Marco Benazzo

The nose oropharynx hypopharynx and larynx (NOHL) classification: a new system of diagnostic standardized examination for OSAHS patients.

The main pathological event of obstructive sleep apnea hypopnea syndrome (OSAHS) is the apneic collapse of the upper airways (UA). Frequently, UA collapse occurs at the same time at different section levels. Identifying the site and the dynamic pattern of obstruction is mandatory in therapeutical decision-making, and in particular if a surgical therapy option is taken into account. Nowadays, awake fiberoptic nasopharyngeal endoscopy represents the first level diagnostic technique to be performed in such patients, but recently, the drug-induced sleep endoscopy (DISE) has been introduced to overcome the limits of the awake nasopharyngeal endoscopy. Whatever diagnostic tool we decide to use, one of the main problems encountered is the standardization of the description of the sites and dynamic patterns of UA collapses. In this paper, the authors describe the NOHL classification, which could be applied during awake and sleep endoscopy, and allows a simple, quick, and effective evaluation of grade and patterns of UA collapse, suggesting its application, especially in therapeutical decision-making and in the analysis of surgical outcomes.

Clinical Outcomes and Complications Associated with TORS for OSAHS: A Benchmark for Evaluating an Emerging Surgical Technology in a Targeted Application for Benign Disease

Background: The aim of this study was to create benchmarks for evaluating clinical outcomes and complications of transoral robotic surgeries (TORS) in a multicenter setting. Methods: 243 TORS for obstructive sleep apnea/hypopnea syndrome (OSAHS) operations, carried out between 2008 and 2012, were analyzed at 7 different centers. The average hospitalization was 3.5 days. The mean patient age was 50 ± 12 years, the average BMI at the time of the procedure was 28.53 ± 3.87 and the majority of the patients were men (81%). Results: The mean preoperative and postoperative apnea/hypopnea index was 43.0 ± 22.6 and 17.9 ± 18.4, respectively (p < 0.001). The mean preoperative and postoperative Epworth Sleepiness Scale score was 12.34 ± 5.19 and 5.7 ± 3.49, respectively (p < 0.001). The mean pre- and postoperative lowest O2 saturation was 79.5 ± 8.77 and 83.9 ± 6.38%, respectively (p < 0.001). Conclusions: Patients undergoing TORS as part of a multilevel approach for the treatment of OSAHS have a reasonable expectation of success with minimal long-term morbidity.

Effectiveness of narrow band imaging in the detection of premalignant and malignant lesions of the larynx: Validation of a new endoscopic clinical classification

The purpose of this study was to assess the value of narrow band imaging (NBI) endoscopy in the diagnosis of pharyngolaryngeal lesions and to demonstrate the validity of a new NBI‐based classification of their vascular pattern.

Efficacy of selective lymph node dissection in clinically negative neck.

OBJECTIVE: The purpose of this study was to evaluate the efficacy of selective neck dissection (SND) for elective treatment of the clinically negative neck in head and neck squamous cell carcinoma (SCC). METHODS: A retrospective review was undertaken on 91 previously untreated patients with T1–4 SCC of oral cavity (23), oropharynx (5), hypopharynx (7), larynx (56), and clinically negative neck (NO), undergoing 126 SND from January 1990 to March 1999 at a single institution. Twenty-five patients received postoperative radiation therapy on the basis of histologic evidence of >2 positive nodes, extracapsular spread (ECS), and/or the presence of advanced primary lesion. RESULTS: On pathologic examination the average number of lymph nodes was 20.5 per neck, occult disease was detected in 14 (11.11%) of 126 necks; of necks with positive nodes, 6 (42.85%) of 14 had ECS. The median follow-up was 36 months. Overall recurrence rate (local, regional, and distant) was 12.8% (11 of 91). Recurrent disease developed in the neck of one patient, outside the dissected field. There was no difference in recurrence rate between pN0 and pN+ patients, as well as between pN+ with or without ECS. Overall survival rate was 84% (77 of 91), with a statistically significant difference between pN0 and pN+ necks. CONCLUSION: SND seems to be a pragmatic approach that is as effective as comprehensive procedures for staging and treating the clinically negative neck.

Voice restoration after circumferential pharyngolaryngectomy with free jejunum repair

Abstract Speech restoration after circumferential pharyngolaryngectomy with free jejunal repair for advanced tumors of the hypopharyngo-esophageal tract remains a difficult problem to solve. We report here the results of secondary voice restoration in six patients who received a Provox 2 type prosthesis and intensive speech therapy after circumferential pharyngolaryngectomy with free jejunum repair. No patient had operative or post-operative complications due to insertion of the prosthesis. No patient had to have the prosthesis removed during the follow-up (8 to 14 months). Analysis of some acoustic parameters of voice (fundamental frequency, waveform perturbations) and qualitative characteristics of speech (intelligibility, pleasantness and acceptability) demonstrated that all the patients were able to produce satisfactory speech after tracheojejunum puncture and speech therapy and were satisfied with their own ability to communicate. Our results are reassuring and we therefore advise that in patients undergoing free jejunum flap reconstruction of the hypopharyngo-esophageal tract voice restoration should be attempted by placing a voice prosthesis through a secondary tracheo-esophageal puncture and providing intensive speech training.

Jejunum free flap in hypopharynx reconstruction: case series.

BackgroundSurgical treatment of hypopharyngeal cancers with extension to the retrocricoid region generally requires a circumferential pharyngolaryngectomy followed by a reconstruction of the removed segment of the upper digestive tract. Historically, many techniques have been used in order to achieve a safe and functional reconstruction. Jejunum interposition is generally considered the best reconstructive technique.MethodsThis study examines the details of the surgical technique, the complications, the oncological and the functional results in a series of 29 consecutive patients submitted to circumferential pharyngoesophageal resection for advanced hypopharyngeal cancer followed by reconstruction with a free flap of jejunum.ResultsThree of the transplants failed because of venous thrombosis. The overall success rate was 90%. There were no general complications. A good swallowing has been preserved in all our patients. All our patients where a phonatory prosthesis was positioned (20/29) were able to achieve speech following speech therapy and all were satisfied with their own capacity to communicate.ConclusionsThe prognosis of hypopharyngeal tumours (18–40% at 5 years) remains poor, but jejunum autografts are being shown to be an excellent choice for the reconstruction of the cervical hypopharyngo-oesophagus offering the patient fast rehabilitation and a reasonable quality of survival. Our experience confirm that this kind of reconstruction is safe with a good results in improving oncologic controls and restoring a good quality of life.

Electrochemotherapy for the treatment of recurrent head and neck cancers: Preliminary results

AIMS AND BACKGROUND Electrochemotherapy is a tumor ablation modality providing delivery into the cell interior of impermeant or poorly permeant chemotherapeutic drugs such as cisplatin and bleomycin. A locally applied electrical field enhances the membrane permeability allowing intracellular accumulation of the chemotherapeutic agent. The aim of the study was to evaluate the effectiveness of ECT for the treatment of a group of patients affected by recurrent of extended primary head and neck cancer and not suitable for standard therapeutic options. METHODS AND STUDY DESIGN From April 2009 to January 2011, we treated with electrochemotherapy a total of 15 patients with head and neck cancers, 13 with squamous cell carcinoma, 1 with basaloid carcinoma and 1 with Merkel cell carcinoma. Electrical pulses were delivered to 33 lesions (3 primaries, 30 recurrences) after an intravenous bolus injection of a dose of 15,000 IU/m2 of bleomycin. In 3 cases, the lesion treated was a pathologic lymph node. RESULTS Of the 31 lesions assessable for the study, 19 (61.5%) showed a complete response, 10 (32.5%) a partial response, 1 (3%) stable disease and 1 (3%) progression of the disease. The objective response 2 months after the procedure was 94%. All the lesions that underwent complete regression were less than 3 cm in their maximum diameter. The 2 assessable cases of pathologic lymph nodes showed a partial or no response. After a follow-up of 2 to 20 months, 29% of the patients were alive and free of disease, 50% were alive with disease, 14% died for disease and 7% died for other causes. CONCLUSIONS Our study confirms the effectiveness of electrochemotherapy in the treatment or local control of recurrent or extended primary head and neck cancer in patients not suitable for standard therapeutic options.

Induction chemotherapy by superselective intra-arterial high-dose carboplatin infusion for head and neck cancer

Abstract To evaluate the feasibility, maximum dose of drug tolerated, technical problems, systemic and local toxicity, response rate, overall and disease-free survival, we studied superselective intra-arterial infusion of high-dose carboplatin as part of a multimodality treatment for head and neck cancer. Forty patients with untreated stage II–IV head and neck squamous cell carcinomas received induction chemotherapy with high-dose carboplatin (three cycles at 2-week intervals using 300–350 mg/m2 per cycle), delivered via superselective transfemoral angiography followed by radiotherapy or surgery plus radiotherapy. No technical complications occurred during or after the infusion. Systemic toxicity was minimal, and local toxicity was moderate. At the end of chemotherapy the overall complete and partial response rate was 90% (36/40) at the primary site and 64% (16/25) at the neck nodes. The median follow-up was 24.4 months (range 3–52). To date 21 patients are alive without disease, 2 are alive with disease, 13 have died of disease, and 4 have developed a metachronous lung tumor. There was a good correlation between the response to chemotherapy and disease-free survival. No statistically significant benefit in survival was observed with respect to other series of head and neck tumors treated with different protocols. However, discriminating between responding and nonresponding patients, this procedure can have a prognostic significance in planning integrated treatments for these types of tumors.

Predicting patients at risk for pain associated with electrochemotherapy

Abstract Background. Electrochemotherapy describes the use of electric pulses to enhance chemotherapy uptake, and has proven highly efficient in treating cutaneous metastases. Patients referred for electrochemotherapy present with diverse clinical pictures, from multiple small lesions to large, ulcerated lesions. Post-electrochemotherapy pain has been observed in some patients. The objectives of this study were to evaluate pain scores before and after electrochemotherapy, and to investigate if patients at risk of post-procedure pain could be identified. Methods. Seven cancer centres in the International Network for Sharing Practices on Electrochemotherapy (INSPECT) consecutively and prospectively reported to a common database. Electrochemotherapy consisted of intratumoural or intravenous injection of bleomycin, followed by delivery of electric pulses in local or general anesthesia. Results. Of 121 patients 39% had metastatic melanoma, 18% squamous cell carcinoma, 16% breast cancer, 13% basal-cell carcinoma, and 14% other malignancies. Median size of the largest nodules was 2.3 cm (range 0.3–40 cm). A majority of patients presented with low pain scores, and this continued through follow-up (74%). A subset of patients had moderate (13%) or severe pain (13%) after treatment. Post-procedure pain was statistically significantly associated with: 1) moderate or severe pain before treatment (p < 0.0001); 2) size of the largest treated lesion (p < 0.01); 3) previous irradiation (p < 0.02); and 4) high treatment current value (p < 0.0001). Conclusion. The majority of patients had no or mild pain after electrochemotherapy. Patients at risk for post-procedure pain could be identified at the pre-treatment visit, and/or at the time of treatment, enabling a pain management strategy for this group.

Sternocleidomastoid muscle flap in esophageal perforation repair after cervical spine surgery: concepts, techniques, and personal experience.

Study Design A retrospective report was conducted on clinical and instrumental data of 3 patients treated for esophageal perforation after anterior cervical spine surgery. Objective To define indications and evaluate the safety and effectiveness of surgical repair of esophageal perforations by means of sternocleidomastoid (SCM) muscle flap in the setting of anterior spinal surgery. Summary of Background Data Esophageal perforation is an occasional or underreported complication in anterior cervical spine surgery. To prevent its potentially devastating and even life-threatening sequelae, prompt diagnosis and treatment are required. No treatment protocol has yet been standardized. In addition to conservative measures, several surgical approaches have been presented, ranging from primary repair to reconstruction with local, regional, or distant flaps. Methods Primary spinal pathology and intervention, esophageal fistulae morphology, diagnostic work-up, clinical course, and surgical techniques for their repair are illustrated in each case. Follow-up data have been gathered by in-person visits. Results Mean time from discovery of perforation to definitive surgical treatment institution was 44.3 days (range: 34 to 61 d). SCM muscle flap way used as reinforcement and protection of a primary esophageal suture in 2 cases and as a patch to the perforation in 1 case. All the fistulae healed without further complications. Mean time to oral feeding resumption was 17.6 days (range: 10 to 27 d) and mean hospitalization time was 19 days (range: 11 to 28 d). All the patients presented with a free oral diet at the last follow-up check. Conclusions Esophageal perforation treatment has to be multidisciplinary and tailored on each individual case. SCM muscle flap, used as reinforcement of a primary suture or as a patch to the lesion, has proved to be effective as definitive treatment for persisting or recurring esophageal fistulae after anterior cervical spine surgery. In this setting, conservative treatments may be inadequate or may actually perpetuate the condition.