Agrício Nubiato Crespo

Primary versus secondary tracheoesophageal puncture for speech rehabilitation in total laryngectomy : Long-term results with indwelling voice prosthesis

OBJECTIVE: To evaluate the long-term use of indwelling Blom-Singer voice prosthesis (VP) for vocal rehabilitation of patients submitted to total laryngectomy (TL). The influence of the timing (primary or secondary) of tracheoesophageal puncture (TEP), use of radiotherapy (xRT), patient age, and length of follow-up were studied to evaluate the success rate of VP use. STUDY DESIGN AND SETTING: Prospective clinical study in a tertiary referral center. Seventy-one patients were submitted to TL and rehabilitated with indwelling VP. All patients were evaluated for vocal functional issues by an otolaryngologist and a speech pathologist at 1 month, then at every 3 months up to 1 year, and then at every 6 months after 1 year of follow-up. The relative data on time of placement of VP, time of VP use, xRT, age, length of follow-up, and life span of each VP were recorded during the follow-up. RESULTS: Eighty-seven percent of the patients underwent primary and 13%, secondary TEP. The follow-up varied from 12 to 87 months, with an average of 38 months for primary and 51 months for secondary TEP. Fifty-nine percent of the patients were submitted to xRT. The general rate of success was 94%, with 97% for primary and 78% (P = 0.07) for secondary TEP; after 2 years, the success rate was 96% for primary and 75% for secondary (P = 0.07) TEP. The use of xRT and patient age had no influence on the success of VP use for primary and secondary TEP, independently of the length of follow-up. CONCLUSIONS: The success rate of voice rehabilitation with VP was 94%. In primary TEP, the success rate was 97%, whereas in secondary TEP it was 78%; 2 years later, it was 96% and 75%, respectively. A tendency for a higher success rate in voice rehabilitation after TL was observed in primary TEP. The use of xRT and age of patient had no influence on the success rate.

Role of margin status in recurrence after CO2 laser endoscopic resection of early glottic cancer

Conclusion. In patients with early glottic squamous cell carcinoma (SCC) submitted to CO2 laser endoscopic resection, local disease recurrence was significantly correlated with the presence of positive additional surgical margins on permanent sections. Objectives. To evaluate the rate of cancer recurrence in patients with early glottic SCC submitted to CO2 laser endoscopic resection according to margin status after resection, stage of disease and postoperative radiotherapy. The rate of larynx preservation and the length of hospital stay were also evaluated. Material and methods. Forty consecutive patients with early glottic cancer were subjected to laser endoscopic resection surgery of glottic cancer followed by frozen-section control of margins, with intraoperative enlargement of margins when positive. Adjuvant radiation therapy or enlargement of previous margins was indicated in the case of positive additional surgical margins on permanent section. Results. Local recurrence occurred in three patients (7.5%), all with positive additional surgical margins on permanent section. Positive additional surgical margins on permanent section were related to 37.5% of recurrences and negative additional surgical margins with 0% of recurrences (p=0.006). All patients spent at most 1 day at the hospital.

Correlação da qualidade de vida e voz com atividade profissional

As disfonias podem comprometer a qualidade da comunicacao e, por consequencia, a relacao social do individuo e assim afetar sua qualidade de vida. Existe hoje necessidade de protocolos objetivos para avaliacao da qualidade vocal que mensurem suas implicacoes na qualidade de vida do paciente. OBJETIVOS: Relacionar qualidade de vida e voz com o grau de disfonia e o uso profissional da voz em um grupo de pacientes disfonicos. MATERIAL E METODO: Realizou-se estudo clinico prospectivo aplicando-se protocolo internacional para avaliar a qualidade de vida e voz em um grupo de pacientes disfonicos. Realizou-se tratamento estatistico dos resultados considerando-se nao-distincao entre profissionais da voz e nao-profissionais da voz e, em seguida, considerando-se esta distincao profissional. RESULTADOS: A disfonia afetou a qualidade de vida em todos os individuos. Nao houve diferenca estatistica entre os grupos, profissionais da voz e nao-profissionais da voz, quanto ao grau de disfonia. Houve correlacao entre qualidade de vida e grau de disfonia, no entanto, considerando-se os grupos separadamente, esta correlacao foi significativa apenas no grupo de sujeitos nao-profissionais da voz. CONCLUSAO: A disfonia afetou a qualidade de vida em todos os sujeitos independente do uso profissional da voz.

Clinical versus computed tomography evaluation in the diagnosis and management of deep neck infection

CONTEXT Deep neck infections have high potential for severe complications and even death, if not properly managed. The difference between clinical and computed tomography findings may demonstrate that clinical evaluation alone underestimates disease extent, which may lead to conservative treatment with worse prognosis. OBJECTIVE To compare clinical and computed tomography findings from neck spaces affected by deep neck infections and to determine the main clinical and radiological features associated with these. TYPE OF STUDY Non-randomized retrospective study. SETTING Department of Otolaryngology and Head and Neck, Universidade Estadual de Campinas. METHODS Medical charts of 65 patients with deep neck infections were evaluated. Age, gender, clinical complaints, physical findings, computed tomography scan and x-ray imaging, microbiology, treatment and outcome were analyzed. All clinical signs and symptoms were evaluated and stratified in order of frequency. The frequency of neck space involvement in such infections was also assessed from the clinical and tomographic evaluation. All clinical and computed tomography findings were compared with surgical observation. RESULTS The most frequent clinical findings were neck swelling, local pain, erythema and locally increased temperature. Physical evaluation showed that the most affected site was the submandibular triangle (49.2% of cases). However, computed tomography showed this to be the lateropharyngeal space (65% of cases) and that more than one deep cervical space was compromised in 90% of cases, as demonstrated by the extent of swelling and increased contrast signs in soft tissue. DISCUSSION The most frequent clinical symptoms of deep cervical infections were cervical pain, increased cervical volume and fever. The important signs seen via computed tomography were increased contrast in soft neck tissues and swelling. Such examination is the most important method for correct evaluation of cervical spaces involved in infection, and thus for correct surgical drainage. CONCLUSIONS The most frequent clinical findings were cervical mass, neck pain, local erythema and locally increased temperature. Computed tomography demonstrated that the lateropharyngeal space was the most affected neck space. More than one deep neck space was compromised in 90% of cases. Clinical evaluation underestimated the extent of deep neck infection in 70% of patients.

Predictive value of sentinel node biopsy in head and neck cancer

Conclusions. The negative predictive value (NPV) of sentinel lymph node biopsy (SNB) in this study was 95%. The accuracy of SNB compared to histopathologic evaluation of surgical specimen of subsequent neck dissection (ND) was 96%. Objective. To evaluate NPV of SNB in head and neck cancer. Patients and methods. This was a prospective clinical study comprising 35 patients (50 necks) with squamous cell carcinoma (SCC) of head and neck with clinically (cN0) and radiologically negative necks, without previous treatment, who underwent SNB with gamma probe and subsequent ND. The NPV, accuracy, sensitivity, and specificity of SNB were compared to histopathologic assessment of surgical specimens from NDs. Negative sentinel lymph nodes (SLNs) on histopathology were evaluated with step serial section (SSS) and immunohistochemistry (IHC). When a neck had a positive SLN, all lymph nodes of subsequent NDs were studied with SSS and IHC. Results. There were primaries of the oral cavity (n=24), lip (n=3), oropharynx (n=3), and larynx (n=5). All patients had detected SLNs. In all, 41 necks were SLN-negative on histopathologic evaluation but 2 (5%) had metastases in non-SLNs after ND. Of these 41 necks, SLNs were level Ib (26%), IIa (45%), III (21%), and IV (8%). Nine necks presented positive SLN on histopathologic evaluation, level Ib (n=3), IIa (n=5), and III (n=2), and subsequent NDs were negative on conventional histopathologic analysis, but after SSS and IHC, two presented micrometastases.

Biomarker analysis in carcinoma ex pleomorphic adenoma at an early phase of carcinomatous transformation.

Diagnostic criteria for intracapsular carcinoma ex pleomorphic adenoma (CXPA) are subjective and vary among authors. Biomarker analysis, which could provide more objective evaluation of these tumors, has rarely been studied in intracapsular CXPA. Immunohistochemical evaluation of c-erbB-2, p53 protein, bcl-2, and Ki-67 was performed in 8 cases of CXPA at an early phase of malignant transformation (4 intracapsular and 4 minimally invasive) and in 17 pleomorphic adenomas (PA). In all cases of CXPA, p53 and Ki-67 were demonstrated predominantly in luminal cells of benign and malignant areas, significantly more in the latter. Few benign myoepithelial cells were p53 positive. c-erbB-2 reactivity was strongly associated with atypical luminal cells. Bcl-2 expression was weak and focal in malignant areas from 2 cases. In conclusion, both p53 and c-erbB-2 proteins appear to be involved at an early stage of malignization of PA. In PA with atypical cells, evaluation of the expression of these 2 markers provides more objective criteria for the diagnosis of intracapsular CXPA.

Neck lymph node metastases to the posterior triangle apex: evaluation of clinical and histopathological risk factors.

Dissection of posterior triangle apex (APEX) is a surgical step in supraomohyoid and lateral neck dissections. The prevalence of lymphatic metastases at this site and the clinicohistopathologic conditions that influence their occurrence have not been established. We have evaluated the prevalence and the risk factors for cervical metastases in lymph nodes of the APEX.

Levels and patterns of expression of hypoxia‐inducible factor‐1α, vascular endothelial growth factor, glucose transporter‐1 and CD105 in adenoid cystic carcinomas with high‐grade transformation

Costa A F, Tasso M G, Mariano F V, Soares A B, Chone C T, Crespo A N, Fresno M F, Llorente J L, Suárez C, de Araújo V C, Hermsen M & Altemani A 
(2012) Histopathology 60, 816–837

Vibratory pattern of vocal folds under tension asymmetry

Objective The aim of this study was to describe and analyze the vibratory pattern of vocal folds in an asymmetric situation. Study Design and Setting Cricothyroid muscle unilateral action was simulated on excised larynges on an experimental bench. Increasing airflow rates were applied to achieve vocal fold vibration. Electroglottography and an optoreflectometer device allowed analysis of separate and simultaneous vocal fold vibration. Spectra of the signals were obtained for each level of airflow variation. Results All experiments showed periodic vibration. A phase shift was noted between the two vocal folds. Subharmonics and biphonation were identified in all the experiments. Conclusion Lax vocal folds were more susceptible to spectral changes with increasing airflow. Significance Knowledge of the consequences of mass, tension, and position asymmetries of the vocal folds is crucial for diagnosis making and defining therapeutic strategies in dysphonic patients. This study may contribute to the understanding of physiology of vocal fold interaction and its compensatory mechanisms.

Granulocytic Sarcoma of the Larynx Preceding Chronic Myeloid Leukemia

The authors report one case of granulocytic sarcoma infiltrating the larynx and cervical lymph nodes in a 50-year-old smoking patient. At the time of diagnosis there was no clinical and laboratory evidence of acute myeloid leukemia or chronic myeloproliferative disease. Four months after diagnosis, bone marrow morphology was consistent with chronic myeloid leukemia, accelerated phase. Cytogenetic abnormalities (Ph 1 chromosome, t(1; 12) (p36; p13), and trisomy of chromosome 20) were also found in hemopoetic cells. Granulocytic sarcoma preceding installation of chronic myeloid leukemia, as described here, seems to be a rare clinical event.