Microelectrodes and radiofrequency for transoral horizontal supraglottic laryngectomy in T3 tumors.

The aim of this manuscript is to show the surgical technique for horizontal supraglottic laryngectomy in T3 carcinomas by a transoral approach using microelectrodes and radiofrequency. From 2009 to 2020, 11 selected cases of T3 laryngeal supraglottic carcinomas invading the pre-epiglottic space, with preserved vocal cords mobility underwent surgery. The technique is described step by step. Average time duration of the larynx surgery was 95 min. Nine percent of the patients presented a profuse hemorrhage 7 days postoperative; in 73% of patients the nasogastric feeding tube was withdrew 10 days after surgery. We emphasize a remarkable short surgical time and high hemostatic effectiveness. The ME tips allow to perform cuts at angles and contribute with a sense of touch. The low cost of the equipment and its easy handling and maintenance is a remarkable advantage over other technologies for transoral surgery.

Informed consent in dentistry and medicine in Spain: Practical considerations and legality

Background: The healthcare practice of dentistry, as well as medicine, is framed within a legal environment. Patients have the right to know all the information related to any action performed on them and dental or medical doctors are obliged to obtain their patient’s prior written informed consent (IC) before undertaking any healthcare procedures. Material and Methods: Here we reviewed the legality and jurisprudence in Spain regarding IC. We also used INFLESZ text readability analysis software to analyse a sample of official Spanish informed consent documents (ICDs) from different surgical and interventional procedures related to dentistry and oral cavity interventions. Results: It is a mistake to confound IC with ICDs. This error prevents physicians from considering the former as a care process in which the patient’s authorisation signature is the last link in a chain formed, almost in its entirety, by the informative process and deliberation alongside the patient. Multiple factors can influence communication between practitioners and their patients. Importantly, treatment adherence is greater when patients feel involved and autonomous in shared decision-making and when the circumstances of their lives are adequately considered. We concluded that although the ICDs we analysed conformed to the requirements set out in international law, they were somewhat difficult to read according to the reading habits of the general Spanish population. Conclusions: Knowledge about the legality of IC helps professionals to understand the problems that may arise from their non-compliance. This is because the omission or defective fulfilment of IC obligations is the origin of legal responsibility for medical practitioners. In this sense, to date, there have been more convictions for defective ICs than for malpractice. The information provided in ICs should include the risks, benefits, and treatment alternatives and must be tailored to the needs and capabilities of the patient to enable autonomous decision-making.(AU)

Use of monopolar microelectrodes and radiofrequency in the treatment of arytenoid edema after partial horizontal laryngectomy and radiotherapy.

We evaluated the tissue reduction effects using monopolar microelectrodes (MME) coupled to a radiofrequency (RF) generator in arytenoid edema caused by postoperative radiotherapy in larynx. This is a retrospective transversal study, which included 15 patients with supraglottic laryngeal carcinoma. All the patients had undergone a partial horizontal laryngectomy and bilateral neck dissection followed by postoperative radiotherapy. The studied group of patients presented laryngeal stenosis defined by arytenoid edema as a complication, requiring permanent tracheostomy for mean of 12 months. The surgical procedure for treating the edema was the transoral approach of the larynx by microlaryngoscopy under general anesthesia; using 180° MME coupled to a 4-MHz RF generator delivering 15 W using coagulation mode. A total of 11 (73%) patients were decannulated. The median time for decannulation was 10 weeks. No complications were reported. After 2 years of follow-ups, no case of re-stenosis was found. MME coupled to RF is a very efficient method to treat arytenoid edema after adjuvant radiotherapy.

Acute tissue damage induced by monopolar microelectrodes and radiofrequency in vocal cords after transoral cordectomy.

INTRODUCTION: In 2006 and 2009, we reported the levels of acute and chronic tissue damage after cordectomy associated with use of the microlectrodes using high frequency energy. In 2010, we shifted to radiofrequency rather than high frequency electrogenerators. OBJECTIVE: The aim of this study is to evaluate acute tissue damage in the larynx after cordectomy using microelectrodes coupled to a radiofrequencygenerator. METHODS: We studied 22 patients with a stage T1 glottic squamous cell carcinoma. The patients were randomly assigned to the two operating mode: cutting or coagulation (11 patients each mode). The strength of the study is that there are no previous studies on the effect of radiofrequency in human vocal cord. RESULTS: Tissue damage was milder when microelectrodes were coupled to a 4 MHz generator operating in the cutting mode. Thus, when using microelectrodes and radiofrequency, we recommend that the cutting mode be used for epithelial incision and the coagulation mode to treat the stroma and muscle and for final hemostasis. CONCLUSION: Microelectrodes and radiofrequency in transoral laryngeal surgery produced mild tissue damage and offer an excellent alternative to the use of high frequency energy.

Computed tomography and magnetic resonance fusion imaging in cholesteatoma preoperative assessment.

The purpose of this study is to describe a method for developing fusion imaging for the preoperative evaluation of cholesteatoma. In 33 patients diagnosed with cholesteatoma, a high-resolution temporal bone computed tomography (CT) scan without intravenous contrast and propeller diffusion-weighted magnetic resonance imaging (MRI) were performed. Both studies were then sent to the BrainLAB work station, where the images were fused to obtain a morphological and color map. Intraoperative findings coincided with fusion CT-MRI imaging in all but two patients. In addition, one false positive and one false negative case were observed. CT and diffusion-weighted MRI are complementary techniques that should be employed to assess a cholesteatoma prior to surgery in many cases. Hence, to combine the advantages of each technique, we developed a fusion image technique similar to those that are routinely employed for radiotherapy planning and positron emission tomography-CT imaging. Fusion images can prove useful in selected cases.

Is testing the voice under sedation reliable in medialization thyroplasty?

OBJECTIVES: Medialization thyroplasty is an accepted method for improving non-compensated unilateral vocal cord palsy. Most surgeons decide the depth of penetration of the prosthesis by monitoring the voice changes in the patient during the surgical procedure. General anesthesia with intubation is incompatible with this procedure. Sedation is recommended. In this study we want to objectivize and quantify the influence of sedation and position on voice in order to know if this anesthetic procedure is justified in medialization thyroplasties. STUDY DESIGN: A prospective study. METHODS: This study involved 15 adult patients who underwent sedation. Voice recordings were performed in each patient in three different positions and conditions: the seated position without sedation, the supine position without sedation, and the supine position under the effects of sedation. The sedation drugs used were midazolam, fentanyl, and propofol. The level of sedation was monitored using the observational scale and the bispectral index. RESULTS: The acoustic data obtained from sustained vowel sounds from patient recordings showed that sedation significantly affected the values of pitch. Compared to recordings from patients without sedation, pitch values in patients under sedation were significantly higher for jitter local and shimmer local recordings and significantly lower for pitch and harmonics-to-noise ratio. The supine position was shown not to influence on the voice. CONCLUSIONS: Sedation exerts an important influence on voice quality. General anesthesia could be an alternative, focusing our attention on monitoring the glottis with a fibrolaryngoscope during the surgical procedure. No sedation at all can also be an alternative.

Transoral resection of supraglottic tumours using microelectrodes (54 cases).

We present the oncological and functional results of surgical transoral resection of supraglottic laryngeal carcinomas using microelectrodes. This prospective multicentre trial was conducted from 2005 to 2009. It included 54 patients (23 T1, 14 T2, and 17 T3) with supraglottic cancer, with a follow-up of 2 years. Outcome measurements were: tracheostomy, hospital stay, nasogastric feeding and recurrences. Four patients required permanent tracheostomies. The mean hospital stay was 8.1 days. Temporary nasogastric feeding was necessary in 13 patients. Postoperative complications included two incidences of haemorrhage requiring surgical intervention and one pneumonia. Four patients out of eight with T3 tumours had regional recurrence; in these cases salvage surgery was performed: two cases by the transoral approach and six total laryngectomies. Clinical results were similar to those obtained with CO2 laser therapy. We list other advantages of the technique and include a literature review.

A novel method for culturing human glottic cells.

OBJECTIVES/HYPOTHESIS: The objective of this basic investigation was to describe a new method of preparing primary monolayer cultures of human glottic cells. To our knowledge, this is the first report of the culturing of healthy human glottic cells. This technique may be of use for other applications in the challenging field of laryngeal diseases. STUDY DESIGN: Individual prospective cohort study. METHODS: Tissue samples were collected from 15 patients who underwent laryngeal surgery due to chronic laryngitis or larynx carcinoma. An inverted phase microscope was used to study the cultured cells, and immunocytochemistry using a mouse anti-human cytokeratin 19 monoclonal antibody was performed to identify epithelial cells. The relationship between the culture results and several patient variables was evaluated. RESULTS: Cultures were positive in 40% of samples. The total and supracricoid laryngectomy groups had the highest rate of culture positivity (P < .02). CONCLUSIONS: The current study provides methodological details that will allow other research groups to replicate this model of glottic cell culture.

A novel SDHD mutation associated with neck paraganglioma.

The aim of this study was to describe a previously unreported mutation in the SDHD gene, which has been linked to familial paraganglioma. Clinical data were collected from all members of the family, which had four siblings affected with paraganglioma. For the index patient, genomic DNA extraction from whole blood was performed using the High Pure PCR Template Preparation kit. The nucleotide sequence in the index patient revealed a deletion in the SDHD gene, c.165_169 + 14del. The loss of nucleotides in the DNA led to production of an anomalous protein. RNA analysis showed the absence of exon 2 in the sequence that corresponded to the mRNA from the index case. Genetic testing of this deletion was extended to the symptomatic and asymptomatic brothers and sisters of the index patient and other family members at risk. The deletion was detected in both symptomatic brothers, in accordance with their phenotype, but not in the asymptomatic sister. In the other asymptomatic brother (II.7) the deletion was detected and magnetic resonance angiography revealed the vascular characteristics of two tumors in both carotid bifurcations. Thus, we report a novel punctual mutation in the SDHD gene, which is related to familial paraganglioma: the deletion was c.165_169 + 14del.

The acromion thoracic flap: A reconstructive resourceafter exeresis of a parotid fibrosarcoma

Sarcomas are rather uncommon in the salivary glands and have a high tendency towards recurrence. The treatmentof choice is surgery, with the first surgical procedure being crucial, as the small size of the tumor is accompaniedby the absence of post-surgery and post-radiotherapy fibrosis, which facilitates the surgery. The evident tendencytowards recurrence makes it advisable to be radical in the exeresis. Often we have to consider a reconstructiveperiod. Negative surgical margins increases the rates of local control. Treatment with radiotherapy is the complementarytreatment indicated for patients with surgical margins less than 2 mm or positive. It has been observedthat this treatment improves the local control of the illness. We present a case of parotid fibrosarcoma of a lowgrade of malignancy that was treated by means of parotidectomy and post-operative radiotherapy. The patient presentedup to three recurrences, one of which required an acromion thoracic flap in order to reconstruct the surgicaldefect. Despite the treatment, the patient ended up dying because one of the recurrences was not operable (AU)

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Abordajes transesfenoidales endoscópicos de los adenomas hipofisarios: una revisión crítica de nuestra experiencia / Transphenoidal endoscopic approaches for pituitary adenomas: a critical review of our experience

Introducción: El abordaje quirúrgico de la región hipofisaria ha evolucionado desde las vías transcraneales, a las sublabiales y transseptales microscópicas hasta los abordajes endoscópicos actuales. Objetivos: El objetivo de este trabajo es exponer y reflexionar sobre nuestra experiencia en el abordaje transnasal transesfenoidal endoscópico de los tumores hipofisarios, con las modificaciones que hemos introducido para mejorar la exéresis del tumor y disminuir la iatrogenia. Material y métodos: A lo largo de 9 años hemos intervenido a 37 pacientes afectos de adenomas hipofisarios mediante abordaje transesfenoidal endoscópico. Utilizamos lentes de 0 y 30 grados, navegador óptico, instrumental habitual de endoscopia nasal y brazo articulado para fijación de la óptica en el tiempo neuroquirúrgico. Se accede a la celda hipofisaria mediante esfenoidotomía bilateral. Resultados: La neumatización esfenoidal ha sido suficiente en todos los pacientes. Las complicaciones postperatorias más frecuentes han sido la diabetes insípida y los transtornos endocrinológicos. Rinolicuorrea postoperatoria en un paciente. Secuela nasal definitiva ninguna. Tiempo medio de estancia hospitalaria 5 días. Conclusiones: El abordaje endoscópico guiado con el navegador aporta grandes ventajas: rapidez, seguridad, disminución de la iatrogenia, preservación de la vía aérea nasal. La resección de un fragmento de tabique nasal adyacente al rostrum mejora la manejabilidad de los instrumentos hacia los márgenes tumorales. La fijación del endoscopio estabiliza la visión y permite al segundo cirujano ayudar con más eficacia (AU)

Background: The surgical approach to the pituitary fossae has evolved from transcranial to sublabial and transseptal microscopic ones, up to the current transsphenoidal endoscopic approach. Objectives: To present our experience in the transnasal transsphenoidal approach for pituitary adenomas and the modifications introduced to improve tumoral resection and to lower iatrogenia. Material and methods: Over nine years, we operated on 37 patients with pituitary adenomas using the transsphenoidal endoscopic approach. We utilised optical lens of 0° (approach) and 30° (adenoma resection), optic navigator, surgical instruments for nasal endoscopic and pituitary surgery. During the neurosurgical step, the endoscope was fixed by an articulated arm. We acceded to the pituitary fossae by a bilateral sphenoidotomy. Results: Sphenoid pneumatisation was sufficient in all the patients. The more common postoperative complications were diabetes insipidus and endocrinology deficiencies. Postoperative rhinoliquorrhea affected only one patient. No alterations of nasal fossae were observed. Mean patient hospitalisation was five days. Conclusions: Transsphenoidal endoscopic approach guided by navigator gives significant advantages: Shorter operating time and fewer complications, greater safety and preservation of the nasal passages. Resecting the sphenoidal rostrum and a fragment of adjacent nasal septum improves surgical instrument management into the pituitary fossae and therefore adenoma resection. Endoscope fixation stabilises the vision and allows the second surgeon to help more effectively (AU)

The acromion thoracic flap: a reconstructive resource after exeresis of a parotid fibrosarcoma.

Sarcomas are rather uncommon in the salivary glands and have a high tendency towards recurrence. The treatment of choice is surgery, with the first surgical procedure being crucial, as the small size of the tumor is accompanied by the absence of post-surgery and post-radiotherapy fibrosis, which facilitates the surgery. The evident tendency towards recurrence makes it advisable to be radical in the exeresis. Often we have to consider a reconstructive period. Negative surgical margins increases the rates of local control. Treatment with radiotherapy is the complementary treatment indicated for patients with surgical margins less than 2 mm or positive. It has been observed that this treatment improves the local control of the illness. We present a case of parotid fibrosarcoma of a low grade of malignancy that was treated by means of parotidectomy and post-operative radiotherapy. The patient presented up to three recurrences, one of which required an acromion thoracic flap in order to reconstruct the surgical defect. Despite the treatment, the patient ended up dying because one of the recurrences was not operable.

[Transphenoidal endoscopic approaches for pituitary adenomas: a critical review of our experience]. / Abordajes transesfenoidales endoscópicos de los adenomas hipofisarios: una revisión crítica de nuestra experiencia.

BACKGROUND: The surgical approach to the pituitary fossae has evolved from transcranial to sublabial and transseptal microscopic ones, up to the current transsphenoidal endoscopic approach. OBJECTIVES: To present our experience in the transnasal transsphenoidal approach for pituitary adenomas and the modifications introduced to improve tumoral resection and to lower iatrogenia. MATERIAL AND METHODS: Over nine years, we operated on 37 patients with pituitary adenomas using the transsphenoidal endoscopic approach. We utilised optical lens of 0° (approach) and 30° (adenoma resection), optic navigator, surgical instruments for nasal endoscopic and pituitary surgery. During the neurosurgical step, the endoscope was fixed by an articulated arm. We acceded to the pituitary fossae by a bilateral sphenoidotomy. RESULTS: Sphenoid pneumatisation was sufficient in all the patients. The more common postoperative complications were diabetes insipidus and endocrinology deficiencies. Postoperative rhinoliquorrhea affected only one patient. No alterations of nasal fossae were observed. Mean patient hospitalisation was five days. CONCLUSIONS: Transsphenoidal endoscopic approach guided by navigator gives significant advantages: Shorter operating time and fewer complications, greater safety and preservation of the nasal passages. Resecting the sphenoidal rostrum and a fragment of adjacent nasal septum improves surgical instrument management into the pituitary fossae and therefore adenoma resection. Endoscope fixation stabilises the vision and allows the second surgeon to help more effectively.