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Background: Despite preservation of the accessory nerve, a considerable number of patients report partial nerve damage after modified radical neck dissection (MRND) and selective neck dissection., Methods: Accessory nerve branches for the trapezius muscle were stimulated during neck dissection, and the M wave amplitude was measured during distinct surgical phases., Results: The accessory nerve was mapped in 20 patients. The M wave recordings indicated that major nerve damage occurred during dissection at levels IIa and IIb in the most proximal segment of the nerve. The M waves evoked from this nerve segment decreased significantly during surgery (analysis of variance; p = .001)., Conclusion: The most significant intraoperative injury to the accessory nerve during neck dissection occurs at anatomic nerve levels IIa and IIb. © 2015 Wiley Periodicals, Inc. Head Neck 38: E372-E376, 2016., (© 2015 Wiley Periodicals, Inc.)

In the case of an aggressive course of recurrent respiratory papillomatosis (RRP), adjuvant therapy can be used besides surgery. The aim of the study was to investigate the influence of vaccination with a quadrivalent vaccine against human papilloma viruses (HPV) types 6, 11, 16 and 18 on the course of RRP. Eleven subjects aged 13-46 years with a rapid growth of laryngeal papillomas were included in the study. They were vaccinated with three doses of the quadrivalent prophylactic HPV vaccine (Silgard(®), MSD) and followed up for 12-52 months. The intervals between the successive surgical procedures, the extension of the disease (Derkay score) at each surgery, and the number of surgical procedures per year before vaccination and after its completion were compared. The mean interval between the surgical procedures was 271.2 days before the vaccination and 537.4 days after it (p = 0.034). The mean number of surgeries per year was 2.16 before the vaccination and 0.93 after it (p = 0.022). The Derkay score did not change significantly after vaccination. Complete remission of the disease was observed in one patient, partial response to the vaccination was observed in seven patients and no response was observed in three patients. In conclusion, vaccination with the quadrivalent HPV vaccine can favorably influence the course of RRP in patients with the rapid growth of the papillomas. It significantly prolongs the intervals between the surgical procedures and reduces the number of procedures needed in the majority of patients. The present investigation can serve as a pilot study for further research. For a final conclusion a longer follow-up and studies on more patients are necessary.

Background: In spite of preservation of the accessory nerve there is still considerable proportion of patients with partial nerve damage during modified radical neck dissection (MRND)., Methods: The nerve was identified during the surgery and its branches for the trapezius muscle mapped with nerve monitor., Results: The accessory nerve was mapped during 74 hemineck dissections and three patterns were identified. In type 1 nerve exits at the posterior end of the sternocleidomastoid muscle (SCm) and then it enters the level V (66%). In type 2 the nerve for trapezius muscle branches off before entering the SCm (22%). In type 3 the nerve exits at the posterior part of the SCm and it joins to the cervical plexus (12%). The nerve than exits this junction more medially as a single trapezius branch., Conclusions: The description of three anatomical patterns in level II and V could help preserving the trapezius branch during MRND.

Background: The temporary tracheostoma's metastases of head and neck cancer had already been reported in the literature. So far, they had been considered as regional dissemination of the malignant disease. We report a case of temporary tracheostoma's metastasis of carcinoma from non-head-and-neck primary site, what has not been reported in the literature, yet. Therefore, it is the first reported case of the systemic dissemination of malignant tumour into temporary tracheostoma., Case Report: Fifty-four-year-old female patient, previously treated for a rectal adenocarcinoma, reported in our office with exophytic pink tissue masses around the temporary tracheostoma. The biopsy and immunohistochemistry findings were consistent with temporary tracheostoma's metastasis of the rectal adenocarcinoma. The patient received palliative radiotherapy and died of systemic progression of the disease., Conclusions: The patients with history of primary cancer of any origin and exophytic proliferating changes around the tracheostoma require an appropriate diagnostic work-up including a biopsy. The type of treatment depends on the extent of the disease, previous therapy and general condition of the patient.

Objective: To investigate the music perception abilities of prelingually deaf children with cochlear implants, in comparison to a group of normal-hearing children, and to consider the factors that contribute to music perception., Methods: The music perception abilities of 39 prelingually deaf children with unilateral cochlear implants were compared to the abilities of 39 normal hearing children. To assess the music listening abilities, the MuSIC perception test was adopted. The influence of the child's age, age at implantation, device experience and type of sound-processing strategy on the music perception were evaluated. The effects of auditory performance, nonverbal intellectual abilities, as well as the child's additional musical education on music perception were also considered., Results: Children with cochlear implants and normal hearing children performed significantly differently with respect to rhythm discrimination (55% vs. 82%, p<0.001), instrument identification (57% vs. 88%, p<0.001) and emotion rating (p=0.022). However we found no significant difference in terms of melody discrimination and dissonance rating between the two groups. There was a positive correlation between auditory performance and melody discrimination (r=0.27; p=0.031), between auditory performance and instrument identification (r=0.20; p=0.059) and between the child's grade (mark) in school music classes and melody discrimination (r=0.34; p=0.030). In children with cochlear implant only, the music perception ability assessed by the emotion rating test was negatively correlated to the child's age (r(S)=-0.38; p=0.001), age at implantation (r(S)=-0.34; p=0.032), and device experience (r(S)=-0.38; p=0.019). The child's grade in school music classes showed a positive correlation to music perception abilities assessed by rhythm discrimination test (r(S)=0.46; p<0.001), melody discrimination test (r(S)=0.28; p=0.018), and instrument identification test (r(S)=0.23; p=0.05)., Conclusions: As expected, there was a marked difference in the music perception abilities of prelingually deaf children with cochlear implants in comparison to the group of normal hearing children, but not for all the tests of music perception. Additional multi-centre studies, including a larger number of participants and a broader spectrum of music subtests, considering as many as possible of the factors that may contribute to music perception, seem reasonable., (Copyright © 2012. Published by Elsevier Ireland Ltd.)

Objective: Mutations in the gap junction protein beta-2 gene ('GJB2') are known to be responsible for mild to profound congenital and late-onset hearing loss. This study aimed to investigate the molecular basis of progressive hearing loss compared with non-progressive hearing loss., Methods: Following clinical otorhinolaryngological evaluation, a genetic analysis was performed in a cohort of 72 patients with progressive sensorineural hearing loss., Results: Pathological genotypes were established in 16 patients (22.2 per cent). Six different gap junction protein beta-2 gene mutations were detected in 15 patients, with the c.35delG mutation responsible for 56 per cent of the mutated alleles. A novel gap junction protein beta-6 gene ('GJB6') mutation (p.Met203Val) was observed in one patient with mild progressive hearing loss., Conclusion: Analyses of gap junction protein beta-2 and -6 genes revealed that similar pathological genotypes, occurring with similar frequencies, were responsible for progressive hearing loss, compared with reported genotypes for non-progressive hearing loss patients. Thus, genotype cannot be used to differentiate non-progressive from progressive hearing loss cases; in this study, patients both with and without an established pathological genotype had a similar clinical course.

Inverted papillomas (IPs) are the most frequent type of sinonasal papillomas. These benign but destructive lesions are known for their high recurrence rate, probably due to incomplete excision. Our aim was to investigate the frequency of human papillomavirus (HPV) infection in patients with IPs and in IPs associated with squamous cell carcinoma (IPsSCC) and to compare it with the frequency of HPV infections in the control group. The influence of HPV infection on the malignant alteration and recurrence rate of IPs was also evaluated. Paraffin-embedded tissue samples from 68 patients with sinonasal IPs and 5 patients with IPsSCC were analyzed in this retrospective study. The control group consisted of 47 patients who had undergone septoplasty or mucotomy of the inferior turbinate. PCR amplification with consensus primer sets was performed to detect alpha-HPVs, and direct sequencing of the PCR products with the same primers was used to determine the HPV genotypes in the samples. We detected HPV DNA in 20 (30.3%) patients with IPs, in 3 (60%) patients with IPsSCC, and in 6 (13%) patients from the control group. The frequency of HPV infection in the study group was statistically significantly higher (p = 0.032) than in the control group. The presence of HPV DNA was not a statistically significant predictor of the recurrence of IPs (p = 0.745) nor was it a statistically significant risk factor for associated SCC (p = 0.32). Since HPV type 11 was the predominant genotype in the IPs, IPsSCC, and in the control cases, we presume that HPV infection may represent incidental colonization rather than being an important etiological factor of IPs.

Respiratory papillomatosis affects the larynx in most cases. It is a relatively rare disease, with potentially devastating consequences for the patient. Many studies have proven the viral etiology of the disease. Surgery is the most successful mode of treatment. Adjuvant therapy is used in cases of aggressive disease. The most successful adjuvant drugs are interferon, various virostatics (e.g., acyclovir, valacyclovir, and cidofovir) and indole-3-carbinol. Vaccination with a quadrivalent vaccine against HPV will probably decrease the incidence of respiratory papillomatosis or help in the treatment of the disease in the future. The results of adjuvant therapy of laryngeal papillomatosis at the University Department of ORL & HNS in Ljubljana are comparable to the results in other centers around the world.

Objectives: Patients who survive malignant tumours have an increased risk of second neoplasms, including those of the salivary glands. Mucoepidermoid carcinoma of the parotid gland is by far the most common type of second salivary gland tumour; other types have rarely been reported. We describe here two patients with a second tumour of the salivary glands., Case Reports: The first patient was a 22-year-old woman with a low grade mucoepidermoid carcinoma of the parotid gland, which developed 21 years after completion of chemoradiotherapy for acute lymphoblastic leukaemia. The second patient was a 40-year-old woman with an epithelial-myoepithelial carcinoma of the buccal mucosa, which arose 11 years after treatment for two malignant neoplasms - retroperitoneal liposarcoma and squamous cell carcinoma of the uterine cervix., Conclusions: It is mandatory that survivors of cancer should be monitored carefully, so that the complications related to their previous disease and therapy are detected early and managed properly.

Background and Purpose: In the majority of patients irradiated for early glottic cancer an abnormal voice was reported. The purpose of the study was to determine the factors influencing voice quality after radiotherapy for T1 glottic cancer., Methods: The voices of 75 male patients irradiated for T1 glottic carcinoma were assessed subjectively and objectively by acoustic analyses and aerodynamic measurements. The laryngeal function and morphology were evaluated by videolaryngostroboscopy. The data on smoking habits, the associated diseases influencing voice quality, the extent of the tumor, the type of biopsy, and the irradiation technique were collected from the medical records. The data on the factors influencing voice quality were compared for patients with a normal/near-normal voice and those with a hoarse voice., Results: Voice quality was at least slightly abnormal in 94.7% and 81.3% of patients, when assessed perceptively and objectively, respectively. Smoking after the completed treatment, more severe morphologic alterations of the vocal folds, dryness of the throat, incomplete closure of the vocal folds and functional voice disorders expressed as supraglottic activity adversely influenced the voice quality. A good correlation between the perceptive voice assessment and the acoustic analyses was established., Conclusions: After the successful irradiation for T1 glottic carcinoma, the great majority of the patients have at least a slightly hoarse voice. A better voice outcome could be achieved if radiotherapy was followed by the patient's cessation of smoking and the appropriate voice therapy.

Purpose: Speech of deaf persons differs considerably from that of speakers with normal hearing. The purpose of this study was to investigate the acoustic changes in articulation of corner vowels in deaf children and adults after cochlear implantation., Methods: Thirteen prelingually deaf children and 12 postlingually deaf adults were included in the study. Voice samples of the isolated corner vowels /a/, /i/ and /u/ were analyzed before and 6-12 months after the implantation. The frequencies of the first (F1) and second (F2) formants, the F1/F2 ratio of all three corner vowels, and the area of the vowel triangle were calculated and compared before and 6-12 months after the implantation., Result: In the adults, no significant differences were detected in the formant frequencies, the F1/F2 ratio or the area of the vowel triangle. However, significant change in formant frequencies was detected in the group of 13 prelingually deaf children. After the implantation the F1 of /u/ decreased significantly, and favorable decreases of the F1 of /i/ and the F1/F2 ratio in /i/ and /u/ were close to being statistically significant. All changes caused better phonological difference between the two vowels. The significant change in the F1 of /u/ and the change of F1 of /i/ resulted in the expansion of the vowel space, which was expressed as an increase in the area of the vowel triangle., Conclusions: We suggest that in children the acquired hearing ability and further development of neuromuscular control of articulation are the reasons for the significant improvement after cochlear implantation. The results also suggest that the area of the vowel triangle is a useful and sensitive indicator of the more precise articulation after implantation. In order to achieve better and faster improvement of articulation, regular speech therapy should be included in the rehabilitation of deaf persons after cochlear implantation.

Purpose: The long term results and patterns of failure in patients with squamous cell head and neck carcinoma (SCHNC) treated in a prospective randomized trial in which concomitant postoperative radiochemotherapy with Mitomycin C and Bleomycin (CRT) was compared with radiotherapy only (RT), were analyzed., Patients and Methods: Between March 1997 and December 2001, 114 eligible patients with Stage III or IV SCHNC were randomized. Primary surgical treatment was performed with curative intent in all patients. Patients in both groups were postoperatively irradiated to the total dose of 56-70 Gy. Chemotherapy included Mitomycin C 15 mg/m2 after 10 Gy and 5 mg of Bleomycin twice weekly during irradiation. Median follow-up was 76 months (48-103 months)., Results: At 5 years in the RT and CRT arms, the locoregional control was 65% and 88% (p = 0.026), disease-free survival 33% and 53% (p = 0.035), and overall survival 37% and 55% (p = 0.091) respectively. Patients who benefited from chemotherapy were those with high-risk factors. The probability of distant metastases was 22% in RT and 20% in CRT arm (p = 0.913), of grade III or higher late toxicity 19% in RT and 26% in CRT arm (p = 0.52) and of thyroid dysfunction 36% in RT and 56% in CRT arm (p = 0.24). The probability to develop a second primary malignancy (SPM) was 34% in the RT and 8% in the CRT arm (p = 0.023). One third of deaths were due to infection, but there was no difference between the 2 groups., Conclusion: With concomitant radiochemotherapy, locoregional control and disease free survival were significantly improved. Second primary malignancies in the CRT arm compared to RT arm were significantly less frequent. The high probability of post treatment hypothyroidism in both arms warrants regular laboratory evaluation.

Objective: To assess the influence of acquired auditory control on some voice parameters in deaf children and adults after cochlear implantation., Study Design: Prospective clinical study., Setting: Tertiary referral center., Patients: Twenty-nine prelingually deafened children and 11 postlingually deafened adults., Interventions: The samples of a vowel /a/ were analyzed with an Multi-Dimensional Voice Program (Kay Elemetrics Corporation, Lincoln Park, NJ) before and 6 to 12 months after the cochlear implantation., Main Outcome Measures: The average fundamental frequency (F0), the short-term variation of F0 (JIT) and the amplitude (SH), the very long-term variation of F0 (vF0) and the amplitude (vAm), and the noise-to-harmonic ratio (NHR) were determined and compared for both age groups. The results of the acoustic analysis performed before the implantation were compared with the results after the implantation for children and adults., Results: Significantly greater JIT, SH, vF0, and vAm were detected in the children than in the adults before and after the implantation. The prelingually deafened children significantly improved the control of their phonation after 6 to 12 months' use of the cochlear implant (JIT: p=0.014, SH: p=0.011, vF0: p=0.014, vAm: p=0.031). In the postlingually deafened adults, no significant improvement was found in any of the studied voice parameters after the implantation. F0 showed little or no change after the implantation in children and adults., Conclusion: As expected, the voice quality of the prelingually deafened children was significantly worse than that of the postlingually deafened adults. After cochlear implantation, the children significantly improved their short-term and long-term F0 and amplitude variability. In adults, no significant improvement was detected. We suppose that the improvement is a consequence not only of the acquired hearing control but also of the adaptation ability of neuromuscular phonation control and the maturing of these control mechanisms in children. In adults, better phonation quality in general and lesser improvement after the implantation can be the results of well-developed and stable phonation patterns.

Carcinomatous metastases in regional lymph nodes worsen substantially the prognosis of patients with oral cavity and oropharyngeal cancer. Due to the high probability of occult metastasis (about 30%), during surgical resection of the primary tumor usually also elective dissection of lymph nodes is performed. Opinions on the extent of the elective neck dissection still differ, whereas selective dissection increasingly gains in importance. The aim of selective dissections, based on the predictability of formation of metastases, is the identification and exstirpation of the sentinel lymph node. In this prospective study the applicability of the concept of the sentinel lymph node in patients with oral cavity and oropharyngeal cancer was analysed. 12 patients with oral cavity and orophangeal cancer, staging T1-T3, all N0 (examined by palpation and sonography) were included. The localization of the sentinel(s) was determined preoperatively by radioisotope (Tc Nanocolloid). Sentinel(s) were identified first with a gamma probe (Neoprobe 2000); we then injected methylene blue into the peritumoral area for easier detection of the sentinel(s). The sentinels were removed and sent for frozen section examination. Regardless of the findings of the frozen section examination modified dissection was carried out. Later we compared frozen sections with paraffin microtome sections of sentinel(s) and of other exstirpated neck lymph nodes. We could identify the sentinel lymph node in all patients, in 6/12 patients we found several sentinels. If sentinels were not affected by tumor cells, there were no metastases in the downstream neck lymph nodes either. If in the sentinel lymph nodes no metastases can be determined, eliminating the environment alone could be sufficient. However, this assumption requires verification in a larger patient group.

The ability of mitomycin C to inhibit fibroblasts in vitro has prompted its use during standard surgical procedures as a means of preventing the development of adhesions and stenosis. We conducted a prospective study to evaluate the effectiveness of topical mitomycin C in maintaining an open external auditory canal in 6 ears of 4 patients with aural fibrotic atresia who were undergoing meatoplasty. During the procedure, we applied 1 ml of mitomycin C (0.4 mg/ml) for 4 minutes to the external auditory canal (in 1 case, mitomycin C was reapplied to an ear 1 month later). Between 3 and 14 months postoperatively, the patency of the ear canal was assessed visually and hearing was evaluated audiometrically. Adequate patency was achieved in 5 of the 6 ears (83.3%), and the air-bone gap in these 5 ears had improved to 10 dB or less. No postoperative complications or sensorineural hearing loss was observed. In this very limited number of cases, we found that the intraoperative use of mitomycin C appeared to have been helpful in preventing scarring in both congenital and secondary fibrotic atresias of the external auditory canal. These preliminary results are encouraging, and a prospective, placebo-controlled study appears to be warranted.

Objective: Some of the voice characteristics of deaf people differ considerably from those of speakers with normal hearing. After a cochlear implantation, auditory control of voice production is possible and the quality of the voice is improved. The aim of this study was to investigate the changes in some of the voice parameters in deaf children after cochlear implantation., Methods: Thirty-one prelingually deafened children implanted unilaterally at the age of 2.5-13 years were included in the study. For all of the children an acoustic analysis (Multi-Dimensional Voice Program, Kay Elemetrics Corp., USA) of the Slovene vowel 'a' was performed before cochlear implantation and 6, 12 and 24 months after the implantation. The fundamental frequency (F0), jitter, shimmer and noise-to-harmonic ratio (NHR) were compared before and after the implantation. The results of the acoustic analyses were compared for the children who were implanted before or at the age of 4 years and the children who were implanted after the age of 4 years., Results: After the cochlear implantation the fundamental frequency did not change significantly. However, an improvement was noticed in the measurements of jitter (p=0.006) and shimmer (p=0.021) as early as 6 months after the implantation. The noise-to-harmonic ratio improved (p=0.013) 24 months after the implantation. The children implanted before or at the age of 4 years showed a significant improvement in jitter (p=0.003) and shimmer (p=0.004) as early as 6 months and in noise-to-harmonic ratio (p=0.021) 12 months after the implantation. In the children implanted after the age of 4 years the only significant change was detected in F0 (p=0.045), 12 months after the implantation, and in Shimmer (p=0.017), 24 months after the implantation., Conclusion: The results of the present study have confirmed that cochlear implantation enables auditory moment-to-moment control of pitch and loudness. The determination of jitter and shimmer in the vowel 'a' sample proved to be a good and early indicator of improved phonation control, even in young children. The deaf children who were implanted before the age of 4 years improved their voice control more quickly and to a greater extent than the children implanted after the age of 4 years.

Objective: The aim of this study was to evaluate the hearing results of revision stapes surgery performed because of previously failed operations and to determine the causes of failure., Study Design: Retrospective review of revision stapes operations., Setting: Tertiary referral center., Patients: Sixty-three consecutive revision stapes operations were performed in 56 patients over a period of 12 years (1992-2004). The indication for revision surgery was recurrent or persistent air-bone gap greater than 20 dB after primary surgical treatment of otosclerosis of the oval window., Results: All patients were operated on to improve hearing. Sixty-three revision stapes operations resulted in closure of the air-bone gap to 10 dB or less in 52.4% of cases. The average postoperative air-bone gap was 13.1 dB, and the mean pure-tone average improvement was 12.9 dB. In six patients (9.5%), revision surgery produced no change in hearing, and in four (6.3%) the hearing decreased by 5 dB or more. In one patient, the operation resulted in a profound hearing loss. Prosthesis malfunction was the most common primary cause of failure (60.3%). The original prosthesis was replaced with a new one in 48 cases. In 30 of these (62.5%), closure of the air-bone gap to within 10 dB was achieved. In 15 cases, the prosthesis was not replaced, and in only four of these (26.7%), closure of the air-bone gap within 10 dB was obtained (p < 0.022)., Conclusion: Revision stapes surgery is less likely to be successful than the primary operation. Closure of the air-bone gap to within 10 dB was achieved in 52.4% of patients. The success rate was better in cases where the original prosthesis was replaced with a new one. The risk for decreased bone-conduction threshold does not seem to be higher than in primary surgery.

Patients with inoperable head and neck tumors were treated concomitantly with radiochemotherapy with mitomycin C and bleomycin in our prospective randomized clinical trial (1991- 1993). For the subgroup of patients with oropharyngeal carcinoma the results with radiochemotherapy were significantly superior to irradiation alone. Such scheme of treatment was then adopted as standard method. Here we present the long-term results and dose- response relationships in patients with inoperable oropharyngeal carcinoma treated by the same radiochemotherapy scheme till 1997. Ninety-five patients with stage III and IV inoperable oropharyngeal squamous cell carcinoma were treated with curative intent, concomitantly with supra-voltage irradiation 2 Gy/day 5 times weekly to 60-73 Gy, bleomycin 5 mg 2 times weekly and. one application of mitomycin C 15 mg/m(2) after 10 Gy. Logistic dose- response curve was calculated. Median follow-up was 85 months. The loco-regional control, disease- free survival and overall survival at 5 years were 55%, 51% and 32% (95% CI: 44-67%, 41-62%, 22-42%), respectively. The probability of new primary malignancy at 5 years was 23%. In multivariate analysis performance status, biological equivalent dose, dose of bleomycin, and stage were identified as independent prognostic factors for loco-regional control, disease-free, and overall survival. Th gamma-value of dose response curve was 2.86. The outcome of the disease was directly proportional to intensity of irradiation and chemotherapy. It appears that in our concomitant radiochemotherapy MiC increased radioresponsiveness of the tumor by its effect on hypoxic fraction.

Purpose: In a prospective randomized clinical study, simultaneous postoperative application of irradiation (RT), mitomycin C, and bleomycin was tested in a group of patients with operable advanced head-and-neck carcinoma. It was expected that the planned combined postoperative therapy would reduce the number of locoregional recurrences and prolong survival., Methods and Materials: A total of 114 eligible patients with Stage III or IV squamous cell head-and-neck carcinoma were randomized to receive postoperative RT alone (Group 1) or RT combined with simultaneous mitomycin C and bleomycin (Group 2). Patients were stratified according to the stage and site of the primary tumor and the presence or absence of high-risk prognostic factors. Primary surgical treatment was performed with curative intent in all patients. Patients in both groups were postoperatively irradiated to the total dose of 56-70 Gy. Chemotherapy included mitomycin C 15 mg/m(2) after 10 Gy and 5 mg of bleomycin twice a week during RT to the planned total dose of 70 mg., Results: At 2 years, patients in the radiochemotherapy group had better locoregional control (86%) than those in the RT alone group (69%; p = 0.037). Disease-free survival and overall survival was also better in the radiochemotherapy group compared with the RT-alone group (76% vs. 60%, p = 0.099; and 74% vs. 64%, p = 0.036, respectively). Patients who benefited from chemotherapy were those with high-risk factors., Conclusion: The results of the present study indicate that concomitant postoperative radiochemotherapy with mitomycin C and bleomycin improves locoregional control and survival in patients with advanced head-and-neck carcinoma. The patients who benefited from chemotherapy were those with high-risk factors.

One method for restoring the anterior floor of mouth defects resulting from T(1) and especially T(2) cancer excision involves the creation of a myomucosal island flap from the dorsal median portion of the tongue and transferring it as a transit flap to the floor of the mouth. We are not the first to advocate this method. In this paper we present a previously unreported, slightly modified technique utilizing this tongue flap. The modification consists of a 90 degrees twisting of the flap to achieve a more appropriate adaptation to the defect. In the case of spreading carcinoma from the floor of the mouth to the central portion of the tongue, a similar paramedian one-sided tongue flap was created instead of a central island tongue flap. Our present experience consists of a small series of 12 patients. The procedures were successful in all patients. No remarkable disturbances of speech or deglutition were observed in any of the patients. There were two complications: one haematoma and one partial necrosis of the tip of the tongue. In our opinion, the reconstruction of the anterior floor of mouth defects using a central island tongue flap has not gained the popularity it deserves.

Children with early brain damage often present with balance disorders. We evaluated the vestibular apparatus function in 110 infants at risk of brain lesions. Our study confirmed a statistically significant correlation between vestibular apparatus dysfunction and the degree of neurological risk. Early recognition of vestibular disorders preconditions adequate rehabilatation and supports the acquisition of motor skills.

Our study aimed to show whether it is useful to preserve the stapedial muscle during the surgical treatment of otosclerosis. The study was carried out on 67 patients with tympanoscopic evidence of otosclerosis. In group A (34 patients) the stapedial muscle was intra-operatively preserved as follows: the stapedial suprastructure with preserved muscle tendon was transpositioned onto the longer arm of the incus and secured with a wire loop. The mean uncomfortable level for sounds was measured after surgery and the results of group A patients were compared with those obtained in group B (33 patients, who underwent standard surgery). One month after surgery, in group A patients, the cochleostapedial reflex was evoked in 21 patients (61.8 per cent) and two months later in 32 patients (94.1 per cent). One month after operation, in group A patients the mean uncomfortable level was 108.8 dB, while three months later it increased to 114.1 dB. In group B, the relevant values were 97.8 dB one month after surgery, and 98.0 dB three months later. Our presumption that stapedial muscle preservation is necessary has been proved by the fact that the patients with the preserved muscle had a higher noise discomfort threshold.

Objective: To evaluate the voices of irradiated patients with early glottic carcinoma and to compare these with the voices of healthy volunteers., Design: Case-control study., Setting: University Department of Otorhinolaryngology and Cervicofacial Surgery, University of Ljubljana, Ljubljana, Slovenia., Subjects and Methods: The voice samples (sustained vowel) of 50 patients (44 men and 6 women) who had been irradiated for T1 (43 subjects) or T2 (7 subjects) glottic squamous carcinoma at least 1 year prior to the study were analyzed with the Multi-Dimensional Voice Program (Kay Elemetrics Corp, Lincoln Park, NJ) and compared with those of a normal group of 50 age- and sex-matched volunteers. Average fundamental frequency, jitter, shimmer, noise-to-harmonic ratio, and degree of voiceless elements were determined. In the irradiated group, videostroboscopy was performed. The patients assessed their voice fatigue., Results: The irradiated subjects demonstrated significantly higher values for jitter, shimmer, and degree of voiceless elements than did the healthy volunteers. The values for noise-to-harmonic ratio were higher in the irradiated group, but the difference was not significant (P =.08). The values for fundamental frequency were almost equal in both groups. In most of the irradiated subjects, some irregularities of the vocal fold vibration were noticed. Many of these patients also reported voice fatigue., Conclusions: Radiation therapy for early glottic cancer results in poorer voice quality compared with normal age- and sex-matched speakers. In most of the irradiated patients, greater than normal effort in voice production was found based on patient assessment. This may result from stiffness of the vibratory source and inadequate compensatory maneuvers in phonation. We suggest that voice therapy during and after radiation therapy may result in better voice quality.

Amyloidosis of the larynx is an uncommon disease and mainly a local occurrence. Hoarseness is the prevalent symptom. Surgical excision of the amyloid masses is the treatment of choice. In the present paper, the authors describe seven cases treated in the last twenty years.

Differences in autofluorescence (fluorescence without photodynamic drugs) between normal and malignant tissues offer new possibilities in detecting and localizing early laryngeal carcinoma. Autofluorescence imaging was performed using a modified fluorescence endoscopy system from Xillix Technologies (Richmond, Canada). Fluorescence was induced by blue light at 442 nm and captured by an image-intensified camera through a laryngeal telescope. The images were then processed by the system and displayed on a video monitor. Normal tissue appeared green while malignant sites appeared reddish-brown. The autofluorescence imaging technique was compared to standard microlaryngoscopy in 108 patients with laryngeal pathologies (in 74 of whom malignancy was suspected). The acquired reflectance and fluorescence images of each lesion were assessed independently as malignant or not malignant by three ENT specialists who were familiar with the procedure but were not provided with clinical data or histopathological information concerning the lesion. The assessments of pathology were determined from the two imaging modalities and were compared to histopathological findings of the biopsy specimens taken from the lesion. The present study showed that autofluorescence imaging can be a useful complementary method to microlaryngoscopy for detecting and delineating laryngeal malignancies. If in the future, the device can be developed for use in an outpatient office, a significant improvement can be made for the early detection of laryngeal malignancies.

The goal of our work was to determine hearing thresholds in patients with hearing impairment due to hereditary motor and sensory neuropathy (HMSN I). In assessment of auditory function we used two methods: pure tone and speech audiometry. Pure tone audiometry was performed using air and bone conducted signals. Speech comprehension was defined with a test battery of monosyllabic words unknown to the patient. By comparing the results of these methods we were able to differentiate whether the hearing loss was of cochlear or retrocochlear origin. We tested 5 patients with HMSN I associated with difficulty in speech understanding. The tests showed mild to severe elevation of pure tone thresholds but no speech perception in any of tested patients. We suggest that this type of hearing impairment be due to the disorder of the auditory nerve function--a neuropathy of the auditory nerve as part of HMSN.

Tracheal and arterial CO2 partial pressures were measured simultaneously in 27 laryngectomized patients both while they were awake and during high-frequency jet ventilation. Tracheal gas was sampled during brief interruptions of high-frequency jet ventilation. Agreement between tracheal and arterial CO2 partial pressures was assessed using the Bland-Altman method. The tracheal-arterial CO2 partial pressures gradient during spontaneous breathing was significantly lower (P < 0.0002) than during high-frequency jet ventilation. During spontaneous ventilation, the bias was -0.77 kPa (95% CI = -0.99 to -0.55 kPa), and the upper and lower limits of agreement were 0.29 kPa (95% CI = -0.11 to -0.7 kPa) and -1.83 kPa (95% CI = -2.24 to -1.43 kPa). During high-frequency jet ventilation, the bias was -1.61 kPa (95% CI = -1.76 to -1.46 kPa), and the limits of agreement were -0.48 kPa (95% CI = -0.75 to -0.21 kPa) and -2.74 kPa (95% CI = -3.01 to -2.47 kPa). Despite the poor agreement between tracheal CO2 partial pressure and arterial CO2 partial pressure, it is sufficient to allow for adjustment of ventilator settings during jet ventilation.

Objective: Pediatricians often send adolescents with dysphonia to the otorhinolaryngologist's office to find the reason for their hoarseness. The aim of this study was to identify the main characteristics of adolescent voice and to determine which characteristic (variable of voice analysis) can distinguish normal variations of voice development from pathologic disorders., Study Design: On the basis of history, indirect laryngoscopy, and stroboscopy, 51 adolescents (22 boys, 29 girls) from age 10 to 17 years were divided into four subgroups: candidates for singing lessons without voice problems, subjects with mutation voice disorders, subjects with functional dysphonia, and subjects with vocal cord nodules. Voice analysis by Multi-Dimensional Voice Program (Kay Elemetrics) evaluated the fundamental frequency, the variability of pitch and amplitude (loudness), and the presence of noise in the analyzed voice sample of each of the subjects. Data were analyzed with the SPSS+/PC Statistical Program., Results: All mean values of variables that describe variability of pitch and amplitude were abnormal in boys and in girls, with greater abnormality among boys. The variability of loudness and specifically the variability of pitch were abnormal in a majority of subjects. A significant negative correlation between age and fundamental frequency was stated in boys only and between age and variability of amplitude in girls only. Variables that express variability of pitch and amplitude correlated positively between themselves. No significant differences were found between the first subgroup (candidates for singing lessons), which represented a normal population, and the other three subgroups (subjects with mutational disorders, functional dysphonia, and vocal cord nodules). In addition, no significant differences were found between the first three subgroups (subjects without voice problems and subjects with functional voice disorders) and the fourth subgroup (subjects with vocal cord nodules: organic lesion of laryngeal mucosa)., Conclusions: According to this study, the main characteristic of adolescent voice is the instability of amplitude (loudness) and specifically the instability of pitch. Female voices appear more stable than male voices. No single variable of performed voice analysis can distinguish normal variation of voice development from pathologic disorders. The reason for this instability can be attributed to more gradual adaptation of the afferent and efferent nervous control to the rapid growth of the phonatory, respiratory, and resonatory organs. In the growing speech apparatus, optimal phonatory patterns can be created; therefore adolescence is an ideal period for treatment of functional voice disorders.

Differences in autofluorescence between normal and malignant tissues offer new possibilities for detecting and localizing early laryngeal carcinomas. In the present study imaging was performed using a specially designed device that exploits differences in fluorescent properties of normal and cancerous tissues without photodynamic drugs. Fluorescence was induced by a helium-cadmium laser, captured by an image-intensified camera and displayed on a video monitor after previous computerization. Thirty patients were evaluated, of whom 18 had suspect malignancies. Laryngoscopic appearances during standard microlaryngoscopy were compared to fluorescence images, computerized fluorescence intensities and histopathological findings. The experience from this study shows that autofluorescence laryngoscopy may be a useful complementary method for detecting laryngeal malignancies.

The results of this study showed that allergy is an important factor in the etiopathogenesis of laryngeal mucosal lesions. Despite adequate treatment, no other unfavourable factors appeared to have significant influence on the results of the treatment. It seems that hypersensitivity to different inhalatory and nutritional allergens make laryngeal mucosa more susceptible for adverse action of other factors: vocal misuse, gastroesophageal reflux (GER), smoking, irritants in the surrounding microclimate, endocrinologic disorders, etc. Acting together, all these factors cause the development of laryngeal mucosal lesions. In the treatment of noninfectious laryngitis, vocal cord nodules, polyps or Reinke's edema, all the stated adverse factors should be identified and suitably diminished or eliminated. Allergy (Ig-E-mediated and non-IgE-mediated) should be considered as only one of the etiopathogenetic factors.

Concentrations of cathepsins A, D and stefins A and B were measured in primary tumor and adjacent normal tissue of 25 patients with laryngeal carcinoma. Median concentrations of both cathepsins and that of stefin B were significantly higher in tumor tissue than in their normal counterparts (cathepsins B and D, P < 0.0001; stefin B, P = 0.01), indicating their possible involvement in the process of tumor spread. Early (T1 and T2) tumors had lower concentrations of stefins A and B than locally advanced (T3 and T4) tumors (P = 0.04). Disease-free and disease-specific survival rates at 45 months were significantly better in patients with tumor concentrations of stefins above or equal to the cut-off values (stefin A, P = 0.001 and P = 0.004; stefin B, P = 0.048 and P = 0.008), indicating that these might be of prognostic value. The concentrations of cathepsins B and D did not correlate with survival.

Differences in autofluorescence between normal and malignant tissues offer new possibilities for detecting and localizing early laryngeal carcinomas. In the present study imaging was performed using a specially designed device that exploits differences in fluorescent properties of normal and cancerous tissues without photodynamic drugs. Fluorescence was induced by helium-cadmium laser, captured by an image-intensified camera and displayed on a video monitor after previous computerization. 40 patients were evaluated, of whom 20 had suspect malignancies. Laryngoscopic appearances during standard microlaryngoscopy, fluorescence images and computerized fluorescence intensities were compared to histopathological findings. The experience from this study shows that autofluorescence laryngoscopy may be a useful complementary method for detecting laryngeal malignancies.

To estimate the prognostic value of cathepsins B, H, L, D and stefins A and B in head and neck carcinoma, their concentrations in cytosols of primary tumours and adjacent normal tissue were measured (cathepsins B, D stefins A, B in 45, cathepsin L in 24 and cathepsin H in 21 patients). Median concentrations of cathepsins B, L, and D were significantly higher in tumour than in the adjacent normal tissue (B and D: p < 0.0001; L: p = 0.004); cathepsin H concentration was higher in normal tissue (p = 0.001). Concentrations of either stefin did not differ significantly between normal and tumour tissue. Concentrations of cathepsins B, H, L, and D were higher in laryngeal than in non-laryngeal normal and tumour tissues. The difference was statistically significant for cathepsin B in tumour tissue (p = 0.045), and marginally significant in normal tissue (p = 0.07). Early tumours had lower concentrations of stefins A and B than locally advanced tumours (stefin A: p = 0.04; stefin B: p = 0.07). Disease-free and disease-specific survival rates were better in patients with concentrations of cathepsin L in tumour tissue below or equal to the cut-off values (p = 0.035; p = 0.05), whereas for cathepsin B the difference was established only for disease-free survival (p = 0.07). The opposite was true for stefin A (p = 0.0002; p = 0.002) and stefin B (p = 0.009; p = 0.003), and in disease-free survival also for cathepsin H (p = 0.055). The concentration of cathepsin D did not correlate with survival. Our data indicate that cathepsins B, H, L and stefins A and B might have prognostic value in head and neck carcinoma.

Purpose: Prospectively designed randomized clinical study was undertaken to assess the efficacy of simultaneous application of irradiation, Mitomycin C, and Bleomycin in treatment of patients with inoperable head and neck carcinoma., Methods and Materials: Between March 1991 and October 1993, 49 patients with inoperable head and neck carcinoma were randomly assigned to receive either radiation therapy alone (group A) or radiotherapy combined with simultaneous application of Mitomycin C and Bleomycin (group B). Patients in both groups were irradiated five times weekly with 2 Gy to the total dose of 66-70 Gy. Chemotherapy regimen included intramuscular application of Bleomycin 5 units twice a week, with the planned dose being 70 units and Mitomycin C 15 mg/m2 applied intravenously after delivery of 9-10 Gy of irradiation. The application of Mitomycin C was planned to be repeated on last day of radiotherapy in the dose of 10 mg/m2. In attempt to enhance the effect of chemotherapeutic drugs, patients in group B received also Nicotinamide, Chlorpromazine, and Dicoumarol., Results: The difference in complete response rate between both treatment groups (24% in group A and 63% in group B) was statistically significant (p = 0.015). The difference in response rate was much more pronounced in patients with oropharyngeal carcinoma only (18% in group A compared to 81% in group B; p = 0.0003), while for all other subgroups added together, there was observed no benefit of multidrug therapy. Median follow-up was 18 months. Disease-free survival of patients in group A (9%) was significantly lower then in group B (48%) (p = 0.001). The difference between both treatment groups was even greater in patients with oropharyngeal carcinoma only: disease-free survival of these patients in group B was 66%, while in group A, all recurred (p = 0.00001)., Conclusion: From results of our prospective randomized study it seems that the group of patients that received multidrug treatment with Mytomycin C, Bleomycin, Nicotinamide, Chlorpromazine, and Dicoumarol as enhancers of radiotherapy fared better than patients treated by radiotherapy alone.

Cowden's disease is a rare predominantly inherited disease, characterized by mucocutaneous lesions, gastrointestinal polyposis and benign or malignant thyroid and breast tumours. The report deals with a typical case of this disease with emphasis on its importance for otolaryngologists.

Introduction: Recurrent otitis media is commonly encountered in children before 3 years of age. Conductive hearing loss up to 40 dB is frequently associated with suppurative otitis media. Good hearing is believed to be critical to the development of normal language. This study was undertaken to evaluate the effect of recurrent otitis media on auditory perception and speech., Patients and Methods: The experimental group consisted of 33 children with a history of at least three episodes of acute otitis media before 2 years of age. A control group of 29 children experienced one or fewer episodes of otitis media in the first 2 years of age. At the time of investigation, all children were 8 to 10 years of age and had attended similar pre-school, kindergarten, and elementary school programs. None showed evidence of mental retardation nor behavioral or emotional disorders. Speech ability was assessed by a battery of tests specific for Slovene language. Subtests of the Wechsler Intelligence Scale for Children were used as well as the Reading and Writing Test., Results: Auditory perception disorders were evident in 88% of children investigated who had a history of at least three episodes of otitis media by 2 years of age. Decreased auditory stimulation during the time of auditory maturation could prevent the development of these functions completely. No statistically significant differences were observed in the development of articulation. These observations underscore the importance of early management of recurrent otitis media during the first 2 years of age.