Walter F. Thumfart

Laser Surgery for the Treatment of Larynx Carcinomas: Indications, Techniques, and Preliminary Results:

The authors have developed four different types of endolaryngeal laser resections for the treatment of larynx carcinomas. These new techniques are based on traditional concepts employed in partial larynx resections. From 1986 onward, 110 patients with laryngeal cancers were treated by endoscopic laser surgery. One hundred six patients were operated on for cure and 4 for palliation. In 9 cases of T3 tumor, complete removal of the tumor was not possible, requiring total laryngectomy. In all T2 cancers of the glottis and subglottis (n = 36), a total resection was possible. Additional staged neck dissection was performed in 16 cases, and postoperative radiotherapy in 10 cases. Follow-up investigations of the patients treated for cure (n = 106) cover a period of 3 to 42 months (mean, 22 months). These revealed 6 recurrences in the larynx, which were treated by laryngectomy. Recurrences in the cervical nodes were seen in 2 patients following resection of a supraglottic tumor and a subglottic tumor, respectively. Seven patients could not be followed up, 4 patients died of intercurrent disease, and 87 patients are alive and free of tumor. At present the number of recurrences and the rate of survival show no significant difference from those previously reported after conventional surgery. The phonatory function is not always predictable and still remains to be investigated. The authors believe that laser surgery may obviate the need for total laryngectomies in selected cases of laryngeal cancer, especially in T2 tumors. However, T3 tumors should not be treated by endolaryngeal laser surgery.

Minimally Invasive Head Holder to Improve the Performance of Frameless Stereotactic Surgery

Frameless stereotactic procedures crucially depend on the firmness of immobilization. Once registered, shifting of the patient leads to inaccuracy, and the patient registration has to be realigned. To overcome the drawbacks of conventional invasive fixation for neurosurgery and the widely accepted fixation with surgical tape in ENT, the Vogele‐Bale‐Hohner (VBH) head holder has been developed. It permits rigid, noninvasive fixation of the head by using an individualized dental cast attached to the upper jaw by vacuum. Oral intubation is uncomplicated. In addition, a special registration device providing well defined reference points can be mounted to the mouthpiece. We report the first promising clinical applications of this device.

Cordectomy versus Arytenoidectomy in the Management of Bilateral Vocal Cord Paralysis

Our objective was to assess the effectiveness of transoral laser cordectomy and laser arytenoidectomy and to compare the results with a view to respiratory and phonatory function and deglutition. Twenty-eight patients with bilateral vocal cord paralysis were included in a prospective study. Eighteen patients had cordectomy, and 10, arytenoidectomy. Lung function tests and voice analysis were performed preoperatively and postoperatively. Subclinical aspiration was determined by endoscopic evaluation of the larynx during deglutition. The results were compared to determine the relative effectiveness of both surgical methods. How volume spirograms documented equally improved flow rates in both groups. The final voice evaluation revealed that maximum phonation time, peak sound pressure levels, and frequency range were reduced in all 28 patients, but the phonatory results varied considerably in each group. Subclinical aspiration was noticed in 5 of 10 patients after arytenoidectomy, but in none of 18 patients after cordectomy. Four of 6 previously tracheostomized patients were decannulated within 2 weeks after surgery, while the other 22 patients had no perioperative tracheostomies. We conclude that transoral laser cordectomy and arytenoidectomy are equally effective and reliable in the management of the restricted airway. Phonatory outcome is not predictable with either surgical procedure. Cordectomy is easier and faster to perform, and subclinical aspiration is not encountered with this procedure.

Distant metastasis of parotid gland tumors

The incidence of distant metastasis in head and neck cancer and especially in salivary gland cancer is relatively low in comparison to other malignancies. However, the presence of distant metastasis heralds a poor prognosis in head and neck cancer, with a median survival of 4.3–7.3 months. Treatment of these patients is usually performed in a palliative setting. Patients with malignant salivary gland tumors should have an X-ray or CT scan of the chest at their initial assessment to exclude the possibility of distant metastasis. The likelihood of developing distant metastasis is associated with high-grade tumors, such as adenoid cystic carcinoma, salivary duct carcinoma, high-grade mucoepidermoid carcinoma and tumors located in the submandibular gland, posterior tongue and pharyngeal tumors. A lower risk of developing distant metastasis is known for all other histological entities of salivary gland tumors. Nevertheless all patients who have a histologically confirmed malignant salivary gland tumor should have lifelong follow-up. On the basis of a clinical case regarding a patient with metastatic parotid gland cancer we present a review of the literature.

Transoral laser resection with staged discontinuous neck dissection for oral cavity and oropharynx squamous cell carcinoma

Transoral laser resection of oral cavity and oropharynx squamous cell carcinoma (OOSCC) is a widely accepted approach in the absence of cervical lymph node metastases. This study investigated the results of transoral laser surgery and discontinuous neck dissection (ND) for OOSCC with clinically obvious or suspected cervical node metastases.

Morphology of the Human Thyroglossal Tract: A Histologic and Macroscopic Study in Infants and Children

The anatomic development of thyroglossal tract remnants is not understood at present. For analysis of morphology and growth patterns of thyroglossal tract remnants, we used histologic whole organ serial sections to determine developmental changes through the first years of life. Larynges of 58 infants and children ages 1 month to 13 years were obtained in whole organ serial step-sections in an axial plane. The slides were stained with hematoxylin and eosin, Alcian blue, and periodic acid–Schiff stains. Altogether, 3,247 histologic slices were examined. The resulting data were then correlated with the age and sex of the specimens. We found, in 24 cases (41.3%), remnants of the thyroglossal tract or ectopic thyroid tissue. In 4 specimens (16.6%), a complete thyroglossal tract could be observed that presented a ventral path in relation to the hyoid bone with no contact with the perichondrium of the cartilage. Hormonal activity of ectopic thyroid tissue was proven in 20 cases (34.5%). Thyroid follicles were located in 2 cases (3.5%) in the hyoid bone. The thyroglossal ducts revealed a modest tendency for a left-sided pathway, whereas thyroid follicles were located more on the right paramedian side. Morphometric data on the development and structure of the thyroglossal tract and the thyroid follicles during infancy and childhood are presented. The study provides quantitative data of clinical interest that elucidate the anatomy of thyroglossal tract remnants. In addition, our investigation supports Sistrunks operative approach for avoiding recurrences in the treatment of thyroglossal duct cysts.

3D-Navigation in der interstitiellen stereotaktischen Brachytherapie

ZusammenfassungZielEs was das Ziel dieser Arbeit, ein 3D-Infrarotnavigationssystem für die Anforderungen der interstitiellen stereotaktischen Brachytherapie zu adaptieren. Damit wird die Planung der Therapie verbessert (prospektive Planung der Nadelpositionen und der Dosisverteilung), und eine virtuelle Simulation wird realisierbar (Kontrolle des vorgeplanten Zugangs bezüglich Verletzungsmöglichkeit von Gefäßen oder Nerven).Material und MethodeDas EasyGuide-Neuro®-Navigationssystem (Philips) wurde so verändert, daß Nadeln, die in der Brachytherapie Verwendung finden, am Pointer befestigt werden konnten und am Bildschirm angezeigt wurden. Um die Genauigkeit der Positionierung zu bestimmen, wurde versucht, an Phantomen definierte Zielpunkte zu treffen. Dazu wurden zwei unterschiedliche Methoden miteinander verglichen. Einerseits das “freie Navigieren”, eine Applikationsmethode, bei der die Nadel mit Hilfe des Navigationssystems geführt wurde, und andererseits das “Navigieren mit Template”, bei der die Nadel über ein ausgerichtetes Template und das Navigationssystem ins Ziel geführt wurde. Es wurde auch getestet, ob ein Maskensystem die Anforderungen der stabilen und reproduzierbaren Lagerung erfüllt. Die Umsetzbarkeit der neuen Methode in die klinische Praxis wurde anschließend an einem anatomischen Präparat geprüft.Ergebnisse91% aller durchgeführten Versuche mit den Phantomen wiesen eine Abweichung <5 mm auf. Die Versuche auf einem stabileren Tisch lieferten deutlich bessere Ergebnisse (94% <4 mm). Kein Unterschied konnte zwischen den Applikationsmethoden (“freies Navigieren” und “Navigieren mit Template”) festgestellt werden.SchlußfolgerungenDie Genaulgkeit der Phantomversuche und die Versuche mit dem anatomischen Präparat zeigten, daß mit stabilen Tischen und Lagerungssystemen auch im klinischen Einsatz ausgezeichnete Ergebnisse erzielt werden können.AbstractAimThe aim of this paper is to describe the adaption of 3D-navigation for interstitial brachytherapy. The new method leads to prospective and therefore improved planning of the therapy (position of the needle and dose distribution) and to the possibility of a virtual simulation (control if vessels or nerves are on the pathway of the needle).Material and MethodsThe EasyGuide Neuro® navigation system (Philips) was adapted in the way, that needles for interstitial brachytherapy were made connectable to the pointer and correctly displayed on the screen. To determine the positioning accuracy, several attempts were performed to hit defined targets onphantoms. Two methods were used: “free navigation”, where the needle was under control of the navigation system, and the “guided navigation” where an algined template was used additonally to lead the needle to the target. In addition a mask system was tested, whether it met the requirements of stable and reproducible positioning. The potenitial of applying this method in clinical practice was tested with an anatomical specimen.ResultsAbout 91% of all attempts lied within 5 mm. There were even better results on the more rigid table (94% <4 mm). No difference could be seen between both application methods (“free navigation” and “navigation with template”), they showed the same accuracy.ConclusionsThe accuracy of the phantom experiments and the confirmation by the experiment with the anatomical specimen showed that excellent results can be expected in clinical practice using rigid tables and patient supporting systems.

Radiotherapy in early glottic carcinoma.

Radiotherapy is widely accepted as primary treatment in the T1 stage of glottic cancer, but controversy surrounds the proper approach to T2 lesions of the glottis. A retrospective review of 90 patients addresses treatment results for T1 and T2 lesions of glottic carcinoma managed by primary radiotherapy with 60 to 64 Gy from 1977 to 1989. Seventy-nine patients met the criteria for local control analysis with a minimum follow-up of 5 years. Radiotherapy alone controlled disease in 93% (43 of 46) of patients with T1 lesions and 18% (6 of 33) of those with T2 tumors (including 10 patients in whom radiotherapy was terminated at 40 Gy because of persistent tumor). Ultimate control of disease for T1 and T2 lesions, including surgical salvage, was 100% and 82%, respectively. Larynx preservation was achieved in 100% of Tl and in 45% of T2 lesions. Extension of tumor and impaired vocal cord mobility showed statistical significance for adverse prognosis (p < .001). This paper discusses how these results affect treatment of glottic carcinoma, particularly in the T2 stage.

Three-Dimensional Navigation in Otorhinolaryngological Surgery with the Viewing Wand

We report our experiences with the ISG Viewing Wand intraoperative 3-dimensional navigation device in endonasal endoscopic procedures of the paranasal sinuses, anterior skull base, and petrous bone. In the last 12 months we have routinely used the wand in 90 patients for treatment of polyposis nasi, for biopsies and removal of tumors in the nasal cavity and at the frontal skull base, for endocrine ophthalmopathy, and in 1 case for cholesteatoma. We present our computed tomography, magnetic resonance imaging, and clinical protocols that allow a precise routine use of the Viewing Wand. In all cases, the system was extremely helpful for intraoperative localization and helped to optimize surgery.

Repeatedly Successful Closure of the Larynx for the Treatment of Chronic Aspiration with the Use of Botulinum Toxin A

Botulinum toxin A was used preoperatively to temporarily paralyze the intrinsic laryngeal muscles to hinder movements during the healing period after operation. In addition, toxin was injected into the cricopharyngeal muscle to allow a better passive drainage of the saliva into the esophagus. We treated six patients. Three suffered from chronic aspiration problems after multiple lower cranial nerve lesions, and three patients were apallic (after stroke and major brain injury). Two weeks before scheduled operation, we injected the toxin into the posterior cricoarytenoid muscles, the aryepiglottic muscles, and the vocalis muscle on both sides, as well as the cricopharyngeal muscle. The amount of injected toxin varied between 1.0 and 1.4 mL, equal to 200 to 280 units of botulinum toxin A (Dysport). After a complete palsy of these muscles (controlled by direct electromyography), a closure of the larynx was performed. After laminotomy and exposure of the intralaryngeal structures, the false vocal cords were mobilized and adapted with sutures. Because involuntary movements of the intralaryngeal musculature were absent, primary healing without complications occurred in all cases. Aspiration and related complications disappeared in all patients. In addition, the intensity of patient care could be considerably reduced. Preoperative use of botulinum toxin A allows sufficient laryngeal closure. This procedure is especially useful in the treatment of children and young adults, preserving the ability of later speech rehabilitation because of the return of voluntary movements of the intrinsic laryngeal muscles 6 months after the injection. Furthermore, this technique, as minimal surgical intervention, can be performed in high-risk patients.