Abstract: The pharyngocutaneous fistula (PCF) is one of the most common post-operative complications in patients undergoing laryngectomy. Up till now, there is no universally accepted algorithm for managing of PCFs and several treatment modalities are used for wound healing. The English language literature was searched using PUBMED databases with the keywords "laryngectomy", "pharyngocutaneous", "fistula", "treatment", and "management" from January 1, 1999 to June 1, 2019; we selected 35 studies according to inclusion criteria and we conducted a systematic review of the articles. The analysis of the international literature shows a high variability of treatment approaches; there is no consensus about conservative treatment and waiting time, and neither about the indication for surgical treatment or the ideal surgical technique. A first attempt of a conservative measure is mandatory in all cases of PCF. In case of failure of conservative measures surgical treatment should be considered: direct closure and local flap are suitable for small defects, pedicled or free flaps showed good to excellent results in closure of large and complex cervical defects. Other non-invasive treatment such as hyperbaric oxygen therapy (HBOT) and negative pressure wound therapy (NPWT) showed promising results but in limited case series. Keywords: laryngectomy, pharyngo-cutaneous fistula, reconstructive surgery, hyperbaric oxygen therapy, negative pressure wound therapy, laryngeal cancer
Abstract Background Studies concerning programmed death‐ligand 1 (PD‐L1) expression in precancerous lesions of head and neck (HN) region have shown variable results. Methods We systematically reviewed the published evidence on PD‐L1 expression in HN precancerous lesions. Results Of 1058 original articles, 14 were included in systematic review and 9 in meta‐analysis. The pooled estimate of PD‐L1 expression was 48.25% (confidence interval [CI] 21.07‐75.98, I 2 98%, tau2 0.18). PD‐L1 expression appeared to be more frequent in precancerous lesions than in normal mucosa (risk ratio [RR] 1.65, CI 0.65‐4.03, I 2 91%, tau2 0.82) and less frequent than in invasive squamous cell carcinoma (RR 0.68, CI 0.43‐1.08, I 2 91%, tau2 0.22). Conclusions PD‐L1 expression could reflect a point of balance between host immune response and cancer escape ability. High heterogeneity and moderate quality suggest that further studies with larger sample size and more rigorous case selection will allow more precise assessment of PD‐L1 expression in HN precancerous lesions.
The endoscopic approach to attic cholesteatoma allows clear observation of the tensor fold area and consequently, excision of the tensor fold, modifying the epitympanic diaphragm. This permits good removal of cholesteatoma and direct ventilation of the upper unit, preventing the development of a retraction pocket or attic cholesteatoma recurrence, with good functional results.An isthmus block associated with a complete tensor fold is a necessary condition for creation and development of an attic cholesteatoma. During surgical treatment of attic cholesteatoma, tensor fold removal is required to restore ventilation of the attic region. Use of a microscope does not allow exposure of the tensor fold area and so removal of the tensor fold can be very difficult. In contrast, the endoscope permits better visualization of the tensor fold area, and this aids understanding of the anatomy of the tensor fold and its removal, restoring attic ventilation.In all, 21 patients with limited attic cholesteatoma underwent an endoscopic approach with complete removal of the disease. Patients with a wide external ear canal were operated through an exclusively endoscopic transcanal approach; patients with a narrow external ear canal or who were affected by external canal exostosis were operated through a traditional retroauricular incision and meatoplasty followed by the endoscopic transcanal approach.In 18/21 patients, the endoscope permitted the discovery of different anatomical morphologies of the tensor fold. Sixteen patients presented a complete tensor fold (one with an anomalous transversal orientation), one patient presented an incomplete tensor fold and one patient presented a bony ridge in the cochleariform region. In all 16 cases of complete tensor tympani fold, the fold was removed and anterior epitympanic ventilation was restored. The ridge bone over the cochleariform process was also removed with a microdrill.
To the Editor: We would like to thank the colleagues for their comments about our article. Gruppo Otologico’s experience has been fundamental for the development, refinement, and diffusion of middle ear surgery techniques, and their attention to our work is an honor for us. We will reply point-by-point to be as clear as possible. 1) Actually, in our article (1), 56.5% of ossicular chain preservation is reported using the exclusive endoscopic transcanal tympanoplasty. The more are the subsites involved, the less is the likelihood of ossicular chain preservation. Subsite B (medial attic) is the most frequently associated with ossicular chain removal. Our colleagues address the fact that in a study involving 230 patients, the ossicular chain preservation rate was 100%, regardless of the epitympanic location. In our experience, cholesteatoma, which involved medial attic (type B), was present in 12 patients (52%) of 23. Only in 2 cases we were able to safely remove the pathology without removing the ossicular chain but only because of 45-degree endoscopic view. In a big population like 230 patients in some cases, cholesteatoma might involve the medial attic, and it seems to us very unlikely that all this patients have been operated without ossicular chain removal. How did they visualize the pathology laying medially to the ossicles? Did they perform a blind removal? How did they check the radicality of their removal? Would this be consistent with the absence of residual pathology in the middle ear? Because the scientific honesty of such a prestigious institution is not to be questioned, some realistic reasons of these results have to be found. Notably, reading the material and methods subheading of the article by Sanna et al. (2), we noticed that the inclusion criteria of the retrospective review were “patients with cholesteatoma who underwent modified Bondy technique.” This kind of inclusion criteria is at high risk of selection bias. The risk would be that the patients who had ossicular chain removal during that kind of surgery for medial attic localization or for extended pathologies were excluded because they did not eventually underwent a Bondy modified technique, who, by definition (2), provides intact ossicular chain and pars tensa preservation. In this way, the sentence, regardless of the location in the epitympanum, would rather be not considering the location in the epitympanum. However, if the exact location in the epitympanum was not considered, results of that study could be referred neither to cholesteatoma medial to the attic nor to those involving several subsites, the latter being treated by more extended operations other than Bondy and, hence, excluded a priori from the study. In the same way, if we analyze the results of our study considering all the patients except those with medial attic involvement, the ossicular preservation rate would be 100% because the 10 patients who had ossicular chain removal also had type B involvement. 2) We also would clarify that our recurrence rate in the middle ear was 8.6% (2 of 23) and not 13% (3 of 23). In fact, as specified in our article, 1 patient had a pearllike residual, which, also in the article by Sanna et al. (2), was considered apart from middle ear pathology recurrence. 3) Our experience with the exclusive endoscopic transcanal tympanoplasty, as stated in the title of our article, must be considered preliminary. Long-term results are necessary to confirm the realiability of this technique. Anyway, in the authors’ opinion, the advantages of mastoid preservation and absence of external incisions and retroauricular tissue dissection should be considered in the choice of the best approach to treat cholesteatoma. Daniele Marchioni, M.D. Matteo Alicandri-Ciufelli, M.D. Gabriele Molteni, M.D. Domenico Villari, M.D. Daniele Monzani, M.D. Livio Presutti, M.D. Otolaryngology-Head and Neck Surgery Department University Hospital of Modena Modena, Italy
Objectives We describe the experience of our otolaryngology department in the treatment of Forestier disease, particularly regarding the diagnostic process, surgical treatment, and postoperative outcomes. Methods The charts of 12 patients who underwent surgical treatment of Forestier disease between January 1, 2003, and January 1, 2009, were analyzed. All patients were subjected to clinical, radiologic, and endoscopic evaluation that confirmed the presence of cervical osteophytes. All patients were treated by a right-sided prevascular transcervical approach to remove cervical osteophytes. A literature review on Forestier disease was also carried out. Results One case of immediate postoperative hemorrhage was reported. During the postoperative follow-up, ranging from 1 to 5 years, all patients underwent cervical radiography and fiberoptic laryngoscopy that confirmed no evidence of recurrence, and all patients remained asymptomatic. Conclusions A prevascular transcervical right-sided approach seems to be an effective treatment for surgical removal of hyperostosis in Forestier disease, with an acceptable rate of complications and recurrence.
