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Summary: Background: Multicomponent defects of the head and neck involving the cervical skin pose a reconstructive challenge for microsurgeons and usually requires two flaps. However, many patients who undergo such surgical treatment had prior treatment with radiotherapy and the availability of recipient vessels for free flap reconstruction may be limited. The purpose of this study was to review our experience in the reconstruction of these extensive head and neck defects using a single ALT free flap. Methods: A total of 21 patients with complex defects of the head and neck involving multiple anatomical subunits, including the overlying cervical skin, underwent reconstruction with a single ALT flap. The clinical, functional, and aesthetic outcomes of these patients were reviewed. Results: The mean hospital stay was 24 days. There was one total flap loss due to pedicle thrombosis. The patient underwent a further ALT reconstruction with no postoperative complications. Cervical fistulas occurred in three patients, and all fistulas were healed by simple wound packing. Three patients with tracheal defect had a functional tracheostoma with adequate stomal patency. A modified barium swallowing study was performed on each patient, and all of them achieved total oral intake. Among them, two patients tolerated only a pureed diet. Conclusions: Complex neck reconstruction can be accomplished with a single ALT flap with good clinical and functional results, minimal morbidity and quick recovery. Keywords: Anterolateral thigh flap, Pharyngeal reconstruction, Microsurgical reconstruction, Neck resurfacing

In Italy, we have experienced Europe's first and largest coronavirus outbreak. Based on our preliminary experience, we discuss the challenges in performing tracheotomy and tracheostoma care in the setting of a new pathogen.

A wide range of disease processes may present with cough, and definitive treatment depends on identifying the cause. Specific treatment of the cause should control the cough, but this may not occur in all cases, and in a sizeable proportion of patients, no associated cause can be found. In the settings of acute cough, symptomatic treatment is often the first line of therapy. Symptomatic treatment must be also considered when the cough interferes with the patient’s daily activities; however most of antitussive preparations have not been shown to be more effective than placebo in adequately performed clinical trials. In this chapter the main antitussive drugs are examined, but for the sake of completeness, it is also discussed some other drugs often used to treat cough, though some of them are not commonly classified as antitussive agents. Finally, it is reported a recent therapeutic approach to refractory cough, represented by the combination of behavioural therapy and the neuromodulator drugs.

none 10 no Oral pigmentations (OPs) are often neglected, although a meticulous examination of the oral cavity is important not only in the diagnosis of oral melanoma, but also for the detection of important clinical findings that may indicate the presence of a systemic disease. OPs may be classified into two major groups on the basis of their clinical appearance: focal and diffuse pigmentations, even though this distinction may not appear so limpid in some cases. The former include amalgam tattoo, melanocytic nevi, melanoacanthoma and melanosis, while the latter include physiological/racial pigmentations, smoker's melanosis, drug-induced hyperpigmentations, postinflammatory hyperpigmentations and OPs associated with systemic diseases. We will discuss the most frequent OPs and the differential diagnosis with oral mucosal melanoma (OMM), underlining the most frequent lesions that need to undergo a bioptic examination and lesions that could be proposed for a sequential follow-up. none Lambertini, M; Patrizi, A; Fanti, P A; Melotti, B; Caliceti, U; Magnoni, C; Misciali, C; Baraldi, C; Ravaioli, G M; Dika, E Lambertini, M; Patrizi, A; Fanti, P A; Melotti, B; Caliceti, U; Magnoni, C; Misciali, C; Baraldi, C; Ravaioli, G M; Dika, E

Background. Stomal recurrence after total laryn- gectomy is 1 of the most serious issues in head and neck sur- gery, both because of the complexity of its management and because of its morbidity. Prior to the introduction of free-tissue transfer, mediastinal tracheostomy has been the standard reconstructive procedure with high rate of complications. The ideal reconstructive solution to these problems must provide well-vascularized soft tissues that can cover the defect after resection and also allow suturing of the tracheal remnant to skin edges without tension. Methods and Results. We describe a case of a 56-year-old man with stomal recurrence after total laryngectomy treated by the use of a tubed anterolateral thigh (ALT) flap to elongate the shortened trachea and simultaneously cover the cervical skin defect. Conclusions. The ALT can be accepted as an ideal free- flap choice for stomal recurrence, because it has maximal reconstructive capacity and produces minimal donor-site mor- bidity. V C 2009 Wiley Periodicals, Inc. Head Neck 31: 1107- 1111, 2009

Complete pathological response after chemo-radiation in anaplastic thyroid cancer: A report of two cases

OBJECTIVES: Minimal-access thyroid surgery, using various techniques, is increasingly being reported. The present study reviews our experience with thyroid surgery using a minimally invasive approach (MIT). STUDY DESIGN: Between October 2002 and December 2004, a prospective nonrandomized study of patients undergoing thyroid surgery was performed to evaluate the variables that might condition the indications to minimally invasive nonendoscopic approach. RESULTS: 296 patients underwent thyroid surgery; 46 of these were eligible for MIT through a 2.5- to 3-cm incision. There was one case of transient inferior laryngeal nerve palsy and no postoperative definitive hypoparathyroidism. MIT was converted to conventional thyroidectomy only in two cases. Cosmetic results were considered excellent by all patients. CONCLUSIONS: Minimal-access thyroid surgery is a safe and feasible alternative to conventional thyroid surgery in selected cases. The advantage that this technique offers, in addition to low morbidity, is an improved cosmetic result.

No abstract available

Background HPV16 is the most prevalent genotype in oropharyngeal squamous cell carcinomas (OPSCCs), but there are few information about intratype variants prevalence and their clinical relevance in these tumors. Moreover, since HPV DNA detection alone is not sufficient to determine a favorable prognosis for OPSCCs, additional diagnostic/prognostic biomarkers are necessary. Objectives To assess the prevalence of HPV intratype variants and evaluate the role of HPV16 DNA methylation as prognostic marker in OPSCCs. Study design We analyzed 81 biopsies of OPSCCs for HPV detection and genotyping with a pyrosequencing-based HPV DNA-test. We also quantified viral DNA methylation frequency in the LCR by pyrosequencing in patients with transcriptionally-active HPV16-infection, analyzing it in function of available clinical/virological data. Results The overall HPV prevalence was 74.1% and HPV16 was confirmed the most prevalent genotype (51/60, 85.0%). Interestingly, we detected, for the first time, HPV16 African variants in 10/51 cases (19.6%), pointing out their clinical relevance also out of the anogenital district. Regarding viral DNA methylation, the E2BS1 showed a significantly higher mean methylation frequency compared to E2BS3/4, as previously observed in high-grade precancerous lesions of the uterine cervix. On the other hand, patient with a mean methylation frequency in the early promoter >10% showed only a tendency to have a worse prognosis. Conclusions Our results highlight both the involvement of HPV16 African variants in OPSCCs development and the necessity of further studies to deepen the role of viral methylation in these tumors, in order to better define similarities/differences compared to cervical cancer.

Objective: Neurostimulation with laryngeal palpation (NSLP) is an intermittent monitoring technique that facilitates nerve identification and permits an assessment of the recurrent laryngeal nerve ...

The aim of the study was to evaluate the effects of a linoleic acid (LA)-based, high LA/ α-linolenic acid (ALA) ratio enteral formula with those of an oleic acid (OA)-based, low LA/ALA ratio formula, on plasma and red blood cell membrane (RBC) phospholipid fatty acid patterns, neutrophil superoxide anion generation, and eicosanoid production (prostaglandin E2 and leukotrien B4). Two groups of 7 adult male patients who underwent laryngectomy for malignancy received the formulas (LA-group or OA-group) between the 1st and the 13th postoperative (po) days. In comparison with the 1st po day, at the 14th po day: the LA-group showed an increase of the LA (p

Background The aim of this study was to assess a prospective, randomized clinical trial (RCT) comparing neurostimulation with laryngeal palpation (NSLP) of recurrent laringeal nerve (RLN) alone with NSLP associated with laryngeal neuromonitoring (LNM) to evaluate the ability of LNM in reducing the rates of RLN palsy. Methods In all, 250 consecutive patients scheduled to have thyroidectomy were randomized to NSLP alone (NSLP group) or NSLP with LNM (LNM group). The primary endpoint was to assess the rate of RLN palsy. Results The incidence of palsy was 2.7% in the LMN group and 2.6% in the NSLP group. No significant statistical difference between the groups was observed either for permanent or for transient paralysis (respectively, Fisher's Exact test: p = 1.0 and p = 1.0). Conclusions This RCT shows that the use of LNM during thyroidectomy does not reduce the rates of recurrent laryngeal injuries compared with NSLP alone. [Registration number: NCT01163045 (http://www.clinicaltrials.gov).] © 2011 Wiley Periodicals, Inc. Head Neck, 2012

To determine the accuracy of neurostimulation with laryngeal palpation (NSLP) and intraoperative neuromonitoring (IONM) to predict the postoperative function of recurrent laryngeal nerve (RLN) in thyroid surgery.Historical cohort study.A retrospective case control study with 993 patients. The control group (799 patients with 1450 nerves at risk) included patients who underwent NSLP and the case group (194 patients with 354 nerves at risk) consisted of those who underwent NSLP in association with IONM. Sensitivity, specificity, positive (PPV) and negative predictive values (NPV), and accuracy were calculated for NSLP and IONM, with nerve palsy as the target outcome.A significant difference in nerve injury between the case and the control group (P = 0.31) was not observed. The presence or absence of laryngeal twitch (LT) (P0.0001) and the acoustic response to electrical stimulation (P = 0.003) were significantly associated with nerve function at the end of the surgery.Our results indicate that NSLP is a safe and reliable intraoperative method of RLN monitoring. Moreover our data confirm that IONM is not a helpful tool to reduce the rate of palsy in thyroid surgery.

Introduction: Neoplasms arising within the parapharyngeal space are rare and represent approximately 0.5% of all head and neck tumors. The majority of these lesions consist of minor salivary gland tumors, tumors of the deep lobe of the parotid gland, and tumors of neurogenic origin (paragangliomi and schwannomi), while branchial cysts are extremely rare. Despite advances in radiographic images, surgical excision remains the definitive technique for the diagnosis of parapharyngeal space tumors. Results and discussion: The authors report a case of branchial cyst of the parapharyngeal space excised through a combined transcervical-transmandibular approach and discuss the several surgical techniques proposed to approach this type of tumors. © Springer-Verlag 2008.

More than 20 years have passed since the introduction of surgical techniques based on distal myocutaneous flaps or micro-vascular flaps in the reconstruction after head and neck cancer resections. The experience gained from the beginning of these techniques until today, has improved the possibility to better predict functional impairment of swallowing in patients and its possible recovery. This contributes to a better counselling of the patient and better prediction concerning his/her quality of life. Despite the time passed and good progress in the development of microsurgical techniques, the literature shows that many differences still remain among Authors concerning choice of flap and its inset in relation to the anatomical sites and the extent of resection. Many other variables may condition post-operative swallowing (pre- or post-operative radiotherapy, general conditions of the patient …) thus contributing to a more difficult comparison of the different series reported in the literature. Personal experience is based upon surgical treatment in >60 patients with advanced bucco-pharyngeal cancer, all of whom evaluated post-operatively by video-endoscopy and video-fluoroscopy. In summary, data collected both from personal experience and the literature show that difficulties still remain in correct evaluation of swallowing in these patients. This is mainly due not only to lack of a commonly accepted scheme of classification to quantify the anatomical defect but also to differences between Authors concerning choice of the type of flap and the mode of inset.

Background. Radiation therapy (RT) is one of the gold standard treatments for early laryngeal cancer, and total laryngectomy is still the most applied surgical procedure after failure. Selected recurrences can be managed by supracricoid partial laryngectomies (SCPLs). Methods. A multi-institutional retrospective analysis was carried out in 78 consecutive patients treated by SCPLs for the recurrence of glottic-supraglottic cancer after RT. Cricohyoido- epiglottopexy was performed in 62, and cricohyoidopexy (CHP) in 16 cases. Results. Disease-free survival at 3 and 5 years were 95.5%. Early and late postoperative complications occurred in 27% and 17.9% of cases. Decannulation and satisfactory swallowing were achieved in 97.4% of cases. Conclusions. SCPLs represent effective surgical organ-pres- ervation strategies in the treatment of selected recurrences after RT failure, resulting in a good local control as well as functional recovery with acceptable morbidity, despite a complication rate which is not negligible. V C 2007 Wiley Periodicals, Inc. Head Neck 30: 372-379, 2008

To evaluate the accuracy of the intraoperative parathyroid hormone (ioPTH) and 6-hour PTH (6hPTH) assay in predicting transient hypoparathyroidism after thyroidectomy.A nonrandomized prospective study was conducted on patients undergoing thyroid surgery.Of 138 patients undergoing thyroid surgery, intraoperative PTH was measured 10 minutes after gland removal. Serum calcium, magnesium, inorganic phosphorus, albumin, and PTH levels were assayed 6 and 16 hours after surgery and daily until patient discharge.The development of postoperative hypocalcemia was associated with low ioPTH (P0.0001) and 6hPTH (P0.0001) values, and the decline of PTH from baseline (P0.0001). The cutoff for percentage decline of ioPTH and 6hPTH (55.7% and 379%, respectively) was more accurate than an absolute value. Accuracy, and positive and negative predictive values were 88 percent, 63 percent, and 100 percent for ioPTH and 75 percent, 46 percent, and 100 percent for 6hPTH, respectively.With the use of ioPTH decline in association with 16-hour corrected calcium, it is possible to distinguish early normocalcemic patients from hypocalcemic ones in most cases.

Objective The purpose of this study was to identify the risk factors for postoperative transient hypoparathyroidism in a group of patients undergoing thyroid surgery. Study Design A prospective study was conducted on 604 patients undergoing thyroid surgery. Subjects and Methods Gender, final diagnosis, extent of resection, biology of pathology, intrathoracic involvement, surgery for recurrent multinodular goiter, and presence and number of parathyroid glands in a surgical specimen were analyzed as risk factors for postoperative transient hypoparathyroidism. The chi-square test and a logistic regression analysis were applied. Results On logistic regression analysis, only the extent of surgery constituted an independent variable for transient hypoparathyroidism ( P = 0.001). Conclusion The extent of surgery to central and/or lateral neck lymph nodes is responsible for a high rate of transient hypoparathyroidism owing to a high probability of unplanned parathyroidectomy or parathyroid gland devascularization.

Swallowing function has been evaluated by means of videofluoroscopy and videoendoscopy in 31 patients submitted to surgery for local extended bucco-pharyngeal carcinoma. Aim was to better predict functional deficits and subsequent recovery perspectives of patients as far as concerns swallowing. In 30 patients, surgery was combined with radiotherapy, pre-operative in 6 cases and post-operative in 24. Site and extension of resection were defined using Urken's classification of hard and soft tissue deficits. In 3 cases, resection included half of tongue base and was followed by direct closure of the surgical defect. In 4 cases, the entire hemitongue (hemibody and hemibase) was resected and repair was performed with a free flap. In 5 cases, the whole tongue base was resected (posterior glossectomy). In 2 of these, direct closure of the gap was performed while the other 3 received a free flap. Another 3 cases required resection of the entire mobile tongue with corresponding buccal floor. All were repaired with free flaps. In 6 cases, resection comprised half the tongue base and adjacent tonsillar fossa and was performed using a transmandibular approach (demolitive in 3 cases, reconstructive in 3). Of these patients, 3 received direct closure and 3 reconstruction with a free flap. In 4 patients, resection included the tonsillar fossa and soft palate while in 5 other patients the whole soft palate was resected in addition to the tonsillar fossa. All these 9 patients received repair with free flaps. The remaining patient underwent resection of the entire oro-hypopharyngeal posterior wall, reconstructed with a free flap. During video-endoscopy examination, both liquid and soft meal ("pudding") were given to patients. Diagnostic parameters studied were: grade of pharyngo-laryngeal sensitivity, latency in onset of pharyngeal swallowing reflux, drop of the bolus in pre-swallowing phase, grade of the pharyngeal residual, inhalation and pooling of saliva. Data collected may be usefully employed not only in predicting the type and grade of swallowing deficit related to the extension of resection and repair technique used, but could also be helpful in the choice of the most appropriate behavioural procedure of rehabilitation for the patient.

Minimal access thyroid surgery, using various techniques, is increasingly being reported. The present study reviews our experience with thyroid surgery using a minimally invasive approach in a group of patients with papillary thyroid carcinoma.A total of 15 female patients with a thyroid nodule, not exceeding 2 cm, proven to be a papillary thyroid carcinoma at preoperative evaluation, underwent a total thyroidectomy with non endoscopic minimally invasive approach.None of the patients presented intraoperative central lymphnode involvement. The cytologic preoperative diagnosis was confirmed by histology in all cases. One case of transient recurrent nerve palsy was observed immediately after surgery. No permanent nerve lesions were documented at 4 months. The hospital stay ranged from 48 to 72 hours. The iodine 131 uptake ranged from 0 to 2.13%, similar to that obtained with open thyroidectomy. All patients were satisfied for cosmetic result.The preliminary results of this study showed that non endoscopic minimally invasive thyroidectomy could be proposed in patients with T1 papillary carcinoma. In our experience the results obtained with this technique are similar to that obtained with open thyroidectomy, with the great advantage of a minimal neck wound and shorter hospital stay. However a higher number of cases and a longer follow-up are needed to confirm the safety of this procedure on the management of papillary cancer of the thyroid.

Oral cavity reconstruction after removal of locally advanced tumors is particularly difficult because anatomical restoration must accurately reproduce the original structure and enable effective and fast rehabilitation of mastication, swallowing, and phonation. The authors report their 2-year experience with 17 patients surgically treated for oral cavity cancer with reconstruction performed with the free anterolateral thigh flap. Thanks to its thinness and pliability, this flap has proven to be perfectly adaptable to the structural peculiarities of the resected areas and has enabled the authors to considerably reduce the cosmetic and functional complications in the donor area observed with other flaps (such as the radial forearm flap). Flap grafting has always been complete and regular, and no intraoperative and postoperative complications have been observed. Swallowing recovery has always been satisfactory. On the basis of the authors' results, their current approach to oral cavity reconstruction is based on the use of flaps that enable anatomical restoration of the resected areas and reduce morbidity of the donor site. They believe that the anterolateral thigh flap can offer all of these opportunities, and the surgery can be simultaneously performed by two surgical teams.

Carcinoid tumour of the larynx is extremely rare. The increasing number of these lesions reported is due to the application of ultrastructural and immunological methods in the diagnosis. Two new cases of this malignant neoplasm are presented and discussed with particular reference to the difficulty in distinguishing carcinoids from other tumours of the larynx. The accurate pathological identification of the tumour is essential for treatment and prognosis.

Commonly used clinical and pathologic criteria are often of limited value in predicting the outcome of patients with undifferentiated nasopharyngeal carcinoma, and new parameters related to the biology of growth of neoplastic cells are still required for better definition of the aggressiveness of these tumors. The prognostic significance of DNA ploidy, measured by image cytometry on isolated cells, and of the mitotic index, proliferating cell nuclear antigen, and p53 protein, all measured by image cytometry in histologic sections, were evaluated on archival tumor tissues from 53 patients with Stage III or IV nasopharyngeal carcinomas. Patients were staged according to the criteria of the International Union Against Cancer and were irradiated according to a conventional radiotherapy schedule. No significant associations were found between biologic parameters and clinical features. Only the stage and the mitotic index were related to patient survival, and, when examined in a proportional hazard regression analysis, both provided independent information. When patients with compromised skull and/or cranial nerves (T4 tumors), who had a very short survival, were eliminated from the analysis, only the mitotic index and proliferating cell nuclear antigen allowed discrimination of a subset of patients with poor prognoses. This study shows that the assessment of cell proliferative activity can provide useful information for better predicting the clinical course of high-risk patients with nasopharyngeal carcinomas and improve therapeutic strategies.

The present study employed immunohistochemical methods to study the cytokeratin (ck) and vimentin expression in 40 cases of laryngeal squamous cell carcinoma. Specific monoclonal isoform antibodies and mixes of antibodies vs. a specific molecule were used in order to determine what cytokeratins were present as accurately as possible. In this sampling two ck patterns were identified based on whether the ck pair 8/18 was present or not. The ck 8/18 positive cases were further broken down into three sub-groups based on the expression of one of the following: the ck 4/13 pair, ck 1/10 pair or vimentin. A statistically significant relationship was found between these sub-groups, the site at which the neoplasm arose and the tendency toward regional metastases. Moreover, it was found that the presence of ck 13 in a squamous cell carcinoma is correlated with the less aggressive forms, as indicated in the literature.

The Authors reviewed a group of 28 pts with early-stage supraglottic carcinoma (T1-T2N0), classified according to UICC (1987), and treated exclusively with radiotherapy (RT) between 1980 and 1991. Until 1990 RT was employed for such tumors when surgery was refused or controindicated, while since 1991 primary irradiation (with surgery in reserve) has been considered the treatment of choice. The total dose ranged from 66 to 70 Gy on the larynx and up to 50 Gy on neck nodes. RT was applied in a daily fraction of 2 Gy five times a week. No significant early complications were observed. Only 1 pt showed residual cronical oedema in the arytenoid region. In none of the pts was tracheostomy necessary. The local control rate obtained after 30 months was 85.7% (24/28). Salvage surgery (horizontal supraglottic laringectomy, HSL) was performed in 3 out of 4 pts with local failure and achieved complete control of the disease. In the last pt the surgery was controindicated because of poor general health conditions. The actuarial survival rate after 5 years is 86.2%. The present series was compared to a group of 152 pts with T1-T2N0 supraglottic cancer treated surgically (HSL) at the same Istitution. In these pts local control and the actuarial survival rates are 85.6% and 89% respectively. According to recent Literature data, the present findings confirm that RT may be administered for the treatment of selected early stage (T1-T2N0) supraglottic squamous cell carcinoma of the larynx with oncologic results equivalent to those obtained with radical surgery. The importance of imaging techniques (TC, MRI) in the correct staging of the tumor is emphasised.

Plasmacytoma is a rare neoplastic disorder arising from B-cell series lymphocytes. It can develop in three clinical variants: a) Multiple Myeloma (M.M.); b) Solitary Plasmacytoma of the bone; c) Extramedullary Plasmacytoma (EMP). EMP generally occurs in the submucosal tissue of the upper airways (80% of cases). This paper reports 22 cases of EMP of the head and neck observed in the last 20 years and reviews pertinent Literature. Four of our cases were located in the nasopharynx, four in the oropharynx and five in naso-sinusal sites. More rarely, the lesion occurred in the larynx (2 cases) or in the oral cavity (3 cases). In 4 patients multiple localizations in the upper airways were observed. Full evaluation was carried out in order to exclude disseminated disease. With the exception of 2 cases which were surgically treated, radiotherapy (RT) represented the treatment of choice in all patients, with doses ranging from 36 to 58 Gy. In 9 cases RT was administered after complete surgical resection. Follow-up time ranged from 13 to 167 months (mean 69.6). A partial response after treatment was observed in 4 cases. In only two of these cases neoplastic residue was observed (further RT allowed complete remission of the disease). In the other two cases, residual masses consisted in amyloid deposits. Three patients developed disseminated disease (MM) after a disease-free period ranging from 3 to 6 years. Five-year actuarial disease was 92%. Although surgery is generally considered a diagnostic tool, in our opinion local disease should always be removed surgically when surgery produces low morbidity. Surgical debulking of the lesion can increase the probability or local radiotherapeutic control.

A retrospective study was carried out on a series of 154 patients affected with vocal cord cancer in stage T1 treated with definitive radiotherapy April, 1979, to November, 1991. According to the 1992 TNM classification (UICC), 121 patients were classified as stage T1a and 33 patients as stage T1b. All patients were treated using parallel opposed fields of a 60 cobalt unit. Field size ranged from 16 to 30 square centimeters and the dose from 4400 to 7000 cGy, but only 15 patients received less than 6400 cGy. All patients were treated with once-daily fractionation (200 cGy/day). Follow-up ranges from 25 to 123 months; the median is 63 months. We observed 14 local recurrences (9.0%), all but one within 36 months from the end of treatment. Ten of 14 patients (71.4%) were rescued by surgery (8 patients underwent total laryngectomy and 2 conservative surgery); 13 patients were lost for intercurrent deaths. The incidence of recurrences is 7.4% for T1a patients (9/121) and 15.1% for T1b patients (5/33). The total dose does not seem to be related to relapse rate since recurrences were found in 6.6% of patients after a dose6400 cGy and in 9.3% of patients who had received higher doses. In our experience, field size did not affect, treatment results (25 cm2: 7.5% recurrences,25 cm2: 10.7%). Besides lesion volume, the main prognostic factor was overall treatment time. The incidence of failure was 3 times lower (5.8%) in the patients who completed the treatment within 7 weeks than in the patients whose treatment lasted more than 8 weeks (16.6%).

Diagnosis of tongue tumours is often retarded mainly because tumours grow prevalently in deep muscular layers. A correct exploration of the region might be difficult solely employing clinical examination. Therefore, it would be useful to confirm the suspect of a neoplastic lesion at the base of the tongue with a promptly available imaging method. These considerations led us to evaluate ultrasonography (US) as a diagnostic tool for neoplastic lesions of this region. Initially 10 normal patients were studied in order to become familiar with US anatomy of the area. In a second phase our study involved 24 patients with diagnosed carcinoma of the tongue base and 26 patients with clinical suspect of neoplasm in the region. US examination was carried out with real-time equipment provided by a 5 Mhz convex transducer. Patients were examined in supine position with the neck hyperextended. Longitudinal, oblique and transverse scan of the submental region were obtained. The study showed that US gives detailed images of the floor of the mouth and the tongue. Neoplastic infiltration of the base of the tongue is clearly recognizable as a hypoechoic area. It was possible to detect masses ranging from 1.4 to 3.8 cm. In cases of larger lesions, US was useful in evaluating deep infiltration, whereas in other cases the method allowed the diagnosis of small lesions with submucosal growth. US did not proved to be highly reliable in the diagnosis of lesions confined to superficial planes (false negative results).(ABSTRACT TRUNCATED AT 250 WORDS)

After having reviewed the principal theories regarding the development of the larynx the authors performed a study on the morphogenesis of the above structure using four horizontally- and sagitally-sectioned human embryos. The conclusion of a study of these sections is that the LC constitutes the primordium of the laryngeal vestibule. From its lateral margin, caudally (Stage 19, Carnegie System), the primitive ventricles begin to form, while in the final stages the EL extends caudally enclosing a small cephalic infraglottic area and therefore completely separating the IG from the LC. Such findings in our opinion would confirm a different embryological derivation of the laryngeal cavity above and below the glottis.

Summary Thirty-six patients with advanced squamous cell carcinoma of the head and neck (SCCHN) were treated with a regimen including cisplatinum (CP) 30 mg/m2 i.v., 5-fluorouracil (5-FU) 500 mg/m2 i.v. bolus, folinic acid (FA) 200 mg/m2 i.v. in a continuous one-hour infusion, and bleomyein (B) 15 mg i.m. on the first and second days and repeated every 28 days. Thirty-three patients (25 with recurrent disease and 8 untreated) are evaluable for objective response. Of these, 4 (12%) achieved CR and 15 (45%) PR. All of the untreated patients responded. The mean duration of response in the patients with recurrent or metastatic disease was 5.5 months (range 2–10+). Remission of symptoms, such as pain and dysphagia, was obtained in 58% and in 44%, respectively. Subjective remission occurred almost exclusively in objectively responsive patients. The major side effects were leukopenia (55%) and nausea/vomiting (58%). This regimen is active in the treatment of advanced SCCHN. The quality of life may be improved in responsive patients.

The correct management of mucoepidermoid tumours is still debatable because of their unpredictable biological course. The issue discussed is that of identifying biological characteristics of these tumours which may have predictive value. Sixteen patients with a mucoepidermoid tumour of the parotid gland, treated at the ENT Clinic of Bologna University over a 15-year period, were reviewed. The follow-up of each patient has been related to the surgical management, in order to evaluate whether superficial parotidectomy provides adequate treatment. No prognostic differences were noted between total and superficial parotidectomy when the latter was clinically appropriate. The histopathological specimens from these patients were reviewed in an attempt to correlate the histological grade of tumour with the course of the disease. Our data suggest that histological evaluation of malignancy alone is insufficient for accurate prognosis. We think that the clinical presentation (facial nerve palsy, pain, etc.) predicts the prognosis with greater accuracy.

In patients undergoing radiotherapy (RT) for malignant neoplasies of the head and neck the availability of a diagnostic method permitting frequent, easy checkups of the latero-cervical lymph nodes would be extremely useful. This is especially so because clinical examination is often hindered by the post-actinic fibrosis of the tissues. Among the methods presently available for this purpose (CAT, NMR, lymphoscintigraphy, xerography, ultrasound) echotomography appears to be the most indicated as it is least invasive, can easily be repeated and is not difficult to perform. The refining of ultrasound techniques would, as reported in the literature, make it possible today to evaluate the effects of RT on latero-cervical metastases both during and some time after treatment. The authors, therefore evaluated the advantages and limitations of the method examining 33 patients undergoing RT for latero-cervical metastases due to head and neck carcinoma. Each patient underwent ultrasound examination prior to, during and at the end of the RT treatment cycle. Once treatment had been terminated 18 underwent latero-cervical neck dissection. Upon termination of the radiation treatment three distinct types of ultrasound behaviour were identified: complete response; partial response; minimal or negligible response. For those patients undergoing surgery this response was compared to lymph node chain histology while, for the others, it was compared to the ultrasound findings of subsequent examinations. The results obtained appear to indicate that a systematic scheduling of ultrasound checkups offers a reliable evaluation of how metastatic adenopathies respond to RT. At times such response can only be completed several months after treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

A microfluorometric method was used to determine the nuclear DNA content in the nasopharyngeal carcinomas (NPC) of 25 patients treated before 1983. Eleven patients are still alive with no evidence of disease (NED), while the rest died of their disease (DOD). All of the patients received a cycle of radiotherapy, while some also received chemotherapy or neck dissections. The neoplastic cells studied were taken from the original biopsy blocks, deparaffinized, isolated by enzymatic treatment and mechanical fragmentation, and then Feulgen-stained. The cytofluorometric measurement was carried out by a microphotometer equipped for fluorescence excitation and connected to a computer. This method allowed us to construct a histogram of the DNA content in the neoplastic cells. Different neoplastic classes were identified and represent the heteroclonality of the tumor, which can be expressed by the heteroclonality index (HCT). From the collected data it appears that the NED patients all had a low HTC (less than 1) and only 7 of the DOD patients had low HTCs (less than 1). Six of the DOD patients with a low HTC were in advanced stages of their tumor at the time of diagnosis, while the remaining patient did not complete his treatment. Our results show that the DNA analysis of the NPC cell population may offer a useful tool in predicting the biological behavior of this tumor and also improving its treatment.

Thirty-seven patients with advanced head and neck tumors were treated with a polychemotherapy regimen (PEV-B: platinum 30 mg/m2 i.v., epirubicin 30 mg/m2 i.v., etoposide 75 mg/m2 i.v. on days 1 and 2 every 28 days, and bleomycin 15 mg i.m. weekly up to the total dose of 300 mg). All but 7 patients were pretreated with surgery and/or radiotherapy. Thirty-six patients were evaluable for response. Partial response (PR) was observed in 19 cases (53%), no change (NC) in 13 cases (36%) and progression (P) in 4 cases (11%). The median duration of PR was 5 months. The most frequent side-effects were leukopenia (78%), vomiting (57%) and alopecia (46%). The median duration of survival was 8 months for the responders and 5 months for the non-responders.

The specific humoral immune response against Epstein-Barr virus (EBV) antigens in patients with nasopharyngeal carcinoma (NPC) was compared to that of patients with infectious mononucleosis (IM) and other EBV-seropositive subjects using immunoblotting technique. Almost all sera from E,BV serologically associated NPC reacted reproducibly with a major group of polypeptides (four to six) of early antigen (EA) complex with molecular weights ranging from 50 kD to 58 kD, and with some additional polypeptides. Sera from IM-patients reproducibly recognized only one polypeptide of 50 kD belonging to the major group of polypeptides of EA-complex. Sera from patients with other types of head and neck cancer and relatively high levels of IgG antibody against viral capsid antigen (VCA) and EA did not react reproducibly with any of the EBV-associated proteins.

The control of early glottic cancer is equally satisfactory with either surgical resection or radiation therapy; this last method gives the patient good functional results. During the period from 1/1978 to 12/1985, 73 patients with early glottic carcinoma (T1 N0 M0) were treated in the Institute of Radiotherapy L. Galvani, University of Bologna; 45 were stage T1a (tumour limited to one vocal cord) and 28 were stage T1b (tumour of both vocal cords or involving anterior commissure); radiation treatment utilised a 60Co machine and 5 x 5 cm fields; the median dose was 67.2 Gy (range 50-76) with conventional fractionation. Ten patients had local recurrence; the median time of recurrence was 13.4 months; 9/10 were treated by surgery and 2/10 died, so the overall control by radiotherapy with surgery in reserve was 100% in T1a tumours and 90.6% in T1b ones. The 5-years disease free survival rate was 93.1% in T1a tumours and 69% in T1b; lesions involving anterior commissure had the worst prognosis, independent of the dose and time-dose factor (3/10 recurrences in the group treated with TDF less than 110 and 4/18 recurrences in the group with TDF more than 110).