Informed consent in ENT. Patient's judgement about a specific consensus form

The concept of informed consent was first used in the 60's. The meaning of this term is the need of a preliminary and valid consensus that places the doctor in an authorised condition whereby he is able to carry out his work. Notwithstanding the importance and delicacy of this topic and the potentially serious consequences, there is not, as yet, universal behaviour, on the part of doctors, regarding the mode of information and documentation on how the patient be informed. In a previous article, the authors outlined the best approach, on the part of the doctor in regard to the patient, in order to obtain valid informed consent. In particular, the specific information for each disease was proposed and this was not limited only to aspects related to type of treatment and possible risks, but thorough, with regard to adhering to the logical course (case history, objective tests, instrumental diagnosis carried out, etc.) that led the doctor to a certain diagnosis and a description of the proposed treatment possibilities as well as the treatment modalities excluded, with relative reasons. The study was designed in such a way as to define the degree of acceptance that this informative method has on the patients. This was achieved by means of a questionnaire filled in by 254 patients hospitalised in our department, about to undergo surgery. Judgement was substantially positive, in that, > 70% of patients agreed that the information was quite or very good, and 90% considered it sufficient or better. This demonstrates that even those subjects who received little information, were, in fact, satisfied with that given. The patient/doctor relationship was also judged positive. The patients felt that it was important to be kept informed about their condition, regardless of the form (written or spoken). In conclusion, the outcome of the questionnaire demonstrates the appreciation. on the part of the patients, regarding the procedure of information used in seeking consensus.

Current role of chemotherapy in exclusive and integrated treatment of malignant tumours of salivary glands

In the management of salivary glands carcinomas, surgery is the treatment of choice. Post-operative radiotherapy is indicated in cases with high risk of loco-regional relapse. Radiotherapy is also standard treatment in cases that are inoperable at onset. Chemotherapy plays a palliative role. Today, the integration between radiotherapy and chemotherapy, which provides increased local control, represents a significant step forward. This integration is important since 5-year survival in tumours with high grade histology is approximately 50%. Overall incidence of metastases is approximately 25%. Primary locations of metastases are lungs, liver, bone, central nervous system and other organs. In cases of metastatic disease, chemotherapy plays only a palliative role.

Closure of tracheo-oesophageal fistula following removal of voice prosthesis; a new surgical technique

The voice prosthesis is today the most widely used and accepted method of voice restoration following total laryngectomy. Fortunately, the cases in which it is necessary to temporarily or definitively close the fistula are rare (request of the patient, leakage from the fistula, aspiration pneumonia). Herein, an analysis is made of these cases and the surgical technique personally developed for the closure of tracheo-oesophageal fistula is described. This technique has been used in 8 patients with good results; moreover, it is a relatively low cost procedure and gives rise to few post-operative complications.

Qualitative and quantitative evaluation of some vocal function parameters following fitting of a prosthesis

The insertion of a prosthesis and restoration with pectoralis major myocutaneous flaps for patients subjected to total pharyngolaryngectomy is a technique now universally accepted; however the literature on the subject is lacking. Our study considers 10 patients subjected to total pharyngolaryngectomy and restoration with pectoralis major myocutaneous flaps who were fitted with vocal function prostheses and a control group of 50 subjects treated with a total laryngectomy without pectoralis major myocutaneous flaps and who were fitted with vocal function prostheses. Specific qualitative and quantitative parameters were compared. The quantitative measurement of the levels of voice intensity and the evaluation of the harmonics-to-noise ratio were not statistically significant (p > 0.05) between the two study groups at either high- or low-volume speech. On the contrary, statistically significant differences were found (p < 0.05) for the basic frequency of both the low and the high volume voice. For the qualitative analysis seven parameters were established for evaluation by trained and untrained listeners: on the basis of these parameters the control group had statistically better voices.

Role of nasal valve in the surgically corrected nasal respiratory obstruction: evaluation through rhinomanometry

The aim of this study was to evaluate the improvement of nasal flow and the fall of nasal resistance in 50 patients that underwent rhinoseptoplasty in our department and discuss the relative importance of valvular and septal deformities in nasal airway obstruction. Fifty consecutive patients underwent rhinoseptoplasty to improve nasal obstruction caused by severe septal deviation, external or internal valvular incompetence, or any combination of the three. We excluded patients with minor septal curvatures, septal perforations, or turbinate hypertrophy. Preoperative and postoperative rhinomanometry was performed on all 50 patients. In all 50 patients, septal and/or valvular surgery lowered nasal resistance in 90% of cases. Septoplasty alone with medial and basal osteotomies did not improve nasal flow (p < 0.4), whereas the correction of valvular obstruction alone increased nasal airflow in a statistically significant way (p < 0.0001). Moreover, patients with both valvular incompetence and septal deviation represented the group in which the greatest preoperative obstruction and the greatest postoperative improvement occurred. Nasal valvular function should be assessed with rhinomanometry in all preoperative rhinoplasty patients with airway obstruction. In many cases, valvular effects may surpass septal deviation as the primary cause of nasal airflow obstruction.

Isolated primary non-Hodgkin's malignant lymphoma of the larynx

We report a case of glottic primary laryngeal lymphoma. Although the head and neck region is a frequent site of origin of extranodal non-Hodgkin's lymphomas, laryngeal involvement is exceptional. Including this case, about 90 primary laryngeal lymphomas have been reported in the literature. Microscopic study showed a diffuse malignant lymphoma of high-grade malignancy (WF sub-division H). A diffuse, large, B-cell-type NHL was diagnosed histopathologically. The patient was treated with combination chemotherapy, including cyclophosphamide, doxorubicin, vincristine and prednisolone (CHOP), which resulted in complete clinical remission after two courses. Four courses of combination chemotherapy were subsequently performed, making a total of six courses of combination chemotherapy. No recurrence has been observed during the 16-month follow-up period.

Primary non-Hodgkin's lymphoma of the nasal cavity. Clinical case report and discussion

Primary non-Hodgkin's lymphoma of the nasal cavity is a disease more likely to affect men than women; it is characterized by a T cell immunophenotype and is often associated with involvement of the paranasal structures and with high recurrence rates. Many authors report that its extremely poor prognosis depends on tumour stage and extension into the paranasal sinuses. Patients with Ann Arbor stage IE limited to only one nasal cavity have better survival rates than those with the same stage but with tumour extension beyond the nasal cavity. Patients with stages IIE, IIIE and IV have a very poor prognosis that does not seem to be affected by the use of conventional chemotherapy. Optimal treatment for the disease is not yet known. The use of radiotherapy alone has been reported in initial stages of the disease; however, given that its prognosis is burdened by frequent local or systemic recurrence or both, combined modality therapy has been applied in all stages. In this case report we describe a case of primary non-Hodgkin's lymphoma of the nasal cavity localized at the middle turbinate, in combination with an updated literature review.

[Post-parotidectomy Frey's syndrome. Treatment with botulinum toxin type A]

The Frey's syndrome, manifest after parotid trauma, is characterized by head and neck hyperemia and abundant sweating of the hyperemic skin in response to gustatory stimuli. The use of the botulin toxin to treat the symptoms in patients with Frey's syndrome has been described in numerous studies. For some time up until now our Center has achieved excellent results using the group A botulin toxin to overcome the hypertonus of the cricopharyngeal muscle in patients who had undergone laryngectomy and were rehabilitated with voice button. We have sought to extend the use of this toxin to Frey's syndrome, a relatively frequent complication of parotidectomy. A total of 86 patients participated in the study: 41 males (47.6%) and 45 females (52.4%) ranging in age from 25 to 77 years (average age 51 years). Of these patients 7 (8.1%) had undergone post-operative radiotherapy. Of the 86 patients studied, 18 referred significant symptoms in terms of abundance and frequency. The syndrome was considered severe if the symptoms were present at each meal and if the patient indicated a significant worsening of his quality of life. Intermittent episodes were indicated by 22 patients. The remaining 46 (43.5%) did not complain of any symptoms. The exact extension of the cervicofacial gustatory sweating was evaluated using the Minor test and the involved region was divided into 1 square centimeters sections. The amount of skin surface involved ranged from 10 to 80 square centimeters. The type A neurotoxin was frozen and was reconstituted with a sterile saline solution at a final concentration of 2.5 UI/0.1 ml. The intracutaneous infiltration was performed without anesthesia, infiltrating 0.1 ml of solution, containing 2.5 UI of toxin into the center of each 1 square centimeters section. Statistical analysis was performed to evaluate the potential relationship between how long the treatment was effective, incidence of recurrence, seriousness of the crises and the following variables: age, sex, histology, cutaneous surface involved, injected dose of botulin toxin and post-operative radiotherapy. In the group of 18 patients with severe symptoms (20.9%) the benefit was immediate in all cases although the recurrence rate was 50%. The Frey's syndrome symptoms disappeared within 7 days of infiltration. In the group of 22 patients with less severe involvement (25.5%), the treatment gave positive, definitive results in 16 patients (72.7%). Those patients whose symptoms persisted were treated a second time with an infiltration of 2.5 UI per square centimeters. We feel that the use of the type A botulin toxin is the most appropriate treatment for the Frey's syndrome. In fact, such treatment offers the following advantages: it is effective within 7 days, has limited side effects, can be applied on an outpatient basis, is inexpensive and is positively considered by the patients.