[Show abstract][Hide abstract] ABSTRACT: In recent years, several endoscopic techniques have been explored in thyroid and parathyroid surgery, but only few gained acceptance among patients and surgeons. Based on extensive human cadaver and animal studies, we developed a technique for transoral partial parathyroidectomy (TOPP), which was performed for the first time in a patient with primary hyperparathyroidism (pHPT). We now report on results and the acceptance of this new technique 2 years after its implementation.
A pilot study was initiated to recruit a total of 10 patients with benign sporadic pHPT and a preoperatively localized parathyroid adenoma eligible for initial parathyroidectomy. The study protocol was approved by the ethics committee, and an insurance for unforeseen complications and risks was procured. Data of all patients evaluated and operated were prospectively collected, and follow-up examinations were carried out for 19 months on average, which included clinical examinations; ultrasonography; Ear, Nose, and Throat (ENT) investigations; and blood testing.
Between January 2010 and May 2012, 75 patients with pHPT and a preoperative localized parathyroid adenoma were eligible for TOPP. After detailed information about the transoral procedure, only five (7 %) female patients consent to undergo TOPP. In three patients, a parathyroid adenoma could be removed via the transoral access, In two patients, the procedure had to be converted to the conventional technique. Median time until resection of a parathyroid adenoma was 122 min (range, 45-175). One patient had a transient recurrent laryngeal nerve palsy, while one patient suffered from a transient palsy of the right hypoglossal nerve and a slight but persisting dysgeusia. Three patients developed a hematoma of the mouth floor and swallowing problems. In four patients, the visual analog scale (VAS) pain score was high (>7) within the first 2 postoperative days.
Although TOPP is feasible, it is poorly accepted by patients and its complication rate is high. Thus, TOPP is nonsense with currently available devices.
Full-text · Article · Apr 2014 · Langenbeck s Archives of Surgery
[Show abstract][Hide abstract] ABSTRACT: Background:
Carcinomas of the oropharyngeal and hypopharynx are difficult to treat because of their aggressive tendency to metastasize and their high recurrence rate.
A retrospective review of 79 patients with recurrences of oropharyngeal or hypopharyngeal carcinomas was performed. The courses of disease from recurrence diagnosis to the valuation date or death were analyzed.
The median survival for patients classified as incurable at recurrence diagnosis amounted to 8 months (95% confidence interval [CI], 5-10 months), patients initially classified as curable at the time of recurrence diagnosis survived an estimated 12 months (95% CI, 8-22 months). No significant differences regarding the survival after diagnosed recurrence could be observed depending on the tumor location or tumor stage.
The knowledge about the courses of disease and especially the remaining lifetime after diagnosed incurability could facilitate the planning of the remaining lifetime in order to achieve the best possible quality of life.
[Show abstract][Hide abstract] ABSTRACT: Surgical excision of the submandibular gland is the treatment of choice for lesions affecting this gland. The data of 87 patients, who underwent a transcervical extirpation of the submandibular gland as a single operation over the past 10 years at a single institution in Germany, were available for analysis. Sialolithiasis (73.5 %) was the most common reason leading to excision, followed by benign (18.5 %) and malignant tumors (8 %). Complications included temporary palsies of the marginal mandibular branch of the facial nerve (5.7 %), the lingual nerve (5.7 %), and the hypoglossal nerve (1.1 %), and wound infections in the form of hematoma (3.4 %) and seroma (1.1 %).
No preview · Article · Oct 2013 · Archives of Oto-Rhino-Laryngology
[Show abstract][Hide abstract] ABSTRACT: Lymphatic malformations of the orbit are rare lesions that constitute approximately 1% to 8% of all orbital masses. They are difficult to treat since they do not remain within anatomic boundaries and tend to penetrate into normal orbital structures. The aim was to analyze clinical courses and therapy options in patients with lymphatic malformations of the orbit.
Thirteen patients with orbital lymphatic malformations confirmed by magnetic resonance imaging between 1998 and 2009 were enrolled in this study. Patients' charts were retrospectively reviewed to analyze clinical courses and treatment options.
Four patients suffered from isolated intraorbital lymphatic malformations without conjunctival involvement, in three of them the masses were completely resected, in one patient close controls were performed. Three patients had isolated intraorbital lymphatic malformations with conjunctival involvement. Surgical volume reduction of the exterior parts of the lymphatic malformation were performed without any complications and satisfying outcome in these cases. Six patients suffered from intra- and periorbital lymphatic malformations. In 3 patients a watch-and-wait strategy was initiated. In the other 3 patients a surgical therapy was performed, one patient additionally received sclerotherapy with OK-432; however, these 3 patients suffered from residual lymphatic malformations.
The presented cases underline the inconsistencies in the malformations behavior and underscore the inability to make specific recommendations regarding treatment. The treatment decision should be based on the size and location of the lymphatic malformation. The untreated patient must be watched for signs of visual detoriation, which may signal the need for therapeutic intervention.
Full-text · Article · Mar 2013 · Clinical and Experimental Otorhinolaryngology
[Show abstract][Hide abstract] ABSTRACT: Surgical treatment remains the mainstay therapy for recurrence of head and neck cancer after previous radiotherapy. In inoperable cases, interstitial high-dose rate brachytherapy is a treatment option for local dose escalation.
A retrospective analysis of all patients who were treated solely with brachytherapy for advanced non-resectable recurrences of squamous cell carcinomas of the head and neck and who previously received radiotherapy was performed.
A total of 12 patients with advanced recurrences were treated with interstitial brachytherapy with a fraction dose of 2-3 Gy and a total focal dose of 20-33 Gy. The shortest survival after brachytherapy was 4 weeks. The longest clinical course without evidence of local recurrence is 4 years and 11 months.
In selected cases brachytherapy can be used as the last-line or palliative therapy for patients with advanced recurrence head and neck carcinomas. Possible complications and the reduction of quality of life due to tracheostomy should be considered.
Full-text · Article · Jan 2013 · Anticancer research
[Show abstract][Hide abstract] ABSTRACT: The migratory ability of tumor cells requires cytoskeletal rearrangement processes. Epidermal growth factor receptor (EGFR)-signaling tightly correlates with tumor progression in head and neck squamous cell carcinomas (HNSCCs), and has previously been implicated in the regulation of cytokeratin (CK) expression. In this study, HNSCC cell lines were treated with EGF, and CK expression levels were monitored by Western blot analysis. Changes in cellular morphology were documented by fluorescence- and atomic force microscopy. Some of the cell lines demonstrated an EGF-dependent modulation of CK expression levels. Interestingly, regression of some CK subtypes or initial up-regulation followed by downregulation at higher EGF-levels could also be observed in the tested cell lines. Overall, the influence of EGF on CK expression levels appeared variable and cell-type-dependent. Real-time cellular analysis of EGF-treated and -untreated HNSCC cell lines demonstrated a rise over time in cellular impedance. In three of the EGF-treated HNSCC cell lines, this rise was markedly higher than in untreated controls, whereas in one of the cell lines the gain of cellular impedance was paradoxically reduced after EGF treatment, which was found to correlate with changes in cellular morphology rather than with relevant changes in cellular viability or proliferation. After treating HNSCC cells with EGF, CK filaments frequently appeared diffusely distributed throughout the cytoplasm, and in some cases were found in a perinuclear localization, the latter being reminiscent to observations by other groups. In summary, the data points to a possible role of EGFR in modulating HNSCC cell morphology.
Full-text · Article · Nov 2012 · Cell and Tissue Research
[Show abstract][Hide abstract] ABSTRACT: Dissection of neck levels I and IIB is time-consuming and can cause comorbidity. This study aimed to determine whether level I and IIB neck dissection was necessary in patients with laryngeal cancer and clinically detectable or nondetectable neck nodes.
This was a retrospective review of 73 patients with laryngeal cancer. Essential clinical data were obtained and analysed to determine the incidence of neck node metastasis in levels I and IIB.
Of the 48 patients with no clinically apparent neck nodes, none had level I metastases and only one had level IIB metastases. Of the patients with clinically detectable neck nodes, three of 21 patients had level I metastases and three of 25 patients had level IIB metastases; these six patients also had additional metastases in level IIA.
Dissection of neck levels I and IIB is justifiable in laryngeal cancer patients with clinically detectable neck nodes and suspicious lymph nodes in the respective level or level IIA. However, in patients without clinically detectable neck nodes, preservation of levels I and IIB is oncologically safe, economical and reduces the risk of comorbidity.
Full-text · Article · Jun 2012 · The Journal of Laryngology & Otology
[Show abstract][Hide abstract] ABSTRACT: Nowadays, the morphological assessment of samples obtained from living patients has a greater importance than the scientific knowledge which is gained by autopsy. Therefore, the aim of the study was a retrospective analysis of causes of death in patients with head and neck cancer.
The autopsy rate, clinical parameters of oncologic patients as well as autopsy findings like lethal complications, distant metastases and second primary tumors were retrospectively analyzed.
From 1968 to 2007 in 91 patients with malignant tumors of the head and neck an autopsy was performed. In these 39 years an autopsy was performed in 45.9% of dead oncologic patients. Autopsy findings revealed distant metastases in 46.2% and second primary tumors in 17.6% of the patients. 49.5% of the patients died from pneumonia, 20.9% from tumor bleeding and 10% from progressive cachexia.
The study confirms the global trend of a decline in autopsy numbers in the last 3 decades. However, as an important instrument of quality assurance autopsies continue to play an essential and indispensable role in medical research.
[Show abstract][Hide abstract] ABSTRACT: The sphenoid sinus is a frequent target of paranasal sinus surgery. Because of the high risk of injuring the surrounding structures (e.g. internal carotid artery, optical nerve) a preoperative imaging is absolutely necessary.
To analyze the possibilities of cone-beam computed tomography (CBCT), which is especially quite a new technique in ENT, in the evaluation of the sphenoid sinus, its surrounding structures, and the corresponding anatomical variations.
This was a retrospective, single-centre study of 580 patients (1160 sides = cases). The Accu-I-Tomo-F17 was used. Pneumatization of sphenoid sinus, course of internal artery, course of optical nerve, and dehiscence of the bony canals were evaluated.
In the case of pneumatization a type I (completely missing or minimal sphenoid sinus) was found in two patients (0.3%), type II (posterior wall of sphenoid sinus is in front of the anterior wall of the sella) in 38 patients (6.6%), type III (posterior wall is between anterior and posterior wall of sella) in 332 patients (57,2%), type IVa (posterior wall is behind the posterior wall of sella without air dorsal the sella) in 104 patients (17.9%), and type IVb (similar to type IVa but with air dorsal the sella) in 104 patients (17.9%). In 1025 cases (89.5%) a smooth course of the internal carotid artery was found whereas a free course could be detected in 120 cases (10.5%). Defects of the bony canal of the optical nerve were found in 16.7% and of the internal carotid artery in 2.7% of the cases. The optical nerve showed a free course through the sphenoid in 151 cases (13.7%) and a smooth course in 1007 cases (87.0%).
CBCT could evaluate all relevant anatomic structures and answer the questions of different anatomical variants. A modified classification of the pneumatization of the sphenoid sinus could be described. Frequencies of anatomical variations are in accordance with the current literature of CT research.
[Show abstract][Hide abstract] ABSTRACT: Lymphangiomas are congenital malformations of the lymphatic system that consist of cysts of varying size. Although they are benign, they can undergo progressive growth with compression and infiltration of adjacent structures. Surgical excision has been the cornerstone of treatment, although total excision of the lymphangioma can be a major challenge and may be associated with severe complications. Therefore, a variety of nonsurgical methods have been proposed to reduce the surgical morbidity and to decrease the recurrence rate. Percutaneous sclerotherapy of lymphangioma involves the injection of sclerosing substances into the lymphangioma cysts. During the past years, different sclerosants and sclerosant techniques have been developed. This review summarizes the current knowledge on sclerotherapy of lymphangiomas of the head and neck.
[Show abstract][Hide abstract] ABSTRACT: The dissection of level V neck lymph nodes often results in a decline of postoperative quality of life due to shoulder dysfunction and pain. The necessity of level V dissection is debatable. The aim of the present study was to evaluate the prevalence of level V metastases in patients with node-positive squamous cell carcinomas of the head and neck.
A review of the clinical and pathological reports was conducted to ascertain the prevalence and distribution of cervical metastases according to neck level V. Statistical analysis was performed using Fisher's exact test.
Level V metastases were found in 19 out of 104 (18.3%) patients. There was only one patient with level V metastases without involvement of other levels. There was no statistically significant correlation between level V lymph node metastasis and several clinical factors.
It seems to be feasible to omit dissection of level V in patients without clinical evidence for level V disease without compromising oncological safety.
No preview · Article · Nov 2011 · Anticancer research
[Show abstract][Hide abstract] ABSTRACT: The trend toward minimally invasive surgery, appropriately applied, has evolved over the past three decades to encompass all fields of surgery, including curative intent cancer surgery of the head and neck. Proper patient and tumor selection are fundamental to optimizing oncological and functional outcomes in such a personalized approach to cancer treatment. Training, experience, and appropriate technological equipment are prerequisites for any type of minimally invasive surgery. The aim of this review was to provide an overview of currently available techniques and the evidence justifying their use. Much evidence is in favor of routine use of transoral laser resection, transoral robot-assisted surgery, transnasal endoscopic resection, sentinel node biopsy, and endoscopic neck surgery for selected malignant tumors, by experienced surgical teams. Technological advances will enhance the scope of this type of surgery in the future and physicians need to be aware of the current applications and trends.
No preview · Article · May 2011 · Archives of Oto-Rhino-Laryngology
[Show abstract][Hide abstract] ABSTRACT: There is still no consensus on the optimal treatment of the neck in oral cavity cancer patients with clinical N0 neck. The aim of this study was to assess a possible benefit of elective neck dissection in oral cancers with clinical N0 neck. A comprehensive search and systematic review of electronic databases was carried out for randomized trials comparing elective neck dissection to therapeutic neck dissection (observation) in oral cancer patients with clinical N0 neck. A meta-analysis of the studies which met our defined selection criteria was performed using disease-specific death as the primary outcome, and the relative risk (RR) of disease-specific death was calculated for each of the identified studies. Both fixed-effects (Mantel-Haenszel method) and random-effects models were applied to obtain a combined RR estimate, although between-study heterogeneity was not found to be significant as indicated by an I(2) of 8.5% (p=0.350). Four studies with a total of 283 patients met our inclusion criteria. The results of the meta-analysis showed that elective neck dissection reduced the risk of disease-specific death (fixed-effects model RR=0.57, 95% CI 0.36-0.89, p=0.014; random-effects model RR=0.59, 95% CI 0.37-0.96, p=0.034) compared to observation. This reduction in disease-specific death rate supports the need to perform elective neck dissection in oral cancers with clinical N0 neck.
[Show abstract][Hide abstract] ABSTRACT: There is increasing demand for surgical procedures which avoid visible scars while maintaining optimal functional and ideal cosmetic results, without compromising the safety or effectiveness of the procedure. Endoscopic techniques have been adapted to abdominal and pelvic surgery and increasingly employed over the past three decades. Although hampered by the absence of a natural cavity, endoscopic techniques have been adapted to surgery in the neck for the past 15 years, particularly for the thyroid gland. While earlier attempts at endoscopic thyroid surgery were performed through incisions in or near the midline of the neck, recent techniques have been developed to place the incisions and endoscopic ports extracervically, or at least away from the midline region of the neck, rendering the cosmetic result more acceptable. Most of these approaches are through the axilla, breast, chest wall or a combination of approaches. Visualization of the thyroid and rate of complications with these approaches are equal to those attained with older endoscopic approaches. Careful patient selection is important for endoscopic surgery. Complications unique to the endoscopic approach are mostly related to insufflation of cervical tissues with pressurized CO(2).
No preview · Article · Apr 2011 · Surgical Endoscopy
[Show abstract][Hide abstract] ABSTRACT: Transluminal interventions via so-called natural orifices are gaining interest because they allow operative treatment without any skin incision. We previously described a transoral access for (para-)thyroid resection in pigs. To proceed with the first clinical trials, we evaluated the safety of the new technique.
Transoral hemithyroidectomies were performed on 10 living pigs using a special cervicoscope and conventional laparoscopic instruments. Follow-up examinations were carried out for 14 days and followed by autopsy, which included macroscopic evaluation, microbiologic investigations, and blood testing. In addition, refinement of the new technique was achieved by developing the techniques in 10 human cadavers. Finally, transoral parathyroidectomies were performed in 2 patients with primary hyperparathyroidism and a preoperatively localized parathyroid adenoma.
All animal transoral hemithyroidectomies were performed without complications. Postoperatively, oral intake, weight gain, and white blood cell count remained normal. At autopsy, the access route, and operative field showed no signs of infection, and microbiologic swabs remained sterile. Based on these results, a transoral parathyroidectomy was performed successfully in 2 female patients with primary hyperparathyroidism; 1 patient experienced a transient palsy of the right hypoglossal nerve.
Transoral parathyroid and thyroid operation is feasible; however, additional controlled clinical studies are required to evaluate the safety and success rates of this new technique.