Single-stage canal wall-down tympanoplasty: long-term results and prognostic factors.

OBJECTIVES: We sought to identify factors associated with anatomic and functional results of canal wall-down tympanoplasty. METHODS: One hundred eighty-nine primary or relapsing cholesteatomas were consecutively operated on by a single surgeon. Cholesteatoma recurrence rates were evaluated. Predictive values of the patient, disease, and surgical characteristics on cholesteatoma recurrence were estimated. The effect of these variables on keratin pearl development, recurrent otorrhea or granulation tissue formation, and hearing function was tested. RESULTS: The mean follow-up was 8 years (range, 4 to 15 years). The cholesteatoma relapse rate (+/- SE) estimated by the Kaplan-Meier method was 2.1% +/-1.1%. No variables were associated with relapsing disease. The log-rank test showed a significantly higher probability of keratin pearls in male patients (16.7% versus 2.1%; p = 0.001), young patients (less than 16 years; 51.4% versus 6.2%; p = 0.0001), patients with unencapsulated cholesteatomas (19.5% versus 5.3%; p = 0.06), patients with petrous or accessory cellularity invasion (17.9% versus 7.1%; p = 0.02), and patients with overlay myringoplasty (25% versus 7.9%; p = 0.03). Recurrent otorrhea and granulation tissue were associated with homograft temporalis fascia myringoplasty (14.3% versus 3.8%; p = 0.04). The overall postoperative air-bone gap was within 20 dB in 30.7%; it was within 20 dB in 43.9% (47/107) for intact or reconstructed ossicular chains and in 13.4% (11/82) for nonreconstructed, eroded ossicular chains (p = 0.0001). The air-bone gap was within 20 dB in 42.6% (46/108) when the mucosa of the tympanic cavity was normal and in 14.8% (12/81) when there was granulation tissue within the tympanic cavity (p = 0.0001). CONCLUSIONS: Single-stage canal wall-down tympanoplasty is an appropriate treatment for acquired tympanomastoid cholesteatoma.

Salvage surgery after radiotherapy for laryngeal cancer: from endoscopic resections to open-neck partial and total laryngectomies.

OBJECTIVE: To evaluate our experience in management of radiotherapy failure using endoscopic resection (ER) with carbon dioxide laser, open-neck partial laryngectomy (ONPL), and total laryngectomy. DESIGN: Retrospective medical record review. SETTING: Referral university hospital. PATIENTS: Seventy-one patients with laryngeal cancer previously treated with radiotherapy (69 patients) and chemoradiotherapy (2 patients) underwent salvage surgery. INTERVENTIONS: The treatment policy encompassed ER for glottic rT1a, rT1b with limited anterior commissure involvement, and rT2 with normal cord mobility carcinoma. All ONPLs were performed for rT1 and rT2 tumors with suboptimal endoscopic exposure, rT2 tumors with impaired cord mobility or transcommissural extension, and rT3 tumors for limited paraglottic space invasion or involvement of the inner portion of the thyroid cartilage. Total laryngectomy was planned in patients who were not suitable for partial laryngectomy owing to poor general condition, for rT3 carcinoma with massive involvement of the paraglottic space, and for rT4a tumors. MAIN OUTCOME MEASURES: Clinical, radiologic, surgical, and pathologic data. Survival curves were calculated using the Kaplan-Meier method. Comparisons between different variables were performed using the log-rank test. RESULTS: Salvage surgery consisted of ER in 22 patients, ONPL in 15, and total laryngectomy in 34. The pT category after salvage surgery was pT1 in 12 patients, pT2 in 20, pT3 in 20, and pT4a in 19. Five-year disease-specific and disease-free survival and laryngeal preservation for the entire series were 72%, 61%, and 40%, respectively. CONCLUSIONS: Survival rates for the entire series were not different from those previously reported using a more aggressive surgical approach without attempts at organ preservation. The laryngeal preservation rate justifies conservative treatment in the presence of limited recurrent lesions.

Prevalence and localization of nodal metastases in squamous cell carcinoma of the oral cavity: role and extension of neck dissection.

Lymph node (LN) metastases represent the most important negative prognostic factor in squamous cell carcinoma (SCC) of the oral cavity, even though controversies still exist regarding their management. The aim of this study was to retrospectively analyze our experience in surgical management of SCC of the oral cavity with particular focus on the prevalence and localization of lymph nodal metastases and recurrences. The clinical records of 89 consecutive patients treated from 1983 to 2002 by concomitant surgery on both the T and N sites, excluding those undergoing salvage surgery, were reviewed. A total of 119 neck dissections (ND) were performed. Survival outcomes were calculated by the Kaplan-Meier method, while univariate comparisons by the log-rank and non-parametric tests were performed between different groups of patients. Five-year overall and determinate survivals were 50 and 57%, respectively. LN metastases were observed in 52% (56% of these showing extracapsular spread) and their presence strongly correlated with determinate survival (p < 0.0001). The prevalence of clinical and occult nodal disease was not related to the pT status. Neck levels II (59%) and I (56%) were most frequently involved. Metastases to level IV accounted for 15% of positive LN, even though 28% of them turned out to be skip metastases. Five neck recurrences were observed, only one of which was salvaged by surgery. The high prevalence of clinical and occult LN metastases in this setting suggests that ND should be performed on a nearly routine basis, even for lesions with a low-T category and a cN0 neck. Moreover, ND should always encompass level IV due to the possibility of skip metastases, particularly in tumors involving the oral tongue. In patients with a cN+ neck, levels from I to V should be addressed, particularly in the presence of metastases at levels III and IV.

Internal jugular vein patency after lateral neck dissection: a prospective study.

In spite of anatomical preservation of the internal jugular vein (IJV), an occlusion rate of the vessel of up to 30% has been documented after selective or modified radical neck dissections. The aim of the present prospective study was to evaluate the patency of the IJV following selective lateral neck dissection (LND) in 34 patients affected by squamous cell carcinoma of the upper aerodigestive tract who underwent surgery concomitantly on the primary site and the neck. Eighteen patients received unilateral and 16 bilateral LND, for a total of 50 IJVs. Postoperative radiotherapy on the neck was delivered in four patients with histologic evidence of micro-extracapsular spread; the impact of this variable on IJV patency was assessed by the Fisher test. A preoperative baseline study of vein patency and flow by ultrasonography (US) was obtained. Postoperative controls were scheduled at 1 week, 1 month and 3 months following surgery. No patient developed either wound infection or a pharyngocutaneous fistula, and no signs or symptoms of IJV occlusion were observed during the postoperative course. At the first US control, 25 IJVs (50%) did not present any alteration in patency, and 23 (46%) and 2 (4%) had a reduced or absent flow, respectively. At the second and third controls, 33 (66%) and 45 (90%) of the IJVs presented with normal flow, respectively. At the end of the study, none of the patients showed evidence of occlusion. Postoperative radiotherapy did not have a statistically significant impact on IJV patency ( P=0.09). In conclusion, long-term IJV occlusion after LND has to be considered an exceedingly rare event with negligible morbidity. However, alterations of IJV flow frequently occur in the immediate postoperative course.