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In hypopharyngeal carcinoma, open partial resection is rarely feasible because of the high rate of chronic aspiration. Transoral laser surgery, however, is not associated with major swallowing problems. Between 1991 and 1995, a total of 29 patients with cancer of the hypopharynx were treated using laser surgical resection. In 25 patients, a neck dissection was performed, and 26 patients were radiated postoperatively. The 5-year overall survival was 48% and tumor-related survival 58%. The outcome was significantly ( P0.048) dependent on the preoperative lymph node status (N(0)=74%, N(+)=34% overall survival). Accordingly, the 5-year survival in stage I and stage II tumors was 71% and in stage III and IV tumors 47%. The highest local control rate was achieved in patients with carcinoma of the hypopharyngeal walls. A major advantage of laser surgery is that resurfacing of the wounds takes place per secundam. No reconstructions with free vascularized grafts have to be performed. There were no functional deficits regarding speech and swallowing in 94%, 100% and 100% of the surviving patients without local recurrence after 3, 4 and 5 years, respectively. No patient had to have a tracheostomy intraoperatively. Laser surgical treatment in combination with neck dissection and postoperative radiotherapy of selected patients with early cancer of the hypopharynx shows comparable results with open surgical procedures and is superior to radiotherapy alone. Given the low postoperative morbidity, transoral laser surgery with the goal of preserving the larynx should gain more importance in the future.

Between 1981 and 1994, 34 patients with squamous cell carcinoma of the supraglottis were treated by transoral carbon dioxide laser resection, 12 of them palliatively. Additional treatment included neck dissection in 21 patients and radiotherapy in 24 patients. The 3-year overall survival was 62%, and the actuarial survival 80%. The overall survival for T1 and T2 tumors was 71%, and that for T3 and T4 tumors was 47%. The overall 3-year survival for the early stages, I and II, was 88%, and that for the advanced stages, III and IV, was 50%. These results are comparable to the outcome after conventional open partial resection. Given the significantly lower morbidity (only 7 patients required tracheostomy), we do not observe an age limit anymore. The transoral method can be recommended as curative treatment in T1 and T2 tumors and in selected T3 and T4 tumors in concert with neck dissection and/or radiotherapy. In patients with advanced inoperable tumors, laser surgery is an excellent alternative to tracheostomy and palliative radiotherapy. Prerequisites for successful application of the transoral carbon dioxide laser resection are adequate resection techniques.

Accurate knowledge of lymphatic drainage facilitates planning of surgery for patients with squamous cell carcinoma of the head and neck. The aim of this study was to evaluate the feasibility of a new injection technique for lymph node detection in patients with squamous cell carcinoma of the hypopharynx and larynx, in whom simple peritumoural injection is hampered by the tumour localisation. Computed tomography (CT)-guided lymphoscintigraphy was performed in a total of 13 patients with squamous cell carcinoma of the hypopharynx and larynx who could not be injected by simple visual inspection. In a first step, contrast medium-enhanced axial 5-mm-thick CT slices of the neck were obtained. After tumour localisation on these CT images, 1–2 ml contrast medium and, in the event of appropriate distribution, subsequently 50 MBq technetium-99m colloid were injected at one to three peritumoural sites under CT guidance. Peritumoural tracer distribution was controlled by thin-slice CT. Subsequently, planar scintigrams from anterior, right and left lateral views were obtained. In all patients, peritumoural colloid application was feasible, as shown on control CT scans. Post injection, neither severe nor minor complications were noted. The patients complained of only low pain sensations with an average score of 1.8 on a pain scale from 0 to 10. Lymphatic drainage was identified in nine of the 13 patients, with a total of 14 detected lymph nodes. In six patients, ipsilateral sentinel lymph nodes were visualised; bilateral sentinel lymph nodes were identified in one patient and contralateral lymphatic drainage was observed in two patients. CT-guided lymphoscintigraphy is a feasible and minimally invasive diagnostic tool for sentinel lymph node detection in patients with squamous cell carcinoma of the hypopharynx and the larynx. In contrast to endoscopic colloid injection under general anaesthesia, this technique seems to be a well-tolerated method for lymphatic mapping prior to surgical procedures.

In squamous cell carcinoma of the head and neck, staging of the neck cannot rule out occult metastatic disease. An improved staging is necessary to avoid elective neck dissection in patients staged as N0. The study was performed to determine the feasibility of the detection of occult metastatic disease by ultrasound-guided fine-needle aspiration cytology (USgFNAC) of sentinel lymph nodes (SLN).Sixteen consecutive patients diagnosed with oral, oropharyngeal, or dermal squamous cell carcinoma who had been staged as N0 underwent lymphoscintigraphy in double tracer technique to localize SLNs. A USgFNAC was performed on SLNs before elective neck dissection. The results of USgFNAC were compared with pathohistologic findings, which were regarded as the gold standard.Seven of 16 patients were upstaged to N+ after histopathologic examination of the neck dissection specimen. In only 1 of these patients was metastatic disease detected by USgFNAC of the SLN.The combination of lymphoscintigraphy and USgFNAC of the SLN improves preselection of N+ patients and, thus, the staging procedures. However, based on present results this method does not seem reliable in deciding whether an elective neck dissection can be avoided. A biopsy of the SLN with close histopathologic work-up seems to be mandatory for the detection of occult metastatic disease, because the merely incidental aspiration of micrometastatic material within normal-sized lymph nodes results in a high number of false-negative results by USgFNAC.

Since knowledge of possible lymphatic drainage may facilitate preoperative planning a method of lymphoscintigraphy with exact correlation of lymphatic drainage to six known cervical compartments is presented. 78 patients with various tumors of the head and neck received 100 MBq Tc-99m-colloid in 3–4 peritumoral sites. 2 ml of perchlorate solution were given orally in order to block the thyroid. Patients received 50 MBq Tc-99m-pertechnetate i.v. for body-contouring 20 min p.i. Planar images were obtained over 5 min each at 30 min and 4–6 h after injection from anterior, right lateral and left lateral using a LFOV-gamma camera. The thyroid was seen in any of the patients. In 28/78=36 % of the patients the injection site was the only focal activity seen. In 50/78=64 % of the patients lymphatic drainage could be observed: 36/78=46 % showed unilateral, and 14/78=18 % exhibited bilateral lymphatic drainage. In all 50 patients showing lymphatic drainage lymph nodes could be easily assigned to the six cervical lymph node compartments described. Accurate correlation of lymphatic drainage and cervical compartments yields the basis for a re-evaluation of its impact in preoperative planning of different procedures of neck dissection.