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Part II of the S3 guideline report deals with the surgical treatment of hypopharyngeal carcinoma, neck dissection for oropharyngeal and hypopharyngeal carcinomas and adjuvant therapy options. Primary surgical therapy ± adjuvant radio- or radiochemotherapy and primary radio- or radiochemotherapy are established as primary therapies for local-regional hypopharyngeal carcinomas. Direct randomized comparisons of both basic therapeutic procedures were never conducted. Available registry data show a worse prognosis of hypopharyngeal carcinoma compared to oropharyngeal carcinomas in all locoregional tumor stages, regardless of the treatment method. For T1N0-T2N0 squamous cell carcinoma of the hypopharynx, there are no relevant differences in overall survival and locoregional relapse rate between primary surgical and primary non-surgical treatment. Primary surgical therapy ± adjuvant radiotherapy or radiochemotherapy and primary radiotherapy or radiochemotherapy are established as primary therapies for advanced but locoregionally limited hypopharyngeal carcinomas. Neck dissection is an integral part of the primary surgical treatment of oropharyngeal and hypopharyngeal cancer. There are only a few randomized studies on non-surgical organ preservation for advanced hypopharyngeal cancer as an alternative to pharyngolaryngectomy, but these have led to the recommendation of alternative concepts in the new guideline. The indication and implementation of postoperative adjuvant radiotherapy and radiochemotherapy for hypopharyngeal carcinoma do not differ from those for HPV/p16-negative and -positive oropharyngeal carcinoma., Competing Interests: Erklärung zu finanziellen Interessen Forschungsförderung erhalten: nein; Honorar/geldwerten Vorteil für Referententätigkeit erhalten: nein; Bezahlter Berater/interner Schulungsreferent/Gehaltsempfänger: nein; Patent/Geschäftsanteile/Aktien (Autor/Partner, Ehepartner, Kinder) an Firma (Nicht‐Sponsor der Veranstaltung): nein; Patent/Geschäftsanteile/Aktien (Autor/Partner, Ehepartner, Kinder) an Firma (Sponsor der Veranstaltung): nein Erklärung zu nichtfinanziellen Interessen Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

In general, a trend towards transoral resection (as opposed to classic open approaches) + neck dissection + adjuvant radio- (chemo-) therapy has been observed for oropharyngeal carcinoma over the last 20 years. Techniques of transoral surgery (TOS), including transoral laser microsurgery (TLM) and transoral robotic surgery (TORS) have been propagated in retrospective comparisons with conventional surgery or primary radiochemotherapy as gentle, minimally invasive procedures with good late functional results. Meta-analyses of mostly uncontrolled retrospective analyses suggest that TORS may have better disease-free survival (DFS) and a reduced risk of free flap reconstruction compared with open surgery. TORS (TOS) was associated with fewer tumor-positive resection margins (R1), a lower number of recurrences, fewer intraoperative tracheostomies, a shorter inpatient stay and a shorter duration of postoperative nasal tube feeding compared to open surgery. In principle, based on the best evidence currently available from registry studies, stage I-II oropharyngeal carcinomas can be treated either with primary surgery or radiochemotherapy with a comparable chance of survival. With comparable evidence for stage III and IVa, p16neg. oropharyngeal carcinomas, the majority of authors advocate primary surgery followed by adjuvant radiotherapy or radiochemotherapy as the treatment of first choice. For p16pos. patients the results of registry studies are inconsistent, although the largest registry study on 450 HPV-positive stage III patients shows a significant superiority of primary surgery + adjuvant radiochemotherapy. Since all registry studies did not adjust for smoking status, among other factors, the current data situation should be evaluated with the necessary caution., Competing Interests: Erklärung zu finanziellen Interessen Forschungsförderung erhalten: nein; Honorar/geldwerten Vorteil für Referententätigkeit erhalten: nein; Bezahlter Berater/interner Schulungsreferent/Gehaltsempfänger: nein; Patent/Geschäftsanteile/Aktien (Autor/Partner, Ehepartner, Kinder) an Firma (Nicht‐Sponsor der Veranstaltung): nein; Patent/Geschäftsanteile/Aktien (Autor/Partner, Ehepartner, Kinder) an Firma (Sponsor der Veranstaltung): nein Erklärung zu nichtfinanziellen Interessen Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht.

Robotic systems for head and neck surgery are at different stages of technical development and clinical application. Currently, robotic systems are predominantly used for transoral surgery of the pharynx and larynx. Robotic surgery of the neck, the thyroid, and the middle and inner ear is much less common; however, some oncological and functional outcomes have been reported. This article provides an overview of the current state of robot-assisted head and neck surgery with a special emphasis on patient benefit and postoperative quality of life (QoL). The focus is placed on the role of transoral robotic surgery (TORS) for the resection of oropharyngeal carcinomas. For this application, reported long-term outcomes show functional post-operative advantages for selected oropharyngeal cancer patients after TORS compared to open surgery and primary radiotherapy. Since TORS also plays a significant role in the context of potential therapy de-escalation for HPV-positive oropharyngeal cancer patients, ongoing trials are presented. Regarding the evaluation of the therapeutic benefit and the QoL of cancer patients, special attention has to be paid to the large degree of variability of individual patients' preferences. Influencing factors and tools for a detailed assessment of QoL parameters are therefore detailed at the beginning of this article. Notably, while some robotic systems for ear and skull base surgery are being developed in Europe, TORS systems are mainly used in North America and Asia. In Europe and Germany in particular, transoral laser microsurgery (TLM) is a well-established technology for transoral tumor resection. Future trials comparing TORS and TLM with detailed investigation of QoL parameters are therefore warranted and might contribute to identifying suitable fields for the application of the different techniques., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

Competing Interests: Interessenkonflikt: Die Autoren geben an, dass kein Interessenkonflikt besteht.

Objectives: Analysis of pre-operative tracheostomy and circumjacent tumour free margins as risk factors in the development of stomal recurrent disease after (pharyngo)laryngectomy. Material and Methods: 124 patients after (pharyngo)laryngectomy were analyzed for disease related data and tumour samples were analyzed for tumour free margins. The overall cohort was divided into patients with/withour pre-operative tracheostomy. Results: 18 patients suffered from recurrent disease (10 stomal, 8 distant metastases). Advanced T-status, female gender, and sub-/glottic tumour manifestation resulted in a higher rate of prior tracheostomy. Pre-operative tracheostomy did not influence the development of stomal recurrency. R0 resection was achieved in 94% of our patients, with significant reduced tumour free margins in patients with stomal recurrency (p=0.002) Conclusion: Pre-operative tracheostomy did not influence the development of stomal recurrent disease. The clinical identification of ventral soft tissue infiltration should result in extensive surgical concepts., (© Georg Thieme Verlag KG Stuttgart · New York.)

Despite all the progress in clinical diagnostics and multimodal therapy, the prediction of oropharyngeal carcinoma remains to be limited. Therefore, it is important to further improve clinical staging to set therapy modalities based on that.In a retrospective pseudonymized study over a 13 years period of time the clinical classification (cTNM) was compared with the histopathologic classification (pTNM) of 84 patients with oropharyngeal squamous cell carcinoma and who were treated primarily with surgery. Furthermore, the existence of occult metastases as well as overall survival as a function of histopathologic extent of the tumor and regional infestation of lymph nodes were considered.The highest agreement between cTNM and pTNM was observed with computer tomography. A definite evaluation with histopathological reliability is not possible with cTNM. MRT examinations showed the tendency to estimate T -, N- and UICC-stage compared with the histopathologic findings. In the context of the examinations of survival probabilities, separated by sex and histopathologic T- and N-categories, a lower overall survival probability was seen for the higher T- and N-category.Despite all the progress in imaging diagnostics for patients with oropharyngeal carcinoma the cTNM, compared with pTNM, is only partially able to determine the TNM classification of the cancer with requested clinical accuracy. With the trend of decreasing predictions and in spite of present-day multimodal therapy it is essential to improve and optimize the pre-therapeutic clinical staging., (© Georg Thieme Verlag KG Stuttgart · New York.)

Over the past 20 years, the therapeutic concepts for the treatment of head and neck cancer have evolved and non-surgical treatment strategies have gained in importance. However, despite improved organ preservation protocols and primary chemoradiation, tumor recurrence is still frequent. Under these conditions, salvage surgery if often the only remaining curative treatment option. Over the past 30 years, advancements in plastic-reconstructive surgery have broadened the surgical spectrum in the head and neck area, offering new treatment options for salvage surgery in recurrent cancer of the pharynx and larynx. Survival after salvage surgery mainly depends on the primary treatment modality as well as the localization and tumor stage at the time of initial diagnosis and local recurrence. For the reconstruction of defects after salvage surgery, pedicled flaps and microvascular free flaps may be utilized. The most frequently used flaps in these situations are the pectoralis major island- or the myocutaneous latissimus dorsi island flap. The radial forearm and the ALT-flap are potentially applicable free flaps. With the use of these flaps, vital tissue is transferred into the previously irradiated area, hereby allowing for reconstruction and functional preservation of the resected area and preventing complications such as fistulas. The expected morbidity and the likelihood of surgical success must be assessed thoroughly in every individual case prior to performing salvage surgery. This review aims to support decision making in these situations., (© Georg Thieme Verlag KG Stuttgart · New York.)

Unlabelled: INDRODUCTION: The regular application of transit time flow measurement in microvascular anastomoses during heart surgery has lead to improvements of the outcome of coronary artery bypass grafts. Our study was meant to discover whether this measurement method was also applicable for evaluation and optimization of microvascular arterial anastomoses of radial forearm flaps., Methods: In this prospective examination a combining ultrasound imaging and transit time flow measurement device (VeriQ, MediStim) was used during surgery to assess anastomotic quality of 15 radial forearm flaps. Pulsatility index (PI) and mean blood flow were measured immediately after opening the arterial anastomosis as well as 15 min afterwards. Furthermore, application time and description of handling were recorded seperately for every assessment., Results: Mean blood flow immediately after opening the anastomosis and 15 min later were 3.9 and 3.4 ml/min resepectively showing no statistically significant difference (p=0.96). There was no significance in the increase of pulsatility index from 22.1 to 27.2 (p=0.09) during the same time range, either. Due to measurement results showing atypical pulse curves in 2 cases decision for surgical revision of the anastomoses was made. All forearm flaps showed good vascularisation during follow-up. Time for device set up, probe placement and measurements was about 20 min. Handling was described to be uncomplicated without exception. There were no noteworthy problems., Conclusion: Transit time flow measurement contributes to the improvement of anastomotic quality and therefore to the overall outcome of radial forearm flaps. The examined measurement method provides objective results and is useful for documentation purposes., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Recently transoral robotic surgery has gained importance in the resection of head and neck tumors, especially in North America. The available resection tools are a fiber guided Tm:YAG-laser and a monopolar cautery, both causing wide coagulation and vaporization zones in healthy tissue. In order to improve the cutting properties we combined the system with a flexible CO2-laser fiber., Material and Methods: 6 patients suffering from T1 and T2 oropharyngeal carcinomas were treated between July 2012 and September 2012. In a prospective study we analyzed the feasibility, cutting properties, speed of resection as well as hemostasis and compared those with the monopolar cautery and the Tm:YAG laser which were recently examined in a series of 17 patients., Results: The application of a CO2-laser fiber with the da Vinci system was feasible and showed good cutting properties. Using a 15 watts energy level resulted in a favourable cutting depth and adequate hemostasis. In comparison to the monopolar cautery or the Tm:YAG laser, smaller coagulation and vaporization zones could be achieved., Conclusion: Cutting properties of the da Vinci system can be improved by using a flexible CO2-laser fiber. Further prospective evaluations will follow., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Within the last years transoral robotic surgery (TORS) has gained importance in the resection of head and neck tumors, especially in North America. In contrast only few groups in Germany have studied this system so far. In respect to potential future developments in surgical robotic systems it seems reasonable to deal with this system., Material and Methods: 17 patients with tumors of the oropharynx, the base of tongue or the supraglottic area were treated with TORS in our clinic, between May 2011 and June 2012. In a prospective study we analyzed the exposure, visualization and resectability of these tumors using the da Vinci-system. In addition, set up and operation time, as well as costs were evaluated., Results: All neoplasms of the oropharynx (n=9) and the tongue base (n=5) could be well exposed, visualized and resected. In the supraglottic area (n=3) 2 tumors could not be properly exposed and therefore resection was converted to a transoral microscopic laser approach. Resection with the cautery spatula tip or the Tm:YAG-laser fibre caused wide coagulation zones, but resulted in good hemostasis. The costs for the medical equipment and the leasing rate were 6280 € per case at our institution., Conclusion: Tumors of the tongue base and oropharynx could be easily visualized with help of the da Vinci-system. The resection of supraglottic tumors can be challenging, due to the arrangement of the robotic-arms and the narrow anatomic conditions. Despite its high costs, the da Vinci-system is a potentially interesting supplementation to existing surgical techniques., (© Georg Thieme Verlag KG Stuttgart · New York.)

The introduction of transoral endoscopic surgery resulted in a significant reduction of surgical trauma and a paradigm change from transcervical to transoral surgical treatment in head and neck tumors. In selected cases minimally invasive transoral resections allow a reduction of morbidity without deteriorating oncological results. Thus, transoral surgical techniques gained more acceptance, led to an extension of the indications and technologies as well as an improvement of surgical instruments.Depending on the anatomical localization transoral treatment strategies and their indications are described and relevant literature is discussed according to new developments and results., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Transoral laser microsurgery (TLM) has led to an expansion of the therapeutic modalities for malignomas of head and neck. This study aims to assess the oncologic results and functional outcomes of TLM in early carcinomas., Patients and Methods: This is a retrospective study of 947 cases with T1-2 carcinomas primarily managed with laser surgery between 1979 and 2007. All cases were assessed for survival, with respect to location, T and N classification and status of surgical margins. Cases were additionally evaluated for incidence of major complications and retention of laryngeal and pharyngeal function., Results: Disease specific survival was 78.6% for oropharyngeal, 68.9% for hypopharyngeal, 82.3% for supraglottic und 95.2% for glottis carcinomas. Survival estimates were found to be significantly better for cases without cervical metastasis and with negative surgical margins. A low rate of major complications (4.7%) were noted. 1% of the patients had a permanent dysfunction of swallowing and 1.1 % needed a permanent tracheostomy., Conclusion: Laser surgery appears to be a very effective management modality for small carcinomas of the head and neck as long as clear surgical margins can be achieved. This technique offers acceptable oncologic results with a low incidence of complications and satisfactory retention of function.

The excision of sentinel lymph nodes has a growing relevance in the diagnosis of oral and oropharyngeal cancer in cases of clinical N0 necks. The validity of sentinel node biopsy as minimally invasive staging tool of the neck in T1-2 tumours can be considered as proven due to most recent international multicentre studies. The present paper describes the technique and follows the newest European guide lines., (© Georg Thieme Verlag KG Stuttgart · New York.)

Human papilloma viruses (HPV) may cause head and neck squamous cell carcinomas. HPV associated carcinomas mostly occur in the oropharynx and particularly in the palatine tonsil and base of tongue. Carcinomas at other sites are infrequently caused by HPV. The viral proteins E6 and E7 are crucial for malignant transformation. They functionally interfere with cellular proteins maintaining genomic integrity such as p53 and cell cycle control such as retinoblastoma protein. However, unlike carcinogens such as tobacco smoke, the virus does not disrupt the coding genes. Reliable HPV detection methods in histological specimens include in situ hybridisation of high risk DNA and immunohistochemical detection of p16. HPV positivity does not proof a causal relation between HPV and tumour. High risk HPV are also detectable in 10-20% of normal mucosal specimens. Irrespective of the various modalities available for treatment, HPV associated head and neck cancers have a better prognosis than their carcinogen caused counterparts. HPV positivity does not object to surgical treatment., ((c) Georg Thieme Verlag KG Stuttgart-New York.)

Extended oropharyngeal carcinoma are frequently resected using an "open" approach via temporary mandibulotomy. One disadvantage of this technique is a visible scar formation at the lower lip and the chin. This can be avoided by remaining continuity/integrity of the lower lip and the chin by a "downfacial degloving" approach. This technique allows an adequate exposition and resection of the tumor with an optimal functional as well as aesthetic result in the lower midface. Downfacial degloving during temporary mandibulotomy in oncosurgery is a simple technique with an optimal functional and aesthetic result.

Background: The value of surgery in multimodal treatment concepts of oral and oropharyngeal cancer, respecting quality of life and survival rates, should be evaluated., Patients: Patients with oral or oropharyngeal cancer were grouped, if tumor-targeted surgery was part of a multimodal treatment concept or if the patients received radiotherapy with or without chemotherapy only. Surgical versus non-surgical therapy, age, disease extent, tumor site and comorbidity as measured by the American Society of Anesthesiologists (ASA) physical status score were included in a Cox proportional hazard analysis. Quality of life was assessed 3 years following treatment employing the EORTC-C30 and H&N35 questionnaires., Results: Patients treated with radiotherapy with or without chemotherapy only (63/140) had a worse survival (hazard ratio 1.7037, 95 % CI 0.9981 to 2.9080, p = 0.0508) than patients treated with surgery (77/140) as a part of a multimodal treatment concept. Disease extent (p < 0.01) and ASA score (p < 0.01) had a significant impact on survival. Quality of life scores were remarkably similar in surgically and non-surgically treated patients., Conclusions: The results of this study indicate that surgery remains a core modality of oral and oropharyngeal cancer treatment. External beam radiotherapy only, also if applied in current fractionation techniques, may not be sufficient to achieve adequate results.

Background: Between June 1998 and January 2005 64 patients of the department of oto-rhino-laryngology, head and neck surgery in Kassel with primary resectable squamous cell carcinoma of the oropharynx underwent neoadjuvant induction therapy. Carboplatin and Paclitaxel were given 6 times once weekly. This combination has proofed to be successful in downstaging and extend survival in patients suffering from head and neck cancer. Afterwards tumor resection was performed in the initial extension of the carcinoma. Dependent on histological findings radiation therapy or radiochemotherapy was carried out., Method: Retrospective data were collected to analyse the effect on the tumor site and cervical lymph node metatasis based on post-chemotherapy clinical and postoperative histological results. In addition correlation between clinical findings and histological outcome and a possible survival advantage in patients with under induction chemotherapy remitted carcinomas was performed., Results: The data showed no improvement in disease free survival in patients with complete remission of the primary tumor site but a significant prolonged survival time for patients with complete remission of the cervical lymph node metastasis.

According to recent publications in the New England Journal of Medicine (TAX323, TAX324) of the study groups around Jan Vermorken and Marshall Posner induction chemotherapy in squamous cell carcinomas of the head-neck area (in the closer: Oro-hypopharynx, oral cavity and larynx) currently seems to generate a worldwide renaissance. Renaissance, because in the last few decades, induction chemo therapy in this group of tumors after lack of survival improvement in the vast majority of studies was again abandoned. The new data raise the question for which entities induction chemo therapy can be recommended (actually, a combination of docetaxel, cisplatin and 5-fluorouracil; TPF)? The unbroken high value of primary surgery with adjuvant radiation or chemo radiation was complementary to primary radio chemotherapy for non resectable tumors until today worldwide. Running studies are sorting out the role of induction chemotherapy in the current context of clarifying optimal multimodal treatment.

Objective: Following extended tumor resections in the head-neck area options immediate defect reconstruction is needed to reduce healing time and improve rehabilitation. Reconstruction of significant areas of mucosal defects is best accomplished by introduction of a pliable regional transplant. The platysma myocutaneous flap has been used for defect reconstruction in head and neck area since more than 20 years. Its popularity is limited. Since 2001 in our department the platysma mucocutaneous flap is used for such reconstructions. We present a retrospective study evaluating our experience with the platysma myocutaneous flap., Method: From 2001-2003 25 patients have been subjected to surgical reconstruction applying the platysma mucocutaneous flap. The primary tumor was located in 16 patients (64 %) in the oropharynx, in 5 patients (20 %) in the hypopharynx and in 4 patients (16 %) in the oral cavity. Evaluation was based on medical records including the operative reports. All patients get a follow up in our outpatient clinic., Results: The platysma flap is easy to harvest and has a low general risk level. Complications are minor and may be avoided by exact preoperative planning. Necrosis of the skin-muscle-flap was observed only after resection of the A. carotis externa (two cases). In these 2 cases an operative revision was necessary (stenting of the pharynx or secondary reconstruction by pectoralis major-flap). The resection of the A. facialis (three cases) did not lead to a serious complication., Conclusions: Considering the exact indication the platysma flap is suitable for reconstruction of surface defects in the pharynx and oral cavity. A special attention is given to the ipsilateral vascular supply and the length of the muscular pedicel. It proved to be a cost effective method due to the less time and personal expenditure.

Background: There are different reports in the literature how often postoperative hemorrhage occurs after laser resection of head-and-neck tumours. This retrospective study investigates the frequency of postoperative hemorrhage after laser surgery of head and neck tumours. Time and extent of bleeding have been considered as well as the localization of the primary tumour and possible general risk factors., Methods and Patients: Between 1998 and 2001, microscopic laser surgery was performed in 223 patients with previously untreated squamous cell carcinomas of the oral cavity, oropharynx, supraglottic and glottic region and the hypopharynx. In case of ultrasonographic or palpable evidence of cervical lymphadenopathy surgery included subsequent neck dissection. The mean age of the patients was 59.2 year., Results: Postoperative bleeding occurred in 14 out of 223 patients (6 %). It was 9 % for oral carcinoma, patients 10 % for oropharyngeal carcinoma, 5 % for supraglottic carcinoma and none for glottic and hypopharyngeal carcinoma. 5 patients were treated conservatively, 4 patients were controlled bei cautery and ligation, 1 patient was treated with ligation of the lingual artery and in 2 cases ligation of the external carotid artery was performed. 1 patient had a fatal hemorrhage., Conclusions: Laser-surgical resection of head and neck carcinomas does not lead to a higher incidence of bleeding complications compared to ordinary surgery.

Purpose: To evaluate the prognostic implication of tumor infiltration and volume in primarily operated oropharyngeal carcinomas., Material and Methods: In 80 patients with oropharyngeal squamous cell carcinomas (pT 1 = 22, pT 2 = 30, pT 3 = 19 and pT 4 = 9), the tumor volume was measured by pretreatment CT and the extent of tumor infiltration determined by postoperative histologic examination. All patients were followed clinically for local tumor recurrence for at least two years after therapy. The statistical analysis consisted of chi 2 and U tests., Results: The local control rate was 79 % (63/80). Of all evaluated anatomic structures, only midline crossing correlated significantly with local recurrence (p = 0.06). No correlation of tumor volume (p = 0.19) or T stage (p = 0.60) with the local recurrence rate was found., Conclusion: After primary surgery, oropharyngeal carcinomas with midline crossing have an increased risk of local recurrence, whereas the tumor volume only has a minor impact on the recurrence rate. This is in contrast to laryngeal or hypopharyngeal carcinomas.

Background: Histologically proven radical resections often lead to severe functional problems especially in upper aero-digestive-tract tumors. Oncologically the combination of external radiotherapy and brachytherapy offers an alternative treatment option. The functional results and the complication rate in stage III and IV tumors of the oral tongue, floor of mouth and oropharynx are described in a patients series., Method: The follow-up includes 17 consecutive patients who were primarily treated by a combination of external radiotherapy and brachytherapy between 1997 and 2000. The oncological benefit (complete remission, disease-free survival), the functional results (mastication, swallowing, speech and pain) and the complications were reviewed., Results: After the follow-up period 16/17 patients were alive. There were 3 major complications, one of them lethal. The functional results resembled those after surgical resections., Conclusions: A combined radiotherapy is a feasible method of treating patients who refrain from surgery. Moreover the application ranges from inoperability to postoperative radiotherapy in cases with close or positive margins. In connection with neck-dissections and therapy of recurrent cancer major complications may occur. In contrast to the general opinion radiation therapy was not superior to surgical resection concerning functional sequelae.

Background: The value of Sentinel Node (SN) concept is a current issue in clinical oncology. Few investigations deal with SN biopsy in head and neck squamous cell carcinomas (HNSCC). For this reason the SN concept was investigated based on the results of the so far largest group of 100 patients., Method: Three groups of patients were investigated. Group 1: In 30 patients (6 x oral cavity, 24 x oropharynx) a dynamic lymphoscintigraphy was performed. Group 2: 60 previously untreated patients (12 x oral cavity, 23 x oropharynx, 16 x larynx, 9 x hypopharynx); neck lymph node status on ultrasound imaging: 39 x N0, 5 x N1, 16 x N2, intraoperative identification of the SN during neck dissection (ND) accomplished according to the extent of assumed lymphogenic metastatic spread; postoperative comparison of the histological result of the SN with the neck dissection specimen. Group 3: 10 previously treated patients (1 x oral cavity, 5 x oropharynx, 1 x larynx, 3 x hypopharynx) in whom an intraoperative SN biopsy was performed., Results: Group 1: In 20/30 patients a cervical lymph drainage could be visualized on dynamic lymphscintigraphy and an activity enrichment above the mean metastatic region could be identified transcutaneously. Group 2: In 34 patients the tumorfree SN1 reflected the regional lymph node status. In 9 patients an isolated tumor metastasis (pN1) was found in the intraoperatively identified SN1 and in a further patient in the SN2 (pN1)., Conclusion: The results of SN biopsy are encouraging in cases of clinical N0-necks. Nevertheless the data demonstrates that extensive investigations followed by a critical analysis of the results are required. The presented results suggest that the value of the SN concept seems to be of minor importance in cases of advanced lymphogenic metastatic spread.

Unlabelled: Voice Restoration with Voice Prosthesis after Total Laryngectomy. Assessment of Survival Time of 378 Provox-1, Provox-2 and Blom-Singer Voice Prosthesis., Background: Indwelling voice prosthesis are used in Trier for voice restoration after total laryngectomy since 1991., Objective and Method: To assess the voice prosthesis survival times the patients of the years 1993-1999 are assessed retrospectively., Participants: 58 patients provided with indwelling voice prosthesis were seen regularly at follow-up. 378 prosthesis were changed. Provox 1, Provox 2 and Blom-Singer-Prostheses were used., Results: The average survival lifetime of the prosthesis was 224 days for Provox-1, 96 days for Provox-2 and 107 days for Blom-Singer respectively. There is no significant difference found between Provox-2 and Blom-Singer Prosthesis. The survival times of the Provox-1 Prosthesis is significant longer., Conclusion: Using indwelling voice prosthesis for voice restoration after total laryngectomy an average survival time of the prosthesis of three months can be expected. There are relevant individual differences. Provox-1 Prosthesis have a significantly longer survival time, but as they are more difficult to handle they are not suitable for routine use. The indication for the choice between Blom-Singer or Provox-2 Prosthesis should be influenced by the surgeons' experience.

Background: Leiomyoma and Leiomyosarkoma are not often found in ENT-diseases., Patients: We report on a 62-year old female patient presenting with a 3 x 4 cm tumor in the oropharynx that had developed within a period of about three weeks. The patient complained of increasing dysphagia and dyspnea especially when lying on the left side. To secure breathing the patient had to be primarily ventilated by placing a needle percutaneously through the conical ligament and was then intubated. For this procedure the patient was positioned on the right side. The tumor measuring 3 cm, was removed surgically., Results: The tumor turned out to be a leiomyomatous neoplasia of undetermined malignant potential. Since an unfavourable behaviour of such neoplasms cannot be excluded, patients with tumors of this type should be followed closely., Conclusions: In this case the tumor leads to an acute dyspnoea and a special procedure of anesthesia was necessary. Therapeutic considerations and differential diagnosis of this very rare tumor of the oropharynx are discussed by reviewing the literature.

Background: Histologically proven radical resections are the goal in patients with head and neck cancer because of improved survival rates. The frequency of histologically radical resections using the median mandibulotomy and the morbidity of this approach for tumors of the oropharynx and the parapharyngeal space are described in a patients series., Methods: The follow-up includes 16 consecutive patients who were operated on by a median mandibulotomy approach between 1995 and 1998. The oncological benefit (tumor free margins), complications and the functional results (ability of opening the mouth mastication, swallowing, speech, cosmesis and pain) were reviewed., Results: In 15/16 cases a histological radical resection was achieved. 14 patients were irradiated postoperatively. In this group 3 patients had an osteoradionecrosis, one an osteomyelitis of the mandible. The functional results were worse in more advanced tumors., Conclusion: The indications for a median mandibulotomy are primarily T3 and T4 tumors of the oral cavity and oropharynx, rarely expansive benign parapharyngeal tumors. In most cases a histological radical resection is achieved even in advanced tumors, probably due to the wide exposure of the involved area. In contrast this approach is associated with a high morbidity.

Background: The influence of comorbidity on the healing process and the prognosis of patients with carcinoma of the head and neck region undergoing surgical treatment is not clear., Patients and Methods: In a retrospective study we examined the influence of coexistent diseases in 203 patients, hospitalized for curative surgical treatment. Findings on admission, supplemented by medical, anaesthesiological and neurological assessments, helped to form two subgroups: one of patients with minimal comorbidity (n = 135) and one with high comorbidity (n = 68). Subsequently the duration of hospitalization, incidence of complications, disease-free interval and survival was statistically compared., Results: The duration of hospitalization, the incidence and degree of complications, the disease-free interval and the overall survival differed significantly, showing better results in the group with low comorbidity., Conclusion: Coexistent, mainly medical, diseases had a significant influence on the results of surgical treatment and prognosis of head and neck cancer.

Study Design: A matched-pair study on the relationship between proliferation associated markers Ki-67, PCNA, and p53 and treatment failure in carcinomas of the oropharynx and oral cavity., Material and Method: Fifty-six T1-T3 carcinomas of the oropharynx or oral cavity, treated uniformly with primary surgery and postoperative irradiation, were investigated. Twenty-eight patients had recurrent disease and were matched with 28 patients with nonrecurrent disease regarding stage and location of tumor as well as age and therapy. MIB1 staining was used to determine the Ki-67 labeling index. Immunohistochemical studies determined the p53 status and PCNA labeling index., Results: Where treatment failed, the Ki-67 labeling index was significantly (p = 0.032) higher (mean = 59.1%) than in patients without recurrence (mean = 50.5%). Mean time to relapse was 45 months (n = 25) for carcinomas with a Ki-67 (MIB1) labeling index above the median (53.7%) of the general study population, compared to 61.7 months for those cases (n = 31) below this median (p = 0.029). The PCNA labeling index did not correlate significantly with tumor recurrence, nor with time to relapse. In 46% of all tumors, p53 overexpression was present. No significant correlation could be found between p53 overexpression and tumor recurrence or time to relapse., Conclusion: Examination of Ki-67 is thought to provide useful prognostic information concerning squamous cell carcinomas of the oropharynx and oral cavity. Overexpression of p53 or PCNA status is not of prognostic value, which is consistent with earlier results. We conclude that the detection of Ki-67 is an unfavorable prognostic factor for squamous cell carcinoma of the oropharynx and oral cavity, at least if treated with a combination of surgery and postoperative irradiation.

Background: Management of the suspected N0-neck (sonography and CT) in squamous cell carcinoma (SCC) of the head and neck is discussed controversially. The question arises whether the sentinel node (SN) concept as it is performed in different areas of clinical oncology is applicable to ear, nose, and throat medicine., Methods: Nine male patients with SCC were studied (4 oropharynx, 2 hypopharynx, and 3 larynx) in whom different lymph node status was diagnosed clinically (5 x N0, 2 x N1, 2 x N2c). After intraoperative scintillation probe detection, the histological examination of the SN with neck dissection (ND) specimen followed., Results: In 7 of 9 cases SN detection was successful. In 4 of 5 cases of clinical N0 status, SN, and ND specimens were free of tumor histologically, while in one patient radiolabel-identified SN showed tumor cells in histological examination. In 2 patients with clinical N1 neck, SN, and ND were histologically tumor-free in one patient and contained one single tumor metastasis located in the SN in the other patient. In 2 patients with clinically and histologically proven N2c neck, lymph nodes located in regions II and III showed metastasis including capsular rupture. In both cases no lymph node radioactivity was detectable during the operation., Conclusions: The results suggest that sentinel lymphonodectomy may be suited for ear, nose, and throat medicine. Before it is applied to clinical practice, further problems must be resolved. These include the short distance between the primary injection side and lymph nodes and the influence of intranodal tumor metastasis on the uptake of the radiolabeled tracer.

Background: Extensive tumors of the oropharynx require an open approach and plastic reconstruction for good oncologic and functional results., Patients and Methods: From January 1988 through December 1996 at the Department of Otolaryngology, Head and Neck Surgery, of the University of Würzburg, 62 patients with extensive tumors of the oropharynx underwent surgical treatment (T2 = 6, T3 = 24, T4 = 32). In 40 patients, the resection was performed via a median mandibulotomy approach, in 22 patients using a lateral pharyngotomy. All patients underwent postoperative radiotherapy up to 70 Gy., Results: Using the Kaplan-Meier method, the five-year survival was 80% for T2, 52% for T3, and 22% for T4. Four patients (7%) presented with a second primary carcinoma, and one also had a third carcinoma. Seven patients who died of T3- and T4-tumors had distant metastases, among them 5 patients who were free of local disease. A regular oral diet was possible on average 14 days postoperatively. All patients underwent tracheostomy. Ninety percent of them were decanulated one year postoperatively., Conclusions: Resection of extensive carcinomas of the oropharynx and microvascular reconstruction produces good oncological and functional results. The best access to extensive tumors is provided by a mandibulotomy. The advantage of this excellent approach outweighs an increasing morbidity in occasional cases.

Background: Basaloid squamous cell carcinoma is a variant of squamous cell carcinoma which is located predominantly in the upper aerodigestive tract. The cardinal histopathologic feature is a biphasic cellular pattern of basaloid and squamous components in a close relationship. Major differential diagnoses include adenoid cystic, adeno, squamous, adenosquamous, and basal cell carcinomas. This entity may commonly pose diagnostic difficulties, especially on small biopsy material, if only the basaloid component of the tumor is included., Case Report: A tumor of the oropharynx (T2) was detected in a 61-year-old man. After endoscopic biopsy, this tumor was histologically identified as an adenocarcinoma. A very rapid tumor growth became obvious during the patient's staging. After pharyngectomy and neck dissection, the histopathological diagnosis was corrected to a basaloid squamous cell carcinoma. The definite diagnosis was not made on biopsy material, because only the basaloid component of the tumor was included., Discussion: Basaloid squamous carcinoma is a biologically aggressive tumor with high proliferative activity and a propensity to destructive local growth and early regional and distant metastasis. Literature predominantly indicates that basaloid squamous cell carcinoma is an aggressive variant of squamous cell carcinoma and is prognostically worse than the regular squamous cell carcinoma., Conclusion: Because of the aggressive biological behavior of basaloid squamous cell carcinoma, radical surgery combined with radiation and chemotherapy is the treatment of choice.

Background: Reestablishing good swallowing function after resection and reconstruction of head and neck tumors is very important for our patients' well-being. Today many different surgical concepts for reconstruction after tumor surgery are in common use. It is necessary to establish a good diagnostic procedure for postoperative assessment of the swallowing function. High-speed cineradiography at a minimum of 50 frames per second is well established for evaluating swallowing problems in head and neck patients., Methods: Thirty-six patients divided into three groups were examined using high speed cineradiography after surgical treatment of pharyngeal and oral cavity cancer. Group 1 (n = 12) included patients with a subtotal or total tongue resection and reconstruction with infrahyoid myofascial flap and jejunal flap; Group II (n = 8), patients with total resection of the oropharynx soft palate and velum and reconstruction with a free radial forearm flap; Group III (n = 15), patients with total laryngopharyngektomy and reconstruction with jejunal flap and siphon and with or without repair of the digastric muscle., Results: Group I: All patients with tongue reconstruction were able to swallow normally from the oral cavity into the pharynx. All patients had normal bolus propulsion because of a good tongue volume and tongue motility. There was only one case of aspiration after total glossectomy with the larynx left in place. All patients could swallow with the head and neck in a normal position. Group II: All patients with reconstruction of the soft palate and velum were able to initiate proper bolus propulsion without nasal regurgitation or rhinolalia aperta. Only one patients suffered from chronic aspiration after hemiresection of the oropharynx and hypopharynx. Group III: All patients with pharynx reconstruction had no problems with bolus transfer through the reconstructed pharynx. Aspiration into the reconstructed pharynx was a major problem for those patients without repair of the digastric muscle (5/8 = 63%). Better results were observed in the patients who underwent repair of the digastric muscle. There was only one case (13%) of aspiration., Conclusions: By using high-speed cineradiography it is possible to make a detailed description of the swallowing function after extensive surgical treatment of pharyngeal and oral cavity cancer. We think that high-speed cineradiography is a very sensitive diagnostic procedure capable of detecting all functional aspects of swallowing. High-speed cineradiography should be one of the standard diagnostic studies performed surgery of the oral cavity and pharynx.

Background: Resection of the soft palate in tumor surgery can lead to significant swallowing disorders. Therefore rehabilitation needs a functional reconstruction of the remaining defects., Materials and Methods: In four years, nine patients received a partial removal, and six patients a total removal of the soft palate including adjacent parts of the oropharynx in six cases due to oropharyngeal carcinoma. Partial defects were reconstructed with a neurovascularized infrahyoidal muscle flap, total defects with fasciocutaneous flaps of the lateral arm, radial forearm or scapula region. The function of the new palate was evaluated by interview, cinematography, and pressure measurements of the pharynx., Results: These investigations demonstrated proper swallowing without aspiration or regurgitation in all cases. Values of 60% of normal pressure behind the palate have been achieved after palate reconstruction with a pressure slope directed into the hypopharynx. Decannulation was possible on average 34 days postoperatively, removal of the feeding tube on average 29 days postoperatively. Now 87% of our patients are free of tumor after a mean observation time of 24 months. In light of the fact that two-thirds of all patients suffered from advanced carcinoma, results can be considered as good. This study shows good functional and oncologic results after tissue reconstruction of the soft palate.

Background: The results of the surgical therapy of patients with extensive squamous cell carcinoma of the oropharynx and their lymph node metastasis, postoperative follow-up, and rehabilitation depend on the collaboration between ear, nose, and throat surgeons and maxillofacial surgeons. Modern reconstruction techniques permit single-session surgical treatment with a reduced period of hospitalization. The most important therapeutic aim is to improve patient well-being., Patients: Over a period of two years, 45 patients underwent the same surgical procedure. These patients were all in stages III or IV of their disease., Results: This procedure consists of a temporary lateral osteotomy of the mandible with or without resection of the mandible, to provide broad exposure of the tumor of the oropharynx. Apart from the broad exposure, the advantage of this surgical method lies in simple reconstruction using a pedicled and microanastomosed flap. Internal fixation with six and four-hole titanium plates is a reliable method for restoring the stability of the mandible. In six patients, complications occurred in connection with the plate fixation. In four patients, we observed osteomyelitis of the fragment fissure or sequestration. Plate fracture and pseudarthrosis occurred in one patient each., Conclusions: In our clinical experience, the microvascular anastomosed radial flap proved to be the ideal free soft tissue transplant. One of its primary advantages is its plasticity and hence good post-therapeutic functional results. The jejunal flap has become less significant them the radial flap; the advantage of mucous membrane transfer is lost after radiation and a corresponding postoperative interval. In patients with large, voluminous defects, the use of myocutaneous flaps, especially from the latissimus dorsi, is still justified.

Fifty-three patients who underwent laryngopharyngeal cancer surgery were examined with a sequential computer manometry system using 4-channel pressure probes. Swallowing coordination is largely independent of the oropharyngeal pressure thrust nor of the pharyngeal transit time and depends mainly on initiation of swallowing. The points of interest are the pharyngeal entrance and outlet. The topographic correlates are the base of the tongue and the upper esophageal sphincter. Resections of the base of the tongue decrease the volume available for pressure generation reducing the driving force of the tongue. Thus, reconstruction at the base of the tongue must provide more bulky-tissue coverage (i.e. myocutaneous flaps) in order to avoid cranial release of pressure and to bring about initiation of swallowing. Resections of the pharyngoesophageal segment cause circular defects that affect the sphincter, reducing hypopharyngeal suction. Thus, the resistance to bolus flow is generally increased, but can be compensated for by an increased driving force of the tongue. Additional pharyngeal and/or lingual resections increase the lumen discontinuity between the wide pharynx and the narrow esophagus, exceeding any compensatory possibilities. Plastic reconstructions therefore have to compensate for different lumina distally. In the region of the upper esophageal sphincter, softer and smoother tissue coverage is warranted in order to facilitate bolus transfer or passive bolus flow if necessary. For that purpose we modified the myofascial pectoralis-major-flap. It covers defects where a soft lining is required. The resistance to bolus flow is reduced, alleviating the need to increase the driving force of the tongue which would otherwise increase to compensate for the defect.

Histological examination of CO2 laser-resected specimens reveals a thin layer of carbonisation, beneath which the cellular architecture is preserved, permitting adequate assessment. With early staged laryngeal, oral and pharyngeal carcinomas, it is usually possible to remove the tumour as a single block, and the margins can be studied by parallel histologic sections. Advanced tumours, regardless of their localisation, demand resection in several blocks. Each tissue block is carefully orientated and the deep surface of every specimen is stained. Accurate mapping of every block is essential to enable the surgeon to identify the precise location of each specimen in the patient. The specimens are vertically sectioned after paraffin wax embedding. Grading, depth of invasion, lateral and basal margins are examined. Like in conventional surgery, it is technically impossible to examine all margins of a large specimen. With vertical sections only limited information can be obtained about lateral and basal margins. If deep tumour infiltration reaches cartilage or bony structures, clear microscopic margins are difficult to prove after laser resection. Finally it must be possible for the surgeon to recreate a complete, 3-dimensional mosaic of the entire lesion to achieve accurate pT-staging.

From 1983 to 1992, 216 free jejunal transplants were performed after resection of malignant tumours for reconstructing the upper oesophageal tract. In two patients reconstruction was performed secondarily and in four cases within the framework of recurrence treatment. In 25 cases the jejunal transplant was sewn in tubular form to the circular insert of the hypopharynx, whereas in the remaining 188 cases the jejunum transplant was sewn as patch. A jejunum transplant was most frequently employed in the tonsillar region (n = 75). Reconstruction of the body of the tongue was performed in 42 cases and of the hypopharynx in 29 cases. Of the 213 patients treated, 175 were irradiated postoperatively. The most severe complications were in 5 cases death from the sequels of the operating, abdominal complications in 15 cases and complete loss of the transplant in 22 cases. Protracted inability to swallow occurred in 15 cases and pneumonia in 16 patients. The five-year survival probability was 39% for the 42 patients suffering from carcinomas of the oral cavity, 53% for the 90 patients with oropharyngeal carcinoma in stage III and 33% in stage IV, as well as 40% with the 29 patients suffering from hypopharyngeal carcinomas. An essential advantage of the free jejunum transplants were the excellent functional reconstruction results. This is demonstrated by examples of various cases. Since the number of treated patients is still too low, it is at present not yet possible to compare this approach with other therapeutic concepts, such as enoral laser surgery resection or radiochemotherapy.

Standard procedures for temporary mandibulotomy are medial or the lateral osteotomy. Median mandibulotomy is associated with destruction of anatomical structures in the floor of the mouth and with lateral osteotomy no preservation of the nervus alveolaris inferior is possible. Therefore, a modification of mandibulotomy is described with wide-field exposure, minimal functional defects and reduction of osteotomy-related complications. The first osteotomy is carried out vertically before the foramen mentale on the buccal compacta of the mandible. A second vertical osteotomy is placed on the lingual compacta posterior to the musculus myohyoideus. Horizontal osteotomies on the alveolar ridge and the basal ridge of the mandible are connected with the vertical osteotomies. Using a chisel, the lingual and the buccal part of the mandible are split sagittally with preservation of the nervus alveolaris inferior located in the buccal fragment of the mandible. The two parts of the mandible are divided to provide access to the oropharynx. Surgical approach to the fossa pterygopalatina and the parapharyngeal space is reached with dissection of the mucosa along the ascending mandible, subluxation in the mandibular joint and reflection of the mandible cranially and posteriorly. The wide access offers a lot of advantages especially in combination with a microvascular flap reconstruction. Fixation of the mandible is carried out with two titanium miniplates at the anterior vertical osteotomy. The wide areas of the split bone marrow, resulting from sagittal splitting, achieved an exact adaptation of the mandibular parts and an easy and sure fixation via miniplates. Therefore, post-operative radiation therapy can be started two weeks after the operation.(ABSTRACT TRUNCATED AT 250 WORDS)

A total of 488 patients with neoplasms (in 474 cases with malignant tumours) of the oropharynx, floor of the mouth and oral cavity, were examined with MRI and CT. MRI proved superior to CT, on account of its coronal and sagittal slice orientation enabling not only a better demonstration of findings, but also improved tumour detection and staging. The diagnostic value of MRI was further enhanced with additional fast and ultrafast MR sequences rather than spin echo sequences alone, as previously practised.

Unlabelled: From 1982 to 1992, large intraoral and pharyngeal soft-tissue defects were reconstructed using myocutaneous island flaps in 95 patients, free jejunal interpositions in 10 patients and forearm flaps in 18 patients at the Magdeburg School of Medicine, Department and Clinic of Otorhinolaryngology. Sixty-five patients were followed up after various time periods in order to assess the functional results. Investigation and evaluation of the individual patients' resultant quality of life were based on a specifically prepared examination questionnaire. In particular, the evaluation included: the mouth opening gap, motility of the tongue, sufficient masticatory area, adequate provision to fit artificial teeth, malocclusion, the extent of mandibular deviation, assessment of the swallowing act, articulation disturbances, paraesthesia, function accessory nerve, atrophy of the trapezius muscle, motility of the cervical spine, flexibility in the shoulder girdle, as well as subjective information obtained from the patients (pain, feeling of dryness, increased salivation, occupational rehabilitation, organisation of leisure time). In 45 patients, biopsy material from the transferred tissue was examined at varied time intervals after primary therapy., In Conclusion: The functional results obtained for the myocutaneous island flaps, the forearm flap and the free jejunal interposition were satisfactory, and only minor differences were noted. From the morphological point of view, all the three types of tissue transfer were found to have adapted adequately to the recipient site.

33 patients were examined after laryngopharyngeal surgery by means of computer manometry using 4-channel-pressure probes. After local tumour resection in the region of tonsils and lateral oropharyngeal wall a slight cranial decrease in pressure results. Resections of the soft palate, glossotonsillar groove, base of the tongue, and of the vallecula lead to a cranial release of pressure reducing the driving force of the tongue. The swallowing action is therefore delayed and completely uncoordinated resulting in dyskinesia of the PE segment. Stenosis in the PE segment after hypopharyngeal resections increases the resistance to bolus transfer. If the base of the tongue is intact the obstruction can be compensated. After laryngectomy the sphincter pressure is decreased reducing the hypopharyngeal suction pump and prolonging bolus transfer. The tongue driving force, however, is increased. As long as the base of the tongue region is intact, pressure is not released and bolus transfer not severely impaired despite missing contraction of the pharyngeal constrictor muscle. Thus, reconstructive procedures after ablative pharyngeal surgery have to provide more "high-volume-tissue" in the base of the tongue (i.e. myocutaneous pectoral flap) in order to initiate swallowing and avoid cranial release of pressure whereas in the PE-segment more "low-volume-tissue" is necessary (i.e. myofascial pectoral flap) to facilitate bolus transfer.

60 patients with advanced carcinomas of the oropharynx and hypopharynx underwent chemotherapy, either with 5-FU/Cisplatin (n = 30) or with 5-FU/Carboplatin (n = 30). The remission-rates (complete and partial remissions) were comparable in both groups. The rate of complete remissions, however, was statistically significant higher in the cisplatinum group (6 patients) than in the carboplatinum group (1 patient). 2 patients of the 5-FU/Cis-group and 4 patients of the 5-FU/Carbo-group developed a progressive disease during chemotherapy. Statistically significant differences were found in the nephrotoxic and myelotoxic side effects between both therapy groups: nephrotoxic side effects were more frequent in the 5-FU/Cis-group, whereas myelotoxic side effects occurred mainly in the 5-FU/Carbo-group. The chemotherapy with 5-FU/Carboplatin was better tolerated by the patients than in the 5-FU/Cisplatinum-group. In the 5-FU/Carbo-group especially a lower rate and severity of loss in weight, nausea, vomiting, alopecia and mucositis/stomatitis was observed. No statistically significant differences were found in ototoxic side effects between both groups.