Frank E. Lucente

Validation of the Charlson Comorbidity Index in Patients With Head and Neck Cancer: A Multi‐institutional Study

Comorbid conditions are medical illnesses that accompany cancer. The impact of these conditions on the outcome of patients with head and neck cancer is well established. However, all of the comorbidity studies in patients with head and neck cancer reported in the literature have been performed using the Kaplan‐Feinstein index (KFI), which may be too complicated for routine use. This study was performed to introduce and validate the use of the Charlson comorbidity index (CI) in patients with head and neck cancer and to compare it with the Kaplan‐Feinstein comorbidity index for accuracy and ease of use. Study design was a retrospective cohort study. The study population was drawn for three academic tertiary care centers and included 88 patients 45 years of age and under who underwent curative treatment for head and neck cancer. All patients were staged by the KFI and the CI for comorbidity and divided into two groups based on the comorbidity severity staging. Group 1 included patients with advanced comorbidity (stages 2 or 3), and group 2 included those with low‐level comorbidity (stages 0 or 1). Outcomes were compared based on these divisions. The KFI was successfully applied to 80% of this study population, and the CI was successfully applied in all cases ( P < 0.0001). In addition, the KFI was found to be more difficult to use than the CI ( P < 0.0001). However, both indices independently predicted the tumor‐specific survival ( P = 0.007), even after adjusting for the confounding effects of TNM stage by multivariate analysis. Overall, the CI was found to be a valid prognostic indicator in patients with head and neck cancer. In addition, because comorbidity staging by the CI independently predicted survival, was easier to use, and more readily applied, it may be better suited for use for retrospective comorbidity studies.

Changing trends in deep neck abscess : a retrospective study of 110 patients

We have conducted a retrospective study of 110 patients with the diagnosis of deep neck abscess who had been seen between 1981 and 1990. Etiologic factors, common pathogens, and antimicrobial therapy were reviewed with reference to diagnostic methods of choice and management principles. The findings were compared with the literature. We have identified trends of change in the following aspects of deep neck abscess: cause, presentation, diagnostic methods, and bacteriology. Management principles of airway protection, intravenous antibiotics, and drainage have not changed.

Complications Associated with 327 Foreign Bodies of the Pharynx, Larynx, and Esophagus:

We intended to identify the types and incidence of complications associated with foreign bodies (FBs) impacted in the upper aerodigestive tract (UADT) and to ascertain factors predisposing to the development of these complications. The design was a retrospective cohort study of 327 patients with UADT foreign bodies admitted to a tertiary care center. The overall incidence (7.6%) and types of complications varied by age. Complications developed in 4.8% of 208 patients 10 years of age and under, with pulmonary complications being most common. In contrast, complications occurred in 12.6% of 119 older patients, with retropharyngeal abscess being the most common (p < .0001). Delayed presentation (>24 hours after the onset of symptoms) was the only factor associated with an increase in the incidence of complications in the younger patients (p = .02). In contrast, pharyngeal location of the FB (p = .0004), the FBs being a fish bone (p = .006), and radiolucency (p = .02) were all associated with an increased incidence of complications in patients over 10 years of age. A significant risk for complications is present for patients admitted for the management of FBs in the UADT. Older patients with sharp FBs are at greatest risk. In this group of patients, close observation in the perioperative period is required, especially if there is evidence of mucosal injury.

Impact of comorbidity on outcome of young patients with head and neck squamous cell carcinoma

Comorbid conditions have a significant impact on the actuarial survival of patients with head and neck cancer. However, no studies have evaluated the impact of comorbidity on tumor‐ and treatment‐specific outcomes. This study was performed to evaluate the impact of comorbidity, graded by the Kaplan‐Feinstein comorbidity index (KFI) on the incidence and severity of complications, disease‐free interval, and tumor‐specific survival in patients undergoing curative treatment for head and neck cancer.

Substernal goiter: A clinical review

Thyroid disease is a very common problem, but indications for surgery are few. We have seen a large number of patients with multinodular goiter. The main indications for surgery in thyroid disease include fear of malignancy, tracheo-esophageal compression, and cosmetic reasons. Tracheo-esophageal compression is most commonly noted in patients with mediastinal goiters. Substernal goiter is defined as those situations in which at least 50% of the gland is in the mediastinal location. Although its incidence has decreased, it remains prevalent in almost every country in the world today. SSG is best diagnosed by a thorough history and physical examination, complemented by airway films, fiberoptic laryngoscopy, and computerized tomography. The most common presenting symptoms are those produced secondary to compression effects. SSG show a poor response to medical treatment. Moreover, given their propensity to cause acute airway symptoms, surgical treatment should be considered in most cases. Extirpation of the gland is best performed through a collar incision, with the addition of a median sternotomy in select few and difficult cases. Median sternotomy is necessary in only 1% to 2% of cases. Operative mortality is negligible, and the incidence of complication is minimized by following strict surgical principles.

Nuclear scanning in necrotizing progressive “malignant” external otitis†‡

The usefulness of radionuclear scanning in the treatment of 18 patients with necrotizing progressive “malignant” external otitis is discussed. A Tc 99‐m bone scan, a valuable test since results are positive in early cases of osteomyelitis of the temporal bone and base of skull, showed increased uptake in all 18 patients. In 6 patients, Ga‐67 citrate scans were obtained at the start of therapy and at 5–6 week intervals thereafter. The serial gallium scans were useful in evaluating the effectiveness of therapy since the uptake decreased with control of infection.

Resection of Tracheal Stenosis with End-to-End Anastomosis

We present our experience with circumferential tracheal resection with end-to-end anastomosis. Between 1985 and 1992 we performed this procedure on 19 patients with tracheal stenosis. The cause of the stenosis was related to intubation and/or tracheotomy in 78.9% of the patients. Two to 8 tracheal rings were resected and a tension-free anastomosis was achieved with mobilization techniques that were limited to suprahyoid release, peritracheal dissection, and chin-to-chest suture. Infrahyoid release and intrathoracic perihilar mobilization techniques were not used. The anastomosis success rate was 94.7%.

Acute Postobstructive Pulmonary Edema

Acute postobstructive pulmonary edema may occur after airway obstruction. A decrease in intrathoracic and intraalveolar pressures causes an increased blood flow into the pulmonary vasculature and favors the development of pulmonary edema. Two mechanisms for the development of acute postobstructive pulmonary edema are proposed: type 1 follows acute airway obstruction, and type 2 follows relief of chronic airway obstruction.

Chyle fistula management.

Chyle fistula is a potentially devastating phenomenon that results from violation of the thoracic duct or right lymphatic duct in the neck, most commonly during radical neck dissection. It may impair nutrition, compromise and delay wound healing, and prolong hospitalization. In view of the morbidity produced by chyle leak discovered postoperatively and the lack of success of its management by aggressive surgical techniques, we have employed a different protocol for the past six years. It is based on careful intraoperative inspection of the neck for possible chyle fistula, minimal but specific surgical handling of the damaged duct, and a postoperative nutritional program designed to reduce chyle formation and facilitate spontaneous closure. The nutritional element involves the use of medium chain triglycerides (MCT) that are easily ingested, rapidly absorbed, and readily metabolized directly into the portal venous system, bypassing the thoracic duct lymphatic system. During a four-year period, 1976 to 1980, 574 radical neck dissections were performed with only six chyle fistulas being detected postoperatively. All have been successfully treated by the protocol with no patients requiring reexploration. There have been no deaths owing to chyle fistula and no complications or side effects from the use of medium chain triglycerides.

Surgical results of orbital decompression for malignant exophthalmos

During the past 75 years, several procedures for surgical correction of malignant exophthalmos have been described. In 1948, Ogura and Walsh first employed the transantral approach for decompression of the orbital contents into the ethmoid and maxillary sinuses. This technique requires controlled incision of the orbital periosteum to balance the eyes.