Laryngeal surgery is reemerging as a key surgical subspecialty similar to its stature in the 1800s because of the increasing importance of the human voice in communication-based societies. Laryngeal and voice problems are universal throughout the world irrespective of age, gender or social stratification and benign vocal edge lesions are the most common problem.In turn, phonomicrosurgery is enjoying tremendous growth and development due to unique collaborations between surgeons, scientists and engineers along with patient expectations. These successes have led to enthusiasm for future developments similar to the nascent era of Laryngology in the 19th century.Outstanding advancements have been achieved during the last 10 years and this progress should expand dramatically as biomaterials to replace the superficial lamina propria are developed. Acknowledgement : The author has a financial interest with Endocraft, LLC.
The preservation of larynx function is a particularly important challenge in head and neck cancer therapy. We considered adaptation and problems associated with vertical partial laryngectomies in particular in reviewing the results of functional preservation operations until present. Vertical partial laryngectomies show a high incidence of complications, such as postoperative fistulation, but in most cases the complications were minor in nature. There were no cases with grave complications, such as postoperative hemorrhaging or total laryngectomies with necrosis of the remnant cartilage. We came to the conclusion that the vertical partial laryngectomy operative method could be safely performed even for a recurrence after radical cure treatment.
Supracricoid laryngectomy with cricohyoidoepiglottopexy (CHEP) involves the resection of the entire thyroid cartilage and paraglottic space. The cricoid cartilage, the hyoid bone, most of the epiglottis and arytenoids are preserved. Laryngeal reconstruction is achieved by suturing the cricoid cartilage and the hyoid bone. This procedure, mainly indicated for cases of late T2, selected T3 and T4 glottic carcinoma, provides radical resection and laryngeal preservation without permanent tracheostomy. We performed this surgery for 22 cases as a primary treatment or as a salvage surgery for cases where radiation treatment failed. Oncologic and functional results are satisfactory. CHEP is considered to be useful as a laryngeal function preserving treatment for locally advanced laryngeal cancer. We also experienced successful laryngeal reconstruction by impaction of the cricoid and the tongue base after extended supracricoid laryngectomy. With a supracricoid laryngectomy, conservation of the hyoid bone is considered essential, and it is contraindicated if tumor infiltrates the hyoid bone. An extended supracricoid laryngectomy was performed on a patient with supraglottic cancer infiltrating the pre-epiglottic space and reaching to the hyoid bone. The larynx was reconstructed by suturing the cricoid cartilage and tongue base. This patient's phonatory and swallowing functions were conserved and the tracheal stoma was closed. While more patients must be studied, conservation of laryngeal function may be possible even when the hyoid bone and tongue base are excised in the course of a supracricoid laryngectomy, thus extending surgical indications.
Objectives : To evaluate the efficacy and toxicity of concurrent chemoradiotherapy in patients with resectable squamous cell carcinoma (SCC) of the larynx and to demonstrate the feasibility of larynx preservation. Patients and Methods : Forty-eight eligible patients were treated with two chemotherapy regimens between March 1998 and September 2003. One of the chemotherapy regimens consisted of a combination of four drugs : cisplatin, 5-fluorouracil, methotrexate, and leucovorin (CF-MTX-LV). The other regimen consisted of two drugs : carboplatin and UFT (CBDCA-UFT). Radiotherapy was delivered 5 days a week using a single daily fraction of 1.8 to 2.0 Gray, to a total dose of 66.6 to 70.2 Gray. Results : The 5-year disease-specific survival and larynx preservation rates of cases receiving CF-MTX-LV were 85% and 50%, respectively. The 3-year disease-specific survival and larynx preservation rates of cases receiving CBDCA-UFT were 94.4% and 73.7%, respectively. The main toxicities in those treatment modalities were neutropenia, dermatitis, mucositis, infection, and nausea/vomiting. Conclusion : Concurrent chemoradiotherapy was safe and well-tolerated in the present study. In terms of larynx preservation, the present regimens appear to be useful for selective patients with resectable SCC of the larynx.
Sixteen patients with advanced laryngeal cancer were treated between 1999 and 2004 with intra-arterial infusion of cisplatin at 64-100mg/m2 and intravenous infusion of sodium thiosulfate (P regimen). For the patients who had received the PF regimen, 5-fluorouracil (5-FU) at 700 mg/m2 was given for 3 days following intra-arterial administration of CDDP. With the patients who had underwent the TP regimen, docetaxel at 10-20 mg/m2 was intra-arterially administered following intra-arterial administration of CDDP. All patients received radiation (50-70Gy). Seven patients were at the T3 stage, nine patients at T4, eight patients had glottic cancer and eight patients had supraglottic cancer. The complete response rates of the primary sites that were achieved were 80% for the P regimen, 50% for the PF regimen, and 100% for the TP regimen. The 5-year overall survival rate and disease specific survival rate of all cases was 58% and 81% respectively. The 5-year laryngeal preservation rates were 53% for the P regimen, below 25% for the PF regimen, and 80% with the TP regimen. Side effects of this treatment were tolerable, with the exception of individual cases of cerebral infarction, neck skin necrosis, and laryngeal necrosis.
Patients with advanced glottic squamous cell cancers (T3, 4) have poor outcomes, losing important functions such as speech despite combined surgery and radiotherapy. The 5-year laryngeal preservation rate by conventional radiotherapy has been reported to be about 23%. Thirty patients with advanced glottic laryngeal cancers were treated by superselective intra-arterial chemotherapy using CDDP and so-dium thiosulfate (STS) from 1997 to 2005. Once a week, 100mg/m2 of CDDP was administered superselectively at 5 mg/min through each feeding artery of the tumor. During the infusion of CDDP, STS at a dose of two hundred fold of the CDDP was injected through a catheter placed in the subclavian vein. The 5-year laryngeal preservation rate was 81% with good functional preservation of larynx. Though we preserve all larynxes, three total laryngectomies had to be performed due to severe dysfunction. It was suspected that dysfunction in these three cases could have been induced by the administration of too high a dose of CDDP. With superselective intra-arterial chemotherapy, we have proposed a new method for determining the dose of CDDP to be administered by measuring tumor volume rather than surface area. We were able to suppress mucositis of normal tissue and local recurrence using CT-angiography.
Autologous fat injection laryngoplasty is a safe and useful management method for patients with unilateral vocal fold paralysis. In this study, autologous fat obtained by liposuction and used as injection material was investigated histologically. The harvested fat tissue from 13 patients who were undergoing injection laryngoplasty was examined by light and electron microscopy. The process of liposuction had not damaged the cell membranes and cytoplasm of the fat tissue. Each harvested fat cell was surrounded by a meshwork of fine reticular fibers. The size and density of fat cells were different from individual to individual. The diameter of the fat cells correlated with the body mass index of the subjects. Sparse and large fat cells tended not to be able to maintain graft volume. We examined 57 patients for voice function (maximum phonation time (MPT), mean airflow rate (MFRc), pitch perturbation quotient (PPQ), amplitude perturbation quotient (APQ), and normalized noise energy (NNEa)) at least 6 months after they had underwent fat injection laryngoplasty. Voice function after surgery had improved significantly for all parameters. Post operative measurements relative to patient population were as follows : MPT below 10 seconds for 28%, MFRc above 250ml/sec for 11%, PPQ above 0.5% for 14%, APQ above 1.5% for 35% and NNEa above 20dB for 46%.
Injection laryngoplasty is a reliable surgical procedure to correct laryngeal incompetence caused by vocal fold paralysis. Although autologous fat has become a popular injection material in recent times, there are numerous problems that need to be addressed in its application in laryngoplasty; such as, injection site of the vocal fold, quantity of injection material, possibility of improvement for glottal gap, and resorption of injected autologous fat. The purpose of this study is to investigate the problems of autologous fat injection in laryngoplasty. The clinical study involved 31 patients with unilateral vocal fold paralysis who had received treatment at the Kurume University Hospital between 2000 and 2003. The pathological study was comprised of 23 patients whose autologous fat harvested by liposuction was utilized as injection material during laryngoplasties between 2000 and 2005. In patients with a small degree of vocal fold bowing, autologous fat was injected locally into the thyroarytenoid muscle lateral to the oblong fovea of the arytenoid cartilage. As a result, the glottal gap decreased and postoperative voice functions, maximum phonation time (MPT) and mean airflow rate during phonation over comfortable duration (MFRc) improved. In patients with a large degree of vocal fold bowing, the autologous fat was injected not only into the thyroarytenoid muscle lateral to the ob-long fovea of the arytenoid cartilage but also into the thyroarytenoid muscle at the membranous portion of the vocal fold. As a result, the glottal gap decreased and postoperative voice functions, MPT and MFRc improved. The fat cell membranes had not been damaged during liposuction harvesting or microinjection by our technique. The diameters of fat cells ranged from 41.3±8-117.1±15.2μm. A few patients with large diameter fat cells showed less improvement compared to those with smaller diameters for the postoperative voice functions, MPT, MFRc, and pitch perturbation quotient (PPQ). These results indicate that fat injection into the thyroarytenoid muscle lateral to the oblong fovea of the arytenoid cartilage produced good postoperative voice function and this procedure can improve a large degree of glottal gap. Resorption of autologous fat may be related to not only the size and density of fat cells but also their proliferation.
In recent year, autologous fat has been used increasingly in intracordal injections for the vocal rehabilitation of patients who had deficient glottal closure. The adipose tissue used has been primarily harvested from the lower abdomen. Patients, however, differ considerably in the amount of fat available from the lower abdomen. Obtaining sufficient fat is often difficult in patents with a low body mass index (BMI). In the case presented here, we harvested fat from the buccal fat pad. We successfully performed a therapeutic intracordal injection of autologous fat harvested from the buccal fat pad for the treatment of unilateral recurrent nerve paralysis.
Vocal efficiency as one of the criteria for evaluating the vocal function has been a subject of investigation in phoniatrics. Advances in instrumentation have made it more practical to measure the subglottic pressure, both DC (direct current) and AC (alternating current) components of the expiratory air flow and SPL of voice. A variety of indices were proposed to represent or substitute the real vocal efficiency which is the ratio of the acoustic power to the subglottic power. They are the air flow rate or, AC/DC where AC is the efficiency value (root-mean-square) of AC component of expiratory air flow and DC is the mean flow rate. Isshiki's (1981) proposed index of glottal flow efficiency (AC/DC ratio) and an instrument designed to measure the index (PA-500) were evaluated. We performed clinical tests to evaluate the new phonation analyzer system (PA-1000). This system is capable of measuring the glottal flow efficiency (AC/DC ratio), glottal flow, SPL, and fundamental frequency simultaneously and continuously for about 6.5 seconds. The new model of phonation analyzer is advantageous over the prototype in that all the measures are digitally recorded so that later any particular portion of interest can be picked up for expression in both digital and analog ways.
The microdebrider is a powered rotary dissection device with suction assistance. In recent years its usage has spread rapidly in otolaryngology. We reported on three cases with laryngotracheal stenosis to which we applied a microdebrider for airway surgery. Case 1 was a 32-year-old male, who underwent a tracheostomy because of glottic stenosis due to idiopathic bilateral vocal cord paralysis. An arytenoidectomy with a microdebrider guided by an endoscope was performed to treat his condition. After surgery, the posterior glottic space was sufficient and the tracheostomy was closed. Case 2 was a 52-year-old female, who underwent a tracheostomy due to laryngeal stenosis caused by cicatricial pemphigoid. A microdebrider was used for tracheal stenosis by cicatrix hyperplasia and a T-tube was kept in place for fixation of the airway. Case 3 was a 97-year-old female, with laryngeal carcinoma, who was suffering from severe glottic stenosis due to a neoplastic lesion. A tracheostomy was first performed, followed by tumor debulking which was accomplished using a microdebrider in an endoscopic procedure. Use of a microdebrider secured a good field of view during the operation. In addition, the microdebrider was considered of high utility value in laryngeal surgeries performed in conditions requiring narrow operation fields.
Recently, many investigators have reported the usefulness of fluorodeoxyglucose-positron emission tomography (FDG-PET) for the diagnosis of malignant head and neck tumors. Little is known, however, about its application for the diagnosis of laryngeal carcinoma. In this study, we investigated the specificity and sensitivity of FDG-PET for detecting laryngeal squamous cell carcinoma before treatment. Thirty-two patients (31 male and 1 female) with laryngeal carcinoma who had visited the Kagoshima University Hospital between Jan. 2003 and Nov. 2005 were retrospectively investigated. All patients at stages T2, T3 and T4, showed FDG standardized uptake value (SUV) greater than 4.0 in the primary sites, except for one patient of T2. In contrast, 6 out of 10 cases diagnosed as T1 showed FDG SUV readings lower than 4.0. Four patients, in T1 and T2 stages, who had remarkably elevated FDG SUV levels in their primary tumors underwent surgical treatment such as partial laryngectomy and total laryngectomy followed by concurrent chemo-radio-therapy. Those findings suggest that PET is useful for the diagnosis of laryngeal carcinoma and that an elevated level of FDG SUV in the primary tumor might indicate higher biological activity of the carcinoma.
The most definitive tools for the diagnosis of Laryngo Pharyngeal Reflux Disease (LPRD) are upper gastrointestinal endoscopy and 24-hour pH monitoring. These diagnostic methods, however, are not common at Ear, Nose and Throat (ENT) clinics. Most otolaryngologists diagnose LPRD based on symptoms, laryngeal findings and proton pump inhibitor (PPI) tests. In this study, forty-three outpatients who had first visited Fukuoka University Hospital between October 2005 to February 2006 (23 male and 20 female) with foreign body sensations in their throats were retrospectively investigated. Their ages ranged from 20 to 79 with a mean age of 57 years. The clinicians were kept blind to the FSSG scores. Patients who had improved by PPI treatment were assinged to the LPRD group. The FSSG questionnaire was evaluated in another group of patients with LPRD as well as a non-LPRD group. When the cut off line is set at 8 points, the positive rate is 48.8% and the FSSG showed sensitivity of 90.9%, specificity of 65.6%, and a positive predictive value of 47.6%. This new questionnaire is useful for the objective evaluation of symptoms in LPRD patients.
We reported on a rare case of morning glory seeds as bronchial foreign bodies. The patient was a five-month-old male infant. He accidentally inhaled morning glory seeds after placing them in his mouth and coughing. The consulting doctor diagnosed that he had caught a cold after examining a chest x-ray image and observing normal sounding respiration. Three days later, his body temperature was 40 degrees and his cough was persisting. Medical consultation was sought again. His chest x-ray revealed that the mediastinum had moved to the right side and the left pulmonary field had inflated abnormally. CT imaging clearly indicated foreign bodies in the left bronchus. We performed a ventilation bronchoscopy. His left bronchus was obstructed by morning glory sprouts. After we removed the sprouts, the child's respiratory sound and chest x-ray results improved. We determined that the morning glory seeds had germinated in the warm and wet bronchus and the enlarged seeds had obstructed his left bronchus.
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