Biomedical subjects
Publications and source records attributed to R Chilla.
There is no generally accepted TNM-classification of parotid cancer. Three suggestions for such a classification were tested with regard to their prognostic value, using our own cases. The results were compared with the prognostic value of 4 histologically defined tumour groups.
Sixty-one patients with malignant nasopharyngeal carcinoma received combined surgical and radiological treatment between 1965 and 1981. Additional cryotherapy was performed in 14 of these patients. The favourable survival rates of the latter, compared with those who had been subjected to radiological treatment alone, indicate the usefulness of this supplemental therapeutic procedure. Its effect could have purely local causes (destruction of the primary tumour prior to radiotherapy) or possibly involve certain immunological processes already demonstrated in other tumour types.
To study the effects of parasympathetic denervation on the secretory activity of parotid fistulae, polyethylene catheters were introduced bilaterally into the parotid main excretory ducts of 10 rabbits, followed by unilateral parasympathectomy performed by segmental resection of the tympanic plexus and the chorda tympani nerve. Although salivary flow from the fistulae of the denervated parotid glands stopped up to 8 days earlier than that from the healthy (control) glands, the effect of parasympathectomy was not strong enough to recommend this operation as the method of choice for the clinical inactivation of persistent parotid fistulae.
Malformations of the salivary glands may be an occult cause of sialadenitis, fistulae, tumours, or xerostomia. Diseases of the salivary glands occurring at atypical sites may result from several forms of dystopia of the glands, or from the presence of accessory or aberrant salivary glands, causing considerable problems in differential diagnosis and therapy.
The effects of occlusion of the parotid excretory duct, after injection of a basic aminoacid solution (prolamine), were studied in 12 rabbit parotid glands one year after prolamine application. 40% of the experimental animals present the picture of an extensive abscess-forming sialadenitis both macroscopically and microscopically. The secretory parenchyma of the gland is almost completely eliminated. Remnants of the injected prolamine solution found in the duct system could possibly be responsible for the abscess formation. At the present experimental stage therapeutic application of prolamine in the human parotid gland cannot be recommended.
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Problems of early recognition, postoperative care, and therapy were studied in 207 patients with malignant tumors of the salivary glands, who were treated from 1965 to 1975. Early recognition of these malignant tumors is hampered by the circumstance that only a very short time span is available for diagnosis of the highly malignant types and by the lack of knowledge about specific risk groups among the population. Important for postoperative care is the high rate of local tumor recurrence, especially of salivary-duct, mucoepidermoid, acinic-cell, and adenoid-cystic carcinomas, ranging from 71% to 83%. Late recurrence is frequent. There is also a close connection between local recurrence and lymphogenic or hematogenic formation of metastases. The therapy of choice for malignant tumors of the salivary glands is surgery and, depending on the tumor type, postoperative irradiation. Chemotherapy is at present still of minor importance. Histologic tumor type and tumor stage determine the extent of the surgical procedures, which range from lateral parotidectomy with preservation of the facial nerve to radical parotidectomy with or without reconstruction of the facial nerve. In spite of radical surgery, many malignomas of the salivary glands, particularly the adenoid-cystic carcinomas, tend to recur. In such cases the long-term prognosis is poor and cannot be improved by postoperative irradiation. Supplemented by the experience gained in postoperative care, we have summarized the guidelines along which these 207 salivary-gland malignomas were treated into a modified concept of therapy.
A sensitive tumor in the anterior parotid region of a young woman intraoperatively proved to be a cavernous hemangioma in the masseter muscle. The pronounced sensitivity of this small tumor suggested a malignant growth, especially an adenoid-cystic carcinoma, which frequently causes chronic pain already in an early stage.
From 1965-1975 we treated 207 patients with malignant tumors of the salivary glands. While the localization of these tumors (minor salivary glands, submandibular gland, parotid gland) had no distinct influence on their prognosis, the influence of the histological tumor type is substantial. After histological reclassification of all tumors with grading of differentiation of adenoid cystic carcinomas (tubular, solid, cribriform), mucoepidermoid and acinic cell carcinomas (both well-, respectively poorly differentiated) we could establish 4 different prognostic groups by observing the respective determinate survival rates. The most favorable prognosis is found for tubular adenoid cystic carcinomas, well-differentiated acinic cell and mucoepidermoid carcinomas (5 year survival rate 100%), followed by the solid and cribriform adenoid cystic carcinomas, the poorly differentiated acinic cell carcinomas and the salivary duct carcinomas (5 year survival rate about 65%). With 5 year survival rates of 40%, the adenocarcinomas, poorly differentiated mucoepidermoid carcinomas and squamous cell carcinomas have a poor prognosis, and the prognosis of the carcinomas in pleomorphic adenoma and of undifferentiated carcinomas is even poorer with a 5 year survival rate of 25%.
Severe intubation injuries of the larynx and trachea are usually caused by prolonged intubation, particularly if the primary intubation was difficult. Due to the persisting, time-consuming therapeutic problems, tracheal and laryngeal stenoses are among the most-feared sequelae of long-term intubation. Therefore many laryngologists reject endotracheal intubation for prolonged respiratory support and recommend an early tracheostomy. Advances in respiration techniques and in the development of tissue-compatible tubes with low pressure cuffs permit, in our opinion, prolonged intubation if this is controlled by repeated endoscopic examination to recognize lesions at an early, still reversible, stage.
A case of an extremely rare lymphangioma of the sphenoid sinus in a 58-year-old woman is described in order to discuss the histogenesis, histopathology, and clinical symptomatology of lymphangiomas located in the base of the skull. The clinically silent course for many years is typical, as is the onset of acute symptoms after bleeding into the tumour. The therapy of choice is to achieve decompression. Prior to this, an aneurysma or a hemangioma should be excluded by fine-needle puncture or by puncture cytology.
Human sialadenosis is a non-inflammatory disease affecting the cephalic salivary glands, mainly the parotid, characterized by a mostly bilateral, painless swelling due to a substantial increase of the glandular parenchyma. After the presentation of clinical, cytological and biochemical data the probable etiology of this disease is discussed. It is concluded that sialadenosis is not a disease of the salivary glands themselves but of their sympathetic innervation.
Of 58 patients whose parotid glands were extirpated because of a chronic parotitis, 90% could be cured. The rate of success of this operation is reduced to 70-80% if its is based on those 31 patients alone who showed the typical symptoms of a chronic-recurrent parotitis. The incidence of persisting facial pareses is about twice as high as after removal of non-inflamed parotid glands. This figure is based on seven patients suffering, with one exception, from only slight disorders of innervation in the region of the angle of the mouth. In our opinion total parotidectomy is the method of choice for the treatment of chronic parotitis, if all attempts at conservative treatment have failed. We attribute our failures to remaining glandular parenchyma that was both inflamed and still secretory-active. To further improve the rate of success of parotidectomy, its combination with procedures suitable for occlusion of the duct system is proposed. In this way one should succeed in completely eliminating any secretory-active gland tissue.
In 29 patients with unilateral lesions of the chorda tympani, the parotid reflex secretions of both sides were simultaneously collected and analyzed. The median value of the flow rate (ml/15 min) of the homolateral parotid gland was reduced to nearly one-half, as compared with the unaltered contralateral side. Concentrations of amylase and protein were not significantly different. Those secretory fibres which join the facial nerve in its intratemporal course seem to reach the parotid gland mainly via the chorda tympani and, to a lesser extent, via the facial nerve directly.
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Xerostomia is a symptom rooted in many causes. Considering the physiology of salivary secretion and its various mechanisms, a systematical classification of these causes can be given. Disorders in reflex evocation and transmission, disorders in the innervation of the salivary glands, in the production and transport of saliva as well as excessive depletion of saliva may lead to xerostomia. Chronic dryness of the mouth can in most instances be attributed today to disturbed innervation of the salivary glands (antidepressive and antihypertensive drugs) and to diseases of the salivary glands (Sjögren syndrome, irradiation). Depending on duration and extent of salivary deficiency, severe changes of the oral mucosa and teeth will develop. Treatment of xerostomia may be performed causally (withdrawal or exchange of drugs inhibiting salivary secretion) but will often only be possible as a symptomatic therapy. For this purpose there are available today saliva surrogate solutions ('artificial saliva') and substances that stimulate the secretion of the still intact salivary gland parenchyma.
Leukoplakia and haemangioma of the oral mucosa can be removed by cryosurgery with excellent success. Cryosurgical treatment of mucosal carcinoma should only be applied if the chances for an operation are restricted by certain factors, for instance poor general condition of the patient or haemorrhagic diathesis. The advantages of cryotherapy as applied to the oral mucosa rest in the bloodless application of this technique and in the possibility to heal, with tender scar formation, mucosal changes even of large dimensions, provided they grow superficially.
Following skin damage resulting from radiotherapy, pancancerous conditions, carcinomas and basal cell carcinomas not rarely pose therapeutic problems. We encountered those problems severally after radiotherapy of the middle face, for instance for lupus vulgaris or basal cell carcinoma. Senile skin changed over the years by climatological influences may create similar problems. Disorders of blood supply and lack of "tissue material" as consequences of radiation-induced skin atrophy are the reasons for the failure of many attempts of plastic surgery aimed at tumor removal and defect repair. Besides that, the conditions for such operative procedures are progressively deteriorating with the number of tumor recurrences. In these instances cryotherapy offers an excellent therapeutic alternative by virtue of the favorable healing tendency of the cryonecrosis including the final, inconspicuous scar formation.