Raimundo Gutierrez-Fonseca

Vertical Partial Laryngectomy versus Supracricoid Partial Laryngectomy for Selected Carcinomas of the True Vocal Cord Classified as T2N0

From an inception cohort of 204 patients with squamous cell carcinoma of the true vocal cord classified as T2N0 and a minimum of 3 years of follow-up, the authors compare the oncological and functional outcomes following vertical partial laryngectomy (group 1; 85 patients) and supracricoid partial laryngectomy (group 2; 119 patients). The 10-year actuarial survival estimate was 46.2% for group 1 and 66.4% for group 2. Survival was statistically more likely to be reduced (p = .019) in group 1 than in group 2. The 10-year actuarial local control estimate was 69.3% for group 1 and 94.6% for group 2. Local recurrence was statistically more likely to occur (p < .0001) in group 1 than in group 2. Salvage treatment resulted in an overall 94.1% local control rate and a 78.1% laryngeal preservation rate for group 1 and an overall 99.2% local control rate and a 94.9% laryngeal preservation rate for group 2. The 10-year actuarial nodal control estimate was 81.7% for group 1 and 93.7% for group 2. Nodal recurrence was statistically more likely to occur (p = .028) in group 1 than in group 2. The 10-year actuarial estimate for patients without distant metastasis was 84.6% for group 1 and 95.1% for group 2. Distant metastasis was statistically more likely to occur (p = .05) in group 1 than in group 2. The hospital mortality rate was 1.2% for group 1 and 0.8% for group 2. The incidence of permanent gastrostomy was 0% for group 1 and 2.4% for group 2. The incidence of permanent tracheostomy was 1.2% for group 1 and 2.4% for group 2. The incidence of completion laryngectomy due to functional problems was 1.2% for group 1 and 0.8% for group 2.

Frontolateral vertical partial laryngectomy without tracheotomy for invasive squamous cell carcinoma of the true vocal cord: a 25-year experience

On the basis of an inception cohort of 270 patients with a previously untreated invasive squamous cell carcinoma of the true vocal cord (232 T1N0M0, 35 T2N0M0, and 3 T3N0M0) and a minimum of 3 years of follow-up, the authors analyze the oncological and functional outcomes following frontolateral vertical partial laryngectomy without tracheotomy. The 5-year Kaplan-Meier actuarial survival estimate ranged from 83.1% for T1 tumors to 67.2% for T2 tumors (p = .005). On univariate analysis, a significant statistical relationship was noted between reduced survival and the following variables: increased age, increased Charlson comorbidity index score over grade 0, increased tobacco intake, increased alcohol intake, increased T stage, local failure, nodal failure, and development of a metachronous second primary cancer. The hospital mortality rate was 0.4%. A significant postoperative surgical complication was noted in 49 patients (18.1%). The predominant significant surgical complication was wound infection (19 patients; 7%), followed by seroma and major subcutaneous emphysema. No significant statistical relationship was noted in a comparison of each significant postoperative complication (including postoperative death) with the variables under analysis. The incidence of secondary tracheotomy was 0.4%. The incidence of completion laryngectomy due to functional problems was 0%. The 5-year Kaplan-Meier actuarial local control estimate was 91% for T1 tumors and 68.7% for T2 tumors (p < .0001). Within the T1 tumors, the 5-year Kaplan-Meier actuarial local control estimate ranged from 96.2% for tumors without anterior commissure involvement to 74.7% for tumors with anterior commissure involvement (p = .0002). On univariate analysis, a significant statistical relationship was noted between an increase in local recurrence and the following variables: increased T stage, anterior commissure involvement, and pathological margin involvement. The overall disease control rate and laryngeal preservation rate were 92.9% and 93.3%, respectively.

Local recurrence after vertical partial laryngectomy, a conservative modality of treatment for patients with Stage I–II squamous cell carcinoma of the glottis

Based on an inception cohort of 103 patients who had local recurrence (Group I) and a witness group of 311 patients who achieved local control (Group II) after vertical partial laryngectomy for Stage I–II glottic carcinoma, the current retrospective study documented the consequences and management of local recurrence.

Capacidad diagnóstica de la resonancia magnética con técnica de difusión no eco-planar en la detección de colesteatomas primarios y recurrentes

INTRODUCTION AND AIMS the aim of this study was to determine the certainty of non-echo-planar imaging diffusion-weighted magnetic resonance imaging (non-EPI DW MRI) in the diagnosis of primary and recurrent cholesteatoma in patients with clinical suspicion of cholesteatoma, assessing the sensitivity and specificity of the test in both groups. METHODS Seventy-five patients with clinical suspicion of cholesteatoma were included in our study. Forty-eight cases had primary suspicion of cholesteatoma and 27 cases had recurrent suspicion of cholesteatoma. All patients received non-EPI DW MRI tests before surgery, and radiological and surgical findings were compared. RESULTS Sensitivity, specificity and the positive and negative predictive value for primary diagnosis of cholesteatoma group were 91.2%, 50%, 81.6% and 70%, respectively. For the recurrent cholesteatoma group these results were 100%, 66.7%, 90.9% and 100%, respectively. CONCLUSION Non-echo-planar imaging diffusion-weighted magnetic resonance imaging is a high sensitivity imaging test for detecting cholesteatoma, for both primary diagnosis and for recurrent cases.

Management options for gustatory sweating (Frey syndrome)

Gustatory sweating (Frey syndrome) is a universal problem after surgery of the parotid region and might be encountered in a large number of pathology cases. Numerous treatment techniques and options have been offered to manage this condition; however, none has met with universal acceptance. This article reviews the history, pathophysiology, incidence, prevention, and management options for gustatory sweating.

Transoral Fully Robotic Dissection of a Parapharyngeal Hemangioma.

AbstractSoft tissue robotics found its trigger for success in minimally invasive surgery. The minimization of the surgical damage is more obvious as the surgical alternative is more aggressive. In head and neck surgery, potential sequelae are both functional and cosmetic. Robotic instrumentation might allow for further development of the transoral approach to the deep regions of the face.The authors present an uneventful, fully robotic, transoral surgical excision of a parapharyngeal hemangioma. The authors discuss management alternatives, surgical risks, and safety measures. The medial approach is the natural choice, provided it is safe and technically feasible. Transoral robotic surgery could be a reasonable minimally invasive approach for selected parapharyngeal tumors.

Letter to the Editor regarding “Robotic or non‐robotic transoral laryngectomy”

Dear Editor, We live in a thrilling era in the rise of robotic surgery. Although transoral robotic surgery is already established as a safe and effective minimally invasive surgical approach for head and neck cancer, surgical tools are constantly evolving and new indications are explored. Recently, the transoral total laryngectomy with a new flexible robotic system was described again in a cadaveric model. The article points out further potentialities brought by robotics and serves to highlight the fact that radical surgery might also benefit from minimal approaches. Lawson et al were the first to describe transoral total laryngectomy with a previous robotic system. The procedure requires that a new stoma is created (the tracheostomy), and, thus, it is necessarily not totally transoral but a hybrid procedure, with a percutaneous transcervical component. Main contributions of the present soft tissue surgical robotic systems are related to improved vision and dexterity. However, current nonrobotic technology also allows improvements with more conventional (and less expensive) instrumentation. One of the authors (M.F.) has taken advantage of advanced optical and surgical devices to take a further step into nonrobotic transoral endoscopic surgery. There is already relevant clinical experience that includes total laryngectomy with what has been named transoral ultrasonic surgery. The main difference with the robotic technique is that most of the dissection is done through the inferior cervical incision. This type of video-assisted dissection is used as a reference in the first description of total transoral total laryngectomy with the flexible robot, although it has been obviated that the model is a nonrobotic technique. The focus of robotics and its indications in head and neck surgery are still a matter of debate. Obviously, there is a distance between what can be done and what might ultimately become a real contribution. Moreover, for this particular indication of radical transoral laryngeal surgery, patients who meet inclusion criteria are uncommon, and, therefore, it is difficult to obtain evidence of medical benefit. Nevertheless, the flexible system could potentially overcome some limitations of the previous devices, as it is specifically designed for a transoral approach. There is also a risk that this strength might become a weakness, as cost justification of the presently dominant robotic system relies on caseload, which in most of the centers is based on a variety of surgical indications in different medical specialties. The transorificial approach is the best of the Flex. This is an added challenge for the flexible system in the short term, as efficiency is a basic argument for the adoption of new surgical technology.

Management of the Airway in Transoral Robotic Surgery for Head and Neck Cancer

Aim of the study: To evaluate the safety and effectiveness of a conservative management of the airway without tracheotomy in a new transoral robotic surgery program for head and neck cancer. Materials and Method: Observational prospective study on a cohort without a control group. We included patients diagnosed of oropharyngeal, hypopharyngeal or laryngeal cancer who underwent transoral robotic surgery between July 2013 and July 2016. Results: Thirty-six patients met the inclusion criteria; 72% were oropharyngeal tumors (most frequently, 13 cases, tumors of the base of the tongue). The most frequent local extension was T2 (18 cases) but almost two-thirds (64%) were classified as advanced tumors (stages III and IV) due to the N stage. Lymph node surgery and transoral primary tumor surgery were staged when required. The intervention was successful in all cases. After robotic surgery, the patients in risk remained intubated for 24 hours. All were managed without a tracheostomy except for a patient with a synchronous diagnosis of sleep apnea (who received a temporary prophylactic tracheostomy) and a case of combined transoral-transcervical surgery (who received a non-programmed tracheotomy). There were no relevant perioperative incidences related to the airway except for a case of delayed bleeding. Conclusions: In our early experience, with a conservative management protocol with two-stage surgery and programmed postoperative intubation, transoral robotic surgery for oncological indications has been feasible and safe without a tracheotomy. *Corresponding author: Jose Granell, Rey Juan Carlos University Hospital,c/ Gladiolo s/n, 28933 Mostoles, Madrid, E-mail: jose.granell@hospitalreyjuancarlos.es

Ajustar el enfoque en cirugía robótica transoral

We read the article by Esteban et al. ‘‘Critical analysis of robotic surgery for laryngeal tumours’’ with interest. We applaud the authors’ initiative and essentially share their critical spirit. However, evidence is rapidly accumulating to endorse robotic surgery for minimally invasive approaches in head and neck cancer. There has been discussion for a long time on the indications for transoral robotic surgery [TORS]), and in many cases the balance has already been swayed by the weight of evidence. Where we disagree, however, is on the focus of the review. An overall critique is apparently made of robotic surgery on the head and neck, focussing on laryngeal tumour indications, when what should be being discussed is its essential usefulness in the oropharynx. The fact that a different department surgically treats oropharyngeal tumours without the aid of the robot is a superfluous argument, since this very status quo is perhaps what the authors should be questioning. Certainly, under current circumstances, no centre would acquire a ‘‘da Vinci’’ to treat laryngeal cancer. Not even for an integral TORS programme. However, why not use it where it exists? The cost of specific consumables for a TORS procedure (VAT included) is D 1027.87: a ‘‘lifetime’’ of the Maryland dissector, or of the spatula tipped monopolar cautery and the set of sterile covers for the stretcher. For the oropharynx, it clearly outstrips any alternative, (not minimally invasive) surgical approach. For the larynx it is simply reasonable from a financial point of view, bearing in mind that the fixed costs of the apparatus (depreciation and maintenance) are unaltered and there are strong arguments in its favour: surgery is easier and faster, more reproducible

Descending Mediastinitis with Mediastinal Abscess after Supracricoid Partial Laryngectomy

We document a rare and not-yet-reported condition after supracricoid partial laryngectomy: The development of descending mediastinitis with mediastinal abscess. We present a case in which early diagnosis and team management allowed for a successful outcome. The pathophysiology of this severe complication, as well as its diagnosis, management, and prevention, is discussed, together with a review of the medical scientific literature.