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PubMed1996

Laser versus cold instruments for microlaryngoscopic surgery.

Controversy has arisen concerning the merits of the CO2 laser in microlaryngoscopic surgery because of the potentially harmful effects that the injudicious application of the laser could have on voice production. In an effort to develop a logical approach to instrument selection, the author examined the use of both cold instruments and the CO2 laser in the treatment of various benign and malignant lesions. A retrospective review of 307 microlaryngeal procedures performed over a 3-year period revealed that 263 (86%) were glottal and 44 (14%) were supraglottal. Of the 263 glottal procedures, 203 (77%) employed cold instruments alone and 60 (23%) used both cold instruments and the CO2 laser. The laser was used to assist in all 44 supraglottal procedures. Therefore, 203 (66%) of 307 procedures were done with cold instruments alone, and 104 (34%) of 307 procedures were performed using the CO2 laser with cold instruments. Lesions were stratified on the basis of pathology and size, as well as surgical approach. A primary phonomicrosurgical principle in glottal surgery is to maximally preserve the vocal fold's layered microstructure (laminae propria and epithelium). Precise tangential dissection was necessary for achieving this goal. For limited lesions, this dissection was best accomplished with cold instruments alone. The CO2 laser facilitated hemostatic surgical dissection for all supraglottal lesions and for selected larger glottal lesions in which bleeding would obscure visualization of the microanatomy of the musculomembranous vocal fold.

Algorithms↗

PubMed1999

Management of the N0 neck during salvage laryngectomy.

BACKGROUND: Radiotherapy is effective treatment for laryngeal carcinoma. Early-stage laryngeal carcinoma has a low incidence of cervical metastasis. Patients initially clinically N0 usually remain N0 when they fail at the primary site. The incidence of subclinical metastasis in these patients is not well described. Watchful waiting or elective neck dissections are advocated. OBJECTIVE: Examine the incidence of subclinical metastatic disease in patients undergoing elective neck dissections with salvage laryngectomy. STUDY DESIGN: Prospective study (1991-1996) of patients who failed radiotherapy and underwent salvage laryngectomy with elective neck dissection. METHODS: Thirty-four patients underwent salvage laryngectomy with neck dissection (30 bilateral, 4 unilateral). All were clinically N0 at initial presentation and remained N0 at recurrence. Pathologic study of the neck dissection specimens was undertaken. Patients were followed for a minimum of 2 years (mean, 4 y). RESULTS: The male-to-female ratio was 4.5:1, with a mean age of 62 years (range, 38 to 75 y). Metastatic disease was present in 6 patients (17%); 4 of 14 (28%) supraglottic, and 2 of 20 (10%) glottic. Presence of disease in the neck according to stage at recurrence was as follows: T2, 2 of 12; T3, 3 of 14; and T4, 2 of 8. Neck disease was ipsilateral in 4 and contralateral in 2 patients (both supraglottic primaries). CONCLUSIONS: Subclinical cervical metastasis may be present in N0 laryngeal carcinoma patients who have recurrence following radiotherapy. Morbidity of a lateral neck dissection is minimal, with excellent control of the neck being possible. Supraglottic and advanced glottic (T3-T4) patients may benefit the most.

Adult↗

PubMed2000

Surgical management of localized amyloidosis.

OBJECTIVE: To demonstrate the role of two-dimensional reconstruction images on computed tomography (CT) in the treatment planning for laryngeal amyloidosis. To discuss the treatment for isolated laryngeal amyloidosis and compare the role of endoscopic versus an open surgical approach to management. STUDY DESIGN: Retrospective review. METHODS: The medical records from 1984 to the present with the diagnosis of localized respiratory tract amyloidosis at Geisinger Medical Center were reviewed. RESULTS: Five previously unpublished cases of localized laryngeal amyloidosis were identified with the supraglottic region the major site of involvement. Hoarseness and airway compromise were the presenting symptoms. CT two-dimensional reconstruction imaging was used to evaluate two cases with extensive laryngeal involvement that required an external surgical approach to relieve symptoms. CONCLUSIONS: Localized laryngeal amyloidosis is a rare disease that requires surgical management when symptomatic. CT two-dimensional reconstruction can be helpful in detailing the extent of disease and planning surgery. A lateral external supraglottic approach has been found to be successful in treating patients with large supraglottic masses.

Adult↗

PubMed2003

Voice, speech, and swallowing outcomes in laser-treated laryngeal cancer.

OBJECTIVE: To describe preliminary voice, speech, and swallowing outcomes in patients treated by endoscopic laser excision of laryngeal cancer with or without adjuvant radiation therapy. STUDY DESIGN: Retrospective review. METHODS: Seventeen surgically treated patients (five T2 glottic and 12 clinically staged T2 supraglottic squamous cell carcinomas) participated in the study. Self-ratings of voice (Voice Handicap Index) and swallowing (M. D. Anderson Dysphagia Inventory) were completed, as well as independent auditory-perceptual ratings of voice and speech recordings. RESULTS: Although no significant difference between Voice Handicap Index, M. D. Anderson Dysphagia Inventory, and listener ratings was identified based on tumor site and irradiation status, there was a trend toward poorer outcomes in patients who received adjuvant radiation therapy. Whereas the patients having supraglottic cancer tended to report better voice but poorer swallowing outcomes, the glottic cancer group displayed the opposite pattern. Severity on Voice Handicap Index correlated significantly with listener severity ratings of speech, suggesting that the patients' perception of their voice handicap was similar to the listeners' judgments of their speech severity. CONCLUSIONS: The results suggest the following trends: 1) Adjuvant radiation therapy was associated with poorer outcomes for voice, speech, and swallowing and may be associated with more impairment than surgery alone and 2) poorer outcomes on voice and swallowing were observed for the glottic and supraglottic cancer groups, respectively. To bolster these preliminary findings, additional outcomes studies in patients treated with conservation therapy are needed.

Adult↗

PubMed2006

Recent developments in airway management of the paediatric patient.

PURPOSE OF THE REVIEW: During the last two years, several studies have enhanced our knowledge about the influence of pharmacological agents and routine airway management manoeuvres on the airway of paediatric patients. New supraglottic airway devices have been introduced into routine paediatric anaesthesia practice, and the design of paediatric endotracheal tubes has been modified. This review summarizes the most recent and relevant scientific developments in paediatric airway management. RECENT FINDINGS: Strong evidence has been gained that the lateral position is the best to ensure a clear airway in anaesthetized or sedated spontaneously breathing children. Remifentanil has emerged as an appealing drug for airway management in anaesthetized or sedated children. The paediatric ProSeal-Laryngeal mask airway offers important advantages over the Classic-Laryngeal mask airway for supraglottic airway management. The newly designed Microcuff paediatric endotracheal tube offers an improved age-appropriate design. SUMMARY: Remifentanil has found a place in airway management in paediatric patients. Recent improvements in the design of paediatric supraglottic airway devices and endotracheal tubes are promising. Further research is needed to consolidate their role in improving the perioperative outcome in paediatric patients.

Analgesics, Opioid↗

PubMed1982

The results of treatment of laryngeal cancer in Auckland New Zealand 1965-1979.

A retrospective review of laryngeal cancer in Auckland over the period 1965-1979 has revealed a generally poorer prognosis for supraglottic cancer than for glottic cancer. The use of radiotherapy for supraglottic cancer and for advanced glottic cancer has not been as successful as primary surgery but has yielded good results in early glottic carcinoma. Salvage surgery after failed radiotherapy was significantly more successful for glottic tumours than supraglottic. Stomal recurrence was more likely if a patient had required an emergency tracheotomy for airway obstruction.

Adult↗

PubMed1985

Pharyngeal resistance in normal humans: influence of gender, age, and obesity.

Investigation into the etiology of obstructive sleep apnea is beginning to focus increasing attention on upper airway anatomy and physiology (patency and resistance). Before conclusions concerning upper airway resistance in these patients can be made, the normal range of supraglottic and, more specifically, pharyngeal resistance needs to be better defined. We measured supraglottic and pharyngeal resistances during nasal breathing in a normal population of 35 men and women. Our technique measured epiglottic pressure with a balloon-tipped catheter, choanal pressure using anterior rhinometry, and flow with a sealed face mask and pneumotachograph. Resistance was measured at a flow rate of 300 ml/s during inspiration. Men had a mean pharyngeal resistance (choanae to epiglottis) of 4.6 +/- 0.8 (SE) cmH2O X l-1 X s, whereas women demonstrated a significantly (P less than 0.01) lower value, 2.3 +/- 0.3 cmH2O X l-1 X s. Supraglottic resistance was also higher in men (P = 0.01). Age (r = 0.73, P less than 0.01) correlated closely with pharyngeal resistance in men, but no such correlations could be found in women. These results may have implications in the epidemiology of obstructive sleep apnea.

Adult↗

PubMed1999

A phase II study of concomitant chemoradiotherapy for laryngeal carcinoma using carboplatin.

PURPOSE: We conducted a phase II study of concomitant chemoradiotherapy with carboplatin for laryngeal carcinoma. MATERIALS AND METHODS: Sixty-four patients with stage II-IV (stage II, 36; III, 19; IV 9) laryngeal carcinoma were treated with concomitant administration of carboplatin (CBDCA) during radiotherapy (CRT group) between 1991 and 1994. There were 36 supraglottic, 25 glottic, and 3 subglottic carcinomas. Patients with stage II and stage III-IV received intravenous CBDCA of 100 mg/m2 and 120 mg/m2 once a week, respectively. Tumor response was assessed at 40 Gy in 16 fractions to select the patients suitable for total laryngectomy or radical radiotherapy of 65 Gy in 26 fractions in 6.5 weeks. The treatment results were compared with the historical control consisting of 56 patients consecutively treated from 1988 to 1990 without chemotherapy (RT group). The two studies were comparable with regard to patient characteristics, including age distribution, gender, tumor location, size, and clinical stage. RESULTS: The actuarial 5-year survival rate was 80.3% for the CRT group and 81.3% for the RT group. A favorable response (complete response or partial response) at 40 Gy was observed in 87.5% of the patients of the CRT group and in 62.5% of the patients of the RT group (chi2 = 7.566, p < 0.01). The actuarial 5-year larynx preservation rate for the CRT group (75%) was significantly higher than that for the RT group (57%) in patients with T2 supraglottic carcinoma (p < 0.05). There was no difference in the larynx preservation rate between the two treatment arms for any T stage of glottic carcinomas. CONCLUSION: CRT using carboplatin improved the tumor response at 40 Gy and consequently achieved a higher larynx preservation rate for T2 supraglottic carcinoma. A clinical randomized trial is indicated to certify the findings of this phase II study.

Antineoplastic Agents↗

PubMedDate not supplied

Follow-up study in head and neck cancer: cure rate according to tumor location and stage.

The purpose of this clinical study was to analyze a long-term follow-up of all the patients with head and neck cancer in our institution. Between 1973 and 1993, 1,355 consecutive cases of head and neck cancerwere diagnosed, treated and followed up regularly. All were subjected to a multidisciplinary approach, and followed up until death or for 10 years with no event of disease. The local relapse rate was 20% and the node-regional relapse rate 15%. Distant metastases were observed in 6% of the patients mainly arising from the nasopharynx (23%) followed by the hypopharynx (11%). The main organ involved was the lung (50%). Median follow-up of the group was 10 years (range 4 months to 15 years). Cancer cure was observed after 5 years in glottic and supraglottic laryngeal carcinoma, oral and nasopharyngeal cancer and after 2.5 years in patients with cancer of the oropharynx and hypopharynx. The highest cure rate was 80% in the glottis, followed by 70% in the supraglottic area, 45% in the mouth, 30% in the nasopharynx, 25% in the oropharynx, and 20% in the hypopharynx. A second primary tumor was observed in 7% of the patients and a third primary in 0.6% of the patients. Only in 7 patients, the second or third primary was seen after 5 years of follow-up. Curability should be observed after 5 years from definitive therapy of glottic, supraglottic, oral and nasopharyngeal and earlier in oropharyngeal and hypopharyngeal cancer. Further follow-up should be discontinued. Second and third neoplasias are the main problems after 5 years of follow-up but their incidence is low.

Adult↗

PubMedDate not supplied

Transcutaneous fine needle aspiration biopsy of the preepiglottic space.

OBJECTIVE: To evaluate transcutaneous fine needle aspiration biopsy of the preepiglottic space for staging supraglottic squamous cell carcinoma. STUDY DESIGN: We studied 28 patients who underwent total or horizontal supraglottic laryngectomy as their main therapy modality due to supraglottic squamous cell carcinoma, followed in some cases by adjuvant radiation therapy. All the patients underwent transcutaneous fine needle aspiration. RESULTS: The cytopathologic examination of the material obtained by aspiration was compared to the histopathologic analysis of the laryngectomy specimens; the efficiency was 96.4%. The method did not cause any morbidity. CONCLUSION: Transcutaneous fine needle aspiration biopsy of the preepiglottic space is useful for preepiglottic space evaluation, with a high correlation with histopathologic results and no morbidity.

Aged↗

PubMed2005

Timing of glottic closure during swallowing: a combined electromyographic and endoscopic analysis.

OBJECTIVES: We performed a case series to enhance our understanding of the coupling between neuromuscular events and glottic closure. METHODS: We performed combined flexible video laryngoscopy and electromyography in 4 healthy human subjects. Hooked-wire electrodes were placed in the superior pharyngeal constrictor, longitudinal pharyngeal, cricopharyngeus, thyroarytenoid, genioglossus, suprahyoid, and posterior cricoarytenoid muscles. A flexible endoscope tip was positioned in the oropharyngeal-hypopharyngeal region. The subjects performed multiple trials each of 10-mL normal and super-supraglottic liquid swallows. RESULTS: Arytenoid movement consistently preceded full glottic closure and was associated with cessation of activity of the posterior cricoarytenoid muscle. In 89% of normal swallows, the glottis was partially open in the video frame before bolus passage. The maximum amount of thyroarytenoid electromyographic activity occurred during endoscopic whiteout. When subjects executed a super-supraglottic swallow, early thyroarytenoid activity coincided with arytenoid contact. CONCLUSIONS: The initial medialization of the arytenoids is due to a decrease in motor tone of the posterior cricoarytenoid muscle. Full glottic closure typically occurs late in the process of swallowing, with activation of the thyroarytenoid muscle. Shifting of arytenoid medialization and glottic closure earlier in the super-supraglottic swallow indicates that glottic closure is under significant voluntary control.

Adult↗

PubMedDate not supplied

High dose preoperative irradiation for advanced laryngeal-hypopharyngeal cancer.

Combined therapy, consisting of 5000 rads delivered in five weeks by total laryngectomy +/- radical neck dissection, was compared with treatment by irradiation (6000-7000 rads) with surgical salvage when clinically possible for radiation failure. Patients were categorized according to site of primary cancer (glottic, supraglottic and pyriform sinus) and staged (T, N, M). Survival was equally good in the two programs for glottic and supraglottic lesions, N0 or N1. The combined treatment program was judged superior for supraglottic and pyriform sinus lesions, N2 or N3.

Adult↗

PubMedDate not supplied

Carbon dioxide laser management of laryngeal stenosis.

A retrospective review of 20 cases of laryngeal stenosis treated with the carbon dioxide laser was conducted at the Medical College of Wisconsin and Northwestern University. The stenoses were grouped into four categories: supraglottic, glottic, subglottic, and combined glottic-subglottic. Twenty patients had 21 lesions excised by 40 laser procedures. Eleven of 21 stenoses were successfully managed by carbon dioxide laser endoscopy: 3 of 3 supraglottic, 6 of 10 glottic, 2 of 4 subglottic, and 0 of 4 combined laryngeal/tracheal stenoses. Eleven of the 20 patients had significant airway improvement or decannulation. Soft tissue stenoses of the supraglottic area respond favorably to carbon dioxide laser excision. In other regions of the larynx, the use of supplemental stents, steroid injections, dilatations, and the micro-trapdoor surgical flap technique in scar stenosis may increase the rate of success. The lower success rate in the posterior commissure, subglottic, and combined laryngotracheal stenoses is due to the circumferential, thick stenosis with a vertical depth of more than 1 cm and the fibrotic fixation of the arytenoid cartilages. Small cicatrices appear to respond better to laser vaporization than the large ones which frequently recur.

Adolescent↗

PubMed1993

Airway protection during breath-holding.

Little is known about laryngeal function during breath-holding. The completeness of laryngeal closure during breath-holding is clinically relevant during the supraglottic swallow. To investigate this phenomenon, vocal cord position was studied prospectively in 10 adults during breath-holding using nasolaryngoscopy with video recording. The position of the vocal cords was not consistent during breath-holding. Some subjects closed the glottis, while others had variable amounts of glottic opening. Straining and vocalizing at the onset of breath-holding produced both glottic and supraglottic closure, increasing the number of levels of laryngeal closure during breath-holding. Nasolaryngoscopy can be used clinically to document the airway protection, the effects of various protective maneuvers, and any resulting aspiration during breath-holding and during the supraglottic swallow.

Adult↗

PubMed1997

Laryngeal adjustment in whispering magnetic resonance imaging study.

Previous studies confirmed that during whispering the glottis is kept open to prevent vocal fold vibration and the supraglottal structures are constricted. However, there has been no study exploring the exact contour of the laryngeal lumen in the frontal dimension during the production of whispering. In order to further elucidate the nature of the laryngeal adjustments regarding the contour of the laryngeal lumen in whispering, and the role of supraglottal constriction in particular, we conducted a physiological study using magnetic resonance imaging. According to the results, the supraglottal structures were not only constricted but also shifted downward, attaching to the vocal fold to prevent vocal fold vibration completely during whispering. The results suggested the underlying mechanism of suppression of vocal fold vibration during the production of whispering.

Humans↗

PubMed1997

Barrier between the supraglottis and the glottis: myth or reality?

Controversial opinions on the existence of a "barrier" between the supraglottic and glottic regions of the larynx are reported. Even if the two areas have different embryological derivations, there is no anatomic evidence of a "barrier" that could prevent supraglottic cancer from extending downward to the glottis. Numerous adequate pathologic studies, including whole organ sections, confirm that for advanced cancers, anatomic compartments delimiting the spread of the neoplastic process from the supraglottis to the glottis do not exist. Therefore, supraglottic laryngectomy should be performed not on the basis of embryological considerations, but on the basis of the actual extension of the neoplastic lesion.

Glottis↗

PubMed1986

The degree to which accuracy of preoperative staging of laryngeal carcinoma has been enhanced by computed tomography.

In this retrospective study, the accuracy of preoperative staging by high-resolution CT and clinical evaluation (indirect-direct laryngoscopy) is compared to the postsurgical pathologic staging of laryngeal cancer. Forty-two patients who were admitted to St. Louis University Hospital between the years of 1978 to 1985 with diagnoses of laryngeal cancer were included. All patients received high-resolution CT scan of the larynx preoperatively and subsequently underwent total or partial laryngectomy. None of these patients received preoperative radiotherapy. The accuracy of the clinical vs. CT staging--as well as the accuracy of the staging by combination of the two modalities--was determined by comparison with the postsurgical pathologic staging. The accuracy was assessed separately for glottic, supraglottic, and transglottic carcinoma. The accuracy of CT staging for glottic carcinoma was 75%. However, clinical evaluation in this group of lesions was very reliable, offering 92.9% accuracy. The accuracy of CT staging increased in the supraglottic and transglottic lesions, to become superior to the clinical staging. With combined information gained by both examinations, the preoperative staging accuracy was 91.4% for supraglottic carcinoma and 87.5% for transglottic carcinoma. It is, therefore, recommended that high-resolution CT should be included in the preoperative staging of laryngeal cancer.

Carcinoma↗

PubMed1999

Influence of gas density on simulated snoring.

According to a recent theoretical model, snoring is related to instability of the upper airway (UA). Factors promoting UA instability include increased gas density. The aim of this study was to test the influence of gas density on simulated snoring production and supraglottic resistance. Supraglottic pressure and flow rate (V') were measured in 10 healthy seated subjects during simulated snoring. Subjects breathed three different gas mixtures: Helium-oxygen, He 79%-O2 21% (He-O2); air; and sulphur hexafluoride-oxygen, F6S 79%-O2 21% (F6S-O2) administered in a random order. Supraglottic resistance (Rsg) was measured on its linear range during quiet breathing and V' was measured at the onset and middle of snoring. Linear Rsg increased and V' conversely decreased with gas density. These data are in agreement with predictions of a mathematical model of the upper airway showing that snoring occurs at lower flow rates when gas density is increased.

Adult↗