Zenker's diverticulum: analysis of surgical complications from diverticulectomy and cricopharyngeal myotomy.

OBJECTIVE: To identify risk factors for postoperative complications in patients undergoing diverticulectomy and cricopharyngeal (CP) myotomy for Zenker's diverticulum. STUDY DESIGN: Retrospective. MATERIALS AND METHODS: A chart review was conducted of all patients with a Zenker's diverticulum who were treated with diverticulectomy and cricopharyngeal myotomy at three tertiary care centers in central Indiana between 1988 and 1998. RESULTS: Of the 24 patients identified, 9 developed postoperative complications (2 medical and 7 surgical). Statistical analysis of multiple potential risk factors revealed that only diverticulum size greater than 10 cm2 at surgery placed the patient at increased risk for postoperative surgical complications. To our knowledge, this is the first report that has specifically addressed diverticulum size as an independent risk factor for postoperative surgical complications following diverticulectomy and CP myotomy. CONCLUSIONS: Given our findings, we recommend considering diverticulopexy rather than diverticulectomy in a patient with a Zenker's diverticulum greater than 10 cm2 in size if a cervical approach is the selected treatment.

Utility of preoperative radionuclide scanning for primary hyperparathyroidism.

This study retrospectively reviews 60 cases of primary hyperparathyroidism, 21 of whom underwent technetium 99 sestamibi scanning and 10 of whom underwent thallium 201/technetium 99 pertechnetate scanning preoperatively. The sestamibi and thallium scans demonstrated an 89.5% and a 62.5% sensitivity rate for adenoma, respectively. Neither scan demonstrated hyperplastic glands well. Although the scans localized adenomatous glands to the correct side well, the ability to localize them more discretely was 68.4% and 62.5%, respectively. In cases of solitary adenoma the effect of an accurate preoperative scan on operative time for bilateral exploration was not significant, whereas the experience of the attending surgeon was significant. Also, the cost of the scans at our institution was greater than the cost of the time saved in performing even unilateral neck exploration. Thus preoperative radionuclide scanning is not cost-effective for the initial exploration of patients with primary hyperparathyroidism and is insufficiently sensitive to make routine unilateral neck exploration for adenoma consistently effective.

An efficiency comparison of four heat and moisture exchangers used in the laryngectomized patient.

Bypassing the upper airway places the burden of humidification on the lower airway. For this reason passive heat and moisture exchangers (HMEs) are used in the laryngectomized patient in an attempt to minimize the effect of lost upper airway function. We measured efficiency and airflow resistance and calculated the costs of four HMEs used in the laryngectomized patient. The HMEs were measured according a modified International Standards Organization (ISO) 9360 standard. The airflow resistance was measured at flow rates of 15, 30, and 60 L/min. The measurements were repeated three times. Costs were calculated with two realistic scenarios. The study found that there are significant differences in moisture output and airflow resistance between the HMEs tested. There are major daily cost differences between these devices. This study shows that filter material and size influence the HME's moisture output efficiency and airflow resistance considerably. The construction differences and filter and housing type have great influence on the HME's daily costs. We believe that knowledge of the efficiency in combination with the average daily costs of the HMEs allows the clinician to make a balanced choice of which filter to use.

Fine-needle biopsy techniques of aspiration versus capillary in head and neck masses.

Fine-needle aspiration and fine-needle capillary biopsy techniques were compared, and the number of samples necessary to assure a diagnostic specimen was determined. In this study, each mass served as its own control, since both aspiration and capillary fine-needle biopsy were performed randomly on each mass. The study found the number of "superior" slides to be evenly distributed between the two biopsy techniques, but a different preference, based on tumor type, was noted for one or the other technique. The "best" slides were obtained from one of the first four samples 92% of the time. The authors concluded that both fine-needle aspiration and capillary biopsy should be used and that three to four samples should be obtained to increase the likelihood of a diagnostic biopsy.

Functional outcome after surgery for prevention of pharyngospasms in tracheoesophageal speakers. Part I: Speech characteristics.

The speech characteristics of 29 patients with primary tracheoesophageal puncture who received either a pharyngeal constrictor myotomy, a unilateral pharyngeal plexus neurectomy, or a unilateral pharyngeal plexus neurectomy with drainage myotomy limited to the cricopharyngeus were studied. All patients used a Blom-Singer low-pressure voice prosthesis. Audio recordings of each patient speaking with both the Blom-Singer tracheostoma valve and manual occlusion of the tracheostoma were recorded at 3 weeks, 6 months, and 12 months after surgery. The three surgical variations were equally effective at preventing pharyngospasms; only 1 patient (10%) in each group had some loss of fluency during the 12-month study period. Neurectomized patients produced significantly higher fundamental frequencies during reading than did patients in the other groups. Residual resting tone in the neurectomized pharyngoesophageal segment may contribute to more favorable speaking frequencies in this group.

Functional outcome after surgery for prevention of pharyngospasms in tracheoesophageal speakers. Part II: Swallow characteristics.

The swallowing function of 29 patients with primary tracheoesophageal puncture who received either a pharyngeal constrictor myotomy, a unilateral pharyngeal plexus neurectomy, or a unilateral pharyngeal plexus neurectomy with a small drainage myotomy limited to the cricopharyngeus was studied. Swallowing function data were collected on each patient at 3 weeks, 6 months, and 12 months after surgery using videofluoroscopy. Differences in swallowing function among the treatment groups were primarily the amounts and loci of oral and pharyngeal residues. The differing patterns of bolus residue may reflect the different mechanisms that were affected by the various procedures. Despite significant changes in some swallow measures, the patients did not complain of dysphagia. Oropharyngoesophageal swallow efficiency--a clinical measure that weighs the amount of bolus swallowed by total transit time--fell within normal limits for each patient group at each evaluation. This measure may be a better index of the patients' perceived normal swallow than the component variables of residue and transit times would suggest.

Management of advanced cervical metastasis using intraoperative radiotherapy.

Seventy-five patients who had advanced cervical metastasis with possible invasion of the deep muscles or carotid artery were approached with aggressive resection and intraoperative radiotherapy (IORT). All metastatic nodes were greater than 3 cm, 65% were fixed on clinical examination, and 35% involved the carotid artery. Forty-six (61%) of the patients had previously received irradiation. Fifteen of the patients required extended neck dissections with carotid resections and grafting. After the resection an average single dose of 2000 cGy of electron beam IORT was delivered. At 2 years, the local control rate within the IORT port was 68% and the absolute survival rate was 45%. Local control rates for close and microscopic margins (76% and 73%, respectively) were significantly better than the control rate for gross residual disease (25%, P < .05). The combination of extended neck dissection, including carotid artery resection if necessary, and IORT appears to offer improved control.

Intraoperative radiotherapy of skull base cancer.

As the head and neck surgeon expands the boundaries of resectability into the skull base, the margin of tumor clearance diminishes. Intraoperative radiotherapy (IORT) can be used as an adjunct to skull base surgery and external beam radiation to enhance local control in areas with close margins or remaining microscopic disease. During the period from May 1982 to May 1988, 25 patients underwent IORT of the skull base following resection and prior to closure to treat microscopic disease in 9 patients, sterilize close margins in 14 patients, and attempt to eliminate remaining gross disease in 2 patients. The types of tumors treated were 13 squamous cell carcinomas, 4 adenoid cystic carcinomas, 3 high-grade mucoepidermoid carcinomas, 3 sarcomas, 1 malignant mixed tumor, and an oncocytic adenocarcinoma. The majority of the tumors either originated in the sinuses or were skull base extensions of oral cavity or oropharyngeal cancers. In 22 patients with 1-year follow-up, IORT prevented local recurrence in 14 (64%) patients. This may represent improved control of local disease in patients who historically have a very dismal prognosis. The indications, techniques, and complications of this exciting therapeutic modality are also reviewed.

Evaluation of swallowing disorders: the modified barium swallow.

Swallowing is a complex process. The diagnosis and treatment of swallowing dysfunction are more objective due mostly to recent research. The performance of a barium swallow, modified to study the dynamics of swallowing and its value in the management of patients with swallowing dysfunction, is described. The conventional barium swallow assesses structure and function of the thoracic esophagus, including gastroesophageal reflux and its sequelae. The modified barium swallow is a dynamic technique designed to evaluate swallowing function and dysfunction as it relates to the oral and pharyngeal phases of swallowing.

Reconstructive and rehabilitative aspects of head and neck cancer in the elderly.

Age should not be considered a contraindication to adequate head and neck oncologic surgery. Reconstructive efforts should be by the most direct means to attain restoration of form and function in one stage. The next significant breakthroughs in the battle against cancer may well come on the cellular or molecular level. We endorse the plea of Endicott for increased education and research directed at the problem of head and neck cancer and rehabilitation as they relate to the geriatric patient.

Intraoperative radiotherapy of head and neck cancer.

Intraoperative radiotherapy (IORT) was developed as an adjuvant to surgery and external beam radiation for aggressive, extensive, or recurrent cancers of the head and neck. This report reviews the indications, technique, response, and complications of IORT. From May 1982 to May 1988, 104 patients received 15 to 20 Gy of radiation delivered through a Lucite cone to areas of high risk of recurrence following resection and prior to closure. The indications for treatment were (1) aggressive primary or recurrent cancer; (2) disease fixed to deep muscle, carotid, or bone; or (3) close margins in an effort to preserve vital structures or function. The IORT was effective in preventing local recurrence in 14 (40%) of 35 patients with 2-year follow-up of squamous cell carcinoma. The complication rate was acceptable. Intraoperative radiotherapy appears to be a safe and beneficial adjunctive therapy for cancers that historically have extremely dismal prognoses.

Applications of the voice prosthesis during laryngectomy.

With the recent introduction of the voice prosthesis for alaryngeal speech rehabilitation, its application in the early postlaryngectomy period is gaining acceptance. One hundred twenty-eight patients received a tracheoesophageal puncture and adjunctive pharyngeal constrictor relaxation during laryngectomy. The voice prosthesis was applied as early as 10 days after surgery, and the results of a 9-year experience are presented. Eighty percent of the population achieved a durable voice, and the complications were infrequent. The results support the primary use of tracheoesophageal phonation as a relatively safe and reliable alternative to total laryngectomy alone.

What is the role of carotid arterial resection in the management of advanced cervical cancer?

From 1977 through 1988, 16 patients underwent carotid artery resection and reconstruction or simple ligation in the treatment of advanced cervical carcinomas. Three patients underwent carotid artery ligation, with postoperative transient ischemic attacks, which resolved, in one patient. In the remaining 13 patients, interposition saphenous vein grafts were used to reconstruct the resected carotid arteries. In one of these 13 patients, the previously unresected carotid artery ruptured and was treated by carotid artery resection with interposition vein grafting and coverage by a myocutaneous flap. There were two immediate postoperative strokes, with excellent neurologic recovery in one, and one late postoperative stroke (6 months). There was one postoperative death. Adjunctive intraoperative irradiation (1500 to 2000 rad) was employed in 15 patients to decrease the risk of recurrent disease. Since 1982, pectoralis major muscle flaps have been constructed in all patients to cover the vein grafts, with no subsequent carotid artery blowouts. Seven patients are free of cancer more than 1 year after surgery. In conclusion, carotid artery resection for the treatment of advanced cervical carcinomas may be accomplished with acceptable morbidity and mortality rates in carefully selected cases. Coverage of the vein graft by a myocutaneous flap appears to protect against carotid artery blowout. Intraoperative irradiation appears to decrease significantly the local recurrence rate of these aggressive tumors.

Surgical salvage for stomal recurrence: a multi-institutional experience.

Recurrence of squamous cell cancer following total laryngectomy constitutes an extremely difficult therapeutic problem. Satisfactory management is elusive and frustrating to the head and neck oncologist. Various recommended therapeutic regimens include symptomatic treatment, palliation with chemotherapy and radiation, and aggressive surgical salvage. While surgery offers the only realistic chance at cure, this procedure is fraught with significant morbidity and a poor success rate. In an attempt to clarify the role of surgical salvage in these patients, experience with 57 patients with stomal recurrence presenting to three head and neck surgical groups will be presented. Forty-one of these patients subsequently underwent definitive surgery. The overall 2-year survival for operated patients was 16% with a 24% determinate survival. Further analysis revealed a 45% 5-year survival with type 1 and 2 lesions and 9% survival with types 3 and 4. Recommendations regarding indications for surgery are made based on this experience.

Sternocleidomastoid myocutaneous flap.

The sternocleidomastoid myocutaneous flap has several applications for reconstruction of defects about the head and neck. It is used for augmentation of facial defects, carotid artery protection, and repair of oral cavity defects. Additional reconstructive efforts suggest the sternocleidomastoid myocutaneous flap can be used for facial reanimation and as an osteomyocutaneous flap incorporating the clavicle for mandibular reconstruction. Reports of unreliable viability and resection of the sternocleidomastoid muscle during neck dissection decreases the applicability of the flap. Twenty-seven sternocleidomastoid flaps were used in 26 patients for head and neck reconstruction. In contrast to the reported 40% to 50% incidence of superficial slough or total flap necrosis, three (11%) flaps developed superficial (cutaneous) slough while two patients developed inclusion cysts. The technique includes elevation of the sternocleidomastoid muscle with the overlying platysma and skin originally described by Owens. The procedure is modified by removing the epithelium on the tunneled portion of the flap. This allows the flap to be used as a one-stage method of reconstruction without sacrificing the additional blood supply from the platysma and overlying dermis.