R. Garrel

Management of descending necrotizing mediastinitis.

Objective/Hypothesis Descending necrotizing mediastinitis is caused by downward spread of neck infections and constitutes a highly lethal complication of oropharyngeal lesions. This infection previously had a much worse prognosis. In recent years, more aggressive management has been recommended. The aim of this study is to evaluate the results with the association of thoracotomy and cervicotomy, medical care in an intensive care unit, and daily washing of drained cervical and thoracic tissues.

Continuous Facial Nerve Monitoring during Pleomorphic Adenoma Recurrence Surgery

Objectives: Surgery of recurrent pleomorphic adenoma (RPA) is known to lead to a high facial nerve complication rate. The efficacy of the continuous facial nerve monitoring (CFNM) technique remains to be proven in RPA surgery. The goal was thus to evaluate facial nerve palsy rates and the recovery period after parotidectomy for RPA using CFNM by way of continuous electromyography and to compare these rates and the operation time with those of patients who had undergone surgery without facial nerve monitoring.

Randomized phase III trial comparing induction chemotherapy followed by radiotherapy to concomitant chemoradiotherapy for laryngeal preservation in T3M0 pyriform sinus carcinoma.

Conclusions. Conventional radiotherapy with concurrent cisplatin is significantly superior to induction cisplatin fluorouracil chemotherapy followed by radiotherapy in terms of laryngeal preservation in patients with T3 hypopharyngeal carcinoma. Despite a high rate of laryngeal preservation no survival benefit was recorded in this selected population. Objectives. To compare conventional radiotherapy with concurrent cisplatin to induction chemotherapy with cisplatin fluorouracil followed by conventional radiotherapy. The primary end point was the preservation of the larynx. The secondary end points included toxicity, causes of death, and survival rates. Patients and methods. Seventy-one adult patients with previously untreated resectable T3 pyriform sinus squamous cell carcinoma were enrolled in the multicenter prospective randomized phase III trial. They were evaluated for organ preservation, survival rates, and toxic reactions. Results. The rates of laryngeal preservation at 2 years were 68% for the induction chemotherapy (IC) group and 92% for the chemoradiotherapy (CR) group (p = 0.016). At 2 years, the event-free survival rates were 36% and 41% for the IC group and CR group, respectively.

Fourth Branchial Pouch Sinus: From Diagnosis to Treatment:

BACKGROUND: Fourth branchial pouch sinus (FBPS) is rare and frequently unknown to clinicians. Misdiagnosis is common and definitive surgery is often made difficult by previous episodes of infection and failed attempts at excision. The purpose of this paper is to clarify the diagnostic criteria and the methods used for the surgical management of FBPS. MATERIALS AND METHOD: From a series of 265 head and neck cysts and fistulae, 7 cases of FBPS were retrospectively reviewed. The surgical technique is detailed. RESULTS: Six cases were located on the left side and one on the right. CT scanning showed an air-filled structure on both sides of the lesser horn of the thyroid cartilage in 2 cases out of 4, and barium swallow found a FBPS in 1 case out of 3. Direct pharyngoscopy allowed confirmation of the diagnosis in all cases and permitted catheterization of the tract with the spring guidewire of a vascular catheter which helped surgical location and subsequent dissection. The recurrent laryngeal nerve was systematically dissected to avoid inadvertent damage. A hemi-thyroidectomy was performed in one case. A transient laryngeal paralysis (lasting 9 months) was noted in a 3-week-old newborn operated on. None of the 7 cases had a recurrence after complete resection of the FBPS (3.7 years average follow-up). CONCLUSION: Symptoms on the right side do not exclude the diagnosis of a FBPS. Endoscopy is the key investigation. It allows confirmation of the diagnosis and catheterization of the tract, which aids the surgical dissection. Total removal of the sinus tract tissue with dissection and preservation of the recurrent laryngeal nerve is recommended. EBM rating: A-1

Objective Voice Analysis in Dysphonic Patients: New Data Including Nonlinear Measurements

Objectives/Hypothesis: This report describes a comparative study of objective voice evaluation using a multiparametric protocol including aerodynamic parameters and linear and nonlinear acoustic parameters recorded on an EVA® workstation and perceptual voice analysis by a jury. Study Design: A total of 449 samples were retrospectively selected including 391 patients with pathological voices (308 women and 141 men) and 58 controls with normal voices (38 women and 20 men). A prospective complementary study concerning 43 female patients and 3 controls is presented. Methods: Objective measures included fundamental frequency (Fo), intensity, jitter, signal-to-noise ratio (SNR), Lyapunov coefficient (Lya), oral airflow (OAF), estimated subglottic pressure (ESGP), maximum phonatory time (MPT) and vocal range. A jury of 4 experienced listeners was instructed to classify voice samples (continuous speech) according to the G (overall dysphonia) component of the GRBAS score on a Visual Analogue Scale (VAS) secondarily transformed in a scale ranging from 0 for normal to 3 for severe dysphonia. Results: It was shown that a nonlinear combination of only 7 parameters in women (vocal range, Lya, ESGP, MPT, OAF, SNR, and Fo) and 6 parameters in men (vocal range, Lya, OAF, ESGP, Fo, SNR) allowed classification of 81% voice samples in the same grade as the jury in women and 84% in men. In the prospective study, 80.5% were correctly classified with the same set of objective measurements. Discussion: The relative importance of the different objective parameters in this type of discriminant analysis is dealt with. Special emphasis is placed on Lya.

Neck restaging with sentinel node biopsy in T1-T2N0 oral and oropharyngeal cancer: Why and how?

Objective: To evaluate the lack of accuracy in neck staging with the classical technique (i.e., neck dissection and routine histopathology) with the sentinel node (SN) biopsy in oral and oropharyngeal T1-T2N0 cancer. Study Design: Cross-sectional study with planned data collection. Setting: Tertiary center care. Subjects and Methods: In 50 consecutive patients, the pathological stage of sentinel node (pSN) was established after analyzing SN biopsies (n = 148) using serial sectioning and immunohistochemistry. Systematic selective neck dissection was performed. The pN stage was established with routine histopathologic analysis of both the non-SN (n = 1075) and the 148 SN biopsies. Results: The sensitivity and negative predictive value of pSN staging were 100 percent. Conversely, if one considers pSN staging procedure as the reference test for micro- and macro-metastasis diagnosis, the sensitivity of the classical pN staging procedure was 50 percent (9/1; 95% CI 26.9-73.1) and its negative predictive value was 78 percent (95% CI 61.9-88.8). Fifteen patients (30%) were upstaged, including nine cases from pN0 to pSN ≥ 1 and six cases from pN1 to pSN2. Two of the pN0-pSN1 upstaged patients died with relapsed neck disease. Conclusion: The SN biopsy technique appeared to be the best staging method in cN0 patients and provided evidence that routinely undiagnosed lymph node invasion may have clinical significance.

The Diagnostic Accuracy of Reverse Transcription-PCR Quantification of Cytokeratin mRNA in the Detection of Sentinel Lymph Node Invasion in Oral and Oropharyngeal Squamous Cell Carcinoma: A Comparison with Immunohistochemistry

Purpose: The main goal of sentinel lymph node (SLN) detection in head and neck squamous cell carcinomas is to limit neck dissections to pN+ cases only. However, intraoperative + diagnosis cannot be routinely done using the current gold standard, serial step sectioning with immunohistochemistry. Real-time quantitative reverse transcription-PCR (RT-PCR) is potentially compatible with intraoperative use, proving highly sensitive in detecting molecular markers. This study postoperatively assessed the accuracy of quantitative RT-PCR in staging patients from their SLN. Experimental Design: A combined analysis on the same SLN by serial step sectioning with immunohistochemistry and quantitative RT-PCR targeting cytokeratins 5, 14, and 17 was done in 18 consecutive patients with oral or oropharyngeal squamous cell carcinoma and 10 control subjects. Results: From 71 lymph nodes examined, mRNA levels (KRT) were linked to metastasis size for the three cytokeratins studied (Pearson correlation coefficient, r = 0.89, 0.73, and 0.77 for KRT 5, 14, and 17 respectively; P < 0.05). Histopathology-positive SLNs (macro- and micrometastases) showed higher mRNA values than negative SLNs for KRT 17 (P < 10−4) and KRT 14 (P < 10−2). KRT 5 showed nonsignificant results. KRT 17 seemed to be the most accurate marker for the diagnosis of micrometastases of a size >450 μm. Smaller micrometastases and isolated tumor cells did not provide results above the background level. Receiver operating characteristic curve analysis for KRT 17 identified a cutoff value where patient staging reached 100% specificity and sensitivity for macro- and micrometastases. Conclusion: Quantitative RT-PCR for SLN staging in cN0 patients with oral and oropharyngeal squamous cell carcinoma seems to be a promising approach.

Modified subtotal laryngectomy with cricohyoidoepiglottopexy-long term results in 81 patients

Standard treatment of early glottic carcinoma is radiotherapy, but involvement of the anterior commissure leads to a reduced cure rate.1 We investigated retrospectively whether our modified subtotal laryngectomy had improved results for early glottic carcinomas involving the anterior commissure, without causing excessive disability to laryngeal functions.

Transoral robotic surgery for the treatment of T1–T2 carcinoma of the larynx: Preliminary study

To determine the feasibility and the preliminary oncological results of transoral robotic surgery (TORS) for the treatment of early stage laryngeal tumors.

Prognostic value of a three-grade classification in primary epithelial parotid carcinoma: Result of a histological review from a 20-year experience of total parotidectomy with neck dissection in a single institution

BACKGROUND The tumour grading of primary parotid cancers (PPCs) remains controversial. METHODS A 20-year standardised single centre treatment has been assessed retrospectively. The histological review of 155 consecutively treated parotid malignancies identified 96 suitable cases for univariate and multivariate survival analyses. RESULTS Treatment involved total parotidectomy, neck dissection and post-operative radiotherapy in, respectively, 91.7%, 83.3% and 70.4% of cases. The 5-year overall survival, disease-specific and recurrence-free survival rates were 79.4%, 83.5% and 70.8%, respectively. Univariate analysis confirmed the classical prognostic factors, i.e. age>60 years, male gender, facial palsy, hardness of the tumour, clinical stage, tumour grade, facial nerve invasion and lymph node metastases. Multivariate analysis identified a three-grade classification just after the clinical stage as the most important prognostic factor. CONCLUSION This study identifies the prognostic significance of intermediate grade tumours.