Kris S. Moe

Quality of life in patients cured from a carcinoma of the head and neck by radiotherapy : The importance of the target volume

PURPOSE To assess the health-related quality of life (QOL) of long-term survivors of carcinomas of different subsites of the head and neck following curative radiotherapy (RT). PATIENTS AND METHODS Patients continuously free from recurrence or second primary tumors treated 1988-1994 were contacted 5.1 to 5.9 years after RT and asked to fill in the EORTC QLQ-C30 core questionnaire and the H&N cancer module. RT had been restricted to the glottis (group A; carcinomas of the vocal cord T1-2 N0), or had included bilateral neck nodes and the primary tumor outside the nasopharynx (group B; AJC Stage II to IV) or within the nasopharynx, respectively (group C; Stage II to IV). Response rate was 97% (group A; n = 41), 69% (group B; n = 26) and 71% (group C; n = 12), respectively. The groups were different with respect to age (older in group A), alcohol consumption (absent in group C) and proportion of females (more in group C). RESULTS Patients with nasopharyngeal cancer reported the highest morbidity on the H&N module (dry mouth, sticky saliva, trismus, problems with teeth, trouble eating). However, these symptoms did not have a high impact on global QOL or function scores on the QLQ-C30 core questionnaire. Patients in group B reported a lower global QOL but less severe symptoms on the module. CONCLUSION The high morbidity of patients treated for a nasopharyngeal cancer may be explained by the location of the target volume which included the bilateral temporo-mandibular joints and the salivary glands. These patients require appropriate care during follow-up and will probably profit most from new RT techniques with sparing of normal tissues.

A Prospective Randomized Double-Blind Trial of Fibrin Glue for Pain and Bleeding After Tonsillectomy†

Objectives: The notable morbidity of tonsillectomy includes considerable postoperative pain and a rate of postoperative bleeding that have remained largely uninfluenced by modern surgical techniques or medication. Fibrin glue is known to have a hemostatic effect in some settings, and there is research suggesting it may also reduce postoperative pain. The objectives of this study were to evaluate the effect of fibrin glue on pain and bleeding after tonsillectomy.

Percutaneous Tracheostomy: A Comprehensive Evaluation

Percutaneous tracheostomy (PT) is an ancient procedure that has recently attracted increasing interest. While there are numerous publications in the literature, there remains confusion due to the large variety of techniques and instruments with which it has been performed and the wide disparity in clinical outcome. This study evaluates the international literature on over 1,500 cases, classifies the techniques that have been used, analyzes the safety of each method, and reports a prospective outcome and cost analysis of 130 cases undergoing what we determined to be the safest method. We found that PT performed with the correct instruments and technique under bronchoscopic surveillance has a lower incidence of complications than open tracheostomy (OT). Cost estimation demonstrated that PT may be significantly more expensive than bedside OT. While we recommend PT as a relatively safe and expedient method of tracheostomy for selected intubated patients in an intensive care unit, it does not offer an advantage for patients who must be taken to the operating room, and should not deprive house officers of necessary experience in OT in this setting.

Transorbital neuroendoscopic surgery.

BACKGROUND Transorbital neuroendoscopic surgery (TONES) pathways attempt to address some of the technical challenges of accessing laterally placed anterior skull base lesions or paramedian lesions that cross neurovascular structures. TONES approaches allow simultaneous coplanar visualization and working space above and below the skull base. OBJECTIVE To present an anatomic study, a description of the surgical techniques, and an analysis of the safety and efficacy of 20 consecutive procedures using TONES for a variety of pathological conditions. METHODS Sixteen patients underwent 20 TONES procedures for anterior skull base pathology, including repair of cerebrospinal leak, optic nerve decompression, repair of cranial base fractures, and removal of 3 skull base tumors. Ten patients were male, and 6 were female. The mean age at presentation was 44 years. Follow-up was 6 to 18 months with a mean of 9 months. RESULTS There were no significant complications or treatment failures in any of the 20 procedures. A variety of pathological conditions were treated, including cerebrospinal fluid leaks, fractures, mass lesions, and tumors. The TONES approach provided up to 4 separate access ports with ample exposure for manipulation and correction of the pathology. CONCLUSION This anatomic and prospective outcome study demonstrates that TONES provides safe and effective coplanar endoscopic access to the anterior and middle cranial base. These novel TONES approaches may be added to the wide range of published minimally invasive armamentarium when approaching challenging skull base pathology.

Computer-Guided Orbital Reconstruction to Improve Outcomes

OBJECTIVES (1) To describe repair of complex orbital fractures using computer planning with preoperative virtual reconstruction, mirror image overlay, endoscopy, and surgical navigation. (2) To test the hypothesis that this technique improves outcomes in complex orbital fractures. METHODS A series of 113 consecutive severe orbital fracture cases was analyzed, 56 of which were performed with mirror image overlay guidance, and 57 of which were repaired without. Data were collected on patient characteristics, fracture severity, diplopia and globe position outcomes, complications, and need for revision surgery. RESULTS The mirror image overlay group showed decreased postoperative diplopia in all fracture types (P = .003); the effectiveness was maximal for fractures that involved 3 or 4 walls or the posterior one-third of the orbital floor (P < .001). The need for revision surgery was greatly reduced in this cohort (4% vs 20%; P = .03). CONCLUSIONS The efficacy of mirror image overlay navigation and orbital endoscopy was studied in one of the largest series of complex orbital fractures in the literature. Based on statistically significant improved outcomes in postoperative diplopia and orbital volume, as well as the decreased need for revision surgery, we accept the hypothesis that mirror image overlay guidance improves outcomes in complex orbital reconstruction and recommend its use for complex orbital fracture repair.

Resorbable fixation in facial plastic and head and neck reconstructive surgery: an initial report on polylactic acid implants.

Objectives The purpose of this study was to evaluate and report our initial experience with a resorbable fixation system in facial cosmetic and head and neck reconstructive surgery. The specific goals were to determine in which settings the absorbable system could be used, to evaluate the outcome of its use, to detail complications that occurred, and to report our observations on advantages and disadvantages of the system compared with traditional methods of osteosynthesis and fixation.

Hyperfractionated radiotherapy and simultaneous cisplatin for stage-III and-IV carcinomas of the head and neck

PurposeTo assess the survival rate, the probability of local control, the patterns of relapse and late sequelae including self-reported quality of life in patients treated with hyperfractionated radiotherapy (RT) and simultaneous CDDP chemotherapy for stage-III to stage-IV carcinomas of the head and neck.MethodsFrom 1988 to 1994, 64 patients (median age 55.5 years) with carcinomas of different subsites, excluding the nasopharynx, were treated in a pilot study with 1.2 Gy bid (6 h interval; total dose 74.4 Gy) and simultaneous CDDP (20 mg/m2 daily, 5 days in week 1 and 5) and followed at regular intervals. Overall survival and local control, as well as the rates of late toxicity, were estimated using the actuarial method. Median follow-up was 3.3 years for all and 5.2 years for surviving patients. To assess the quality of life, the EORTC QLQ-C 30 questionnaire and the H&N35 module questionnaire were sent to the patients surviving with no evidence of disease or second primary tumors; they were answered by 15/23 (67%).ResultsOverall survival was 37% at 5 years, whereas disease-specific survival was 59%. Twenty-three patients died from uncontrolled head and neck cancer. Second primary tumors were observed in 13 patients, most frequently in the lung. Local control without salvage surgery was 74% at 5 years for all subsites and stages, and loco-regional disease-free survival was 72%. Eleven patients developed distant metastases, which was the only site of failure in 6 cases. Salvage surgery was successful in 2 cases. The actuarial estimates of ≥ grade-3 late toxicity was 4% for the mandibular bone and 23% for dysphagia, and 50% of the patients experienced a permanent xerostomy. Self-reported global quality of life in surviving patients was good (mean 68 points on a scale 0 to 100); consequences of impaired salivary function had most impact on nutritional and social aspects.ConclusionsHyperfractionated RT with concomitant CDDP is well tolerated and highly efficient in controlling moderately advanced to advanced cancers of the head and neck. Second primary tumors are the main cause of death after 3 years and were observed outside of the irradiated area, most frequently in the lung. Even after RT of large volumes to a high dose, salvage surgery can be successfully performed in individual cases. Self-reported quality of life of surviving patients is good, despite xerostomy-associated nutritional difficulties.ZusammenfassungZielAnalyse der Überlebensrate, des krankheitsspezifischen Überlebens, des Rezidivmusters, der Spättoxizität sowie der subjektiven Lebensqualität nach hyperfraktionierter Radiotherapie (RT) und gleichzeitiger Cisplatin-Chemotherapie (CDDP) bei Patienten mit mindestens zwei Jahren Beobachtungszeit im Rahmen einer prospektiven Phase-II-Studie.Patienten und MethodeIm Rahmen einer Pilotstudie (1988 bis 1994) wurden 64 Patienten (medianes Alter 55,5 Jahre) mit Stadium III oder IV kombiniert behandelt: RT 1,2 Gy zweimal täglich bis 74,4 Gy, CDDP 20 mg/m2 täglich an den Tagen 1 bis 5 der ersten und fünften Woche. Die Überlebenskurven sowie die Toxizität wurden aktuariell berechnet. Die mediane Beobachtungszeit war 3,3 Jahre für alle respektive 5,2 Jahre für die überlebenden Patienten. Zur Einschätzung der Lebensqualität wurden 23 tumorfrei überlebende Patienten angefragt, den EORTC-QLQ-C30-Fragebogen sowie das ergänzende Modul für Kopf-Hals-Tumoren H&N35 auszufüllen.ErgebnisseDas Gesamtüberleben betrug nach fünf Jahren 37%, während das krankheitsspezifische Überleben mit 59% deutlich höher lag. 23 Patienten sind am Tumor verstorben. Zweittumoren, hauptsächlich Lungenkarzinome (n=8), wurden bei 13 Patienten registriert und waren die hauptsächliche Todesursache nach über drei Jahren. Die lokale Tumorkontrolle ohne zusätzliche Chirurgie betrug 74% nach fünf Jahren und war für alle Lokalisationen und Stadien gleich; die lokoregionäre Tumorkontrollrate lag bei 64%. Fernmetastasen ohne ein lokoregionäres Therapieversagen wurden bei sechs Patienten gesehen. Eine „Rettungschirurgie” wurde in zwei Fällen erfolgreich durchgeführt. Die aktuarielle Spätkomplikationsrate ≥ Grad 3 betrug 4% für den Kieferknochen und 23% für Dysphagie; 50% der Patienten hatten eine bleibende komplette Xerostomie. Die globale Lebensqualität war gut (im Mittel 68 Punkte auf einer Skala von 0 bis 100). Folgen der gestörten Speichelsekretion hatten die größte Auswirkung auf die funktionelle Behinderung der Ernährung sowie der sozialen Kontakte.SchlußfolgerungenDie hyperfraktionierte RT mit gleichzeitiger CDDP-Gabe wird hinsichtlich Spättoxizität gut toleriert und ist effizient zur Behandlung fortgeschrittener Kopf-Hals-Tumoren. Im Gegensatz zu chirurgischen Serien treten Zweitkarzinome praktisch nur außerhalb des ursprünglichen Tumorbereichs auf. Eine „Rettungschirurgie” nach initialem Therapieversagen ist auch nach RT mit 74,4 Gy in Einzelfällen erfolgreich. Die selbstrapportierte Lebensqualität bei den Langzeitüberlebenden ist generell gut trotz gewisser, vorwiegend xerostomiebedingter Einschränkungen.

The Evaluation and Treatment of Lower Eyelid Paralysis

The lower eyelid conforms precisely across its length to the complex topography of the cornea, conjunctiva, and globe. Along with the upper eyelid, it protects the eye from foreign bodies, prevents desiccation, and helps circulate the tear film from its origin in the lacrimal gland to its drainage at the lacrimal puncta. Paralysis of the lower eyelid may result in ectropion, lid laxity, epiphora, and lagophthalmos. This article presents a structural approach to the evaluation and treatment of lower eyelid paralysis and describes the surgical procedures designed to correct the three-dimensional anatomic abnormalities underlying this disorder. These procedures are frequently performed in conjunction with upper lid procedures that are described in a previous article by Bergeron and Moe in this issue of the journal.

Lateral Transorbital Neuroendoscopic Approach to the Lateral Cavernous Sinus

Objective To design and assess the quality of a novel lateral retrocanthal endoscopic approach to the lateral cavernous sinus. Design Computer modeling software was used to optimize the geometry of the surgical pathway, which was confirmed on cadaver specimens. We calculated trajectories and surgically accessible areas to the middle fossa while applying a constraint on the amount of soft tissue retraction. Setting Virtual computer model to simulate the surgical approach and cadaver laboratory. Participants The authors. Main Outcome Measures Adequate surgical access to the lateral cavernous sinus and adjacent regions as determined by operations on the cadaver specimens. Additionally, geometric limitations were imposed as determined by the model so that retraction on soft tissue structures was maintained at a clinically safe distance. Results Our calculations revealed adequate access to the lateral cavernous sinus, Meckel cave, orbital apex, and middle fossa floor. Cadaveric testing revealed sufficient access to these areas using <10 mm of orbital retraction. Conclusions Our study validates not only the use of computer simulation to plan operative approaches but the feasibility of the lateral retrocanthal approach to the lateral cavernous sinus.

Applications and outcomes of orbital and transorbital endoscopic surgery.

Objective. To prospectively evaluate the safety, effectiveness, and utility of orbital and transorbital endoscopic surgery. Study Design. Case series with planned data collection. Setting. Level 1 trauma center and tertiary academic hospital. Subjects and Methods. Consecutive sample of 107 patients undergoing orbital or transorbital endoscopic operations. Main Outcome Measures. Ability to achieve intraoperative goals using endoscopic approach; occurrence of predetermined intraoperative or postoperative complications. Results. One hundred seven patients (aged 6-83 years) underwent orbital or transorbital endoscopic surgery for 6 different indications. Seven incisions were used. Endoscopic orbitotomies were made through all 4 orbital walls to access surrounding structures. Intraoperative goals were achieved endoscopically in 106 patients. Mean follow-up was 3 months (mean ± SD, 3.0 ± 3.5). No complication was directly related to surgical approach or use of endoscopy. Seventeen complications were detected in 2 categories: persistent diplopia and persistent vision change. No patient had vision loss. No nonfracture patient suffered a complication. Subgroup analysis demonstrated no difference in surgical success rates when compared with transnasal and transantral medial orbital wall and orbital floor repair and cerebrospinal fluid leak repair. Endoscopic visualization was advantageous in several respects: superior visualization and lighting, particularly posterior to the equator of the globe; image magnification; and video monitoring for education and operating room staff involvement. It also facilitated surgical navigation and computer-aided reconstruction. Conclusion. Orbital and transorbital endoscopy are versatile, effective, and safe approaches useful for addressing diverse urgent and elective problems. In appropriate clinical situations, these procedures may offer better access and visualization than open or transnasal approaches.