Advances in Oto-Rhino-Laryngology最新文献

Laryngeal electromyography (LEMG) is an important diagnostic and prognostic tool in neurolaryngology. This chapter presents the advances in LEMG in the last 5 years based on clinical trials. LEMG is in most cases an office-based procedure for decision making in neurolaryngology. When performed in a standardized way, LEMG helps to differentiate abnormal function of the vocal folds from nonorganic disorders. It is mainly used to confirm the diagnosis of vocal fold paralysis (VFP) and is less frequently used for the diagnosis of myopathies and motor neuron disorders. Also, the value of LEMG for other diseases than VFP is presented. First consensus recommendations for standard performance of LEMG have been published. This will facilitate the comparison of results from different researchers in the future. For many years, LEMG focused on the thyroarytenoid muscle. Data are presented showing that now more and more studies are performed including other laryngeal muscles, most importantly the posterior cricoarytenoid muscle and cricothyroid muscle. Diagnostics and estimating the prognosis for patients with VFP remains the most important issue for LEMG. First meta-analyses are now available analyzing which LEMG parameters are the best prognosticators for recovery or persistent palsy. Due to the advances in multichannel LEMG, laryngeal nerve monitoring can now control the recurrent laryngeal nerve and the external branch of the superior laryngeal nerve during thyroid surgery. Finally, also the advances of LEMG for laryngeal pacing, guided laryngeal injections, laryngeal electrostimulation, and other indications beyond otolaryngology are discussed.

Anterior skull base tumors represent a challenge for radiation therapy (RT) planning given the close proximity of the target lesion to numerous critical structures in this complex anatomic location. Despite this challenge, surgery followed by postoperative RT is a common treatment paradigm for malignant sinonasal tumors that has been associated with improved outcomes compared to single-modality treatment. Therefore, technological advancements allowing for increasingly conformal target coverage and sparing of organs at risk are important to accomplish the goal of delivering RT with the highest therapeutic ratio possible. Such advances include both intensity-modulated RT and volumetric-modulated arc therapy, which allow RT to be delivered more precisely than ever before. Furthermore, stereotactic radiosurgery can deliver highly conformal doses of external beam RT in a single or limited number of fractions for the definitive or postoperative management of benign lesions of the anterior base of the skull. These sophisticated photon-based RT strategies have allowed for exciting advances in the contemporary treatment of anterior skull base tumors that will continue to improve patient outcomes and reduce toxicity for years to come.

The inclusion of systemic therapy in the multimodal approach of locally advanced sinonasal cancers, at least in some selected histologies, may improve locoregional control and reduce the frequency of distant metastasis, allowing longer survival. Response to induction chemotherapy is a strong prognostic factor for a patient's outcome and it may improve disease control by surgery and radiation. Concurrent chemoradiation aims at increasing locoregional control in squamous cell cancer of the head and neck; this is particularly important in sinonasal cancers, with a risk of local relapse of about 30%. Selected histologies may benefit from specific drug combinations, according to varying chemosensitivity. Intestinal-type adenocarcinoma carrying a functional p53 protein may be treated with preoperative cisplatin, 5-fluorouracil, and leucovorin. Sinonasal undifferentiated carcinoma is a chemosensitive disease, where the multimodal approach is necessary to counterbalance the severe prognosis. Sinonasal neuroendocrine carcinoma and olfactory neuroblastoma may benefit from systemic treatments, but their added value has not been so clearly defined yet. Multimodality trials are ongoing to test the activity of induction chemotherapy followed by locoregional curative treatment. A deeper knowledge of the molecular deregulations of these diseases could help in identifying targeted therapies.

Sinonasal adenoid cystic carcinoma is a rare malignancy characterized by an insidious growth pattern and a tendency for perineural spread along major and minor nerves, resulting in invasion of the skull base and intracranial extension. Therefore, many patients present with advanced disease and involvement of critical structures, making treatment difficult and potentially associated with high morbidity. Surgery represents the mainstay of treatment of the primary tumor. Complete resection of the tumor with negative margins, whenever feasible, is associated with better survival outcomes. However, in the case of extensive involvement of vital structures (e.g., carotid artery, cavernous sinus, optic nerve, Meckel's cave) or when radical surgery could seriously affect the patient's quality of life, a function-preserving subtotal removal of the tumor followed by irradiation can be proposed. The role of surgery is limited to a biopsy in unresectable lesions that are more suitable for non-surgical treatments (e.g., exclusive chemoradiation). Given the difficulty in obtaining negative margins and the propensity for submucosal and perineural spread, adjuvant radiotherapy is strongly recommended. Recently, heavy-particle radiotherapy using protons or carbon ions has emerged as a promising treatment with improved local control. Local failures (60%) and distant metastases (40%) are common and can occur even decades after definitive treatment. The 5-year overall survival ranges from 55 to 70% and it exceeds that of other sinonasal malignancies, but dramatically drops down at 10 years (40%) and further decreases at 20 years (15%). Therefore, a prolonged follow-up of at least 15 years, and possibly lifelong, is mandatory.

Adduction arytenopexy is a surgical procedure that allows the surgeon to position the arytenoid cartilage in a vocally favorable position with a suture. It is not needed in most cases of vocal paralysis when there is favorable synkinesis and good positioning of the arytenoid body. When there is a large posterior gap (intercartilaginous region), height discrepancy, or an anteriorly displaced arytenoid, adduction arytenopexy is used to suture the arytenoid cartilage into the posterior and medial aspect of the cricoarytenoid joint facet, bringing the medial bodies of the arytenoid cartilages together allowing increased closure resulting in higher dynamic range in postoperative voices. It increases the tension in the vocal fold, allowing for improved vocal quality. Adduction arytenopexy is typically combined with medialization laryngoplasty to support the vocal fold and increase the subglottic pressure that can be achieved. Cricothyroid subluxation is performed to allow the surgeon to select the degree of tension to match the opposite, working vocal fold. When there is accumulation of secretions and food in the ipsilateral dilated pyriform sinus, a hypopharyngoplasty is added to decrease the volume of the pyriform sinus and improve swallowing.

The history of research on the voice of opera soloists shows that there are certain functional features of the cranial nerves and cortical nerve centers. In this chapter, we review the most important findings in the field of canto voice neuroanatomy, which we corroborate with the results of our team research and experience. Our study focuses on the nerve structures involved in phonation at each level of the vocal formants: infraglottic, glottic, and oropharyngeal. We consider this research to have direct applicability in the fields of neurolaryngology, neuroscience, phoniatry, but also in the academic teaching. At the same time, the present study is a starting point for future research works on the anatomical and functional particularities of the structures involved during the act of phonation in canto soloists.

The anterior skull base can be divided into three segments: a midline and two symmetrically placed segments located laterally. The midline segment is the roof of the nasal cavity and serves as a watershed between the sinonasal tract and the intracranial space, whereas the lateral segments separate the intracranial compartment from the orbital content. Several peculiar anatomical areas make up the midline segment (posterior frontal plate, cribriform plate, ethmoidal roof, planum sphenoidale, and tuberculum sellae), while the lateral segments are more regular, formed by flat laminae (orbital plates of the frontal bones and lesser wings of the sphenoid). Here we detail each segment of the anterior skull base, emphasizing major landmarks, providing classifications and measurements of key areas, and cautioning the endoscopist about areas to avoid or minimize the occurrence of cerebrospinal fluid leaks, as well as providing recommendations and tips. Several endoscopic and sectional macroscopic anatomical images provide the reader with an informative, illustrative, and broad perspective of anterior skull base anatomy.

Sinonasal malignant mucosal melanoma (SNMM) is a rare, aggressive, and capricious tumour accounting for 4% of sinonasal malignancies. Recent studies suggest an increasing frequency. There are few large published series, but all authors report poor outcomes irrespective of treatment of approximately 25% 5-year survival. As a consequence, the American Joint Committee on Cancer (AJCC) have restaged all SNMMs as T3 or greater, irrespective of extent. Surgery remains the principle treatment modality. Survival and recurrence data analysis from a single-centre prospective cohort of 125 cases (all treated surgically with or without radiotherapy) showed 5-year overall survival was 28% and disease-free survival was 23.7%. Local control was achieved for a median of 21 months, with a 5-year disease control rate of 27.7%. However, endoscopically resected cases showed a significant overall survival advantage up to 5 years, confirming that endoscopic resection of SNMM does not adversely affect outcome and may even be beneficial up to 5 years. These findings are supported by other recent series in the literature. Radiotherapy did not improve local control or survival in this study, though there is debate in the literature as to its value. Cervical metastases confer a dramatically worse outcome. Chemotherapy has not previously shown much advantage, but more recently immunologic manipulation with drugs such as ipilimumab have shown promise. Thus far, the mutation status does not appear to affect survival outcomes, but NRAS mutations are relatively frequent and could be targeted in this disease by MEK inhibitors in the future.

Laryngeal synkinesis as a form of defective healing is the rule rather than the exception in persistent vocal fold paralysis. It typically occurs 4-6 months after the onset of the recurrent laryngeal nerve paralysis. The incidence is up to 85%. Not all laryngeal muscles need to be equally affected. Reliable evidence can only be provided by a laryngeal electromyography. Physiological co-activation of the laryngeal muscles during antagonistic maneuvers must be considered. Although synkinesis undeniably worsens the prognosis for a motion recovery, it protects the muscle fibers from degeneration. A differentiation is required between favorable synkinesis (type I according to Crumley), which does not always require further therapy in the case of unilateral paralysis, and unfavorable forms of synkinesis (type II-IV) according to Crumley, which are associated with a functionally relevant malposition of the vocal fold(s) or with vocal fold jerks. Particularly when bilateral vocal fold motion does not return, type I synkinesis can be a good prerequisite for new dynamic therapy approaches, such as laryngeal pacing. The rarely occurring type II-IV synkinesis should, whenever possible, be transformed into a more favorable type I synkinesis by selective or non-selective reinnervation at an early stage of the disease. The latter applies to expected muscle atrophy with insufficient regrowth of nerve fibers.