Abstrakt ORL Srpen 2009

“Carcinoma cuniculatum of the oral cavity: A histological and clinical dilemma.”

Jalisi, S., S. Seo, et al. (2009).

Laryngoscope 119(SUPPL. 1): 8.


Objectives: To describe a rare case and explain the management options for carcinoma cuniculatum of the oral cavity Study Design: Case Report Methods: Description of the diagnosis and management of a patient with carcinoma cuniculatum at a tertiary medical center. The pathological criteria for diagnosis are reviewed. Results: The patient is a 73 year old male who presented initially with a painful lesion involving the lateral right portion of his tongue in 2004. Multiple biopsies showed no cancer. He was finally referred to the head and neck surgery service and was diagnosed with squamous cell cancer. He underwent transoral robotic partial glossectomy and an ipsilateral modified radical neck dissection. The final pathology was carcinoma cuniculatum with all neck nodes negative for cancer. Conclusions: Carcinoma cuniculatum can present in an indolent manner and biopsies can usually give a false diagnosis of benign lesion or pseudoepithelial hyperplasia. Both clinical and histological features need to be considered in the accurate diagnosis of this cancer.




“A pilot study to evaluate the use of the da Vinci surgical Robotic system in Transoral surgery for lesions of the oral cavity and pharynx.”

Mardirossian, V. A., M. C. Zoccoli, et al. (2009).

Laryngoscope 119(SUPPL. 1): 7.


EDUCATIONAL OBJECTIVE: At the conclusion of this presentation, the participants should be able to discuss the role of robotic surgery in the head and neck. OBJECTIVES: The da Vinci Robotic Surgical System (Intuitive Surgical, Inc., Sunnyvale, CA) has been used in many fields with great success including: Urologic, General, Cardiothoracic, and Gynocological surgeries. The same benefits that this method offers to these specialties can be utilized in the realm of the head and neck. The aim study of this study is to evaluate the potential advantages of Transoral Robotic Surgery (TORS) specifically looking at precision, dexterity, visualization and exposure of the surgical site, surgical time, recovery of speech and swallowing function, degree of pain and discomfort and incidence of bleeding. STUDY DESIGN: Prospective Clinical Trial. METHODS: 10 patients with lesions of the oral cavity and pharynx were recruited for this study. The following timing parameters were recorded: 1. intraoperative set up time. 2. Time to obtain surgical bed exposure. 3. The duration of the surgery. 4. Days until swallowing recovery. 5. Days until speech recovery. Additionally, the following parameters were recorded: 1. Quality of surgical bed exposure. 2. Complications. 3. Pain intensity/duration. 4. Operative bleeding. 5. Postoperative Bleeding. RESULTS: All ten surgeries were performed between June 2007 and October 2008. The intraoperative set up time was generally less than 45 min, the major part being less than 30 min. Minimal time (less than 4 min) was required in order to obtain an excellent surgical exposure in all cases. The duration of the surgery was less than 95 min with a maximum of blood loss of 100 mililiters. There were no intraoperative or postoperative complications and speech and swallowing recovery generally did not exceed 2 days. There was minimal postoperative pain and residual bleeding. CONCLUSIONS: The Da Vinci robotic system is a safe and reliable instrument for transoral removal of lesions in the oral cavity and pharynx. Our study supports this conclusion with minimal time to speech and swallowing recovery after surgery, along with reduced postoperative pain and absence of complications in our patients.




“Feasibility of transoral lateral oropharyngectomy using a robotic surgical system for tonsillar cancer.”

Park, Y. M., J. G. Lee, et al. (2009).

Oral Oncol 45(8): e62-66.


Conventional surgical approaches for tonsillar carcinomas have a great risk for developing treatment-related morbidity. To minimize this morbidity, transoral lateral oropharyngectomy (TLO) using the robotic surgical system was performed, and the efficacy and feasibility of this procedure was evaluated. TLO was performed using the da Vinci surgical robot (Intuitive Surgical, Inc., Sunnyvale, CA). It consists of a surgeon’s console and a manipulator cart equipped with three robotic arms. The surgeon is provided with three-dimensional magnified images from the endoscopic arm and can control two instrument arms for delicate operations from the console. Safe resection of tonsillar carcinoma was possible with the three-dimensional magnified images. When proceeding with resection of the buccopharyngeal fascia, we could prevent damage to the carotid artery, which is located posterolateral to the tonsillar fossa, since the joint at the distal part of the robotic arm can be bent freely from side to side. By using the 30 degrees endoscope, we can achieve a better surgical view of the base of the tongue area. TLO was performed successfully in all five patients without surgical complications. The mean operating time was 44 min, and an average of 19 min was required for setting up the robotic system. TLO using the robotic system will be a good option for organ preservation therapy in the treatment of carcinomas of the tonsil and the tonsillar fossa in the future.




“Endoscopic partial supraglottic laryngectomies: Techniques and results.”

Remacle, M., G. Lawson, et al. (2009).

Otolaryngology – Head and Neck Surgery 141(3): 374-381.


Objective: The aim of this study was to evaluate long-term results of endoscopic surgery for supraglottic carcinoma. Study Design: Case series with chart review. Setting: Tertiary care university hospital. Subjects and Methods: From 1992 to 2004, 45 patients diagnosed with supraglottic squamous cell carcinoma (two Tis, nine T1N0, 27 T2N0, two T2N1, one T2N2, four T3N0) underwent different types of endoscopic supraglottic laryngectomies according to the European Laryngological Society (ELS) classification: three limited excision (type I); 27 medial without resection of the preepiglottic space (type IIb); one medial with resection of the preepiglottic space (type IIIa); three medial with resection of the preepiglottic space (type IIIb); nine lateral (type IVa); two lateral (type IVb). Results: Overall survival was 93 ± 4 percent (SE) after three years and 89 ± 6 percent (SE) after five years. The median follow-up is 3.7 years. Patients with clinically N0 necks were found to have positive nodes in eight (19%) cases. Two cases of postoperative hemorrhage were controlled by electrocautery. All of the patients without previous treatment for larynx cancer regained swallowing function within five days to three weeks after surgery. Mean duration of hospitalization was 12.5 days. Conclusion: Endoscopic partial laryngectomies, as defined by the ELS classification, for selected supraglottic squamous cell carcinoma proved to be an excellent alternative to radiotherapy and open neck surgery. © 2009 American Academy of Otolaryngology-Head and Neck Surgery Foundation.




“Current trends in initial management of laryngeal cancer: The declining use of open surgery.”

Silver, C. E., J. J. Beitler, et al. (2009).

European Archives of Oto-Rhino-Laryngology 266(9): 1333-1352.


The role of open surgery for management of laryngeal cancer has been greatly diminished during the past decade. The development of transoral endoscopic laser microsurgery (TLS), improvements in delivery of radiation therapy (RT) and the advent of multimodality protocols, particularly concomitant chemoradiotherapy (CCRT) have supplanted the previously standard techniques of open partial laryngectomy for early cancer and total laryngectomy followed by adjuvant RT for advanced cancer. A review of the recent literature revealed virtually no new reports of conventional conservation surgery as initial treatment for early stage glottic and supraglottic cancer. TLS and RT, with or without laser surgery or CCRT, have become the standard initial treatments for T1, T2 and selected T3 laryngeal cancer. Photodynamic therapy (PDT) may have an emerging role in the treatment of early laryngeal cancer. Anterior commissure involvement presents particular difficulties in application of TLS, although no definitive conclusions have been reached with regard to optimal treatment of these lesions. Results of TLS are equivalent to those obtained by conventional conservation surgery, with considerably less morbidity, less hospital time and better postoperative function. Oncologic results of TLS and RT are equivalent for glottic cancer, but with better voice results for RT in patients who require more extensive cordectomy. The preferred treatment for early supraglottic cancer, particularly for bulkier or T3 lesions is TLS, with or without postoperative RT. The Veterans Administration Study published in 1991 established the fact that the response to neoadjuvant CT predicts the response of a tumor to RT. Patients with advanced tumors that responded either partially or completely to CT were treated with RT, and total laryngectomy was reserved for non-responders. This resulted in the ability to preserve the larynx in a significant number of patients with locally advanced laryngeal cancer, while achieving local control and overall survival results equivalent to those achieved with initial total laryngectomy. Following this report, similar “organ preservation” protocols were employed in many centers. By 2003, results of the RTOG 93-11 trial, utilizing CCRT as initial treatment, were published, demonstrating a higher rate of laryngeal preservation with this protocol. Surgery was reserved for treatment failures. This concept changed the paradigm for management of advanced laryngeal cancer, greatly reducing the number of laryngectomies performed. While supracricoid laryngectomy has been employed for selected patients, total laryngectomy is the usual procedure for salvage of failure after non-surgical treatment. © 2009 Springer-Verlag.




“The HD-panoramic visualization system: A new visualization system for ENT surgery.”

Strauß, G., N. Bahrami, et al. (2009).

European Archives of Oto-Rhino-Laryngology 266(9): 1475-1487.


This work examines the application possibilities of a new visualization system, the Panoramic Visualization System (HD-PVS), in ENT surgery. The Panoramic Visualization System (PVS) is a novel optical system that is neither an endoscope nor a microscope. It has a focal length of 200 mm, a wide field of view and is used together with an HD camera and an HD monitor (HD-PVS). The analysis of the visualization quality took place in laboratory conditions using 4 close-to-surgery scenarios with altogether 40 data points. Further, the system was used on patients in 45 procedures (tympanoplasty, parotidectomy, neck dissection, septumplasty, transfacial approaches). The results were analyzed following the ICCAS workflow-scheme and with standardized questionnaires. In the analysis of the visualization quality, the PVS exhibited the best total evaluation in the lab test in two out of four scenarios. In one of four scenarios, the PVS as well as the microscope achieved the maximum attainable score. In one out of four scenarios, the endoscope attained a better result than the PVS. The microscope was never superior to the HD-PVS in terms of image quality. In four out of five clinical applications, the PVS was evaluated as operational with slight modifications. Most development is needed in middle ear surgery applications. The remaining procedures already benefit in the system configuration examined here, and they were regularly accomplished with support of the PVS. The present study offers a good basis for introducing the PVS to ENT surgery. The advantages over the existing gold standard include lower initial costs for the optical system than for an operating microscope since the HD-video system is often already in place, smaller space requirements than a microscope, equal or at times better visualization quality than the microscope, the possibility of videoendoscopic representation of surgeries in which this was impossible before, and better ergonomic conditions. © 2008 Springer-Verlag.




“Transoral robotic surgery: Does the ends justify the means?”

Weinstein, G. S., B. W. O’Malley Jr, et al. (2009).

Current Opinion in Otolaryngology and Head and Neck Surgery 17(2): 126-131.


PURPOSE OF REVIEW: Head and neck surgical science has developed dramatically during the past 20 years with a major focus on organ preservation surgery. Among these organ preserving surgeries are the selective neck dissections, supracricoid partial laryngectomies, transoral laser surgeries, and now a newcomer, transoral robotic surgery utilizing the da Vinci surgical system. Transoral robotic surgery is in its infancy, but, indeed, there have been some questions raised about the role of these innovative robotic surgical techniques. RECENT FINDINGS: This article will review, point by point, the questions that have been raised concerning the feasibility; safety and efficacy; teachability; and cost effectiveness of transoral robotic surgery. SUMMARY: Although the present literature reports early findings, without long-term oncologic outcomes, the results are consistently encouraging. Training programs have already yielded successes. Indeed, multiple institutions have shown that transoral robotic surgery programs can be successfully established yielding excellent clinical outcomes. In addition, early studies of swallowing function following transoral robotic surgery show swallowing outcomes that are superior to some of the reported chemoradiation results for equivalent lesions. © 2009 Lippincott Williams & Wilkins, Inc.