Narrow Band Imaging (NBI) endoscopy is reported to be effective in diagnosing infinitesimal superficial cancer in the upper gastrointestinal tract and highly accurate in the diagnosis of early stage cancer in the oropharynx and hypopharynx. NBI endoscopy is rapidly coming into wide use in recent times. In our study we evaluated the effectiveness of diagnosing laryngeal cancer by NBI endoscopy, especially in distinguishing between benign and precancerous lesions, determining the cancer spread area, finding recurrent cases and providing early diagnoses. NBI endoscopy was found to be effective in distinguishing cancer from benign lesion and in determining the cancer spread area, however, we had difficulties diagnosing some recurrent cases after radiotherapy. NBI endoscopy was effective for early diagnoses but we sometimes found gaps between endoscopic diagnoses and pathological diagnoses. Further investigation is necessary with more cases.
For preservation of laryngeal function with laryngeal cancer patients, the treatments of choice are (chemo) radiotherapy or partial laryngectomy. Recently chemoradiotherapy is performed in many cases; however, surgical treatments are required particularly with cases involving young patients, for tumors with poor radiosensitivity or with patients with a prior history of radiotherapy on the neck. Surgical partial laryngectomies are divided into two approaches: open neck and transoral. With the transoral approach, laser microsurgery is an established treatment for laryngeal preservation and is a less invasive treatment; however, the surgical view through microscope is narrow and when blockwise resections are performed, then pathological evaluation is difficult. For transoral en bloc resection of supraglottic cancer, we used a distending laryngoscope with a rigid video-endoscope and laparoscopic surgical instruments. The combination of the distending laryngoscope and the rigid video-endoscope gave us a wide view of the operative field and facilitated bimanual manipulation by allowing a wide working space. In our institution, the same surgical technique could be applied for T1, T2 and a part of T3 supraglottic cancer(n=9)and hypopharyngeal cancer (n=21). Recovery of postoperative swallowing function, the tracheostomy rate, the number of surgical complications, and survival outcomes were evaluated. These results were compared with previous cases treated with open neck surger (n=28). In comparison with open neck surgery, transoral surgery could quicken swallowing recovery, reduce tracheostomy and complication rate, and maintain an equivalent survival outcome.
Eleven patients who had laryngeal squamous cell carcinoma were treated with intra-arterial chemoradiotherapy between 2004 and 2008 at the Kurume University Hospital. Five of the 11 patients had supraglottic cancer, others had glottic cancer, and 1 had subglottic cancer. Two patients were at Stage II, 7 patients were at Stage III, and 2 patients were at Stage IV A. The treatment was intra-arterial CDDP (75-100mg⁄body) infusion using the Seldinger method together with irradiation (60-71Gy). All of the patients could be treated with intra-arterial chemoradiotherapy without having to stop the treatment. Complete remission was achieved in all patients, and we have not discovered the recurrence of any tumors yet. The laryngeal preservation rate was 100％. Observed side effects were as follows: 4 patients had Grade I pharyngitis, 2 patients had Grade I dermatitis from irradiation and 1 patient had Grade III pancytopenia. Intra-arterial chemoradiotherapy for laryngeal cancer may be the most effective treatment which allows for laryngeal preservation.
Surgical treatments for restoring swallowing function, such as cricopharyngeal myotomy or laryngeal elevation are effective interventions for severe dysphagia. There are, however, some pitfalls including therapeutic differentiation between surgeries and rehabilitation, causes of insufficient postoperative results, and long-term outcomes. We herein discussed these issues via our cases that underwent surgical management. By retrospective analysis of cases with Wallenberg's syndrome, rehabilitation could successfully restore swallowing function in cases with fair pharyngolaryngeal sensory function and swallowing reflex. These are important factors for considering the course of treatment. None of the four cases with predominant pseudo-bulbar palsy due to cerebrovascular disorders had sufficient oral food intake restored. The highly disordered activities of daily living were thought to be additional contributing factors of poor postoperative results. Skilled surgical procedure is a clear necessity. In the long-term, local scarring or systemic functional deterioration may lead to reworsening of swallowing function. Clinicians should be aware of these issues in treating dysphagic patients surgically.
Laryngomalacia is the most common of congenital laryngeal anomalies and usually resolves without intervention by the second year of life, however, severe laryngomalacia has been shown to be frequently accompanied with synchronous laryngeal anomalies and comorbidities. Laryngoscopy only reveals the collapse of supraglottic structures (epiglottis, aryepiglottic folds and arytenoids) with inspiration. Video recording during a laryngoscopic examination is recommended. Laryngomalacia was classified in four types: epiglottic type, aryepiglottic fold type, arytenoid type and combined type, based on McSwiny's categorization. We investigated 59 patients with severe laryngeal stridor during hospitalization. Of the 59 cases, 24 (40.7％) of them had laryngomalacia, ten of whom (41.7％ of the 24) had laryngeal lesions, 13 patients were intubated, tracheostomies were performed on 4 patients, supraglottoplasties were performed on 2 patients and laryngotracheal separation was performed on 2 patients. Two patients with acquired laryngomalacia were shown, one had a tongue cyst and another had a foreign body in the pharynx. Six patients that had cerebral paralysis with severe laryngomalacia were demonstrated as having the acquired type. In these patients laryngoscopy reveals severe mucosal edema and swelling of supraglottic structures.
Our study involved a case population of 87 children with pediatric vocal cord motion impairment. We reviewed the associated airway conditions, treatment and prognostic outcomes of vocal cord palsy（31 bilateral and 26 ipsilateral cases）, vocal cord paresis（22 cases）, and paradoxical vocal cord movement（PVCM）（5 cases）. With bilateral vocal cord palsy and paresis, the most common symptom was stridor, whereas dysphonia was most common with ipsilateral vocal cord palsy. Cardiovascular diseases are strongly associated with left vocal cord palsy. Recovery was noted in 5 of 87（6％）cases within 1 year, and 20 cases（23％）within 5 years. Conservative treatment is adovocated in pediatric vocal cord dysfunction due to the risks of undergoing a tracheostomy. There is an expectation of high recovery rates within several years.
Our department of pediatric otorhinolaryngologic diseases examines and treats many cases of hearing impairment and upper respiratory airway obstruction issues. We reported on a bifida epiglottis of an infant (4-month-old male), an epiglottis cyst of a 1-month-old male, a laryngeal web (1-month-old female), a larynx papilloma（recurrent respiratory papillomatosis of 9-month-old female）, a congenital subglottic stenosis (2-month-old male) and a congenital laryngeal atresia (30-week-old female). We disuccused the symptoms, diagnosis, and the therapies for each disease.
Fifteen cases of laryngotracheal stenosis following endotracheal intubation in infants and children were reported. Eight patients were intubated at birth, 3 patients had anomalies and 5 patients were premature infants with respiratory distress syndrome. These 8 patients received tracheostomies between 1 to 12 months of age. The other seven were intubated between 1 to 9 years in age. They had endotracheal intubation for 7 to 45 days due to miscellaneous maladies such as asthma, cerebral hemorrhage, virus associated hemophagocytotic syndrome as well as other ailments. Six patients had tracheostomies because of severe dyspnea. Although subglottic stenosis was most common in the case of population, but long-term intubated premature infants had other regions of stenosis besides the subglottis. The management of tracheostomy is important to maintain an adequate airway and preserve phonatory function while using the smallest tube that will permit adequate ventilation. In 10 patients who had undergone tracheostomies under 2 years of age, 7 patients could speak when plugging the tube with their finger. Two patients could decannulate by waiting and one patient by resection of granulated tissue in the area of the tracheostomy. Three of 5 premature infants were treated by external surgical reconstruction using a laryngeal stent, and one patient could be decanulated. Six of 7 patients in the latter group were decanulated by an endoscopic operation using a CO2 laser and the open stent method (trough method).
Vocal fold scarring due to injury, inflammation or surgery results in stiffness of the layer structure of the vocal fold. In addition, the mucosal waves are singnificantly affected, thereby resulting in severe dysphonia. Many therapeutic strategies have been attempted for the treatment of vocal fold scarring including voice therapy, steroid injection, injection laryngoplasty, tissue engineering and regenerative medicine. Our surgical method involves the removal of the vocal fold scarring under laryngomicrosurgery. From 2001 to 2007, we performed our phonosurgery technique on 18 patients with vocal fold scarring. The 15 patients whom were observed over two months (6 men and 9 women) ranged in age from 19 to 67 years (average age, 42.9 years). Our observations involved evaluation of subjective symptoms, as well as stroboscopic and phonometer examinations. The operation is performed under the general anesthesia. The approach is to resect the vocal fold nodule-like scarring and to resect vocal fold scarring under the mucosal epithelium. Twelve of the 18 patients had satisfactory post-surgery traveling waves and phonation. Definitive strategies in the treatment of vocal fold scarring have yet to be established. Our surgical method to treat scar formation is to remove the scar tissue under the mucosa. The key point is that we strive to attain the most excellent wound healing in order to achieve the closest reproduction of a normal vocal fold structure.
We reported on a surgical closure of the larynx with removal of the thyroid cartilage and the cricoid cartilage for a 23-year-old patient with intractable aspiration pneumonia complicated by severe motor and intellectual disability. We performed the new glottic closure procedure reported by Kano M et al (2008). The larynx was opened via midline thyrotomy after removing both the thyroid and cricoid cartilage to gain a wide surgical field. The edge of the bilateral vocal cords were cut and opened by a horizontal incision, and those were separated into superior and inferior mucosal flaps and sutured at the midline above and below. The sternohyoid muscle flap was inserted into the open space between the superior and inferior mucosal flaps sutures. Because of the minimal surgical trauma and highly successful outcome, this method is thought to be highly useful and safe procedure for surgical closure of the larynx in high-risk patients with severe motor and intellectual disability whose treatment options are markedly limited.
We reported on a 27-year-old male with inspiratory dyspnea because of an epiglottic deformity. The symptom is similar to laryngomalasia. Sleep apnea was not evident from the results of a sleep study conducted from 2000 to 2008. Neither a deviatomy of nasal septum nor thoracoplasty for funnel chest was able to improve the inspiratory dyspnea. The symptom was managed eventually by a partial epiglottidectomy. The patient is doing well without obvious complications.
We reported on a case of intratracheal granulation after the closure of a tracheostoma. A 69-year-old man underwent neck debridement and a tracheostomy to treat a deep neck infection. During the tracheostomy, the isthmus of the thyroid gland was resected and ligatured for both resected ends. After the deep neck infection improved, the tracheostoma was closed. Two months later, he complained of pharyngolaryngeal discomfort and of dyspnea. An intratracheal nodule was observed between the subglottic and the tracheal sections by flexible endoscopy. Two ligatures of silk thread were seen at the tip of the tumor. Computed tomography showed an intratracheal tumor with a different density from the thyroid gland. He underwent a tracheostomy again and the nodule was resected stimultaneously. The nodule was pathologically diagnosed as inflammatory granulation, which was not observed in the specimen of thyroid gland tissue. There has been no recurrent intratracheal granulation for twelve months since the operation. It was suggested that the granulation in this case was caused by the ligature thread. It is necessary to observe the space from the subglottic to the tracheal regions when the patient complains respiratory symptoms after the closure of a tracheostoma.
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