthesia: case report and review of the literature.

Extracranial involvement of the recurrent laryngeal nerve and the hypoglossal nerve is known as Tapia's syndrome. Ipsilateral paralysis of the vocal cord and tongue is present. Lesion of these nerves may be a rare complication of airway management. Herein, a case of Tapia's Syndrome complicating transoral intubation during general anaesthesia in a rhinoplasty operation, together with a review of pertinent literature to evaluate the incidence and the possible pathogenic mechanism of the lesion. There are recent reports in the literature on mono or bilateral paralysis of the XII or laryngeal recurrent nerve after use of laryngeal mask with a pathogenic mechanism of compression. Furthermore, there are reports, following oro-tracheal intubation, of recurrent laryngeal paralysis, likely legacies to the compression of the anterior branch of inferior laryngeal nerve by the cuff of the oro-tracheal tube against the postero-medial part of the thyroid cartilage. Hypoglossal nerve damage could be caused by a stretching of the nerve against the greater horn of the hyoid bone by a laryngeal mask or oro-tracheal tube or compression of the posterior part of the laryngoscope or oro-tracheal tube. In our case, the lesion probably occurred as the result of a two-fold compressive mechanism: on one hand, compression by the cuff of the endo-tracheal tube due to excessive throat pack in the oro-pharynx; on the other hand a prolonged stretching mechanism of these nerves may have occurred due to excessive anterior and lateral flexion of the head. From the data reported in the literature, as in our case, complete recovery of function is generally achieved within the first six months. This progressive recovery of function suggests nerve damage of a neuro-praxic type, which is typical of compression injury. In conclusion, the response of this rare complication confirms the importance not only of the position of the head and patient on the operating table but also the meticulous and correct performance of the routine manoeuvres of airway management.

Videofluoroscopy and videoendoscopy in evaluation of swallowing function in 31 patients submitted to surgery for advanced buccopharyngeal carcinoma.

Swallowing function has been evaluated by means of videofluoroscopy and videoendoscopy in 31 patients submitted to surgery for local extended bucco-pharyngeal carcinoma. Aim was to better predict functional deficits and subsequent recovery perspectives of patients as far as concerns swallowing. In 30 patients, surgery was combined with radiotherapy, pre-operative in 6 cases and post-operative in 24. Site and extension of resection were defined using Urken's classification of hard and soft tissue deficits. In 3 cases, resection included half of tongue base and was followed by direct closure of the surgical defect. In 4 cases, the entire hemitongue (hemibody and hemibase) was resected and repair was performed with a free flap. In 5 cases, the whole tongue base was resected (posterior glossectomy). In 2 of these, direct closure of the gap was performed while the other 3 received a free flap. Another 3 cases required resection of the entire mobile tongue with corresponding buccal floor. All were repaired with free flaps. In 6 cases, resection comprised half the tongue base and adjacent tonsillar fossa and was performed using a transmandibular approach (demolitive in 3 cases, reconstructive in 3). Of these patients, 3 received direct closure and 3 reconstruction with a free flap. In 4 patients, resection included the tonsillar fossa and soft palate while in 5 other patients the whole soft palate was resected in addition to the tonsillar fossa. All these 9 patients received repair with free flaps. The remaining patient underwent resection of the entire oro-hypopharyngeal posterior wall, reconstructed with a free flap. During video-endoscopy examination, both liquid and soft meal ("pudding") were given to patients. Diagnostic parameters studied were: grade of pharyngo-laryngeal sensitivity, latency in onset of pharyngeal swallowing reflux, drop of the bolus in pre-swallowing phase, grade of the pharyngeal residual, inhalation and pooling of saliva. Data collected may be usefully employed not only in predicting the type and grade of swallowing deficit related to the extension of resection and repair technique used, but could also be helpful in the choice of the most appropriate behavioural procedure of rehabilitation for the patient.

[Deglutition in patients treated with reconstructive laryngectomy]. / Studio della deglutizione nei pazienti sottoposti a laringectomia ricostruttiva.

INTRODUCTION: We stress the importance of dynamic radiologic studies of swallowing in the patients submitted to reconstructive laryngectomy. MATERIAL AND METHODS: January, 1989, to December, 1996, we examined 36 patients submitted to reconstructive laryngectomy, namely cricohyoidoepiglottopexy in 34 cases, cricohyoidopexy in 1 case and Guerrier's cricohyoidoepiglottopexy in 1 case. Dynamic radiologic studies were performed with fluoroscopic videorecording (Sony U-Matic RM 580) from an X-ray unit. The study was performed with the patients standing or sitting, initially acquiring AP and LL fluoroscopic images of the oropharyngeal region at rest and during swallowing. The patients then swallowed 2 boluses of 5 ml liquid (60%) and semiliquid (250%) barium. When aspiration was suspected, we began with a 2-ml bolus. RESULTS: The patients were grouped by symptoms: group A patients had no symptoms, group B patients had dysphagia and group C patients presented aspiration. The functional changes were: reduced pharyngeal contraction, reduced epiglottis deflection, reduced hyoid bone elevation, aspiration, altered upper esophageal sphincter function. The organic alterations were: parapharyngeal diverticulum, pharyngeal stenosis, posterior pharyngeal wall introflexion. Three group A patients had severe posterior pharyngeal wall introflexion, 4 had marked retention and 2 of them presented postswallowing aspiration. Two group B patients had major retention, 1 cricopharyngeal incoordination, 3 posterior pharyngeal wall introflexion, 2 a pseudodiverticulum and 2 a luminal stenosis. Seven group C patients had intraswallowing and 3 postswallowing aspiration. CONCLUSION: The videofluorographic identification of organic and functional complications, sometimes unknown in asymptomatic patients, is useful for therapy and suggests the speech specialist the best compensatory mechanism to improve the patients' swallowing and consequently their quality of life. Moreover, videofluorography of swallowing is a very useful tool in the follow-up, to monitor treatment outcome after rehabilitation.

Detection of deglutition disorders after reconstructive laryngectomy. Clinical and radiological evaluations.

Subtotal reconstructive laryngectomy is an appropriate surgical procedure for intralaryngeal squamous cell carcinoma. After this surgery the functions of the larynx are greatly modified. These functions may be retained if at least one cricoaryténoid is preserved with good function. The aim of our study was to determine the recovery of swallowing in the late postoperative period and to establish the possible causes of dysphagia. 34 patients previously submitted to reconstructive laryngectomy were studied by clinical and endoscopical evaluation as well as videofluoroscopic examination. The results of our study confirm what has been reported by other authors, that is that the sphincter function greatly altered in the early postoperative period, is progressively restored, especially when both arytenoids are preserved. Videofluoroscopic examination frequently showed the asymptomatic false passage of liquid boluses.

[Extramedullary plasmocytoma (EMP) of the head and neck: a series of 22 cases]. / Plasmocitoma extramidollare (P.E.M.) della testa e del collo: considerazioni su 22 casi.

Plasmacytoma is a rare neoplastic disorder arising from B-cell series lymphocytes. It can develop in three clinical variants: a) Multiple Myeloma (M.M.); b) Solitary Plasmacytoma of the bone; c) Extramedullary Plasmacytoma (EMP). EMP generally occurs in the submucosal tissue of the upper airways (80% of cases). This paper reports 22 cases of EMP of the head and neck observed in the last 20 years and reviews pertinent Literature. Four of our cases were located in the nasopharynx, four in the oropharynx and five in naso-sinusal sites. More rarely, the lesion occurred in the larynx (2 cases) or in the oral cavity (3 cases). In 4 patients multiple localizations in the upper airways were observed. Full evaluation was carried out in order to exclude disseminated disease. With the exception of 2 cases which were surgically treated, radiotherapy (RT) represented the treatment of choice in all patients, with doses ranging from 36 to 58 Gy. In 9 cases RT was administered after complete surgical resection. Follow-up time ranged from 13 to 167 months (mean 69.6). A partial response after treatment was observed in 4 cases. In only two of these cases neoplastic residue was observed (further RT allowed complete remission of the disease). In the other two cases, residual masses consisted in amyloid deposits. Three patients developed disseminated disease (MM) after a disease-free period ranging from 3 to 6 years. Five-year actuarial disease was 92%. Although surgery is generally considered a diagnostic tool, in our opinion local disease should always be removed surgically when surgery produces low morbidity. Surgical debulking of the lesion can increase the probability or local radiotherapeutic control.

A case of Merkel-cell carcinoma metastatic to the tonsil.

Metastatic tumours are rare in the tonsil. We describe a 69-year-old male patient who had previously undergone a resection of a Merkel-cell tumour of the left forearm and subsequently presented with a left tonsillar tumour. Biopsy revealed a metastatic Merkel-cell carcinoma. Our patient is the first described case of Merkel-cell carcinoma metastasizing to the tonsil. The clinical and histopathological picture of this rare tumour is presented, along with a review of literature.

[Ultrasound staging research of progressive pathology of the base of the tongue]. / L'indagine ecografica nello studio della patologia espansiva della base linguale.

Diagnosis of tongue tumours is often retarded mainly because tumours grow prevalently in deep muscular layers. A correct exploration of the region might be difficult solely employing clinical examination. Therefore, it would be useful to confirm the suspect of a neoplastic lesion at the base of the tongue with a promptly available imaging method. These considerations led us to evaluate ultrasonography (US) as a diagnostic tool for neoplastic lesions of this region. Initially 10 normal patients were studied in order to become familiar with US anatomy of the area. In a second phase our study involved 24 patients with diagnosed carcinoma of the tongue base and 26 patients with clinical suspect of neoplasm in the region. US examination was carried out with real-time equipment provided by a 5 Mhz convex transducer. Patients were examined in supine position with the neck hyperextended. Longitudinal, oblique and transverse scan of the submental region were obtained. The study showed that US gives detailed images of the floor of the mouth and the tongue. Neoplastic infiltration of the base of the tongue is clearly recognizable as a hypoechoic area. It was possible to detect masses ranging from 1.4 to 3.8 cm. In cases of larger lesions, US was useful in evaluating deep infiltration, whereas in other cases the method allowed the diagnosis of small lesions with submucosal growth. US did not proved to be highly reliable in the diagnosis of lesions confined to superficial planes (false negative results).(ABSTRACT TRUNCATED AT 250 WORDS)

[Role fo ultrasound in the study of latero-cervical metastases]. / Ruolo dell'ecografia nello studio delle metastasi laterocervicali.

In patients undergoing radiotherapy (RT) for malignant neoplasies of the head and neck the availability of a diagnostic method permitting frequent, easy checkups of the latero-cervical lymph nodes would be extremely useful. This is especially so because clinical examination is often hindered by the post-actinic fibrosis of the tissues. Among the methods presently available for this purpose (CAT, NMR, lymphoscintigraphy, xerography, ultrasound) echotomography appears to be the most indicated as it is least invasive, can easily be repeated and is not difficult to perform. The refining of ultrasound techniques would, as reported in the literature, make it possible today to evaluate the effects of RT on latero-cervical metastases both during and some time after treatment. The authors, therefore evaluated the advantages and limitations of the method examining 33 patients undergoing RT for latero-cervical metastases due to head and neck carcinoma. Each patient underwent ultrasound examination prior to, during and at the end of the RT treatment cycle. Once treatment had been terminated 18 underwent latero-cervical neck dissection. Upon termination of the radiation treatment three distinct types of ultrasound behaviour were identified: complete response; partial response; minimal or negligible response. For those patients undergoing surgery this response was compared to lymph node chain histology while, for the others, it was compared to the ultrasound findings of subsequent examinations. The results obtained appear to indicate that a systematic scheduling of ultrasound checkups offers a reliable evaluation of how metastatic adenopathies respond to RT. At times such response can only be completed several months after treatment.(ABSTRACT TRUNCATED AT 250 WORDS)