Fernando Luis Dias

How to minimize complications in thyroid surgery

BACKGROUND In ancient times, operations on the thyroid gland caused unacceptable morbidity and mortality. Only after the landmark work of Kocher, the technical principles of thyroidectomy were solidly established, and are still valid nowadays. METHODS Revision article on practical suggestions to decrease morbidity associated with thyroidectomy, as well as warning against common pitfalls that the surgeon may encounter. RESULTS The following subjects are objectively addressed: how to manage upper airway obstruction, how to avoid non-esthetic scars and how to recognize the most prevalent anatomic variations concerning the recurrent nerve, the external branch of the superior laryngeal nerve and the parathyroid glands, in order to decrease operative morbidity. CONCLUSION The Head and Neck Surgeon must be fully aware of the complex anatomy of the central visceral compartment of the neck, as well as must be prepared to handle some complications of thyroidectomy that can be life-threatening.

Adenoid cystic carcinoma of the maxillary sinus: a clinical-pathological report of 10 years of experience from a single institution.

Adenoid cystic carcinoma (ACC) is the most common malignant salivary gland tumour of the maxillary sinus. The present study describes 24 cases seen over a period of 10 years at the Brazilian National Cancer Institute. Socio-demographic, clinical, pathological, and follow-up data were retrieved from the medical files for the period 1997-2006. The mean age of the patients was 51.1 years. Twenty-one (87.5%) presented advanced tumours. The main signs and symptoms found were a tumour mass (87.5%), pain (50%), nasal obstruction (25%), and epistaxis (20.8%). Most cases (62.5%) were treated with surgery and radiation therapy. Follow-up data showed two patients (8.3%) with residual disease, local recurrences in four (16.7%) patients, and distant metastasis in five (20.8%). The overall 5- and 10-year survival rates were 72.61% and 62.11%, respectively. Maxillary sinus ACC has an aggressive but indolent behaviour, typically presenting at an advanced T stage that reflects a poor prognosis for patients.

Treatment Results of T4a and T4b Oral Cavity Cancer

OBJECTIVES: To evaluate the treatment results and outcome of T4a and T4b oral squamous cell carcinoma (OSCC) at a single institution. METHODS: The charts of 251 consecutively untreated T4 OSCC patients (reclassified by AJCC 2002) eligible for treatment (surgery plus RT, exclusive RT, RT plus QT) were retrospectively analyzed. Factors with possible impact on survival were analysed. Survival rates were calculated according to the Kaplan-Meier method. RESULTS: 196 patients were classified T4a and 55 as T4b. 49% percent of patients underwent radical surgery plus RT, 30.6% received RT /-CT and 17.2% had palliative RT. The 5-year disease-free (DFS) and overall (OS) survival rates for those who had surgery plus RT were 49.5% and 42.5%, respectively, in comparison with 30.4% and 37.3% for patients undergoing RT /-CT, respectively. Univariate analysis revealed that age, N-stage, and type of treatment (p .003, p .006, and p .001, respectively) were predictors for local control in T4a and T4b patients. In multivariate analysis, type of treatment was independent predictor for DFS and OS (p .0001, and p .0001, respectively). CONCLUSIONS: Radical surgery plus radiotherapy was shown to be the best therapeutic option for T4a OSCC patients. This study also emphasized the role of TNM classification as a reliable prognostic indicator.

Swallowing evaluation after supracricoid laryngectomy using FEESST

OBJECTIVES: Comparative evaluation of swallowing function in patients treated with Supracricoid Partial Laryngectomy with CHEP reconstruction (SPL-CHEP), using Flexible Endoscopic Evaluation of Swallowing with Sensory Testing (FEESST) and videofluoroscopy. METHODS: Swallowing function was analyzed using FEESST and videofluoroscopy. Patients were endoscopically evaluated for pooling, spillage, penetration and aspiration during ingestion of different food consistencies. The laryngeal adductor reflex and laryngopharyngeal sensation were evaluated with touch and calibrated air pulses of 4, 6 and 10 mmHg. Fluoroscopic visualization was used to identify the overall efficiency and physiology of swallow. Pooling, penetration and aspiration were noted. RESULTS: Forty-four patients were included. Mean age was 60.7 years. All patients were evaluated using both methods. Most (56.8%) were stage III on pathological examination. Only one arytenoid was preserved in 61.4%. Mean time to decannulation and oral feeding were 8.7 and 8.2 weeks, respectively. Complete airway closure during swallowing was observed in 86.4%. Arytenoid reflex after air pulse of 4, 6 and 10 mmHg was presented respectively in 4.5%, 18.2% and 29.5%. FEESST with all consistencies revealed pooling in 81.8%, penetration in 18.2%, but no aspiration among all patients. Eight patients (18.1%) had silent aspiration seen on videofluoroscopy. CONCLUSIONS: Swallowing disorders are frequently observed in patients after SPL-CHEP. Videofluoroscopy, better than FEESST, is important to diagnose silent aspiration. FEESST gives information about laryngeal sensitivity due to anatomical and functional changes. Both exams are important for re-education and rehabilitation of swallowing after partial laryngeal surgery.

Changing Faces, Minimally Invasive vs.Traditional Techniques

Recent advancements in medical technology and the demand for minimally invasive surgery have led to the growing popularity of a confusing variety of minimally invasive techniques for facial rejuvenation. These minimally invasive procedures fall into three broad categories: (1) surgical techniques such as percutaneous suture suspension, (2) injectable agents such as tissue fillers and botulinum toxin A, and (3) nonablative treatments to stimulate collagen formation and tighten skin such as Thermage, Titan, and Fraxel. It is often difficult for the practicing facial plastic surgeon to determine if it is appropriate to recommend a particular minimally invasive treatment in favor of a traditional surgical approach. New treatments are constantly introduced and treatment protocols keep evolving, manufacturers launch aggressive advertising campaigns with difficult-to-substantiate claims, and patients may insist on nonsurgical treatment modalities. In this miniseminar, an expert in each category of minimally invasive surgery will provide insight into the history, science, indications, and representative results expected from each technique. A respected panel of leaders in facial plastic surgery will then discuss the merits of these minimally invasive procedures in comparison with established techniques in a case discussion format.”

Influence of clinical prognostic factors in neck metastasis from malignant parotid tumors

Abstract Objectives: Analyze the factors influencing lymph nodes metastasis in parotid malignant epithelial tumors. Methods: We retrospectively reviewed the files of 150 patients treated in our institution and by the authors, from 1974 to 1998. Twenty-three patients were excluded of this study because of nonsurgical treatment. The remaining 126 patients were treated with surgery and 75 patients had postoperative radiotherapy. Thirty-four patients were treated with parotidectomy plus neck dissection. The mean age was 49-years-old. According the UICC/1997 TNM Classification, we classified 49 patients as Stage I, 27 as Stage II, 22 as Stage III, and 28 as Stage IV. The influence of those factors on the presence of neck metastasis was analyzed using the chi-square method and multivariate analysis. Results: Forty patients had mucoepidermoid carcinoma, 18 patients had adenocarcinoma NOS, 18 patients had acinic cell carcinoma, 15 patients had adenoid cystic carcinoma, 11 patients had malignant mixed tumor, 11 patients had salivary duct carcinoma, 3 patients had basal cell adenocarcinoma, 3 patients had epithelial-myoepitelial carcinoma, 2 patients had malignant myoepithelioma, 2 patients had anaplastic carcinoma, 1 patient had primary squamous cell carcinoma, 1 patient had terminal duct adenocarcinoma, and 1 patient had papillary cystadenocarcinoma. Twenty-four patients had recurrences, 17 local recurrences, 4 patients had neck recurrences, and 3 locoregional recurrences. Seventeen patients had distant metastasis. The presence of neck metastasis was influenced by 4 factors in univariate analysis, age ( P 0.05), tumor classification ( P 0001), grade ( P 03), and histology ( P 003), and in multivariate analysis, Grade ( P 01) and tumor classification ( P 0001). Conclusions: The tumor classification and grade are an important factor to predict neck metastasis.

International symposia: Update in salivary gland tumors

Abstract Moderator: Eugene N Myers, MD; Parotidectomy for nonsalivary tumors-Claudio R Cernea, MD; Recurrent pleomorphic adenomas-Jacob Kligerman, MD; Prognostic factors of salivary gland cancers-Roberto A Lima, MD; Intraoperative decisions about the facial nerve-Pavel Dulguerov, MD; Reflexions about the adenoid cystic carcinoma-Ronald H Spiro, MD; Treatment of the neck in cancer of the salivary glands-Fernando L. Dias, MD.

Supracricoid laryngectomy (CHEP) functional results

resectable lymph node metastases, 16 had unresectable primaries, 13 refused surgery, 13 had distant metastases, 8 had coexisting primaries, 12 had severe cardiopulmonary disorders, 9 had multiple risks, and 3 died prior to the initiation of any kind of therapy. Five-year overall survival was 26.6% for all 228 patients, 35.9% for the 136 patients with surgical treatment, 59.3% for the 46 patients who were treated with larynxsparing procedures, and 12.9% for those not treated surgically. Conclusion: Only 59.6% of 228 unselected, consecutive patients were suitable for surgical treatment. For these, no postoperative fatalities were observed. Five-year overall survival was significantly better for patients who qualified for surgery (35.9% vs 12,9%), but only 27.5% of them had their larynx preserved after 5 years.