Advances in Oto-Rhino-Laryngology最新文献

Most cancers occur in developing countries, and therefore, a discussion about cancer care would be incomplete without providing a developing world perspective. This chapter focuses on challenges and practices relating to hypopharyngeal cancer in limited-resource public healthcare systems in developing countries and specifically in Sub-Saharan Africa, India and South America and by extension, most patients in the developing world. Management of hypopharyngeal cancer must be adapted to the availability of specialised diagnostic and therapeutic services, radiotherapy and surgical expertise, and tailored to patient factors such as reliability of follow-up and social support. A particular challenge for physicians is to decide who can be denied the opportunity to be cured when the burden of cancer cases exceeds available resources. Public education campaigns about reducing risk factors for hypopharyngeal cancer are an important aspect of reducing the burden of cancer.

Hypopharyngeal cancer patients have a very poor prognosis and limited therapeutic options. Seventy to eighty per cent of all hypopharyngeal cancer patients will require palliative and/or end-of-life care for incurable end-stage disease during the course of their illness. The overall proportion of hypopharyngeal cancer patients not qualifying for initial curative treatment, or requiring palliation and supportive care over time is higher than for any other subsite of the head and neck. Surgery and radiotherapy usually have a very limited role in this setting, while systemic therapy will usually compete with supportive care as the best approach. Advances in medicine and oncological treatments for the management of patients with recurrent head and neck cancer have given physicians the opportunity to prolong life where possible. However, this increase in survival might not be clinically meaningful if patients do not simultaneously experience palliative benefits, such as a reduction in symptoms and an improvement in their overall quality of life (QoL). The optimal outcome of palliative treatment is the control of symptoms with minimal treatment toxicities while improving QoL. It remains unclear if current palliative treatment options are better at improving QoL than the best supportive care. An intervention that results in insufficient or unacceptable functional status to the extent that the patient cannot achieve treatment goals - even in the course of prolonging life - is questionable. When used for palliative care purposes, surgery, chemotherapy and radiotherapy commonly have limited effectiveness in improving QoL. Moreover, if these treatments are not congruent with a patient's end-of-life goals, they could constitute low-value care.

Hypopharynx cancer continues to pose a clinically challenging head and neck subsite, driven not only by the unique set of patient, anatomic and disease factors but also by the paucity of robust clinical data to guide clinical decision making. The standard of care of radical surgery (pharyngolaryngectomy) in combination with postoperative radiotherapy was the previously accepted norm in the setting of advanced hypopharynx cancer, but this was often at the expense of significant morbidity. In the absence of survival benefit for advanced staged disease with radical surgical approaches, over the last 2 decades, the philosophy of quality of life in survivors has driven the agenda for new therapeutic approaches. The adoption of functional larynx preservation strategies has seen a paradigm shift in the treatment of this subsite since the 1990s with the advent of chemoradiation and intensity-modulated radiotherapy, thereby introducing a reducing trend for radical surgery. However, radical surgery (pharyngolaryngectomy) has a role in the non-functioning larynx (either pre- or post-treatment), in advanced volume disease and the more technically challenging salvage setting because of residual or recurrent disease. In earlier stage disease, transoral laser microsurgery and robotic surgery have shown good oncological benefits. Crucially, determining appropriate personalised treatment decisions in this challenging cohort of patients requires discussion within a multidisciplinary team framework.

It is not uncommon for patients with hypopharyngeal cancer to present at an advanced stage of disease. Surgical treatment provides a cure for the tumour with immediate relief from obstruction to the airway and the swallowing passage. Careful planning of surgery is important to ensure good outcome of treatment and prevent complications, some of which may be fatal. The shape of the hypopharynx resembles that of a funnel, with a wide circumference above in continuity with the oropharynx, and a small circumference below where it joins with the cervical oesophagus. As a result, while small tumours require the partial removal of the hypopharynx, large tumours, especially those involving the post-cricoid region, warrant a complete, circumferential pharyngectomy. For tumours that invade the cervical esophagus, transcervical approach is still feasible, and this is facilitated by the removal of the manubrium, allowing access to the tumour and resection with clear margins. In the presence of synchronous tumours lower down in the esophagus, pharyngo-laryngo-esophagectomy is indicated. Successful reconstruction of defects after tumour extirpation allows proper wound healing and early delivery of adjuvant radiotherapy. It is also important to ensure quick recovery of the long-term swallowing function. It ranges from the use of the soft tissue flap with skin island that is sutured as a patch to the remnants of the pharyngeal mucosa, to the use of a visceral flap, such as the free jejunal flap, to repair the circumferential pharyngectomy defects. The treatment protocol is personalized according to the extent of the tumour and the characteristics of the patients.

The management of hypopharyngeal cancer is challenging because of poor patient survival and the potential effects of treatment on breathing, voice and swallowing. In general, early stage hypopharyngeal cancer can be primarily treated by radiotherapy or conservative transoral or open surgery, whereas advanced stage hypopharyngeal cancer can be treated by non-surgical protocols if the patient has no loss of functions (dysfunctional larynx) and/or cartilage invasion (T4a). Factors to determine individualized patient treatment include resectability, tumour volume, distant metastases, comorbidity, age, patient's preference, functional imaging parameters, response on induction chemotherapy and employing functional imaging parameters performed in the pre-treatment phase and repeated in the early treatment phase when employing a non-surgical treatment strategy.

Early throat symptoms are common and a diagnosis of hypopharyngeal cancer rare; therefore, confirming or excluding a serious diagnosis is missed or overlooked by both the patient and the practitioner - however, symptoms such as throat clearing and food sticking, which persist in adult patients who have the social habit of tobacco usage and/or drink excessive alcohol should be examined by a specialist to exclude the presence of hypopharyngeal cancer. Late symptoms/signs include neck swelling (uni- or bilateral), dysphagia, odynophagia, otalgia, dysphonia, dyspnoea and stridor. Associated with advancing age and social habits, many patients have co-morbidities such as diabetes mellitus, respiratory, cardiovascular disease and behavioural health disorders that play a major role in selecting the optimal treatment and thus a likely worse long-term outcome. The majority of cases when diagnosed are at an advanced stage including evidence of local cervical nodal metastasis and distant metastasis. The TNM staging system continues to be the "gold standard" for reporting and evaluation of treatment outcomes, but more recent reports show that the use of "tumour volume" obtained from disease stage scanning of both the T and N stage are better predictors of a successful disease response outcome for the selection of a non-surgical option. Patients at presentation and those that survive curative treatment are associated with the highest risk of developing a second primary tu mour - synchronous or metachronous, involving the lung and/or the oesophagus.

So common is vertigo that diverse healthcare professionals, from audiologists to orthopedic surgeons, will eventually encounter it in their patients, if not in themselves. So treatable are vestibular disorders that it is an immense advantage to know how to assess the vestibular system. This review summarizes the history and physical examination that will help diagnose common vestibular disorders presenting with vertigo.

Bilateral vestibular schwannomas are almost pathognomonic of neurofibromatosis type 2 (NF2). As a result of these tumors, hearing loss is the presenting symptom in 60% of adults and 30% of children with NF2. It is often bilateral. The best means of preserving hearing in patients with NF2 is conservative management. Even so at least 28% of patients have progression of hearing loss following diagnosis. The likelihood of progression of hearing loss is, at least in part, determined by the type of mutation. Treatment of vestibular schwannomas often has a detrimental effect on hearing. Only 41% of patients having stereotactic radiosurgery maintain their hearing at 5 years. Treatment with bevacizumab maintains medium-term hearing in 38% and improves it in 48%. Surgery to remove vestibular schwannomas invariably leads to complete loss of ipsilateral hearing, although in a very limited number of patients hearing preservation surgery may be possible. For those that lose their hearing but have an intact cochlear nerve, for example, conservative management, radiotherapy treatment or cochlear nerve preserving surgery, cochlear implantation has been shown to be an effective option although outcomes are not as good as traditional implant candidates (mean sentence testing scores in quiet: stable untreated tumors 69%; radiotherapy treated tumors 49%; cochlear nerve preserving surgery ∼40%). For those that do not have a functional cochlear nerve, auditory brainstem implantation (ABI) is an option. The non-user rate in this group is 13%. The mean sentence score in users with ABI alone is 12%. ABI therefore acts, in most cases, as an aid to lip reading and rarely provides open set speech discrimination.

A new electrophysiological system for intraoperative, continuous, near-real time monitoring of cochlear nerve function through acoustic stimulation in the ear canal and recording of the evoked dorsal cochlear nucleus potentials (DNAPs) by a specially designed DNAP electrode placed directly on the brainstem is described. The system is denominated "(cerebellopontine angle) CPA Master" and is designed for hearing preservation surgery in the cerebello-pontine angle, through the retro-sigmoid or the retro-labyrinthine approach. As an additional novelty within the field, the system allows intraoperative mapping and thus precise localization of the cochlear nerve in its entire trajectory from the brainstem to the fundus of the internal auditory canal, which is a major advance in relation to atraumatic dissection of the nerve. The system can be used for surgery of all types of CPA tumors, for example, vestibular schwannomas, meningiomas and epidermoid cysts, but also for vestibular nerve section and vascular decompression. The system also allows evaluation of the electrical functionality of an anatomically intact cochlear nerve in translabyrinthine surgery, thus predicting the benefit of optional cochlear implantation.

The Eustachian tube is a complex structure connecting the middle ear to the nasopharynx that contributes to the normal function of the middle ear. Eustachian tube dysfunction (ETD) is thought to contribute to the majority of middle ear pathology, although the mechanisms and the degree to which it contributes to middle ear disease is poorly understood. We describe the anatomy and physiology of the Eustachian tube, define ETD, discuss the methods for measuring ETD and describe recent advances in treatment.