Auris Nasus Larynx

Endoscopic sinus surgery with and without computer assisted navigation: A retrospective study Publication date: August 2019 Source: Auris Nasus Larynx, Volume 46, Issue 4 Author(s): Bruno Galletti, Francesco Gazia, Francesco Freni, Federico Sireci, Francesco Galletti Abstract Objective In the last years endoscopic sinus surgery (ESS) is improved with the introduction of computer assisted navigation (CAN). In this retrospective study we evaluated the usefulness of CAN in endoscopic sinus surgery and studied its advantages over conventional endoscopic sinus surgery. Methods We retrospectively reviewed the records of 96 patients with chronic rhinosinusitis (CRS). 48 patients undergoing endoscopic sinus surgery with surgical navigation (A group) and other 48 without navigation (B group). Data about percentage of complications, olfactory function (Visual Analogue Scale), Sino-nasal Outcomes Test (SNOT-22), Rhinosinusitis Quality of Life (RhinoQoL), recurrence (CT Lund–Mackay score), total nasal resistance (rhinomanometry) and duration of the intervention were collected and analyzed. Results A group evidenced a decrease of recurrence rate (p = 0.009), a reduction of total nasal resistance (p = 0.007), of frontal recess stenosis (p = 0.04) and of nasal symptomatology (p = 0.008). QoL had a better improvement in group A. Rate of other complications and olfactory function did not show statistically significant differences between the two groups. The average calibration time was approximately 11 min in the A group. Total time of surgical procedure does not evidenced statistically significant difference between the two groups (p > 0.05) but if it is considered only the time of the surgical intervention, the difference of duration is significant reduced statistically (p < 0.05) in CAN surgery. Conclusion Computer assisted navigation in ESS can be useful for the most experienced surgeons, especially in the frontal recess surgery, decreasing the recurrence rate and reducing the total nasal resistance.

Corrigendum to "Reliability and validity of the Japanese version of the Glasgow Edinburgh Throat Scale (GETS-J): use for a symptom scale of globus sensation" [Auris Nasus Larynx 45 (2018) 1041–1046] Publication date: August 2019 Source: Auris Nasus Larynx, Volume 46, Issue 4 Author(s): Nao Takahashi, Kaori Mori, Hironori Baba, Takanobu Sasaki, Masaaki Ohno, Fumio Ikarashi, Naotaka Aizawa, Kunihiro Sato, Akio Tsuchiya, Hideyuki Hanazawa, Masahiko Tomita, Yamato Kubota, Yuka Morita, Kuniyuki Takahashi, Arata Horii

Surgical treatments for a case of superior canal dehiscence syndrome associated with patulous Eustachian tube Publication date: August 2019 Source: Auris Nasus Larynx, Volume 46, Issue 4 Author(s): Ryoukichi Ikeda, Hiromitsu Miyazaki, Masahiro Morita, Daisuke Yamauchi, Tetsuaki Kawase, Yukio Katori, Toshimitsu Kobayashi Abstract Objectives The patulous Eustachian tube (PET) and superior semicircular canal dehiscence syndrome (SCDS) have similarity in their symptoms and similar effects caused by positional changes, causing difficulty in the differentiation between the two disorders. This report describes a case of both SCDS and PET that was eventually successfully treated. Methods A 68-year-old man presented with hyperacusis to his own footsteps and gait disturbance. He had been diagnosed as PET two years before and had been treated by insertion of a silicone plug (Kobayashi plug) at the other hospital. Clinical case records, audiological data, cervical vestibular-evoked myogenic potential (cVEMP), Eustachian tube function tests and computed tomography (CT) were taken in the sitting position. Results While the CT confirmed superior semicircular canal dehiscence, the results of cVEMP was not typical of SCD likely due to preexisting hearing impairment in the right ear with a history of middle ear surgeries for the treatment of PET. He received round window reinforcement (RWR) and achieved relief from his symptoms but six months after the surgery, he visited again with complaints of autophony of his own voice and breathing. The tympanic membrane was found to move synchronous with respiration, and Eustachian tube function tests and the sitting CT confirmed the recurrence of severe PET. He had his silicone plug exchanged (increase in size of the Kobayashi plug) and achieved relief from symptoms. Conclusions The present case was a rare instance showing that PET and SCDS can occur simultaneously in a patient. The patient achieved relief from symptoms after treatment with RWR and insertion of the Kobayashi plug.

Thrombosis of the internal jugular vein in the ENT-department — Prevalence, causes and therapy: A retrospective analysis Publication date: August 2019 Source: Auris Nasus Larynx, Volume 46, Issue 4 Author(s): Janina Hahn, Melanie Nordmann-Kleiner, Thomas K. Hoffmann, Jens Greve Abstract Objective Less than 5% of deep vein thrombosis is due to thrombosis of the internal jugular vein. Genetic, malignant or inflammatory underlying diseases as well as insertion of venous catheters can be responsible for this pathology. Due to its rare occurrence, it is difficult to find systematic research about thrombosis of the internal jugular vein. Methods We performed a systematic analysis of present patient data from our ENT department with the electronic patient record considering the period from 2012-2017. Search terms were "thrombosis" and "jugular internal vein". We identified 41 patients with the requested diagnosis and performed further analysis of the cases. Internal jugular vein thrombosis was diagnosed in all patients using Duplex sonography and/or CT/MR angiography. Results Paraneoplastic thrombosis was found in 22/41 patients (54%), in 15 of the 22 (68%), the tumor was located in the ENT region. Two out of seven (29%) of the patients with tumor entities outside the head and neck region had thrombosis of the internal jugular vein as the first symptom of the disease. Another 14/41 patients (34%) had underlying inflammatory diseases – mostly streptococci-associated – for example a cervical abscess. In two patients, insertion of a central-venous catheter was causal, in three patients we could not find any reason for the development of thrombosis. Conclusion To diagnose the rare and often asymptomatic thrombosis of the internal jugular vein, ultrasound of the cervical region should always include vascular imaging. Thrombosis of the internal jugular vein results mostly paraneoplastic or due to inflammation/abscess. It can be the first symptom of a malignant primary disease and always requires detailed diagnostic clarification. Level of evidence 4.

Foreign bodies in the ear, nose, and throat in Japan: association with sociocultural and geographical conditions Publication date: August 2019 Source: Auris Nasus Larynx, Volume 46, Issue 4 Author(s): Ryohei Oya, Arata Horii, Atsuhiko Uno, Yoshiaki Kawasaki, Hidenori Inohara Abstract Objective Foreign bodies (FBs) in ear, nose, and throat (ENT) are common ENT emergencies but are sometimes life-threatening. However, FBs could be avoidable by the efficient announcement about the risk of these occurrence to the public. Fish bones are commonly found as throat FBs, and small toys are commonly found as pediatric ear and nose FBs. We hypothesized that there were relationships between the occurrence of FBs and sociocultural/geographical conditions. The purpose of this study is to clarify the risk factors of FBs in ENT regions related to eating customs and weather conditions. Methods From April 2009 to March 2014, 94,479 patients visited the Chuo Emergency Clinic (CEC) in Osaka, which is a local emergency center for Osaka prefecture in Japan. Among them, 3229 patients with throat FBs, 577 children (0–15 years of age) with ear FBs, and 1999 children (0–15 years of age) with nose FBs were enrolled into the present study. Monthly trends in the number of throat FBs were examined in relation to fish eating customs. The monthly average of the daily ratio of pediatric patients with ear or nose FBs to the total number of patients were examined in relation to weather parameters using a database of the Japan Meteorological Agency. Results The incidence of throat FBs was significantly higher in July and January (p < 0.05, analyzed by ANOVA and Tukey–Kramer test), presumably because Japanese people have more chances to eat fish in these months due to the traditional fish-eating customs. There was also a significant correlation between the number of pediatric patients with ear and nose FBs and the bad weather parameters including daily rainfall (r = 0.76, p = 0.0043; r = 0.57, p = 0.050, respectively, analyzed by the Pearson product-moment correlation coefficient). This is because children would spend longer time inside on rainy days, which increases the chance of putting a small toy part in the ear and nose. Conclusions FBs in throat and ear/nose occurred more frequently in the specific periods to eat fish and rainy days, respectively. Therefore, public announcement on the risk of occurrence of FBs based on sociocultural and geographical data is helpful to prevent FBs.

Pigmented villonodular synovitis occurring in the temporomandibular joint Publication date: August 2019 Source: Auris Nasus Larynx, Volume 46, Issue 4 Author(s): Fuminori Nomura, Yosuke Ariizumi, Yusuke Kiyokawa, Akihisa Tasaki, Yumiko Tateishi, Nobuaki Koide, Hiroaki Kawabe, Takashi Sugawara, Kentaro Tanaka, Takahiro Asakage Abstract Objective Pigmented villonodular synovitis occurring in the region of the temporomandibular joint is a rare disease, requiring a review of the treatment method, follow-up period. Method Refer to the past literature, along with a retrospective search. Results An excision, including the skull base bone, was performed in all cases; however, recurrence was found in one case on which fractional excision was performed. Past reports have also indicated that en bloc resection was considered desirable. Conclusion It is necessary to perform en bloc resection on patients with pigmented villonodular synovitis occurring in the region of the temporomandibular joint. Furthermore, due to reported cases of recurrence after a long period of time, follow-up observations of about 10 years are considered necessary.

Postoperative myxedema coma in patients undergoing major surgery: Case series Publication date: August 2019 Source: Auris Nasus Larynx, Volume 46, Issue 4 Author(s): Daniel Yafit, Narin Nard Carmel-Neiderman, Nadav Levy, Avrham Abergel, Alexander Niv, Ravit Yanko-Arzi, Arik Zaretski, Anat Wengier, Dan M. Fliss, Gilad Horowitz Abstract Objective Myxedema coma is a serious complication of hypothyroidism that can be precipitated by major surgery. It is extremely rare, with only a few reports in the literature. This study aims to present a relatively large case series of post-surgical myxedema coma and to analyze medical and surgical risk factors. Methods Analysis of the patients' surgical records and medical charts. Results Four patients developed postoperative myxedema coma and were evaluated for risk factors. Three had known hypothyroidism. Two had undergone large head and neck composite resections necessitating a free flap repair for malignant disease. One had undergone coronary artery bypass graft for ischemic heart disease, and another had undergone endoscopic cholecystectomy for complicated cholecystitis. All four patients required prolonged hospitalization, including treatment in the intensive care unit. One patient had undergone full cardiopulmonary resuscitation directly related to the myxedema coma state. Conclusion We present a series of four patients who developed myxedema coma following major surgery. We recommend that patients with known hypothyroidism who are scheduled for major surgery should be tested for thyroid function status and assessed for postoperative risk of hypothyroidism. Those who develop complications following major surgery, should be immediately tested for thyroid function to rule out myxedema coma.

Utility of response assessment PET-CT to predict residual disease in neck nodes: A comparison with the Histopathology Publication date: August 2019 Source: Auris Nasus Larynx, Volume 46, Issue 4 Author(s): Khuzema Saifuddin Fatehi, Shivakumar Thiagarajan, Harsh Dhar, Nilendu Purandare, Anil K. DCruz, Devendra Chaukar, Sarbani Ghosh Laskar, Kumar Prabhash, Venkatesh Rangarajan Abstract Objective To assess the ability of Positron Emission Tomography-Computed Tomography (PET-CT) scans to detect residual disease in neck nodes with the Histopathology (HPR) as the gold standard. To obtain a Standardized Uptake Value max cutoff in these patients to predict residual disease in neck. Methods Head and neck squamous cell carcinoma patients who underwent Salvage neck dissection with or without primary site surgery post Concurrent Chemo-Radiotherapy (CCRT) during the period January 2008–December 2017 were included. All patients had response assessment PET-CT scan at 10–14 weeks. Agreement analysis was performed between PET-CT and HPR, fine needle aspiration cytology and HPR. Positive predictive value, Negative predictive value of PET-CT to detect residual neck nodal disease in comparison to HPR was analyzed. A Receiver Operating Characteristic (ROC) curve was plotted between the SUV max values and the HPR. A SUV max cutoff value was obtained from the ROC curve. Results A total of 75 patients were included. Thirty-one underwent salvage neck dissection along with surgery for primary disease and 45 underwent salvage neck dissection alone. PET-CT showed good agreement with the HPR to detect residual disease in neck nodes (Kappa = 0.604). PET-CT had a PPV and NPV of 87.5% and 79.15% respectively as compared against the HPR. A SUV max cutoff of 4.62 had a specificity of 92.3% and sensitivity of 73.5% to detect residual disease in neck nodes on the HPR. Conclusion PET-CT surveillance is an accepted treatment strategy. A neck node with SUV max of 4.62 and above is most likely to harbor residual nodal disease. Level of evidence: Level 2b

☆Comparison of transcutaneous laryngeal ultrasound with video laryngoscope for assessing the vocal cord mobility in patients undergoing thyroid surgery Publication date: August 2019 Source: Auris Nasus Larynx, Volume 46, Issue 4 Author(s): Manish Kumar Shah, Babita Ghai, Nidhi Bhatia, Roshan Kumar Verma, Naresh Kumar Panda Abstract Objective We evaluated the accuracy and feasibility of transcutaneous laryngeal ultrasonography as an alternative to videolaryngoscopy for assessing vocal cord mobility to rule out recurrent laryngeal nerve injury following thyroidectomy. Methods Forty-five adult patients scheduled to undergo elective thyroidectomy under general anesthesia were included. Preoperatively, indirect laryngoscopy and transcutaneous laryngeal ultrasonography was done for assessing vocal cord mobility. Intraoperatively, following induction, patients were intubated using videolaryngoscope. On completion of the surgical procedure, one anesthetist performed videolaryngoscopy so as to record vocal cord mobility while the patients were being extubated in deep plane of anesthesia. Simultaneously another anesthesiologist performed transcutaneous laryngeal ultrasonography.Vocal cord mobility, changes in hemodynamics and total time duration for the two procedures was recorded. Indirect laryngoscopic assessment and flexible fiberoptic laryngoscopy was done on postoperative day 1 and 7 respectively. Results Postoperative videolaryngoscopy picked up bilaterally mobile vocal cords in 88.8% cases. Transcutaneous laryngeal ultrasonography could correctly identify 39(86.6%) of these patients, with 1(2.5%) patient being misdiagnosed as having bilaterally immobile vocal cords. Further, videolaryngoscopy identified 5 patients of vocal cord palsy, of which transcutaneous laryngeal ultrasonography correctly identified 3 (60%) patients. Hence, in comparison to videolaryngoscopy, the sensitivity, specificity, positive predictive value, and negative predictive value of transcutaneous laryngeal ultrasonography for assessment of vocal cords was 75%, 95.1%, 60%, and 97.5% respectively. Conclusion In patients undergoing thyroidectomy, transcutaneous laryngeal ultrasonography can serve as a non-invasive, bedside screening tool for assessing vocal cord palsy postoperatively.

MiR-196b affects the progression and prognosis of human LSCC through targeting PCDH-17 Publication date: August 2019 Source: Auris Nasus Larynx, Volume 46, Issue 4 Author(s): Min Luo, Gang Sun, Jing-wu Sun Abstract Objective To explore the effect of miR-196bon the biological features of human laryngeal squamous cell carcinoma (LSCC) through targeting PCDH-17. Methods miR-196b and PCDH-17 expressions were determined in tissues, and the targeting relation of miR-196b and PCDH-17 was verified through dual-luciferase reporter system. In vitro, Hep-2 cells were divided into the Control, miR-196b inhibitors, miR-NC, PCDH-17, and miR-196b mimics + PCDH-17 groups. The miR-196b and PCDH-17 expressions were determined by qRT-PCR or/and Western blot, and the biological features by MTT, Annexin V-FITC/PI, wound-healing and Transwell assays. Results MiR-196b was found to be up-regulated, while PCDH-17 was down-regulated in a negative correlation in LSCC patients, which was related to histological grade and TNM stage. And low expression of miR-196b and high expression of PCDH-17 contributed to an increase in the 5-year-survival rate of LSCC patients. Besides, miR-196b directly targeted PCDH-17, while miR-196b inhibitors could up-regulate the PCDH-17 in Hep-2 cells. Moreover, miR-196b inhibitors and PCDH-17 curbed Hep-2 cell proliferation but facilitated the apoptosis, with decreases in cell invasion and migration. In addition, no statistical significance was found in cell proliferation, apoptosis, invasion and migration between Control group and miR-196b mimics + PCDH-17 group. Conclusion LSCC patients exhibited the up-regulated miR-196b and down-regulated PCDH-17, which are correlated with the major clinical features and prognosis. Inhibiting miR-196b may suppress proliferation, migration and invasion abilities, and promote apoptosis of Hep-2 cells via targeting PCDH-17.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

Dermatologic Surgery

Aesthetic Outcomes of Nasal Burow's Grafts With Interdomal Sutures After Mohs Micrographic Surgery BACKGROUND Post-Mohs reconstruction of distal nasal defects is challenging. Many repair options exist, each with advantages and disadvantages. Utilization of a Burow's graft in combination with manipulation of the underlying nasal cartilages with interdomal sutures is an underreported yet effective repair option. OBJECTIVE To present the authors' experience with Burow's grafts facilitated by interdomal sutures for repair of nasal defects after Mohs micrographic surgery (MMS). MATERIALS AND METHODS Patients who underwent repair with Burow's grafts and interdomal sutures from 2013 to 2017 at a single university were identified. Demographics, follow-up, and complications were recorded. Two independent, board-certified dermatologists evaluated photographs for cosmesis and alar symmetry. RESULTS Thirty-one patients were identified. A total of 5/31 patients (16.1%) experienced minor complications without permanent sequelae. A total of 4/31 (12.9%) patients underwent cosmetic revision. No incidences of pincushioning, nasal valve dysfunction, or graft necrosis occurred. Aesthetic ratings were good to excellent with mean visual analog score of 80.8. Alar symmetry was excellent. CONCLUSION A Burow's full-thickness skin graft facilitated by an interdomal suture to maintain nasal tip orientation and projection is an elegant repair technique for distal nasal oncologic defects with good to excellent aesthetic outcomes. It should be considered in the armamentarium for repair of distal nasal defects after MMS. Address correspondence and reprint requests to: Michael W. Pelster, Advanced Dermatology, 2950 Cullen Pkwy, Suite 102, Pearland, TX 77584, or e-mail: michael.w.pelster@gmail.com The authors have indicated no significant interest with commercial supporters. © 2019 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.

Patient Expectations Influence Postoperative Facial Satisfaction Measured by the FACE-Q Skin Cancer Module: A Pilot Study No abstract available

Primary Cutaneous Umbilical Melanoma: The Michigan Experience BACKGROUND Primary cutaneous umbilical melanoma is rare. Thorough information regarding its characteristics and treatment, including use of sentinel lymph node biopsy (SLNB) staging, is difficult to obtain. The unique anatomy of the umbilicus adds to the complexity of diagnosing and treating melanoma at this site. OBJECTIVE To improve understanding of diagnosis and treatment of primary cutaneous umbilical melanoma through presenting 7 new cases and reviewing 39 cases in the literature. MATERIALS AND METHODS The University of Michigan melanoma database query and review of the literature regarding reported cases of primary umbilical melanoma. RESULTS In 7 new and 39 previously reported cases of primary cutaneous umbilical melanoma, we describe signs and symptoms, histopathologic features, differential diagnosis, relevant anatomical considerations, and definitive treatment including SLNB when applicable. CONCLUSION Our series, combined with a thorough literature review and compilation of findings, provides a better understanding and appreciation of melanoma in the unique anatomical site of the umbilicus, with a reminder to carefully examine the umbilicus during a full skin examination in patients at risk of melanoma. Primary umbilical melanoma presents and can be appropriately treated similarly to cutaneous melanoma in other sites, with attention to relevant anatomy. Address correspondence and reprint requests to: Kelly B. Cha, MD, PhD, University of Michigan Health System, 1910 A. Alfred Taubman Center, 1500 E. Medical Center Drive, Suite 5314, Ann Arbor, MI 48109, or e-mail: kellycha@med.umich.edu The authors have indicated no significant interest with commercial supporters. © 2019 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.

How Patients Value Scar Length Versus Scar Appearance and the Effect of Income Level on Willingness to Pay: Results From a Multicenter Discrete Choice Experiment No abstract available

Safety of Subcutaneous Infiltration of Carbon Dioxide (Carboxytherapy) for Abdominal Fat Reduction: A Pilot Study No abstract available

Cutaneous Leiomyosarcoma: A SEER Database Analysis BACKGROUND Cutaneous leiomyosarcoma is a rare dermal neoplasm usually arising from the pilar smooth muscle. It is considered a relatively indolent neoplasm, and there is debate whether designation as sarcoma is appropriate. Owing to some conflicting data in the literature, however, its behavior warrants further clarification. OBJECTIVE To determine the clinical behavior and demographic and pathologic characteristics of cutaneous leiomyosarcoma. MATERIALS AND METHODS The Surveillance, Epidemiology and End Results database was used to collect data on cutaneous leiomyosarcoma and 2 reference populations: cutaneous angiosarcoma (aggressive) and atypical fibroxanthoma (indolent). Demographic and oncologic characteristics were examined, and overall survivals (OS) and disease-specific survivals were compared. RESULTS Leiomyosarcoma and atypical fibroxanthoma displayed lower stage (localized: 69.7% and 66.8% respectively), smaller size (<3 cm: 90.5% and 72%), and lower rates of disease-specific mortality (2.9% and 7.8%) compared with angiosarcoma. Patients with leiomyosarcoma had a 5-year disease-specific survival rate of 98% and OS rate of 85%. CONCLUSION Cutaneous leiomyosarcoma shows outcomes similar to atypical fibroxanthoma. It is nearly always indolent and should be distinguished from more aggressive cutaneous and subcutaneous sarcomas. Clear communication of the biologic potential may be best achieved using alternate diagnostic terminology such as "atypical intradermal smooth-muscle neoplasm." Address correspondence and reprint requests to: Paul N. Bogner, MD, Departments of Pathology and Dermatology, Roswell Park Comprehensive Cancer Center, Elm and Carlton Streets, Buffalo, NY 14263, or e-mail: Paul.Bogner@roswellpark.org The authors have indicated no significant interest with commercial supporters. © 2019 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.

Introducing the L-Lift—A Novel Approach to Treat Age-Related Facial Skin Ptosis Using A Collagen Stimulator No abstract available

Commentary on Intralesional Deoxycholic Acid as a Neoadjuvant Treatment for a Large Lipoma No abstract available

Time to Move on From Prescribing Oral Antibiotics as Prophylaxis for Mohs? No abstract available

Outcomes for Basal Cell Carcinoma Treated With Vismodegib Extended Alternate Day Dosing No abstract available

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

he contribution by MRI and CT in the clinical staging of early glottic cancer (T1-T2) for the evaluation of submucosal areas that can change the stage of the disease and reassess the therapeutic approach. In particular, MRI shows a sensitivity of 100% and a specificity of 97% in assessing areas such as paraglottic space, anterior commissure, thyroid, and arytenoid cartilages, with various indications for conservative surgery. Instead, the sensitivity of CT reaches lower values, 40%, but it has high specificity (100%). In our series, CT staging was accurate in 70% of cases, while the MRI was accurate in 80% of cases.

Early Glottic Cancer: Role of MRI in the Preoperative Staging

https://www.hindawi.com/journals/bmri/2014/890385/  

Eugenia Allegra,1 Pierpaolo Ferrise,1 Serena Trapasso,1 Orazio Trapuzzano,2 Antonio Barca,2 Stefania Tamburrini,3 and Aldo Garozzo1

1Department of Experimental and Clinical Medicine-Otolaryngology Head and Neck Surgery, University of Catanzaro, Viale Europa, Località Germaneto, 88100 Catanzaro, Italy
2Department of Experimental and Clinical Medicine-Radiology, University of Catanzaro, Viale Europa, Località Germaneto, 88100 Catanzaro, Italy
3Department of Radiology, Pellegrini Hospital, 80135 Naples, Italy

Received 7 June 2014; Revised 12 July 2014; Accepted 23 July 2014; Published 14 August 2014

Academic Editor: Martin G. Mack

Copyright © 2014 Eugenia Allegra et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Percentage of concordance between pathological, MRI, and CT T staging with  value.

T staging CT MR value Correct stadiations 88% 66% 0.24 Understadiations 11% 0% 0.47 Overstadiations 0% 33% 0.02 Concordance between pathological, MRI, and CT staging with  value, according to laryngeal subsites. Laryngeal site Pathological involvement MRI CT  value Number Number (%)* Number (%)* Paraglottic space 6 6 (100%) 2 (33%) 0.06 Thyroid cartilage 4 4 (100%) 2 (50%) 0.41 Arytenoid cartilage 2 2 (100%) 2 (100%) n.v. Cricoid cartilage 0 0 (100%) 0 (100%) n.v. Anterior commissure 8 8 (100%) 2 (25%) 0.0098 (%)*: accuracy.

Abstract

Introduction. Clinical staging is the most important time in management of glottic cancer in early stage (I-II). We have conducted a prospective study to evaluate if magnetic resonance imaging (MRI) is more accurate than computed tomography (CT) about tumoral extension, to exactly choose the most appropriate surgical approach, from organ preservation surgery to demolitive surgery. Materials and Methods. This prospective study was conducted on 26 male patients, with suspected laryngeal neoplasia of glottic region. The images of MRI and CT were analyzed to define the expansion of glottic lesion to anterior commissure, laryngeal cartilages, subglottic and/or supraglottic site, and paraglottic space. The results of MRI and CT were compared with each other and with the pathology report. Results. CT accuracy was 70% with low sensitivity but with high specific value. MRI showed a diagnostic accuracy in 80% of cases, with a sensitivity of 100% and high specificity. Statistical analysis showed that MRI has higher correlation than CT with the pathology report. Conclusion. Our study showed that MRI is more sensitive than CT in the preoperative staging of early glottic cancer, to select exactly the eligible patients in conservative surgery of the larynx, as supracricoid laryngectomy and cordectomy by CO2 laser.

1. Introduction

Laryngeal cancer represents 4.5% of all malignancies and 28% of cancers of the upper aerodigestive tract. Ninety percent of the malignant tumors of the larynx are composed of squamous cell carcinomas, with different distributions of prevalence based on the specific subsite affected (glottic, supraglottic, and subglottic site) [1]. The clinical staging with the assistance of diagnostic imaging is the most important time of therapeutic planning, which should ensure oncological radicality in respect of the clinical outcomes for patients. For this reason, it is necessary to stage the laryngeal cancer in a correct way in order to choose the most correct therapeutic approach based on the available options, from organ preservation strategies (radiotherapy, partial resection/cordectomy with CO2 laser, and conservative partial reconstructive surgery) to demolitive surgery. This is especially true for glottic tumors at an early stage of disease, which have demonstrated high rates of local control with organ preservation techniques such as radiotherapy (RT) (84%–95%) and partial resections (85%–100%) [2–4]. Indirect laryngoscopy is the first step in diagnosis and clinical evaluation of the tumor extension, but it is an external investigation and therefore has limitations in the assessment of the implication of the deep structures (such as anterior commissure, thyroid cartilage, and paraglottic spaces), which is discriminating for the extension of surgical resection. A valuable aid is provided by computed tomography (MDCT) and magnetic resonance imaging (MRI) for the evaluation of deep structures, because the involvement of these areas is generally considered as a contraindication for radiotherapy and surgical conservative procedures. It is not a formal contraindication, as supracricoid laryngectomies are still preservation surgery. In these cases, frontolateral vertical laryngectomy or vertical hemilaryngectomy or partial supracricoid laryngectomy with cricohyoidoepiglottopexy (CHEP) or cricohyoidopexy (CHP) is oncologically more suitable, because of removing thyroid cartilage, vocal folds, and paraglottic spaces, although with greater morbidity and increased time of hospitalization. In addition, the reconstruction of the vocal folds allows maintenance of physiological larynx functions like phonation and swallowing, with improvement of the quality of life in these patients [4–7]. For these reasons, it is important to evaluate precisely the extent of tumor preoperatively to plan the correct procedure to assure clear margins to the patient to avoid local recurrence.

CT and MR imaging are routinely used to differentiate between limited and gross cartilage invasion.

Some studies have shown that MRI is more sensitive than CT in the evaluation of cartilage tumor invasion [8–10]. However, cartilage invasion is sometimes overestimated [11–13].

The overestimation of the magnetic resonance protocol is probably related to the presence of peritumoral inflammation, which amplifies/inflates the boundaries of abnormal tissues [14].

We have conducted a prospective study to evaluate if MRI is able to provide more accurate information than CT about the tumoral extension to the anterior commissure, the cartilages, and the possible infiltration of paraglottic spaces in laryngeal glottic cancer at an early stage (I-II); the purpose is to exactly select patients who are eligible for laryngeal conservative surgery (supracricoid laryngectomy and cordectomy by CO2 laser), to ensure the oncological radicality and improve clinical outcome.

2. Materials and Methods

2.1. Patients

The study was conducted at the Department of Otolaryngology, University of Catanzaro (Italy). From August 2011 to November 2013, 26 male patients, aged 52–79 years (median, 63.6 years), with suspected laryngeal cancer of glottic region assessed by indirect laryngoscopy were enrolled; the symptomatology was predominantly characterized by hoarseness and cough. The study was performed with the approval of Institutional Review Board of "Magna Graecia" University of Catanzaro, Italy; all patients give their informed consent to the study.

All patients were subjected to a diagnostic workup including indirect laryngoscopy, MRI and CT of the neck (with and without contrast), and biopsy. In order not to invalidate the results, MRI and CT scans were performed before laryngeal biopsy, so that the images do not prove altered by the presence of peritumoral inflammation. The evaluation of CT and MRI was performed independently by two radiologists who were unaware of the laryngoscopic features and surgical findings. Of 26 patients six were excluded from the study because they were treated with radiotherapy after biopsy confirmed tumor diagnosis (four patients refused surgery and two patients had poor general conditions). Of 20 patients, 14 were smokers, four ex-smokers, and two had never smoked.

Stage of disease in all patients was clinically assessed according to the 7th edition of the TNM classification established by the American Joint Committee on Cancer (AJCC) [15]. The physical examination by indirect laryngoscopy showed unilateral involvement vocal fold in 8/20 (40%) patients and bilateral vocal fold involvement in 12/20 (60%) patients. The T staging by indirect laryngoscopy classified eight patients as T1a, 6 T1b, and 6 T2, with impaired cordal motility.

Patients are currently included in a follow-up program including visits every 3 months with video-laryngoscopy and radiological examinations such as ultrasound of the neck, chest radiography, CT, and MRI, in agreement with clinical evidence.

2.2. Staging by MRI

MR images were obtained with a Philips Achieva 1.5 T MR system. MR examinations were performed with an anterior surface neck coil and T1-weighted spin echo and T2 turbo spin echo images in axial and coronal projection, without contrast, diffusion weighted imaging (DWI) and T1w spin echo sequences with fat saturation after paramagnetic contrast infusion of gadolinium chelate were obtained. The number of the sections was 20 for all sequences. The sections were 3-4 mm of interspace thickness with a 1 mm intersection gap. The evaluation of cartilage invasion followed the new criteria proposed by Becker et al. Specifically, T2-weighted or T1-weighted post-Mdc cartilage signal intensity greater than that of the adjacent tumor was considered to indicate inflammation, and signal intensity similar to that of the adjacent tumor was considered to indicate neoplastic invasion [16]. The DWI was performed to better discriminate peritumoral edema from neoplastic tissue, but, at present, there are no studies reporting the performance of DWI. The advantage introduced by DWI sequence consists in obtaining information about the cellularity of tissues [14–16].

The T staging by MRI classified eight patients as T1a, 6 T1b, and 6 T3.

2.3. Staging by CT

CT images were obtained with a Toshiba Aquilion CX 64 Multislice CT system. The axial cuts of neck and chest were performed with 2-3 mm of thickness and with 1 mm of intersection gap, before and after intravenous administration of contrast medium [17]. CT criteria used for determining neoplastic invasion of the thyroid cartilage include sclerosis, erosion, lysis, and transmural extralaryngeal tumor spread [17]. The T staging by CT classified 12 patients as T1a and 4 T3; the presence of the disease was not detected in four cases.

2.4. Statistical Analysis

The images of MRI and CT were studied to define the expansion of glottic lesion, involvement of anterior commissure, infiltration of laryngeal cartilages and the possible extension to subglottic and/or supraglottic, and the invasion of paraglottic space. The results of MRI and CT were compared with each other and with the definitive pathological examination, each of the two methods for calculating the sensitivity, and the specificity and positive predictive value. For statistical analysis we employed the MedCalc software (version 13.0.6) using the "comparison of proportion" test; the values lower than 0.05 () were considered statistically significant.

3. Results

Through histopathological examination, 18 of 20 (90%) were histologically diagnosed as squamous cell carcinoma of the glottis and were staged according to AJCC pTNM staging system, 7th edition [15], resulting in eight as pT1a, 4 pT1b, and 6 pT3; two of the ten patients clinicoradiologically classified as T1a had histopathological diagnosis of squamous cell papilloma.

According to preoperative clinicoradiological staging the classification was T1a in 10 patients (50%), T1b in 4 patients (20%), and T3 in 6 patients (30%). Based on clinicoradiological staging, patients were subjected to excisional biopsy with CO2 laser in two cases (classified as squamous cell papillomas by histopathological examination), cordectomy with CO2 laser in four cases (4 T1a without involvement of anterior commissure), supracricoid laryngectomy with CHEP and reconstruction of vocal cords in 10 cases (4 T1a, 4 T1b, and 2 T3), and total laryngectomy in four cases (4 T3).

3.1. Concordance between MRI and Pathological Staging

MRI classified in a correct way 16 of 20 patients (80%), with four overstaged patients: two lesions classified as cT1b by MR were pT1a and two lesions classified as cT1a were squamous cell papillomas at pathological examination (no tumor).

About the examination of anterior commissure, laryngeal cartilages, and paraglottic space, MRI has been shown to be a very sensitive method (100%), with two false positives, high specificity (97%), and a positive predictive value of 90%, as calculated from the data in Table 1.

Table 1: Concordance between MRI and pathological staging: true positive (TP), false positive (FP), true negative (TN), and false negative (FN), according to laryngeal subsites.

3.2. Concordance between CT and Pathological Staging

CT classified in a correct way 14 of 20 patients (70%), with six understaged patients: two lesions classified as cT1a by CT were pT1b, two lesions classified as cT1a were pT3, and two tumors were not detected by CT examination. The two cases of squamous cell papillomas were interpreted in a correct way. About the examination of anterior commissure, laryngeal cartilages and paraglottic space, CT has been shown to be a little sensitive method (40%), with eight false negatives (Figures 1 and 2) but with high specificity (100%), as calculated from the data in Table 2.

Table 2: Concordance between CT and pathological staging: true positive (TP), false positive (FP), true negative (TN), and false negative (FN), according to laryngeal subsites.

Figure 1: Carcinoma of the right vocal cord: (a) endoscopic view; (b) CT image: the paraglottic space seems preserved (green indicator) without cartilaginous alterations; (c) T2w MR image: the paraglottic space seems involved with focal invasion of the thyroid cartilage (green indicator).

Figure 2: Bilateral glottic carcinoma with involvement of anterior commissure: (a) endoscopic view; (b) CT image: contrast enhancement of right vocal fold, but the commissure seems preserved (green indicator); (c) T1w MR image after contrast shows involvement of right true vocal cord, anterior commissure, and anterior part of left vocal fold (green indicator).

3.3. Data Analysis

In our series, there is a statistically significant difference between MRI and CT in identifying the involvement of anterior commissure (), and a considerable difference also exists in the study of paraglottic space, even if it does not reach statistical significance () (Table 3). Moreover, taking into account the correspondence of the clinical-radiologic T staging with pT staging, a percentage of understadiations equal to 0% for MRI and 33% for CT emerge, which reaches statistical significance (). CT scans are charged with a large number of false negatives, while MR has found two cases of false positives. In our study, CT does not overstage the cases in contrast to MRI, but the difference does not reach statistical significance. CT scans showed no lesions in patients with papillomas, while MR showed asymmetry of the glottis with gradient contrast enhancement of the lesion and suspicion of malignancy. CT has estimated the involvement of paraglottic spaces in two cases of six and the infiltration of thyroid cartilage in two cases of six, while MRI is not responsible for errors in these assessments. In two cases there was an involvement of arytenoid cartilage; both CT and MRI have been equaled in these assessments. Results of data comparison are summarized in Table 4.

Table 3: Concordance between pathological, MRI, and CT staging with  value, according to laryngeal subsites.

Table 4: Percentage of concordance between pathological, MRI, and CT T staging with value.

4. Discussion

This prospective study evaluates the contribution by MRI and CT in the clinical staging of early glottic cancer (T1-T2) for the evaluation of submucosal areas that can change the stage of the disease and reassess the therapeutic approach. In particular, MRI shows a sensitivity of 100% and a specificity of 97% in assessing areas such as paraglottic space, anterior commissure, thyroid, and arytenoid cartilages, with various indications for conservative surgery. Instead, the sensitivity of CT reaches lower values, 40%, but it has high specificity (100%). In our series, CT staging was accurate in 70% of cases, while the MRI was accurate in 80% of cases. By Kuno et al., the accuracy of CT in staging was 80% and 87.5% for the MR, without significant differences between RMI and TC in the assessment of anterior commissure and paraglottic space, while for the determination of cartilaginous invasion MR showed a higher sensitivity than CT, which instead resulted to be significantly more specific. However cartilage invasion is sometimes overestimated, resulting in unnecessary total laryngectomies in some patients [13].

Again, the integration of DWI into the magnetic resonance protocol has the potential to increase the specificity [16].

The ability of CT in the evaluation of the cartilage invasion has been studied by several authors resulting in a variable sensitivity from 46% to 74% and a specificity variable from 87% to 94% [8, 10, 18–20]. By applying Becker's criteria for cartilage invasion for the evaluation of all laryngeal cartilages (extralaryngeal spreads and erosion/lysis) and for the evaluation of cricoid and arytenoid (single sclerosis), the sensitivity arrives at 82% and specificity at 79% [17]. Hartl et al. evaluated the role of CT for detecting cartilage invasion in early glottic tumors and showed a sensitivity of 10.5% and a specificity of 94%, overestimating the cartilage invasion in case of injury involving the commissure and overestimating it in case of lesion with impaired vocal fold mobility; they emphasized the inability of CT in the evaluation of focal invasion of the internal perichondrium in thyroid cartilage [21].

About RMI, Castelijns et al. asserted that CT and MRI were equally specific, while MRI was more sensitive than CT [8]. Becker claimed higher sensitivity of MRI than CT (89% versus 66%) but less specificity (84% versus 94%) [10]. In 1998, Declercq et al. showed a sensitivity of MRI equal to 100% [22] and in 2001 Atula et al. showed equivalence of the sensitivity and specificity of 67% [23]. Banko et al. have demonstrated accuracy equal to 100% in the evaluation of anterior commissure using MRI [24], similar to that found by Zbaren et al. equal to 83% [18]. About the evaluation of early glottic carcinomas, Bertrand et al. considered CT as a first line investigation, using only later on MRI for the examination of dubious areas such as the anterior commissure, subglottis, and arytenoid cartilages [20]. Anterior commissure is an area of particular interest, because its particular conformation may be a resistant space to tumoral deep space extension, until the thyroid cartilage, and configures it as a decisive factor for the choice of surgical resection. In fact, X-space's dense fibrous structures act as a barrier to extension in depth and may lead to spreading along the surface on the mid line till subglottic region [25–27]. This behavior contraindicates conservative surgery. In our series, CT has understaged the invasion of thyroid cartilage and paraglottic space; in a patient with bilateral glottic cancer, CT has not evaluated the invasion of anterior commissure, and in another case of glottic tumor it has not identified any tumoral alterations.

In the literature, the debate about the best therapeutic approach for glottic cancer that involves the anterior commissure is still open. In a review, 64 patients with T1 glottic cancer were treated with radiotherapy; 14 patients had involvement of commissure and they had a local control rate of 76% at 2 years and 58% at 5 years, with statistically significant difference [28]. In another review, 53 patients with glottic carcinoma were treated with radiotherapy: 8/14 (57.1%) patients with involvement of anterior commissure had locoregional recurrence of disease [29]. In another series, 200 cases classified as T1 were treated with radiotherapy and they had a local control rate of 89% in case of commissure involvement compared to 94%, when the commissure was not involved [30]. The anterior commissure, therefore, remains as one of the most adverse independent prognostic factors [31]. The CO2 laser treatment for glottic carcinomas involving the anterior commissure is supported by Steiner et al., while Eckel argues that it is burdened by high rates of recurrence (37.1%) [32, 33]. Sachse et al. compare the effectiveness of two conservative treatments, CO2 laser excision and partial laryngectomy, in 119 tumors classified as T1-T2, and they show that the involvement of anterior commissure greatly reduces the local control rate in patients treated with CO2 laser resection [34]. Zohar et al. and Laccourreye et al. reported a local control rate of 90% with supracricoid laryngectomy (SCL) in case of glottic tumors involving the anterior commissure, compared to 72% with radiotherapy [35, 36]. The modified supracricoid laryngectomy (MSCL) with reconstruction of vocal folds results oncologically safe in case of involvement of anterior commissure without recurrence at five years and with a local control rate equal to 90.5%, also increasing the quality of voice and life than the SCL [4–7].

Based on these considerations, it is clear in the treatment of early glottic cancer that it is important to identify the involvement of anterior commissure, paraglottic spaces, and laryngeal cartilages: the possible involvement of these deep structures could contraindicate CO2 laser treatment or radiation, because of its high rate of recurrence or chondronecrosis. Any focal involvement of arytenoid cartilages or paraglottic space and thyroid cartilage requires a more radical treatment, using LSC or MSCL, preserving functional laryngeal functions [5].

5. Conclusion

In our study, statistical analyses have showed that MRI could be considered a helpful diagnostic method for preoperative staging of laryngeal tumor and decision making of the best therapeutic option in these patients. MR imaging has several advantages with respect to multislice CT and few limitations (artifacts related to movement, namely, breathing, swallowing, and vessel pulsation). MRI allows a multiparameter analysis (T1 weighted, T2 weighted, DWI, and postcontrast acquisition). This multiparameter approach amplifies the contrast resolution. Moreover the lack of accurate evaluation radiologic imaging and substaging of disease can change therapeutic planning and patients survival. Data from our study are very encouraging. Even though MRI is more expensive, longer, and not always feasible for patients compared to CT scan (poor compliance, any contraindications), based on the above considerations, we believe that it could be considered the investigation of choice in the clinical evaluation of early glottic lesions for the planning of therapeutic interventions, because of its high sensitivity and elevated degree of diagnostic accuracy. However, the evaluation of MR images needs high experience and an interdisciplinary collaboration.

Conflict of Interests

The authors declare that there is no conflict of interests regarding the publication of this paper.

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