Evaluation of two noninvasive repositioning systems for computer-assisted oral implant surgery in oral cancer patients

PURPOSE

Reconstructive surgery in oral cancer patients uses thick flaps, which may render the placement of miniscrews for stabilizing radiosurgical templates difficult. The realization of noninvasive systems for the repositioning of surgical templates has been proposed. The present study aimed to assess the clinical usefulness of these noninvasive repositioning systems.

MATERIALS AND METHODS

Two noninvasive (ie, without osseous anchorage) repositioning systems (one intraoral, one intra- and extraoral) were tested. They were coupled with a computer-aided system for oral implantation. The criteria for evaluation were: accuracy, cost, time for placement and removal, and six additional subjective criteria (ease of use and production, bulk of the device, patient comfort, stability during surgery, and ergonomics).

RESULTS

Nine edentulous patients undergoing surgery to the oral cavity, oropharynx, or pharynx; external radiotherapy of the mandible; or microvascular flap reconstruction were included. Twenty-seven implants were placed in the mandibles of seven patients. For the extraoral system, the angular deviation between planned and achieved position was 6.04 degrees, with differences of 2.14 mm at the tip and 2.16 mm at the base. For the intraoral system, deviations were 5.05 degrees, 1.13 mm, and 1.82 mm, respectively. Subjective criteria were consistent with expected values, especially ease of use, comfort, and ergonomics.

CONCLUSIONS

Noninvasive systems remain less accurate than templates stabilized by miniscrews and should be reserved for treating arches in which miniscrews cannot be placed. These methods may be unacceptable in areas where vital structures may be damaged by a misguided implant, and further studies are required. More satisfactory results should be obtained in partially edentulous patients.

Learning to eat after radiation therapy for throat cancer

PURPOSE

The initial purpose was to find more expedient ways for learning to eat for personal rehabilitation. The secondary purposes were to inform other radiation therapy patients and to inform clinicians and therapists involved in rehabilitation of throat cancer patients.

METHOD

This is an account of personal experiences of the author who is a throat cancer survivor. This rehabilitation engineer, and his social worker wife, systematically sought and found more effective ways for learning to eat again.

RESULTS

More effective approaches for discovering, preparing, presenting and consuming food by recovering throat cancer patients were identified.

CONCLUSION

The rehabilitation process for patients with radiation damage to the throat can be enhanced through simple methods and dedicated efforts of the patients themselves.

Recovery of swallowing function following surgery for advanced buccopharyngeal carcinoma

More than 20 years have passed since the introduction of surgical techniques based on distal myocutaneous flaps or microvascular flaps in the reconstruction after head and neck cancer resections. The experience gained from the beginning of these techniques until today, has improved the possibility to better predict functional impairment of swallowing in patients and its possible recovery. This contributes to a better counselling of the patient and better prediction concerning his/her quality of life. Despite the time passed and good progress in the development of microsurgical techniques, the literature shows that many differences still remain among Authors concerning choice of flap and its inset in relation to the anatomical sites and the extent of resection. Many other variables may condition post-operative swallowing (pre- or post-operative radiotherapy, general conditions of the patient ...) thus contributing to a more difficult comparison of the different series reported in the literature. Personal experience is based upon surgical treatment in >60 patients with advanced bucco-pharyngeal cancer, all of whom evaluated post-operatively by video-endoscopy and video-fluoroscopy. In summary, data collected both from personal experience and the literature show that difficulties still remain in correct evaluation of swallowing in these patients. This is mainly due not only to lack of a commonly accepted scheme of classification to quantify the anatomical defect but also to differences between Authors concerning choice of the type of flap and the mode of inset.

Defining the stenotic post-laryngectomy tracheostoma and its impact on the quality of life in laryngectomees: development and validation of a stoma function questionnaire

OBJECTIVES

The aims of this study were to identify if: (i) size of stoma contributes to quality of life (QoL) in laryngectomees; (ii) stoma size has an impact on routine stoma care and function; and (iii) an optimal stoma size exists below which patients experience stoma problems.

DESIGN

Cross-sectional study of laryngectomees.

SETTING

Two tertiary care centres.

PARTICIPANTS

Fifty-seven patients who had undergone total laryngectomy one to five years ago and using tracheo-oesophageal speech as their primary communication means.

MAIN OUTCOMES MEASURES

Three main measures were studied: 1 a new study specific questionnaire designed to assess problems with function and care of the end tracheosto- ma; 2 QoL as assessed by the head and neck QoL instrument; 3 a precision custom designed sizer to measure the minimum stoma diameter.

RESULTS

The final study-specific questionnaire contained four items assessing different aspects of stomal function. From raw total scores an overall stomal score was generated. The stoma score was moderately correlated to emotion and speech domains in head and neck Quality of Life questionnaire, indicating that different concepts were being measured. The mean minimum stoma diameter was 15.9 +/- 2.9 mm. There was a significant increase in the area under the receiver operating characteristic curve beyond a threshold value of > or 15 mm; smaller sizes were associated with a poorer stoma score (Mann-Whitney test, P < 0.001). No patient found the stoma sizer use distressing.

CONCLUSIONS

Size of stoma significantly contributes to QoL in laryngectomees and stomas with minimum diameters of 14 mm or less are associated with adverse effects on routine stoma function. The study-specific stoma function questionnaire appears to be a useful instrument.

Recovery issues for African Americans following treatment of oral cavity/pharynx cancer

Despite the high incidence of oral cavity/pharynx cancer (OCPC) in African Americans, there is little scientific evidence to date that describes the recovery process following treatment of OCPC in this population. Ethnic differences in an array of psychosocial factors, such as emotional regulation styles and social networks, may influence the recovery course with different morbidities and mortality than European Americans. This paper provides an overview of the current literature pertaining to recovery from treatment of OCPC in the African American population.

[Epidemiological analysis of patients cure in frame of emergency in ORL clinic in Warsaw, stepińiska 15/21 in 1996]

Study the epidemiological and clinical features of patients attending the emergency in the Clinic during 12 months to think whether the emergency is still needed as a one of method of curing. 4892 patients attended the emergency. Parameters analyzed were: age, sex, hour and day of arrival, place of living, initial signs, hospitalization and surgical services. The most frequent reasons for coming to the emergency were: ear disease (32.2%--middle ear otitis), nose disease (662 patients), bleeding nose (559 patients). The most frequent reason for hospitalization were swallowed foreign body (16.5%), tumor of the larynx and pharynx (16%), vestibulary nerve (12.9%). Emergency is an important sector of hospital activity, with a mean 55 per day (week-days), 87 per day (week-end and out of job days). The majority men disease were facial traumas, women were disease of vestibulary nerve, sudden hearing loss. However, 33% of the consultation in the emergency apper to be real medical emergencies, others could be appropriately provided by a general practitioner.

An evaluation of functional outcomes (speech, swallowing) in patients attending speech pathology after head and neck cancer treatment(s): results and analysis at 12 months post-intervention

We have earlier reported establishing a computerized database to audit functional outcomes in patients who underwent head and neck cancer treatment in Victoria, Australia and attended speech pathology services from April 1997-April 1999. This paper presents the statistical analyses and results from this study. Speech pathologists collected, prospectively, functional outcome data on 293 patients who underwent head and neck cancer treatment, and sent these for analysis to La Trobe University. Clinician and patient assessments of outcomes: speech, swallowing, activity, pain, employment, health, QOL status were made. Initial data on 293 patients were collected and data on mortality and morbidity were compiled at three, six and 12 months post-treatment. Within twelve months, 74 patients had died. Three, six and/or 12-month follow-up data was available on 219 patients, with both clinician and patient assessments of status completed. The status forms are presented as appendices to this paper. Complete status forms on 179 patients at 12 months were obtained. This clinical audit of functional outcomes represents the first study of this kind, collecting data from speech pathologists and patients in a multi-centre study of patients with head and neck cancer. We present data to demonstrate optimal recovery of function at six months, such that this may represent a good reference point for reporting and comparison of functional outcomes.

Surgeon information giving practices prior to laryngectomy: a national survey

Prior to the proposed development of a pretreatment counselling package for patients with cancer of the larynx or pharynx, a study was undertaken to determine current information giving practice prior to laryngectomy. A postal questionnaire was sent to all UK ENT consultants registered in the Medical Directory. The response rate was 88%, with 48% meeting the study's entry criteria. Counselling practice varies widely. Surgeons report an average of 15 min available for discussion with the patient: 84% gave the diagnosis and discussed the treatment options at the same consultation. The size of the department, as measured by cases seen per year, did not correlate with the consultation time although it did with the numerous different issues discussed. Whilst the survey supports the need and desire for an appropriate counselling package, many surgeons feel that they alone know what the patient's information needs are.

Reconstruction of the voice after laryngectomy

Voice reconstruction and rehabilitation are important for quality of life for patients after surgical ablation of tumors in the larynx or pharynx. In addition to the esophageal voice, the artificial larynx, and external voice devices, the following procedures have been developed: (1) after laryngectomy with preservation of pharynx, neoglottis or TEP can be performed; (2) after laryngopharyngectomy a forearm flap with TEP, or a jejunal transfer with TEP or voice tube shunt can be selected; and (3) after laryngopharyngoesophagectomy, either pharyngogastrotomy with TEP, or colon segment interposition with TEP can be employed. The voice tube shunt is improving, and allograft transplantation is currently under investigation.

[Indication of tracheostomy for advanced oral or mesopharyngeal cancer resection]

In advanced oral or mesopharyngeal cancer requiring reconstruction, preventive tracheostomy have been performed to insure an airway postoperatively. However, tracheostomy often causes difficulty in swallowing and stress in the postoperative period for the patients. We have devised a strategy to avoid tracheostomy as much as possible in the cases requiring reconstruction except for the cases with over 2/3 resection of the base of the tongue or with prospective difficulty of re-intubation. Eleven cases were treated without tracheostomy out of 20 cases operated on with reconstruction in our hospital from 1995 through 1997. These patients were managed under nasal intubation for less than 2 days on average with careful observation postoperatively. In 11 non-tracheostomized cases, 1 case experienced venous thrombosis of a free flap and tracheostomy was performed at the salvage operation. Other 10 non-tracheostomized case were compared with 10 tracheostomized cases who were treated from 1991 though 1995. It was revealed that non-tracheostomized cases tended to have shorter periods until they could speak or eat, and also have a shorter postoperative admission term. In these cases, we have not experienced serious complications such as aspiration pneumonia or dyspnea, instead, special care in the postoperative period was needed. Thus, certain advanced cases who undergo curative resection followed by reconstruction can be managed without tracheostomy. The indication of tracheostomy in surgery for oral or mesopharyngeal cancer should be decided carefully.

[The benefit of head rotation on pharyngoesophageal dysphagia from three cases of paraganglioma in the parapharyngeal space]

The benefit of head rotation to the affected side is indicated during swallowing in patients complaining of dysphagia with unilateral pharyngeal palsy and/or laryngeal palsy. We experienced three cases of severe dysphagia after operations for giant paragangliomas (two vagal paraganglioma and one carotid body tumor) in the parapharyngeal space. During operation, the transmandibular transpterygoid approaches were applied to ensure better surgical views, and tracheostomy was performed to keep the airway open after operation. In each case, dysphagia during the pharyngeal stage of swallowing was significantly improved with rehabilitation using of this head rotation. We believe that rather than forbid oral intake, using an active bolus with head rotation is important for cases where dysphagia in the pharyngeal stage of swallowing is present with unilateral pharyngeal and/or laryngeal palsy. Repetitive swallowing exercises are important to reacquire the complicated movement of swallowing. Additionally, an active bolus flowing into the pyriform sinus on the healthy side will prevent a relaxation disorder of the cricopharyngeal muscle on that side. Furthermore, compensatory movement of the arytenoid on the healthy side improves dysphagia. We emphasize the usefulness of head rotation during swallowing rehabilitation for dysphagia with unilateral pharyngeal and/or laryngeal palsy in spite of its simplicity.

Rehabilitation outcomes of long-term survivors treated for head and neck cancer

BACKGROUND

Little is known about the rehabilitation outcomes of long-term survivors following treatment for head and neck cancer. There are, for example, no studies on physical and psychosocial rehabilitation outcomes of T1 glottic larynx carcinoma, despite the fact that these form the majority of head and neck cancer sites. Thus, this investigation afforded a unique opportunity for examining similarities and differences among T1 glottic larynx patients, laryngectomy patients, and those who had surgery for cancer of the oral cavity and/or oropharynx along a variety of physical and psychosocial dimensions.

METHODS

To describe the impact of these three types of head and neck cancer and their treatment on the physical and psychosocial functioning of long-term survivors, a self-report questionnaire was completed by 110 patients treated between 2 and 6 years previously in a major cancer center.

RESULTS

Data indicate that a higher percentage of patients treated with laryngectomy or commando procedures still experience severe psychosocial distress between 2 and 6 years after their last treatment than do patients treated with radiotherapy for a T1 carcinoma of the glottic larynx. Psychosocial and physical complaints are still reported by many laryngectomy patients, apparently the result of problems in effective communication with others. Many commando procedure patients experience problems with respect to food intake, and with disfigurement and its consequences. T1 larynx patients mainly experience a considerable number of physical complaints. The greater the time that had elapsed since treatment, the fewer the psychosocial problems associated with head and neck tumors. Open discussion of the illness in the family, social support, and perceptions of adequate information from the specialist are the most important predictors of positive rehabilitation outcomes.

CONCLUSIONS

This study indicates that T1 larynx patients report many physical complaints even though several years had elapsed since treatment. Also, laryngectomy patients may need psychosocial guidance for a longer posttreatment period and that health care personnel must involve the partner as much as possible in all communications. Commando procedure patients in particular feel hindered by their disfigurement and its consequences. Future research with respect to validation of the specific head and neck modules is needed.

Split, free, jejunal transfer for pharyngoesophageal and soft-tissue reconstruction

Pharyngoesophageal reconstruction utilizing free jejunal transfer is well established. Extensive resection or debridement for extensive tumor, infection, or radiation may necessitate additional soft-tissue coverage. The authors report a successful reconstruction using a split, free, jejunal transfer to provide simultaneous pharyngoesophageal and soft-tissue coverage.

[Use of a stoma-pouch after temporary pharyngostoma and neck fistula following surgery in the head and neck region]

The authors report on a new way of stoma care that to their best knowledge has not been used yet in head and neck surgery patients. Their cases demonstrate the usefulness of this method for the rehabilitation of patients with pharyngeal stoma of any origin.

[Recent progress in the treatment of oral and pharyngeal cancer]

Today, in the treatment of oral cancer, combined resection and reconstructive surgery has shown marked progress. Especially, the surgical procedures of bone graft after mandibulectomy have been seen widespread application. In the treatment of nasopharyngeal cancer, adjuvant chemotherapy after therapeutic dose of irradiation indicates a better survival rate than radiation alone, and in advanced nasopharyngeal cancer, a wide resection is effective for cure. In the surgical treatment of hypopharyngeal cancer, by the immediate reconstruction of pharynx with jejunum, patients can eat orally in a short time. The most important problem in the treatment of head and neck cancer is development of effective chemotherapy against distant metastases.

[Reconstruction of the oral and pharyngeal mucosa by a microsurgical method using a jejunal graft]

The microsurgery is a new, modern method of the reconstructive surgery which has made the free transplantation of the jejunal graft possible. The jejunum transplanted with microvascular anastomosis lends itself mainly to replacing the segmental and concentrical defect of the initial part of the alimentary tract, but the splitted jejunal graft cut along the antimesenterical side, because of its favourable biological nature, can be used for reconstruction of the oral and pharyngeal mucosus membrane. The authors applied the splitted jejunal graft in four cases for the reconstruction of oropharyngeal defects due to excision of malignant tumours. In harmony with literary data good result is reported on.

Mandibular reconstruction with metal plate and myocutaneous flap

The combination of a myocutaneous flap with a three dimensional, bendable reconstruction plate has provided very satisfactory results in restoration of mandibular defects following surgical resections in irradiated patients. Twenty-four cases have been treated and evaluated prospectively using this technique. Patients requiring postoperative irradiation were excluded from this study. Two groups were identified. Group A (n = 20) required a myocutaneous flap to resurface the soft tissue defect and Group B (n = 4) were treated by primary closure. No failures were encountered in the group handled primarily with a myocutaneous flap combined with an AO plate. One failure occurred in the group closed primarily. Nine (38%) of the patients have maintained their plate for over 1 year. Twelve (55%) have functioned for more than 9 months. Of the remaining three (7%), one failed and the other two have been in place for more than 5 months. The results of this study demonstrate that a well-vascularized soft tissue bed in combination with stainless steel plate provides a very satisfactory, functional, esthetic and reliable method in rehabilitation of mandibular defects primarily in irradiated patients.

Reconstruction of the mandible with autogenous bone following treatment for squamous carcinoma

In a series of 24 patients treated for squamous carcinoma of the oral cavity and oropharynx, 26 mandibular reconstructions using 27 grafts or flaps were performed. Reconstruction was immediate in 23 cases and delayed in three. There were five 'simple' bone grafts, 10 pedicled compound myocutaneous flaps, and 12 vascularized free compound flaps. Operative mortality was 12% and complication rate 65%, but 70% of the grafts survived till death or follow-up of the patients. Three 'simple' bone grafts failed and were removed. Three of five compound pectoralis major flaps failed along with one of five pedicled compound latissimus dorsi flaps. Only one vascularized free compound flap was lost. The major cause of graft failure was intra-oral suture line dehiscence exposing the bone to saliva. Under these circumstances, bone graft necrosis occurred when blood supply to the bone was poor--viz. 'simple' grafts and compound pectoralis major flaps. The vascularized free compound flaps were most reliable but the need for jaw preservation where possible and better patient selection are recognized.

Rehabilitation problems after pharyngogastric anastomosis

Fifty-three patients had pharyngolaryngoesophagectomy during the years 1965 to 1976 for lower hypopharyngeal or cervical esophageal cancer. The operative mortality--defined as the percent of patients who died within seven days of operation--was 7.5%, which is reduced to 5.6% if one patient with inoperable disease is excluded. Twenty-eight percent of patients survived for longer than one year, and there have been no problems with swallowing. Communication is possible in every patient who possesses good motivation, but the problems of long-term management of calcium metabolism still require attention.

Rehabilitation of partial laryngectomy patients

Rehabilitation and function following three anatomically discrete forms of partial laryngectomy (hemilaryngectomy, subtotal supraglottic laryngectomy, and partial laryngopharyngectomy) were studied in 68 patients. Study parameters included posttreatment respiration, deglutition, taste, smell, and hearing function; articulation and voice analysis; and social, communicative, and vocational adjustment. The major portion of the study involved specific testing of posttreatment voice quality and articulation. Recorded word lists and sentences were evaluated by independent observers regarding breathiness, hoarseness, harshness, pitch, loudness, and intelligibility. These data were analyzed employing a Statistical Package for the Social Sciences (SPSS) through the Washington University computer facilities.