A.A. Dünne

Current concepts in the classification, diagnosis and treatment of hemangiomas and vascular malformations of the head and neck

Abstract There are many different classifications of vascular anomalies. As the correct classification of the vascular lesion has a direct influence on therapy it is difficult to decide which treatment should be considered as the treatment of choice. Based on an extensive review of the literature and personal experience of the treatment of more than 200 patients with hemangiomas or vascular malformations of the head and neck, a clinical classification is described that allows vascular lesions to be categorized in order to plan purposeful treatment. In general, hemangiomas represent the main group of vascular lesions in infancy and childhood. They are usually apparent a few weeks after birth and are characterized by an initially rapid growth of epithelial cells, followed by spontaneous involution. Hemangiomas should be differentiated from vascular malformations that are present at birth but may not be evident clinically. Spontaneous involution of vascular malformations has never been reported, whereas laser therapy can induce involution of hemangiomas at an early stage in a majority of cases. In certain situations steroids or surgical removal may seem to be the appropriate therapy of choice. In contrast, vascular malformations have to be treated according to their histopathology and location, as well as their hemodynamic features as shown radiographically with angiography. The accurate diagnosis of vascular anomalies is essential for further treatment, as shown by clinical experience at the University of Marburg.

Sentinel node detection in N0 cancer of the pharynx and larynx.

Neck lymph node status is the most important factor for prognosis in head and neck squamous cell carcinoma. Sentinel node detection reliably predicts the lymph node status in melanoma and breast cancer patients. This study evaluates the predictive value of sentinel node detection in 50 patients suffering from pharyngeal and laryngeal carcinomas with a N0 neck as assessed by ultrasound imaging. Following 99m-Technetium nanocolloid injection in the perimeter of the tumour intraoperative sentinel node detection was performed during lymph node dissection. Postoperatively the histological results of the sentinel nodes were compared with the excised neck dissection specimen. Identification of sentinel nodes was successful in all 50 patients with a sensitivity of 89%. In eight cases the sentinel node showed nodal disease (pN1). In 41 patients the sentinel node was tumour negative reflecting the correct neck lymph node status (pN0). We observed one false-negative result. In this case the sentinel node was free of tumour, whereas a neighbouring lymph node contained a lymph node metastasis (pN1). Although we have shown, that skipping of nodal basins can occur, this technique still reliably identifies the sentinel nodes of patients with squamous cell carcinoma of the pharynx and larynx. Future studies must show, if sentinel node detection is suitable to limit the extent of lymph node dissection in clinically N0 necks of patients suffering from pharyngeal and laryngeal squamous cell carcinoma.

Number and location of radiolabeled, intraoperatively identified sentinel nodes in 48 head and neck cancer patients with clinically staged N0 and N1 neck

The value of sentinel node (SN) biopsy for squamous cell carcinoma of the head and neck (HNSCC) has not been determined yet. A critical evaluation of this concept seems to be mandatory with regard to the increasing acceptance of SN biopsy in other tumor entities. Against the background of the results of 48 previously untreated patients, a reproducible technique for SN biopsy in the head and neck level, which has been adjusted to the special topographic conditions of this anatomic region, is presented. Methods included intraoperative SN biopsy, which was performed in 48 previously untreated patients suffering from squamous cell carcinoma (2× lower lip, 8× oral cavity, 20× oropharynx, 15× larynx, 3× hypopharynx). Using ultrasound imaging, 43 patients were staged as N0 necks, and 5 patients were staged as N1 necks. Fine-needle aspiration cytology (FNAC) was performed in cases of doubt. Surgery on the neck was carried out according to the suspected stage of lymphogenic spread once the SN1 as well as one or two further hot nodes (SN2, SN3) had been identified. Numbers and distribution of the intraoperatively excised nodes SN1–3 were documented according to their relation to the tumor location. Post-operatively, the histologic results of the intraoperatively excised nodes SN1–3 were compared to the histologies of the neck dissection specimen. Results showed that in all 48 patients, a SN1 could be identified intraoperatively. In 20 cases an additional SN2 and in 6 cases a SN3 was diagnosed. In carcinomas of the lower lip and oral cavity, the SN1 was found in 4 cases in level I (2× lower lip, 2× floor of the mouth) and in 6 cases in level II (6× lateral tongue). In carcinomas of the oropharynx, the respective nodes were found in 17 of 20 cases in level II (carcinomas of the tonsil) and in 3 cases in level III (carcinomas of the base of the tongue). In supraglottic carcinomas the SN1 was identified in 8 of 10 cases in level II and in 2/5 patients with glottic carcinomas, while in 3/5 glottic carcinomas as well as in all hypopharyngeal carcinomas, the SN1 was found in level III. In relation to the predictiveness of the detected SN, it has to be remarked that in 38 patients a SN1 free of tumor was representative for the regional lymph node status (pN0). An isolated metastasis (pN1) was diagnosed in the SN (9× SN1, 1× SN2) in 10 patients. In conclusion, the results of a SN biopsy modified to a strictly intraoperative method of detection are encouraging. Critical indications showed that a thorough and standardized technical performance of the injection as well as a mandatory, so far unchanged, neck dissection form the basis for the development of a SN concept for SCCs of the upper aerodigestive tract. The value of the SN concept, however, currently remains unclear for patients suffering from HNSCC.

Value of sentinel lymphonodectomy in head and neck cancer patients without evidence of lymphogenic metastatic disease

OBJECTIVE Only few communications deal with the value of sentinel node (SN) biopsy for head and neck squamous cell carcinoma (HNSCC). Based on the results of 38 investigated patients with clinically N0-neck the feasibility of SN biopsy in HNSCC is critically discussed. PATIENTS AND METHODS Thirty-eight previously untreated patients with clinically N0-neck were staged by intraoperative SN biopsy. After intraoperative identification of the hottest node (SN(1)) and further less tracer accumulating lymph nodes (SN(2), SN(3)), patients were treated by different types of neck dissection (ND), adjusted to the location and extent of the primary tumour. Postoperatively the histologic results of the SN(1-3) and the entire ND specimen were compared. RESULTS The stage of cervical metastatic disease was demonstrated by a disease-free SN(1) in 32 patients. In five patients an isolated metastasis could be proven in the intraoperatively identified SN(1), while in the remaining patient an isolated metastasis was found in the SN(2). CONCLUSION Intraoperative SN biopsy seems to be valuable for the detection of occult lymph node metastases in HNSCC. This method might help to limit the extent of ipsilateral ND, if used as an intraoperative staging procedure to investigate the first draining tracer accumulating lymph nodes (SN(1-3)).

Extent of surgical intervention in case of N0 neck in head and neck cancer patients: an analysis of data collection of 39 hospitals

In the discussion on the treatment of the clinical N0 neck in head and neck cancer, the sentinel lymphonodectomy is gaining more and more in significance. Prior to a multicentre study on the value of sentinel lymphonodectomy, it seemed to be desirable to collect data on the current practice of neck dissection in German ENT departments. First a standardised questionnaire was sent to 50 hospitals in Germany. It contained questions on the respective therapeutic concepts (uni- or bilateral modified radical neck dissection versus selective neck dissection, wait-and-see policy) in histologically proven squamous cell carcinoma (G2) and defined localisation of the primary tumour (T1-T2 carcinoma of the oral cavity, the oropharynx and hypopharynx as well as larynx). Summing up the evaluation of 39 anonymously answered questionnaires, it can be stated that no uniform therapeutic concept for the treatment of the cervical lymph nodes in carcinomas of the upper aerodigestive tract based on the stage of lymphatic metastatic disease exists. It seems to be essential to elaborate such a concept in order to be able to compete in the international context. Likewise, a widespread uniform therapeutic strategy would be the basic prerequisite for the initiation and realisation of multicentric therapy studies.

Endoscopic sentinel lymphadenectomy as a new diagnostic approach in the N0 neck

Sentinel lymphadenectomy was developed to reduce the extent of surgical interventions in cancer patients. The sentinel node (SN) concept was first established for melanoma and breast cancer; within some years, it also became increasingly popular for head and neck cancer. As soon as the required sensitivity of the method proves to be feasible in the daily clinical routine, the discussion about the best surgical approach to single or multiple SN(s) will arise. Different objectives may here compete with each other. The incision should render the best exposure of the operation site and should be expandable in case further lymph node regions have to be dissected. Finally, a good functional as well as a good cosmetic result is desirable. Endoscopic lymph node excisions were performed in patients suffering from squamous cell carcinoma of the upper aerodigestive tract located in different sites (1× uvula, 2× epiglottis, 1× glottis). In preoperatively performed ultrasonic imaging (B-mode-ultrasonography), N0 necks were assessed. In contrast to previously reported endoscopic techniques in humans, the presented method requires no insufflation of carbon dioxide or external retraction of the skin. Following laser surgical resection of the primary tumor, the SN and further lymph node(s) with accumulation of tracer substance were identified and resected endoscopically via an incision that was afterwards extended to a normal neck dissection incision. Reports of histopathologic examination of the sentinel node(s) were compared to the respective neck dissection specimens. The presented method may help to reduce the degree of invasiveness frequently attributed to sentinel lymphadenectomy once the method has been established for head and neck cancer.

Epiglottopexy for the treatment of severe laryngomalacia

Abstract. Laryngomalacia is the most common cause of stridor in newborns and infants. Up until now, different surgical techniques for the treatment of this disease have been described. We report on a modified technique, the so called epiglottopexy, which is a laser-surgical treatment strategy in severe laryngomalacia. A total number of six children (ages: 6 weeks–10.4 years) were treated for life-threatening stridor, which was due to an isolated posterior displacement of the epiglottis during inspiration. In two patients, shortened aryepiglottic folds contributed to the stridor. In all of the children, a modified technique of epiglottopexy was performed transorally; in two cases, this was followed by laser surgical transection of the aryepiglottic folds. Epiglottopexy on the base of the tongue was performed using single suture stitches following laser-surgical vaporization of the corresponding mucosal areas of the epiglottis and the base of the tongue. No intra- or postoperative complications were observed. All six children demonstrated significant airway improvement without any further stridor. Deglutation was not impaired. The presented laser-surgical technique seems to be an appropriate therapy for treatment of severe forms of laryngomalacia characterized by an isolated posterior displacement of the epiglottis during inspiration.

Indikationen zur Halsoperation bei nicht nachweisbaren LymphknotenmetastasenTeil 2. Neck dissection beim klinischen N0-Hals

ZusamenfassungDas lymphogene Metastasierungsverhalten der im Kopf-Hals-Bereich lokalisierten Karzinome wird maßgeblich von der Lymphgefäß- und Lymphkollektordichte bestimmt. In Abhängigkeit von der zu erwartenden Metastasierungswahrscheinlichkeit des im Bereich der oberen Luft- und Speisewege, der Haut, der Speicheldrüsen und der Schilddrüse lokalisierten Karzinoms wird die Indikation zur Halsoperation beim klinischen N0-Hals gestellt. Die dabei vorzunehmende Neck dissection kann grundsätzlich 2 Zielsetzungen haben. Sie kann als Staging-Verfahren oder als Therapiemaßnahme verstanden werden, wobei der therapeutische Nutzen der selektiven Neck dissection beim klinischen N0-Hals von Karzinomen der oberen Luft- und Speisewege angesichts einer Rate an okkulten Metastasen von durchschnittlich etwa 25% zunehmend an Bedeutung gewinnt. Nach einer grundsätzlichen Diskussion zur Indikation einer selektiven Neck dissection beim klinischen N0-Hals werden verschiedene Fragestellungen zu definierten Tumorlokalisationen und Tumorentitäten erörtert.

Intraoperative lymphatic mapping in cases of midline squamous cell carcinoma

Objective To analyze the value of intraoperative lymphatic mapping in cases of midline primary head and neck squamous cell carcinoma (HNSCC) in clinically staged N0 necks. Material and methods Eleven patients with HNSCC of the epiglottis (2 T1, 6 T2, 3 T3), all of whom were staged with a neck status of N0 using sonography and CT, underwent intraoperative peritumoral 99mTc-nanocoll injection (4 sites; 45 MBq), radiolabeled detection and analysis of up to 3 hot sentinel nodes (SNs) during elective neck dissection. Results Gamma probe use revealed bi- and unilateral intranodal tracer uptake in 6/11 and 5/11 patients, respectively. In 2/6 patients with bilateral intranodal tracer uptake an SN with an isolated metastasis was found at one neck site while the other four patients were tumor-free in the SNs. Of the five patients with unilateral intranodal tracer uptake, three had radiolabeled SNs containing isolated metastases whereas two had no cancer detected, giving a total occult cancer rate of 45% (5/11). No cancer was found in non-labeled nodes. Conclusions Intraoperative lymphatic mapping correctly identified the stage of metastatic disease. Unilateral tracer uptake represented the pathway of occult metastatic spread in 3/5 patients and the disease-free neck status of both neck sites in 2/5 patients. No patient had occult bilateral cancer. Future investigations should be done to determine whether intraoperative lymphoscintigraphy can guide the indication for unilateral only or bilateral neck dissection in these patients.

Malleostapedotomy – The Marburg Experience

BACKGROUND The surgical procedure for patients with otosclerosis routinely is incus stapedotomy. In case of otosclerosis with incus necrosis or a bony fixation of the malleus and incus, malleostapedotomy is performed. PATIENTS AND METHODS Between May 2002 and September 2003, malleostapedotomy was performed in 6 out of 34 patients with otosclerosis. In 2 primary cases, a middle ear dysplasia was found. The malleus was fixed in 2 further primary cases. Two revision surgeries were performed with incus necrosis present. A titanium piston was used, which was fixed at the malleus handle and introduced into an opening of the footplate. RESULTS The preoperative air-bone gap was reduced from 36 dB(A) to 13 dB(A) after surgery for an average checkup time of 3 months. The length of the prostheses varied from 6.3 to 7.5 mm. No patient showed a hearing loss or vertigo after surgery. CONCLUSION Malleostapedotomy is the technique of choice in case of an additional pathology of the ossicular chain in patients with otosclerosis. Larger numbers of patients and long-term investigations need to compare the results of malleostapedotomy with those of a conventional incus stapedotomy.