How often is total laryngectomy necessary for the treatment of T1 failures after radiotherapy or cordectomy?

Between 1992 and 1998, 547 patients (pts) with laryngeal SCC were diagnosed and treated in our department, 145 (27%) of whom presented with glottic tumors T1N0M0 (125 T1a and 20 T1b). Seventy-eight (54%) were treated surgically with cordectomy and 67 (46%) with radiotherapy. After a median follow-up time of 43 months, 22 (15.2%) of the 145 pts presented with recurrent disease. In more detail, 16 (13%) of the 125 T1a pts and 6 (30%) of the 20 T1b pts had recurrences. Among the 78 surgically treated patients only 4 (5%) had recurrence, while 18 (27%) of the radiotherapy group relapsed. The difference is statistically significant (log rank test, P = 0.0001 < 0.05). After salvage treatment, of the 67 pts of the radiotherapy group 57 (85%) remain disease-free, 49 (73%) retaining their larynx intact and 1 only having undergone cordectomy. Among the cordectomy group 75 (96%) pts remain disease-free with only 1 having had a total laryngectomy. Using the Kaplan-Meier method and calculating the disease-free survival regardless of salvage treatment, there is no doubt that surgical treatment statistically is more successful than radiotherapy (log rank test, P = 0.01 < 0.05). Analysis of parameters such as tumor differentiation and T1a or T1b staging, which indeed influence the overall recurrence rate, did not alter the favorable outcome after surgical treatment.

Factors influencing quality of life in laryngectomized patients.

The aim of this study is to estimate the quality of life postlaryngectomy. A questionnaire was used. Fifty-six patients were enrolled answering 26 questions. The mean age was 60.2 (40-76) years and median post-treatment time 43 (7-120) months. The most frequent complaints of the patients were increased bronchial discharge (66%) and reduced olfactory function (63%). Communication problems with strangers was mentioned by 57% and with their family by 29%. With regard to the psychological status, 30% were ashamed of their voice, 32% were ashamed of their appearance, 42% stated that they were rather depressed, and 30% were feeling lonely. More than 3 out of 4 patients believed that their everyday life had been altered. Half of the patients experienced financial difficulties and 37% were not participating in social meetings outside their house. Statistical analysis was used in order to calculate the severity of each category of problems which the patient faced using the scale from 0 to 1. The average grade for functional disorders was 0.31, for communication problems 0.47, for psychological problems 0.29, for social problems 0.27, and for financial problems 0.51.

Wegener's granulomatosis presenting with bilateral facial nerve palsy.

Primary manifestation of Wegener's granulomatosis in the mucosa of the middle ear is rather rare, and has been reported as presenting with serous otitis media, chronic otitis media, sensorineural hearing loss, and, in rare instances, unilateral facial palsy. Bilateral facial palsy has never been reported. This last fact constitutes the interest in our report of a 23-year-old female patient who presented with symptoms of recurrent bilateral otitis media, eventually developing sensorineural hearing loss and bilateral facial palsy. Soon thereafter neurological symptoms appeared and lung extension was noted. Histological examination of repeated biopsies taken from the nasal and middle ear mucosa was not conclusive for the suspected disease, and c-ANCA titers were also initially repeatedly negative. Eventually, positive lung biopsy and elevated c-ANCA titers when the patient had developed pulmonary granulomas confirmed the diagnosis of Wegener's granulomatosis. Mastoid surgery with facial nerve decompression of the most severely afflicted side did not result in the recovery of facial nerve function. Medical therapy with corticosteroids and cyclophosphamide improved the clinical picture but were ineffective in improving the bilateral sensorineural hearing loss and the facial paralysis on the operated side. We would contribute to the literature a unique case of bilateral facial nerve palsy due to Wegener's granulomatosis.

Transiently evoked otoacoustic emissions as a prognostic indicator in idiopathic sudden hearing loss.

Idiopathic sudden sensorineural hearing loss (ISHL) remains a controversial topic. So far, there are no proven objective auditory factors to establish prognosis. Otoacoustic emissions reflect the functional integrity of the outer hair cells. The aim of this study was to assess the presence of transiently evoked otoacoustic emissions (TEOAEs) in the early stages of ISHL cases as a prognostic indicator. Thirty patients hospitalized for ISHL were included in the study. All patients underwent pure-tone audiometry (PTA) and TEOAE recordings on the admission day and at least three measures on the subsequent eight days. The audiometric threshold improvement at each frequency was correlated with the TEOAE parameters on each measure. Finally, the presence of TEOAEs on early examination was correlated with PTA threshold improvement. Twenty-three out of 30 patients experienced hearing recovery. Fourteen of the recovered patients had recordable TEOAEs or acceptable TEOAE peak amplitudes in some frequency bands on the first two measures, despite having audiometric thresholds greater than 40 dB HL. It thus seems that TEOAEs might serve as a clinical tool for prediction of recovery in ISHL cases.

The efficacy of medication on tinnitus due to acute acoustic trauma.

Seventy-two young males suffering from acute acoustic trauma with tinnitus due to gunshots were included prospectively in the study. Forty of the subjects had the left ear affected, four the right ear and the remaining 28 sustained bilateral acoustic traumas. The mean time of admission after onset of symptoms was 28 days (5-88 days). The subjects were randomly categorized into three groups: group A received trimetazidine, prednisolone and complex B vitamins; group B were treated only with trimetazidine; and group C received prednisolone and complex B vitamins. At 3-month follow up, tinnitus had been completely eradicated in only eight subjects and had in 17. No statistically significant difference was found between the three groups concerning improvement of tinnitus. However, it was found that early admission predisposed towards better prognosis. The degree of hearing improvement after medication did not seem to correlate with the relief of tinnitus.

Second primary neoplasms in patients with laryngeal carcinoma.

OBJECTIVES: To better define the characteristics of second primary malignancies appearing in patients suffering from head and neck cancers, and more specifically laryngeal carcinoma, and to elicit those parameters that may be of assistance in better diagnosing, treating, and predicting outcome in such patients. STUDY DESIGN: Retrospective review of a group of 514 compliant subjects, examined and treated during an 8-year period until 1996. After initial diagnosis and subsequent treatment, rigorous follow-up ensured systematic screening of the subjects, who underwent standard examinations in outpatient clinics for periods of up to 56 months. RESULTS: Of 514 cases followed, presence of second primary neoplasms was established in 42 or 8.17%, 8 being synchronous and 34 metachronous of the original primary lesion. CONCLUSIONS: Respiratory and upper gastrointestinal localizations were primarily affected, incidence was highest in septuagenarians, and staging of the primary was found to be irrelevant to the incidence rates of second primaries. No statistical significance was attached to the fact that supraglottic primary tumors showed slightly higher second primary rates; the same applying for well-differentiated primary tumors compared with poorly differentiated ones. Modality of treatment surgery, and radiotherapy being the options in question-did not in the long run statistically influence incidence rates. Throughout, reference to current literature and this study's relevance in light of similar efforts were taken into account.

[Voice rehabilitation after total laryngectomy. Voice prostheses or esophageal replacement voice?]. / Stimmrehabilitation nach totaler Laryngektomie. Stimmprothesen oder Osophagus-Ersatzstimme?

BACKGROUND: During the last years tracheoesophageal fistula has a well established role and in several units is now the principal means of speech rehabilitation following laryngectomy. The purpose of this study is to present the long term results after using the Provox voice prosthesis and to compare the phonetic results obtained with this means of speech rehabilitation with esophageal speech. PATIENTS, METHODS, AND RESULTS: During the last 7 years, 265 laryngectomy patients were trained in our Department in an effort to develop esophageal speech. One hundred and twelve of them developed comprehensive speech of various quality. In another group consisting of 35 patients, a Provox low-resistance, self-retaining prosthesis was fitted. Twenty-nine of them developed a very good voice. Ten patients of each group were tested in order to estimate the quality of voice of the two methods. Three measurements were obtained from each patient: the maximal intensity, the maximal phonation time, and the number of syllables with one breath. CONCLUSION: All the results confirmed the better quality of the tracheo-esophageal speech. The main two advantages of the prosthesis are the effortless speech due to the low resistance of the valve and the simple maintenance by the patient. The most important disadvantage is the cost and the need to occlude the stoma during phonation. Conclusively each method of speech rehabilitation should be selected individually according to the needs, desire, and abilities of every patient.

Treatment of unresectable recurrent head and neck carcinoma with 13-cis-retinoic acid and interferon-alpha. A phase II study.

Sixteen patients with unresectable recurrent head and neck carcinomas were treated with 13-cis-retinoic acid and interferon-alpha. All patients had presented with recurrences after having been treated primarily with surgery and radiotherapy, while two of them had also received induction chemotherapy. The site of relapse was strictly locoregional in all cases (only at the primary site in three cases, at the cervical lymph nodes only in four cases and both at the primary site and the neck in the remaining nine cases. Two patients were female, and 14 male, with an age range of 47-72 years (median 61 years). Interferon-alpha was administered subcutaneously at a dose of 3 x 10(6) IU every second day. The dose of retinoids was 40 mg per os every day. The duration of treatment was two to 14 months (median seven months). There were two cases of partial response (tumour regression > 50 per cent), eight cases of stable disease lasting for three to seven months (median four months) and six cases presented with progressive disease. All patients died after a survival of three to 17 months (median 9.5 months). Toxicity was generally minimal. We believe that the results are not encouraging, but also not disappointing. The fact that toxicity was indeed mild, with not a single case of life-threatening sequellae even after prolonged administration of the two agents, allows us to conclude that an increase of the dose of IFN-alpha might be more beneficial. Selection of patients with more 'favourable' recurrences will give a better chance to the treatment combination to prove its real efficacy. Larger numbers of patients have to be treated and evaluated before definite conclusions can be reached.

[Treatment of postoperative "uncontrollable" nosebleed by embolization of the maxillary artery]. / Behandlung des postoperativen "unstillbaren" Nasenblutens durch Embolisation der A. maxillaris.

BACKGROUND: Embolization of the maxillary artery is a successful treatment, alternative in cases of recurrent severe nosebleeds when anterior and posterior nasal packing have failed to achieve permanent control. PATIENTS AND METHOD: Two cases of male patients are presented who suffered from severe nosebleeds after a submucous resection of the septum, electrocautery of the inferior turbinate, and submucosal conchotomy. Anterior and posterior nasal packing proved to be unsuccessful. Angiography of the internal and external carotid artery was performed and selective embolization of the mayillary artery with absorbable material followed. RESULTS: In both cases embolization was successful and uneventful. Twenty-four hours after treatment, the nasal packing was removed and no recurrence was observed. CONCLUSION: Selective embolization of the maxillary artery is a successful alternative for the treatment of severe recurrent nosebleeding-equally effective with surgical ligation of the bleeding arteries.

Cisplatin and continuous infusion of fluorouracil followed by radiation and weekly carboplatin in the treatment of locally advanced head and neck cancer: a Hellenic Cooperative Oncology Group study.

Induction chemotherapy followed by radiation has been extensively studied in an effort to improve local control and possibly overall survival of patients with locally advanced head and neck cancer. From June 1989 until May 1991, 39 patients with locally advanced squamous cell carcinoma of the head and neck (SCCHN) were treated with 3 cycles of induction chemotherapy, consisting of cisplatin (100 mg/m2 d 1) and fluorouracil (1000 mg/m2 d 2-6) followed by radiation potentiated by weekly administration of carboplatin (60 mg/m2). Surgery was performed in selected patients with residual disease after the combined modality approach. Four cycles of adjuvant chemotherapy with carboplatin (325 mg/m2) and bleomycin (15 u) were administered in those patients who demonstrated a partial response after locoregional treatment. There were 36 men and 3 women with a median age of 56 (range 39-74) years and Karnofsky performance status of 70 (range 60-100). The primary site of the tumor was nasopharynx (8), oropharynx (8), hypopharynx (3), oral cavity (4), larynx (13), paranasal sinus (2), and salivary glands (1). Thirty-two (82%) patients presented with stage IV disease. After the completion of induction chemotherapy, 14 (36%, 95% CI 21-53%) patients achieved a complete response (CR). This CR rate was increased to 56% (95% CI, 42-74%) after locoregional treatment. Main toxicities included nausea/vomiting (56%), leukopenia (40%), anemia (30%), thrombocytopenia (10%), stomatitis (28%), diarrhea (17%), and alopecia (12%). Median relapse-free survival was 18 (1-50) months, median time to progression was 13 (0.3-58.5) months, and median survival 19 (0.3-59) months. Induction chemotherapy with cisplatin and fluorouracil followed by radiation potentiated with carboplatin is feasible. However, this combined modality approach, as applied in the present study, does not appear to yield superior results than those reported with chemotherapy followed by radiation alone.

[Chondroma of the parotid gland. Clinical--histologic--immunohistochemical findings of a rare case]. / Chondrom der Glandula parotis. Klinische--Histologische--Immunohistochemische Befunde eines seltenen Falles.

A unique extraskeletal chondroma is reported which occupied the entire right parotid gland of a 32-year old man. The midsized tumour was hard and well circumscribed. Its histological pattern was typical of a chondroma with lobules of hyaline cartilage and several areas of calcification. The chondrocytes were positive for S-100 protein and negative for smooth muscle and myoepithelial markers. Epithelial neoplastic elements, as found in pleomorphic adenomas, were not detected in the present case, neither morphologically nor immunohistochemically.

[Rare benign space-occupying processes of the larynx]. / Seltene benigne raumfordernde Prozesse des Larynx.

Two rare benign space occupying lesions of the larynx are presented. The first case was a big lateral saccular cyst in a female 68 years old and the second a myxolipom of the larynx in an old man, 80 years old. The presenting symptoms, in both cases, were progressive dyspnea und dysphagia. The therapy was the surgical removal of the lesion with the "open" approach. The importance of the CT scanning is emphasized as well its usefulness in the diagnosis and in the definition of the extension of the lesion.

True giant-cell tumour of the mastoid. A case report.

The authors describe a case of a very extensive giant-cell tumour of the mastoid in a 5 1/2-year-old girl. This is very rare, and it is only the fourth one documented in the English literature. The age of the patient is of great importance, as well as the fact that the middle and the inner ear were not involved, although the tumour was very extensive. Radical surgical removal of the tumour was performed, as the treatment of choice, without any signs of recurrence one year post-operatively. The diagnostic problems of giant-cell lesions of bones are briefly discussed.