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Background: Long-term functional outcomes are poorly characterized for salvage laryngectomy. We identified predictors of esophageal stricture and swallowing function after salvage laryngectomy in a large cohort., Methods: A retrospective study of 233 patients who underwent salvage total laryngectomy for recurrent/persistent squamous cell carcinoma of the larynx or hypopharynx after radiation (XRT) or chemoradiation (CRT) was performed. Primary outcomes were esophageal dilation within 1 year, time to dilation, and gastrostomy tube dependence. Multivariate logistic and Cox regressions were used for statistical analysis., Results: Dilation was performed in 29.9% of patients. Dilation was twice as likely in patients with post-operative fistula compared to those without (Hazard Ratio (HR) 2.10, 95% Confidence Interval (CI) 1.06-4.13, P = .03). Every year between XRT/CRT and salvage was associated with 10% increase in dilation (HR 1.09, 95% CI 1.03-1.17, P = .01). No factors were associated with dilation by 1 year. About 10% of patients were at least partially gastrostomy tube-dependent 1 year post-operatively. At last follow-up (median 29 months), this rate was 13%. Patients with supraglottic recurrence had an increased risk of gastrostomy tube dependence at 1 year compared to glottic (OR 16.7, 95% CI 1.73-160, P = .02). For every 10 pack years pre-salvage, the OR of requiring tube feeds at last follow-up was 1.24 (95% CI 1.04-1.48, P = .02)., Conclusions: Fistula and pre-salvage smoking were associated with stricture post-salvage laryngectomy. No factors were associated with dilation by 1 year. Supraglottic recurrence and smoking were associated with gastrostomy tube dependence. These findings are important for pre-operative counseling prior to salvage laryngectomy., Level of Evidence: Level 4 Laryngoscope, 131:1229-1234, 2021., (© 2020 American Laryngological, Rhinological and Otological Society Inc, "The Triological Society" and American Laryngological Association (ALA).)

Background: Tuberculum sellae meningiomas frequently extend into the optic canals, which leads to a progressive longitudinal visual loss. Therefore, in addition to tumor removal, unroofing and exploration inside the optic canal are important procedures., Objective: To perform endoscopic endonasal tumor removal with optic canal decompression for small primary or recurrent meningiomas associated with a progressive visual loss at the inferior-medial optic canal, which corresponded to a blind corner in the ipsilateral pterional/subfrontal approach., Methods: We retrospectively reviewed 2 cases of primary meningiomas that arose in the inferior-medial optic canal and 4 recurrent cases from the remnant inside the medial optic canal that had previously undergone craniotomy for tuberculum sellae meningiomas, and were treated by the endoscopic endonasal approach., Results: All tumors were detectable and could be removed without manipulation of the affected optic nerve. The average maximum diameter of the tumor was 8.4 mm (range: 5-12 mm). Two patients who had a long history of progressive visual disturbance and papillary atrophy did not recover from severe visual disturbances postoperatively. However, others showed considerable improvement, maintaining postoperative visual function during follow-up. There were no postoperative complications., Conclusion: Endoscopic endonasal approach has several advantages for meningiomas in the medial optic canal and associated with progressive visual disturbance. In surgery of tuberculum sellae meningiomas, optic canal decompression and exploration inside the optic canal are important procedures to avoid symptomatic recurrence, which may be facilitated by the endoscopic endonasal approach. Papillary atrophy and duration of visual deterioration are predictive factors for postoperative visual outcomes., (Copyright © 2019 by the Congress of Neurological Surgeons.)

Background: To avoid permanent neurologic deficits and preserve brain function in and near the eloquent area, intraoperative electrical stimulation mapping (IESM) is necessary. However, little is known about how these subcortical regions are involved in calculation processing function in patients with glioma., Case Description: We report the case of a 56-year-old, right-handed woman working at a primary school as a teacher who had recurrent left parietal glioma. She underwent initial surgical resection for a low-grade glioma present in the left parietal lobe 14 months before recurrence. The latest magnetic resonance imaging results revealed an enhancing lesion in the cavity of the initial resection with an infiltrating tumor in the parietal lobe. Preserving language function and calculation processing was critical; therefore, she underwent awake surgery using IESM. Thus, the calculation site was elicited by subcortical electrical stimulation at the bottom of the tumor cavity during second resection. At the same point, she could speak normally but could not calculate repeatedly when stimulated. Therefore, we stopped tumor resection. After diagnosing anaplastic astrocytoma, she underwent radiation therapy and chemotherapy. She resumed her normal life as a teacher with preserved language and calculation processing. Eventually, 31 months later, she died from disease progression., Conclusions: In this report, IESM performed during awake surgery in a subcortical site demonstrated a crucial role played by the dominant parietal lobe in calculation., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Object: Craniopharyngiomas (CPs) are histologically benign tumors, yet they may carry an unfavorable prognosis. "Giant" tumors are associated with worse prognosis. Our aim was to evaluate the impact of tumor's size on different short- and long-term clinical factors., Methods: Between 2002 and 2012, a total of 36 consecutive CP patients less than 18 years of age and with at least 12 months of post-operative follow-up (FU) underwent a total of 54 operations for excision of CPs. Gross total resection (GTR) was the goal for all the first surgical resections. Twenty-seven patients were identified as eligible for inclusion in this study. Data were retrospectively collected by reviewing pertinent clinic/office notes and inpatient records as well as pre- and post-operative imaging. Long-term neurosurgical, ophthalmological, and endocrinological outcomes were obtained from records of the most recent FU office visit. Statistical analysis was performed to compare data from patients with tumors greater than or equal to 4.5 cm (nine patients) to those with smaller ones (<4.5 cm; 18 patients)., Results: Mean age at the time of surgery was 5.4 years (median 5 years, range 1.3-15.3 years) for patients in the large-tumor group (LTG) and 8.9 years (median 9.6 years, range 2.1-17.1 years) for the small-tumor group (STG). Average duration of follow-up was 82.1 and 105.4 months for LTG and STG patients, respectively. There was a noticeable difference in the rate of emergent surgeries between the two groups (33.3 vs. 5.5 % in the LTG and STG, respectively; p = 0.055) as well as in recurrent surgeries (RR = 3.76; CI = 95 %, 1.793-7.877) and radiotherapy (RR = 2, 95 % CI 0.775-5.154). Rates of residual tumor on both initial post-operative imaging and last FU imaging were significantly increased in LTG patients (44.5 vs. 27.7 % and 66.6 vs. 16.6 %; respectively). Progression-free survivals (PFS) assessed at 2 and 5 years were 33.3 vs. 73.3 % (RR = 2.2, 95 % CI = 0.171-1.202) and 33.3 vs. 53.3 % (RR = 1.6, 95 % CI 0.221-1.765) in favor of smaller tumors. No difference in 2-, 5-, and 10-year overall survival was found. We found no significant difference in mean BMI at last follow-up between the two groups (23.83 ± 4.86 and 27.33 ± 8.09, respectively; p = 0.27), although significantly more patients in the LTG had shorter stature (mean height SDS -1.72 ± 1.88 and -0.17 ± 1.08 in LTG and STG patients, respectively; p = 0.027)., Conclusion: Tumor's size has significant impact on the management of CP in children. It affects both short-term factors (initial symptoms, urgency of surgical resection, extent of resection, and perioperative morbidity) as well as long-term parameters (PFS, rate of adjuvant treatments/recurrent surgeries, and metabolic/endocrinal/ophthalmological and functional outcomes). We think that a proper, world-wide accepted definition of what is "large," "giant," or even "monstrous" CP should be established. This will enable carrying multi-institutional studies on a larger group of patients, allowing further determining the importance of tumor's size in the management and outcome of craniopharyngiomas in children.

Compression induced by a pituitary tumor on the optic chiasm can generate visual field deficits, yet it is unknown how this compression affects the retinotopic organization of the visual cortex. It is also not known how the effect of the tumor on the retinotopic organization of the visual cortex changes after decompression. The authors used functional MRI (fMRI) to map the retinotopic organization of the visual cortex in a 68-year-old right-handed woman before and 3 months after surgery for a recurrent pituitary macroadenoma. The authors demonstrated that longitudinal changes in visual field perimetry, as assessed by the automated Humphrey visual field test, correlated with longitudinal changes in fMRI activation in a retinotopic manner. In other words, after decompression of the optic chiasm, fMRI charted the recruitment of the visual cortex in a way that matched gains in visual field perimetry. On the basis of this case, the authors propose that fMRI can chart neural plasticity of the visual cortex on an individual basis and that it can also serve as a complementary tool in decision making with respect to management of patients with chiasmal compression.

We report on a young woman operated for a ganglioglioma involving the right auditory cortex (AC), presenting with auditory seizures. Despite a normal pre-operative examination, a specific post-operative disorder affecting the perception of a human voice occurred. The patient was unable to recognise the tone of familiar voices while she recognised the expressed content. A temporal lobectomy for recurrence was performed two years later. The patient recovered from the voice perception deficit. This report shows that (1) a discrete site within the AC is specifically involved in the perception of tone of the human voice (2) functional compensation is possible.

Objective: The visual outcome in patients with tuberculum and diaphragm sellae meningiomas treated with microsurgery was evaluated. Prognostic and diagnostic values of short- and long-term postoperative visual outcome and etiology for postoperative visual deterioration are discussed with special attention., Methods: Clinical data for 30 surgically treated patients with tuberculum and diaphragm sellae meningiomas were reviewed retrospectively. The mean duration of the follow-up period was 75.9 months (range, 12-151 mo). Mean tumor diameter and volume was 25.9 mm (range, 16.3-63.3 mm) and 12.4 cm (range, 2.3-125.6 cm). A visual impairment score was used to assess the short-term (< or =2 wk after surgery) and the long-term (>6 mo after surgery) postoperative visual outcome. Various predictive factors for visual outcome were tested statistically., Results: Complete resection was achieved in 23 out of 30 (76.7%) patients. Average preoperative, short- and long-term visual impairment scores were 48.2, 43.4, and 40.9, respectively. Favorable visual outcome was achieved in 80% of patients in the short term and 70% in the long term. Short-term postoperative aggravation of visual function was an ominous sign of further aggravation or at least of little hope for recovery, whereas there was a tendency to improve in the long term if short-term postoperative visual function showed favorable outcome. Recurrence or regrowth of tumor fully was responsible for late deterioration of visual function. No significant prognostic factor for visual outcome could be found., Conclusion: Short-term postoperative visual outcome was a strong indicator of permanent visual outcome after surgery for tuberculum sellae and diaphragm sellae meningiomas.

Objective: To evaluate the role of partial laryngectomy to treat glottic cancer after failure of radiation therapy., Design: A 12-year retrospective outcome analysis., Setting: University referral center., Patients: A total of 19 patients who underwent partial laryngectomy to treat glottic cancer after failure of radiation therapy., Results: The follow-up period in this group ranged from 31 to 144 months. After surgery, a laryngocutaneous fistula was observed in 4 cases, and flap necrosis occurred in 2, but these complications were successfully managed. Maximum phonation time after surgery ranged from 3 to 28 seconds (median phonation time, 10.2 seconds). Of these 19 patients, 3 developed local recurrence. These cases were successfully treated with total laryngectomy. A surgical margin of less than 1 mm was found to be a significant risk factor for local recurrence after partial laryngectomy., Conclusions: These results indicate that partial laryngectomy is a useful option for the treatment of irradiation failure in the treatment of stage I and stage II vocal cord carcinomas. However, careful follow-up is mandatory for patients with a small surgical margin.

Radiosurgery is a management approach used to treat patients with vestibular schwannomas. The goals are long-term tumour growth control, maintenance of cranial nerve function and prevention of new deficiencies. We sought to determine long-term outcomes measuring the potential benefits against the neurological risks of primary radiosurgery. Gamma Knife radiosurgery was applied as a treatment modality for 289 patients with vestibular schwannomas from April 1992 to April 2002. The long-term results of 100 patients who underwent radiosurgery were evaluated. 60 patients received a primary treatment, 40 other cases presented with previously performed subtotal microsurgical resection or recurrence of disease (12-96 months, median 39). The median treatment volume was 3.4 ccm and the median dose to the tumour margin was 13 Gy. The median patient follow-up time was 76 months (range 60-120 months). Four tumours progressed after primary radiosurgery. Tumour control rate was 96%. Useful hearing (Gardner-Robertson I/II) was preserved in 16 patients (55%). Clinical neurological improvement occurred in 50%. Adverse effects comprised neurological symptoms (incomplete facial palsy) (House-Brackman II/III) in six cases (four recovered completely), mild transient trigeminal neuropathy in five cases, and morphological changes displaying rapid enlargement of preexisting macrocysts in two patients and tumour growth in two other patients. Microsurgical resection was performed in four cases (4%) and two patients underwent a shunting procedure because of hydrocephalus formation (2%). In patients who had undergone previous microsurgery, no new cranial nerve deficit was observed. Radiosurgery is an effective method for growth control of vestibular schwannomas and is associated with both a low mortality rate and a good quality of life. Accordingly, for the preservation of cranial nerve function radiosurgery is a useful method for the management of properly selected patients and is comparable to microsurgery.

Background and Purpose: The radiologic assessment of suspicious brain lesions after stereotactic radiotherapy of brain tumors is difficult. The purpose of our study was to define parameters from single-voxel proton MR spectroscopy that provide a probability measure for differentiating neoplastic from radiation-induced, nonneoplastic lesions., Methods: Seventy-two lesions in 56 patients were examined using a combined MR imaging and MR spectroscopy protocol (point-resolved spectroscopy, TE = 135 ms). Signal intensities of cholines, creatines, N-acetyl aspartate, and the presence of lactate and lipid resonances were correlated to final diagnoses established by clinical and MR imaging follow-up, positron emission tomography studies, or biopsy/surgery. Statistical analysis was performed using the t test, linear discriminant analysis, and k nearest-neighbor method., Results: Significantly increased signal intensity ratios I(tCho)/I(tCr) (P <.0001) and I(tCho)/I(NAA) (P <.0001) were observed in neoplastic (n = 34) compared with nonneoplastic lesions (n = 32) and contralateral normal brain (n = 33). Analysis of I(tCho)/I(tCr) and I(tCho)/I(NAA) data yielded correct retrospective classification as neoplastic and nonneoplastic in 82% and 81% of the lesions, respectively. Neither I(NAA)/I(tCr) nor signal intensitities of lactate or lipids were useful for differential diagnosis., Conclusion: Metabolic information provided by proton MR spectroscopy is useful for the differentiation of neoplastic and nonneoplastic brain lesions after stereotactic radiotherapy of brain tumors.

Baroreflex dysfunction (BRD) is an uncommon but perplexing clinical entity that occurs after an operation performed in the head and neck. Cases of BRD have occasionally been reported after bilateral carotid endarterectomies and in rare brain-stem tumors. We describe, for the first time to our knowledge, BRD in a patient after nasopharyngectomy and bilateral carotid isolation for recurrent nasopharyngeal carcinoma.

Between May 1986 and February 1990, 126 consecutive men underwent lower urinary tract reconstruction by means of bilateral ureteroileal urethrostomy using a Kock ileal reservoir. The early complication rate was 11.1%. Late complications requiring rehospitalization or reoperation have been surprisingly few: 1 for prolapse of the afferent antirefluxing nipple valve, 1 for calculi and 4 for artificial urinary sphincter placement due to unsatisfactory continence. Good continence has been achieved in 94% of the patients during the day and in 84% at night. Tumor recurred in the pelvis in 5 patients, with 4 requiring cutaneous urinary diversion. All patients had progression or died of metastatic disease. Our experience has yielded extraordinary results in terms of patients acceptance with few late complications or need for reoperation.

A series of 57 patients affected either by optic nerve sheath meningiomas (15 patients) or by secondary meningiomas extending into the orbital apex or optic canal (42 patients) has been reviewed. Proptosis (80%), progressive visual loss (76%), and visual fields defects (63%) were the most common pre-operative complaints. All patients underwent transcranial surgery. Radical tumour resection was possible in 9 out of 15 primary and 22 out of 32 secondary tumours. Overall, 27% of the patients obtained improved postoperative visual acuity, 62% remained unchanged, and 11% were worse. The postoperative visual outcome was related to the degree of pre-operative visual impairment. In a period between 38 and 68 months, 5 meningiomas recurred. The time to progression of partially resected lesions ranged between 9 and 68 months.

The patient was a 26-year-old man with Cushing's disease who underwent transsphenoidal microscopic surgery for a pituitary microadenoma. His postoperative course was uneventful, but he died suddenly five years after the operation. At autopsy, a ruptured dissecting aneurysm with marked atherosclerosis was observed in the aorta. In the pituitary, a small focus of adrenocorticotropic hormone (ACTH) producing adenoma, possibly residual adenoma, was detected and Crooke's degeneration was observed in the non-tumorous pituitary gland. But immunohistochemical patterns of pituitary hormones in the non-tumorous pituitary gland were normal and the adrenal cortex was unremarkable. In the hypothalamus, corticotropin-releasing hormone immunoreactivity was not detected and arginine vasopressin was sporadically positive. Considering these findings, this patient may have developed subclinical hypercortisolism due to the residual adenoma at the time of autopsy, despite clinical remission. Cushing's syndrome is considered to be a risk factor dissecting aneurysm, and in this case the metabolic changes in Cushing's disease may have influenced the development of the dissecting aneurysm. Periodic cardiovascular re-evaluations should therefore be performed when there is clinical remission of Cushing's syndrome.

Experimental brain tumors were excised from rats for sequential observation of changes in local capillary permeability during the postsurgical period. Experimental brain tumor-bearing rats were prepared by stereotaxic transplantation of cultured tumor cells and the resultant tumor was delineated by administration of a dye. Following excision of the stained tumor by craniotomy, sequential changes in local capillary permeability were quantitatively followed-up by autoradiography, using 14C-amino-isobutyric acid as a tracer. Capillary permeability was enhanced following surgery, reaching a maximum both in the extent and degree on the third day. After undergoing a gradual reduction, it showed a marked increase for the second time in a very small area on the 10th postoperative day. A recurrence of the tumor was responsible for this late but marked increase. For a control group, the caudate nucleus was excised from normal rats, followed by observation of the sequential changes in the local capillary permeability. Due to surgical procedure, capillary permeability reached a maximum both in the extent and degree on the 5th postoperative day (slightly later than in the tumor group). This change in capillary permeability was less pronounced than in the tumor group. The difference in the conditions of surgery--tumor excision and partial excision of a normal brain tissue--appeared to explain this difference. The results of this study indicated that it is more desirable to give water-soluble antineoplastic agents early during the postoperative period for chemotherapy of a malignant brain tumor after surgery.

The results from 100 patients with 103 acoustic neurinomas who were operated on between February 1979 and April 1992 are presented. All patients were placed in the half-sitting position and operated on by the same surgeon using the suboccipital-trans-meatal approach. Postoperative facial nerve function was good in 56%, moderate in 20% and poor in 24% of our patients. Preservation of useful hearing was achieved in 21%: the smaller the tumor, the better the functional result. However, the early symptoms of acoustic neuromas (tinnitus, dizziness, feeling of unsteadiness) were only slightly improved by the operation. The result concerning tinnitus seemed to be better after sacrificing the cochlear nerve. The number of patients with ataxia increased postoperatively, although objective ataxia decreased. Dizziness improved regardless of the tumor size.

The authors analysed the data obtained from their experiences in extensive head and neck resections as well as reconstructive treatments using myocutaneous flaps. They tried to evaluate the reconstructive approach in terms of morbidity and functional results. Sixty-nine patients, treated from January 90 to November 92 for advances intra-oral cancer, were considered in this study. The reconstructive procedure in 68 cases was the pectoralis major myocutaneous flap while in 5 cases the trapezius flap was utilized. Even though the oncological results were poor, the functional ones were quite encouraging. In fact, the assessment of speech and swallowing was extremely satisfactory in 83% of the cases. The morbidity related to both flap procedures was low and the patients' life quality was good. Indeed, the use of a free flap offers additional advantages, without necessarily compromising safety of the reconstruction. Free flaps in general allow greater leeway in flap design and donor-site choice than pedicled flaps. Several reports have already demonstrated the versatility, usefulness and reliability of these flaps, especially in intra-oral reconstruction. The intricate nature of microsurgery and the expense of microsurgical equipment inhibit this kind surgery in many institutions around the world where the standard myocutaneous flaps would be a more practical procedure. In conclusion, even those patients with a poor prognosis may be considered potential candidates for demolitive and reconstructive treatment with which satisfactory results may be obtained.