We performed endoscopic laryngeal microsurgery with powered ENT instruments or laparoscopic surgical instruments on 23 cases that went under general anesthesia. In all cases, endoscopic laryngeal microsurgery was performed successfully with these instruments. Resection of tumors and granulomata was easily and safely achieved with powered ENT instruments and instruments properly designed for endolaryngeal surgery like the hand-piece type CO2 laser. Laparoscopic surgical instruments were also useful to remove supraglottic cysts or tumors, but slightly difficult to use for glottic lesions.
Angiolytic lasing utilizing the KTP⁄green laser has become a popular means to treat various laryngeal lesions. This laser can photocoagulate vascular lesions with minimal heat damage to surrounding tissues, which is advantageous because it avoids postoperative scar formation on the vocal folds. This laser has proven useful in treating hemangioma, microvascular lesions, hemorrhagic polyp as well as recurrent papillomatosis, dysplasia, and CIS on the vocal folds. Since the laser causes minimal bleeding during the procedure, office based surgery is well indicated. The rationale, set up, and surgical technique are discussed in this manuscript.
Scarring of the vocal folds can result from blunt laryngeal trauma or more commonly due to surgical iatrogenic injury after the removal of vocal fold lesions. The scarring results from the replacement of healthy tissue with stiff fibrous tissue that can irrevocably alter vocal function, leading to a decreased or absence of the vocal fold mucosal wave. Current treatments for this complex condition are inconsistent and often produce suboptimal results. This study reviews the outcomes of 13 patients who, in an office setting, underwent transcutaneous chordal steroid injections with curved needles for vocal fold scarring. This injection technique was performed under local anesthesia. Results were evaluated by videostroboscopy, perceptual evaluation of the GRBAS scale, and acoustic analysis before and after the injections. Injections were given from 2 to 5 times. These steroid injections did not completely clear scar lesions in all patients, although videostroboscopic observations revealed improvement in 11 patients. In perceptual evaluations, all cases experienced a progressive improvement of voice quality with the passage of time after the injections. With the acoustic findings, all parameters showed significant improvement after the injections. Our experience showed a positive response of scars to steroid injection therapy. Repeated transcutaneous chordal steroid injections using curved needles offer significant improvement in the management of vocal fold scars.
Symposium II : New Development in Basic Research on Laryngology
Our group reported on the use of artificial airways on human cases. These airways were composed of polypropylene mesh and rings as the frame and collagenous sponge as the scaffold. Clinical applications resulted in near successful results. It is important to have a clear understanding of the mechanisms of laryngeal or tracheal regeneration for the purpose of determining a way to achieve more rapid regeneration. In this report, the mechanism of laryngeal regeneration with artificial airways was analyzed, and the effects of hybrid airways with fibroblasts on laryngeal regeneration were evaluated. After reconstruction of laryngeal defects on rats with artificial airways, the migration of macrophages, the thinning and thickening of collagenous fiber, the differentiation of epithelium, and vascularization were observed in turn. It was found that laryngeal regeneration utilizing hybrid airway reconstruction occurred more rapidly than with artificial airways only. It was suggested that fibroblasts played an important role in laryngeal regeneration and that a hybrid artificial airway with fibroblasts contributed to rapid laryngeal regeneration.
Some symptoms of laryngeal and tracheal diseases are associated with specific times of the day. For example, cough aggravation in the middle of the night is frequent complaint of patients with airway inflammation. We speculated that these symptoms were under the control of the circadian clock, and the clock genes in the airway epithelium played some important roles. The present study addresses the role of the circadian system in day-night changes of the respiratory functions in mice. In all airway tissues investigated (i.e. laryngeal, tracheal, bronchial, and lung), we observed clear rhythmic expression of the clock genes. Oscillations were abolished in arrhythmic Cry1⁄Cry2 knock out mice and after lesioning of the master clock in the suprachiasmatic nucleus (SCN) in the wild-type. These findings indicate that respiratory cells contain a functional peripheral oscillator that is controlled by the SCN. Signals from SCN are mainly transmitted by the vagal nerve since performing a unilateral vagotomy completely abolished rhythms in Per2 protein levels in the ipsilateral side of the submucosal glands, but not in the contralateral side. Furthermore, we found that the muscarinic acethylcholine receptor genes Chrm2, Chrm3, Chrm4 are expressed in a circadian manner. Thus, laryngeal and tracheal clocks mediated circadian expression of muscarinic acethylcholine receptors and parasympathetic signaling between SCN and airways are essential pathways in conferring circadian time information to the larynx and the trachea. We consider that airway clocks could be the key in solving the nocturnal aggravation of respiratory symptoms.
The aim of this study is to clarify the local immune status in the larynx affected by infection or carcinogenesis associated with HPV. Cytological samples for the detection of HPV and laryngeal secretions for the collection of immunoglobulin (Ig) were obtained from 31 patients with laryngeal diseases during microscopic surgery of the larynx. Histological results were as follows: 12 patients with squamous cell carcinomas, 4 with laryngeal papillomas and 15 with other benign laryngeal diseases. HPV-DNA testing from cytological samples was performed with the Hybrid Capture 2 assay method. High risk HPV-DNA was detected in 25% (3⁄12 cases) of laryngeal cancers. Low risk type was detected in three laryngeal papillomas only. The mean IgM, IgG, IgA and secretory IgA concentrations in HPV-DNA positive cases were more than double compared to respective concentrations in HPV-DNA negative cases. In particular, a significant difference was observed between the concentrations of secretory IgA of the two groups. A comparison of laryngeal cancer and benign laryngeal diseases revealed that patients with laryngeal cancer had a higher concentration in each Ig isotype in laryngeal secretions than patients with benign laryngeal diseases. When the mean concentrations of each antibody isotype in the 12 cases with laryngeal cancer were compared between HPV-DNA positive (3 patients) and HPV-DNA negative (9 patients), the mean IgM, IgG, IgA, secretory IgA concentrations in HPV-DNA positive cancer showed a tendency to be higher than those in HPV-DNA negative cancer. Our results suggest that the local immune response in the larynx is activated by infection or carcinogenesis caused by HPV. It is strongly considered that secretory IgA activity inhibits infection or proliferation of HPV in the larynx.
Educational Panel Respiratory Physiology of Laryngeal Diseases and Sleep Breathing Disorders
Several studies have reported that the most effective breathing pattern is nasal breathing during wakefulness and open-mouth breathing induce upper airway narrowing by the morphological changing of the upper airway. The aim of the present study was to conduct an objective investigation of upper airway morphological changes corresponding with changes in breathing patterns using sleep endoscopy and three-dimensional imagery of the upper airway by a volume rendering technique with MDCT images. Result: The endoscopic findings of tongue retreating during wakeful mouth breathing were obtained with both obstructive sleep apnea syndrome (OSAS) patients and a normal control. It was confirmed that the narrowing of the upper airway with OSAS patients worsened. Three-dimensional images of the upper airway by a volume rendering technique with MDCT images was also successful in obtaining findings in changes of breathing patterns using endoscopy. It was very helpful to be able to observe from any angle. Conclusion: These methods have potential in establishing an objective evaluation method, as well as being very useful in providing a visually descriptive explanation to patients.
Vocal cord palsy during sleep is strongly associated with Multiple System Atrophy (MSA) and sometimes results in sudden death due to airway obstruction. Nasal continuous positive airway pressure (nCPAP) is a recommended therapy since it can increase the patency of a closed airway due to vocal cord palsy. In this study, I described the motion of the vocal cords of MSA patients using a specialized MRI that runs silently. Several papers reported that there were combinations of upper airway obstructions and pharyngeal obstructions before vocal cord palsy. In addition, it was reported that a tracheotomy would be necessary in cases of bilateral vocal cord palsy in awakened states, and that the prognosis of MSA is still difficult after a tracheotomy because of the increase of central sleep apnea. MSA is one of the most difficult diseases to treat due to the various combinations of upper airway obstructions, coexistent obstructions and central sleep apnea⁄hypopnea. As otolaryngologists, we should recognize the difficulty in managing MSA and consider better treatments for MSA than current ones.
Multiple system atrophy (MSA) is a chronic neurologic disorder characterized by atypical Parkinsonism and autonomic dysfunction. Sudden death during sleep is common among MSA patients. Sleep laryngoscopy demonstrates the restriction of vocal cord abduction with a markedly reduced size of the glottic chink. Vocal cord abductor paralysis (VCAP) is considered to be an important predisposing factor of sudden death in MSA. The aim of this study is to elucidate the effects of VCAP on sleep and the utility of awake and sleep laryngoscopy in understanding MSA. We recruited 34 patients with MSA presenting with snoring (12 men and 22 women; with the following statistical means: age, 60.2 years; disease duration, 4.3 years; International Cooperative Ataxia Rating Scale [ICARS], 51.3). After performing arterial blood gas analysis, spirometry and polysomnography (PSG), awake and sleep laryngoscopy were performed. Sleep laryngoscopy revealed that eighteen patients exhibited VCAP, whereas the remaining patients didn’t. Between these two groups, there were no significant differences in the following findings; sex, disease duration, ICARS, daytime blood gas analysis results and PSG findings (mean SpO2 during sleep, AI, AHI and arousal index). Seventeen of the eighteen patients who presented with VCAP exhibited bilateral arytenoidal tremor with awake laryngoscopy, while another group didn’t have an identifiable arytenoidal tremor. These findings suggest that MSA should be assessed by sleep laryngoscopy. It is difficult, however, to routinely perform sleep laryngoscopy. While an early diagnosis of VCAP is difficult to make utilizing awake laryngoscopy, the presence of an arytenoidal tremor may be a guide towards predicting VCAP.
Gastroesophageal Reflux (GERD) and Laryngopharyngeal Reflux (LPRD) may be associated with night time reflux, snoring and sleep apnea; however, uncertainty remains whether reflux episodes are related to apneic episodes. The argument that the coincidental correlation of the severity of reflux-induced symptoms with the severity of obstructive sleep apnea is evidence against precipitation of apneic episodes by reflux episodes is unconvincing. While CPAP treatment improves the symptoms of GERD and LPRD, and treating GERD improves sleep disturbance, it is uncertain whether these treatments improve sleep apnea. It is necessary to consider additional treatments of GERD such as Proton Pump Inhibitors (PPI).
Obstructive Sleep Apnea Syndrome (OSAS) is the condition of complete (Apnea) or partial (hypopnea) airway collapse during sleep. The cardinal daytime symptoms are excessive daytime sleepiness and non- rejuvenating sleep due to recurrent arousals and interrupted sleep caused by intermittent hypoxia and hypercapnia. OSAS is sometimes associated with serious cardiovascular complications, hypertension, stroke and abnormal glucose metabolism. The primary location of airway collapse is in the pharyngeal area, involving the tonsils, soft palate, and tongue base; all of which lay within the ENT specialty. The larynx is not usually a common site for collapse during sleep because of its rigid cartilaginous framework. In our department, the site of collapse is usually investigated through endoscopic examination during drug induced sleep. In the course of endoscopic examinations, a transient collapse in the laryngeal supraglottic structures is sometimes noticed. Nasal continuous positive airway pressure (CPAP) is considered the gold standard therapy for OSAS. For various reasons surgery is recommended as the primary treatment for patients experiencing OSAS due to the collapse of laryngeal supraglottic structures. Patients with mild to moderate OSAS and a corresponding AHI (apnea hypopnea index) less than 20 are restricted by the Japanese insurance system to be treated with CPAP. Another reason is the possibility of serious airway obstruction in that region if an infection and superimposed edema were to occur. In this paper we discuss the surgical procedure which is done in our department for patients with OSAS when the main site of obstruction is in the larynx or in laryngeal surrounding tissues.
Thyroplasty type I was performed on 12 patients in the terminal stage of cancer with unilateral vocal cord paralysis. The mean age at the time of surgery was 78.6. years. Of these patients, there were 8 cases of lung cancer, and single cases of thyroid anaplastic cancer, malignant lymphoma, thymus cancer, and chronic heart failure. The preoperative mean maximum phonation time (MPT) was 2.8 seconds, which became 10.8 seconds (p<0.01) postoperatively. In all patients, preoperative silent aspiration improved. Postoperative survival times ranged from 1 to 9 months. Among these patients, a few cases indicating arytenoid adduction were observed. Thyroplasy type I can be done safely in a short time without suffering. For patients in the terminal stage of cancer, the reduction of the suffering from breathy hoarseness due to unilateral vocal cord paralysis is beneficial.
We used the Reflux Symptom Index (RSI) for the diagnosis of laryngopharyngeal reflux disease (LPRD) with 38 patients. Eighteen patients had RSI scores >13. The remaining 20 patients had RSI scores ≤13. We used the Frequency Scale for Symptom of GERD (FSSG) for 20 patients. We prescribed proton pump inhibitors (PPI) for all 38 patients. The RSI score of 38patiens decreased statistically for 4weeks. That of 18 patients (RSI >13) also did for 4 weeks. The FSSG scores also decreased over the same period; however, there is not interrelation between the RSI and FSSG scores. Those findings suggest that RSI is useful for the diagnosis of LPRD.
We retrospectively reviewed clinical findings of 73 patients with acute epiglottitis who were hospitalized and received treatment between April, 1993 and October, 2008. There were 52 men and 21 women and their ages ranged from 19 to 70 years old (median : 47). The most frequent seasons the patients suffered from acute epiglottitis were spring and autumn. The chief symptoms were sore throat in 67 cases (91.7%), dyspnea in 24 (32.9%) and high fever in 20 (27.2%) followed by small number of patients with other symptoms, such as incongruity of pharynx etc. We divided the patients into the groups: stage I, stage II and stage III based on the classification of Kikuchi. There were 31 Stage I (42.4%), 18 stage II (24.6%) and 24 stage III (32.4%) patients. In the stage III, 14 (19.1%) fulminant type patients were included. We confirmed that the Kikuchi classifications well reflected the clinical status of epiglottitis. As a treatment, all patients were treated with intravenous antibiotics, and intravenous steroids were administered to 71 (97.2%) patients. Six (8.2%) of stage III cases required air way management by tracheostomy
Recurrent respiratory papillomatosis, caused by low-risk human papilloma viruses, is a chronic disease of the upper respiratory airway. The larynx is most frequently affected organ. Many treatment modalities such as CO2 laser and cidofovir have been applied to control this disease in less invasive way. Cidifovir is an anti-viral agent and has been expected to eradicate human papilloma virus. However, this agent has not been commercially available in Japan yet. Here we report two cases of recurrent laryngeal papillomatosis were treated with topical cidofovir injection. The patients received local injection for three times in 4 weeks. The diseases have been controlled and there have been no adverse effect for 32 months and 17 months.
The effectiveness of intra-arterial chemoradiotherapy (IACRT) against advanced laryngeal cancer has recently been reported. Yet, the indication of IACRT in cases with neck lymph node metastasis has not been discussed. Although planned neck dissection after radiotherapy is performed at many institutions, the radiotherapy often cause unfavorable postoperative complications. We treated a 57-year-old male, whose chief complaint was hoarseness, at our university hospital. Fiberoptic examination revealed an irregular tumor on the right subglottic lesion extending to the right ventricle. Images from computed tomography suggested the presence of metastatic cervical lymph nodes. Subglottic squamous cell carcinoma of the larynx (T2N2bM0) was histologically diagnosed. As a treatment, selective neck dissection for the cervical metastasis was first performed. During surgery, the supra-and inferior-thyroidal arteries were preserved. Ten days after the surgery, IACRT for the local tumor was given every other week using the supra-thyroidal artery. The IACRT was continued for five weeks and, as a result, the tumor has completely disappeared. The patient has been free from recurrence for more than a year.
We reported on three cases of the laryngeal amyloidosis. The three male patient's ages were 74 years (case 1), 36 years (case 2) and 62 years (case 3). All patients had complained of hoarseness. In Cases 1 and 2 we found yellowish masses in their larynxes, vocal cords and false cords. Case 3 had lesions in the pharynx in addition to the larynx. In all cases biopsies were performed through microlaryngoscopy and their histological diagnoses were amyloidosis. Their hoarseness had not subjectively improved. All cases were recurrent.
In the treatment of early-stage larynx cancer, radiotherapy or operations such as partial laryngectomies are performed to preserve laryngeal function. A partial vertical laryngectomy is performed for laryngeal function preservation, and is suitable for cases in which the tumor exists at the unilateral vocal cord and spreads to the commissura anterior, but progress is less advanced in the unaffected vocal cord. Recently, the partial vertical laryngectomy is not performed for initial treatment, and has been increasingly used as salvage surgery when the tumor recurs after irradiation. In this instance, we may recognize postoperative complications by damage to the skin and subcutaneous tissue. We report here on a partial vertical laryngectomy with reconstruction using a thyroid gland flap.