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PubMed2004

The treatment of early laryngeal cancers (T1-T2 N0): surgery or irradiation?

BACKGROUND: Carcinoma of the larynx is the most common cancer affecting the head and neck region. In Northern Europe, early laryngeal cancer is almost universally treated by irradiation, but elsewhere it is treated by surgery. The main aim of this study was to determine whether there was any difference in survival between the two main therapeutic options. The secondary aim was to assess speech and voice quality in a small, randomized sample of patients from each treatment group. METHODS: The subjects investigated were 488 patients with T1-2, N0 squamous cell carcinoma of the larynx. The patients form an unselected sequential group of our institution's experience with treating this disease over three decades. Four hundred nineteen patients were treated by irradiation, and 69 were treated with surgery. Most surgical patients were treated earlier in the series, whereas radiotherapy later became the treatment of choice. The primary outcome measures were recurrence at the primary site, recurrence in the neck, and tumor-specific survival. The secondary outcome measure was speech and voice quality. Statistical analysis was by univariate and multivariate analysis of association and survival. Surgery included horizontal or vertical partial laryngectomy and various minor procedures on the glottis, including cordectomy. Over a 30-year period, radiotherapy was administered to a dose of 60-66 Gy given over 30-33 daily fractions. RESULTS: Surgery tended to be performed early on in the series and radiotherapy thereafter. Surgery was more likely to be carried out for supraglottic disease. These differences apart, the radiotherapy and surgery groups of patients were well matched. The 5-year tumor-specific survival for those treated by irradiation was 87% and for surgery it was 77% (p=.1022). Glottic cancer and T1 disease were associated with high 5-year survivals: 90% and 91%, respectively. Supraglottic site and T2 disease both had a poorer prognoses: 79% and 69%, respectively. The differences for both sets of data were significant. There was no significant difference in primary site recurrence rates for the two treatment modalities, but regional recurrence was higher in the surgery group. Further analysis demonstrated that this was not a function of surgery per se but rather of the unit's policy toward the N0 neck at the time surgery was carried out. Regarding speech and voice quality, radiotherapy was far superior to surgery. All patients in the radiotherapy group but only 3 of 10 in the surgery group were judged to have a good or normal voice (p=.0017). CONCLUSIONS: Both surgery and irradiation are equally effective at treating early laryngeal carcinoma. Speech and voice were highly significantly better in patients treated by irradiation than in those treated by surgery.

Carcinoma, Squamous Cell↗

PubMedDate not supplied

Needle aspiration biopsy of the pre-epiglottic space.

Clinical staging of supraglottic carcinoma requires evaluation of the pre-epiglottic space (PES). To explore the role of fine needle aspiration biopsy of the PES in the staging of epiglottic carcinoma, endoscopic transvallecular fine needle aspiration biopsies of the PES were performed in 16 patients with epiglottic carcinoma. The results of aspiration cytology were compared with CT scanning and postoperative histopathologic sections of the PES after total or supraglottic laryngectomy. This preliminary report shows that needle aspiration biopsy of the PES is a safe and sensitive technique, having a high correlation with histopathologic follow-up. Needle biopsy, along with CT scan, is clinically useful in staging the PES, which cannot be examined directly.

Aged↗

PubMedDate not supplied

Pearson near-total laryngectomy: a reproducible speaking shunt.

BACKGROUND: Since 1980, Pearson and his associates at the Mayo Clinic have accrued an increasing number of patients whom they have treated with what is now designated as a "near-total" laryngectomy rather than a total laryngectomy. Despite the positive reports of the value of this procedure in providing speech by an internal shunt, the use of this total laryngectomy alternative has not gained wide acceptance. We report our experience with treating 11 patients during a 3-year period using the near-total laryngectomy. METHODS: Between September 1989 and September 1992, 11 patients with the following anatomic lesions were offered and accepted the option of the near-total laryngectomy: (1) T3 or early T4 glottic squamous cell carcinoma that did not involve the interarytenoid space or the vocal process of the opposite arytenoid; (2) T3 supraglottic squamous cell carcinoma with a fixed vocal cord in which a supraglottic laryngectomy could not be performed; (3) T2, T3 pyriform sinus squamous cell carcinomas; (4) radiotherapy failure early glottic lesions in which a vertical hemilaryngectomy for salvage was not able to be performed and met the requirements in (1); and (5) large hypopharyngeal lesions in which the larynx would be sacrificed to prevent aspiration but was not involved with tumor. RESULTS: Nine of 11 patients (82%) attained successful speech in an average of 5.3 months. Two of the 11 patients required a completion laryngectomy, both due to wound complications. All but two of the patients received postoperative radiotherapy. Of the nine successful speakers, five have had an occasional droplet of fluid through the shunt; three have been on a permanent basis and two transient. Eighty-nine percent of the speaking patients (8 of 9) are alive without disease, a mean of 25.5 months after therapy completion. CONCLUSION: The near-total laryngectomy can be performed outside the Mayo Clinic with creditable results, with 82% of the patients attaining successful speech, an average of 5.3 months postoperatively. Eighty-nine percent of the speakers have had a mean disease-free survival of 25.5 months. Analysis of larger series from multiple institutions in conjunction with voice analyses of these patients compared to those with tracheoesophageal punctures is needed to confirm our initial enthusiasm for this procedure.

Carcinoma, Squamous Cell↗

PubMed1988

The acoustic role of tracheal chambers and nasal cavities in the production of sonar pulses by the horseshoe bat, Rhinolophus hildebrandti.

The acoustic role of the enlarged, bony, nasal cavities and rigid tracheal chambers in the horseshoe bat, Rhinolophus hildebrandti (Fig. 2) was investigated by determining the effect of their selective filling on the nasally emitted sonar pulse and on the sound traveling backwards down the trachea. Normal sonar signals of this bat contain a long constant frequency component with most energy in the second harmonic at about 48 kHz. The fundamental is typically suppressed 20 to 30 dB below the level of the second harmonic (Fig. 1). None of the experimental manipulations described affected the frequency of the sonar signal fundamental. Filling the dorsal and both lateral tracheal chambers had little effect on the emitted vocalization, but caused the level of the fundamental component in the trachea to increase 15 to 19 dB in most bats (Table 2). When only the dorsal chamber or only the two lateral chambers were filled, the effect was less striking and more variable (Tables 3 and 4), suggesting that the tracheal fundamental is normally suppressed by acoustic interaction between these three cavities. Filling the enlarged dorsal nasal cavities had no effect on the tracheal sound. The effect of this treatment on the nasally emitted sonar pulse was inconsistent. Sometimes the fundamental increased 10 to 12 dB, other times the intensity of all harmonics decreased; in still other cases the second, third or fourth harmonic increased, but the fundamental remained unchanged (Tables 5, 6, and 7). When bats were forced to vocalize through the mouth, by sealing the nostrils, there was a prominent increase in the level of the emitted fundamental (10 to 21 dB) and in the fourth harmonic (6 to 17 dB). In one instance there was also a significant increase in the level of the third harmonic (Tables 8 and 9). The supraglottal tract thus filters the fundamental from the nasally emitted sonar signal, although the role of the inflated nasal cavities in this process is unclear. We conclude that a high glottal impedance acoustically isolates the subglottal from the supraglottal vocal tract. The tracheal chambers do not affect the emitted sonar signal, but may attenuate the fundamental in the trachea and prevent it from being reflected from the lungs back towards the cochlea. It may be important to prevent the reflected fundamental from stimulating the cochlea, via tissue conduction, along multiple indirect pathways which would temporally smear cochlear stimulation.(ABSTRACT TRUNCATED AT 400 WORDS)

Animals↗

PubMed2005

Airway control via the CobraPLA during percutaneous dilatational tracheotomy in five patients.

PURPOSE: To evaluate the use of the new supraglottic airway device CobraPLA (CPLA) for performing percutaneous dilatational tracheotomy (PDT) utilizing continuous fibreoptic visualization of the larynx and trachea and uninterrupted airway control. CLINICAL FEATURES: The percutaneous tracheotomies were carried out in five patients (four males and one female; mean age 72 yr, mean height 164.6 cm, mean weight 74 kg) following the Griggs technique under continuous fibreoptic vision and airway control provided by the CPLA. The mean time required for removal of the ETT, positioning of the CPLA, and confirmation of adequate ventilation and cuff seal was 78 sec. The mean time for the entire PDT procedure was six minutes and 57 sec. In one patient a 7-mm tracheostomy cannula was used, and in the other four patients an 8-mm cannula was used. The hemodynamic and respiratory variables remained stable during the entire procedure; there were no adverse events. At no point was there any significant difficulty in placing the CPLA or in providing ventilation or oxygenation. Each procedure could be observed easily in its entirety through the FOB. CONCLUSIONS: This technique can be considered simple and safe because it is video-assisted and ensures a continuous airway control. The CPLA offers several advantages over some other supraglottic devices when performing this surgical procedure.

Aged↗

PubMedDate not supplied

Preemptive vessel dilator cricothyrotomy aids in the management of upper airway obstruction.

PURPOSE: Our objective was to demonstrate that preemptive vessel dilator cricothyrotomy may be useful when managing the patient with airway obstruction. METHODS: An Institutional Review Board approved retrospective study was undertaken in 88 patients for whom this technique was selected. The anesthesiologists and surgeons identified as authors were directly involved in the care of these patients. All vessel dilator cricothyrotomies were performed in the operating rooms of University Hospital, UAB, Medical Center. The patients selected for this airway management technique were afflicted with some type of supraglottic lesion, usually squamous cell carcinoma, which was obstructing their airways to an extent that complete airway obstruction during induction of anesthesia was a significant possibility. Prior to induction of anesthesia, the vessel dilator was inserted into the tracheal lumen through the cricothyroid membrane as described. Oxygenation was maintained with jet ventilation from a Sanders jetting device. Age, sex, weight, initial and lowest O(2) saturation, first recorded ETCO(2), blood pressure and duration of jet ventilation were recorded. RESULTS: The airways were successfully managed in all 88 patients with this technique. There were no deaths, and no postoperative hypoxic sequelae; also complications were minor. CONCLUSION: Vessel dilator cricothyrotomy as a preemptive procedure in the management of patients with significant supraglottic airway obstruction may be a useful addition to the anesthesiologists' armamentarium of airway management devices.

Adult↗

PubMedDate not supplied

Hypercapnic respiratory failure and partial upper airway obstruction during high frequency oscillatory ventilation in an adult burn patient.

PURPOSE: To present a case of severe hypercapnic respiratory failure in an adult burn patient and to describe our clinical problem solving approach during support with an unconventional mode of mechanical ventilation. CLINICAL FEATURES: A 19-yr-old male with smoke inhalation and flame burns to 50% total body surface area was admitted to the Ross Tilley Burn Centre. High frequency oscillatory ventilation (HFOV) was initiated on day three for treatment of severe hypoxemia. By day four, the patient met consensus criteria for acute respiratory distress syndrome. On day nine, alveolar ventilation was severely compromised and was characterized by hypercapnea (PaCO(2) 136 mmHg) and acidosis (pH 7.10). Attempts to improve CO(2) elimination by a decrease in the HFOV oscillatory frequency and an increase in the amplitude pressure failed. An intentional orotracheal tube cuff leak was also ineffective. A 6.0-mm nasotracheal tube was inserted into the supraglottic hypopharynx to palliate presumed expiratory upper airway obstruction. After nasotracheal tube placement, an intentional cuff leak of the orotracheal tube improved ventilation (PaCO(2) 81 mmHg) and relieved the acidosis (pH 7.30). The improvement in ventilation (with normal oxygen saturation) was sustained until the patient's death from multiple organ dysfunction four days later. CONCLUSION: During HFOV in burn patients, postresuscitation edema of the supraglottic upper airway may cause expiratory upper airway obstruction. The insertion of a nasotracheal tube, combined with an intentional orotracheal cuff leak may improve alveolar ventilation during HFOV in such patients.

Accidents, Traffic↗

PubMed2006

[Leiomyosarcoma of the larynx].

Leiomyosarcoma is usually found in the female genital tract, retroperitoneum, the wall of the gastrointestinal tract and subcutaneous tissues. An appearance of this malignant tumor in the larynx is extremely rare and may be difficult to diagnose. Because of its rarity, little information exists on management and prognosis. We report on a 64-year old male with a supraglottic leiomyosarcoma who was treated with supraglottic laryngectomy and postoperative radiotherapy. After 19 months the patient was well and free of disease. The most commonly used diagnostic and therapeutic procedures are analysed in a review of the 46 published cases of laryngeal leiomyosarcoma.

Combined Modality Therapy↗

PubMed2000

[Enlarged ventricular sacculus in laryngeal carcinoma--in increased risk in tumor surgery].

The case of a 60-year-old female patient with a supraglottic larynx carcinoma (T3N2CM0) and bilateral enlargement of the laryngeal sacculus is presented. On one side, the sacculus opened atypically into the left vestibular fold. The sacculus is a physiologic part of the roof of Morgagni's ventricle, the size of which can vary greatly. These canal-like structures can be the point of origin of cysts, laryngoceles, mucoceles, and pyoceles. Laryngoceles are present in about 5% of larynx carcinomas; their cause is not precisely known. Frequently, a computer tomogram suggests the coincidence of larynx carcinoma and laryngoceles or a large laryngeal sacculus. In oral panendoscopy, these ventricular distensions are difficult to detect even using 70 degrees rigid endoscopes. A planned supraglottic partial resection must take into account early tumor growth along the performed canals in the preepiglottic space. In this patient, a laryngectomy was performed due to the bilateral involvement of the vocal process and the anterior commissure.

Carcinoma, Squamous Cell↗

PubMed1998

Upper airway obstruction and pulmonary abnormalities due to lymphoproliferative disease following bone marrow transplantation in children.

We report three patients who developed severe supraglottic airway obstruction due to Epstein-Barr virus lymphoproliferative disease following allogeneic bone marrow transplantation. In addition to enlarged pharyngeal lymphoid tissue seen in all three patients, two had supraglottic airway narrowing and two developed pulmonary lymphoproliferative disease. They were treated with unmanipulated T cells or EBV-specific cytotoxic T lymphocytes. Life-threatening upper airway obstruction is a radiologically detectable complication of allogeneic bone marrow transplantation in children.

Adolescent↗

PubMed2001

MR imaging of primary malignant lymphoma in the larynx.

We present MR findings in a patient with primary laryngeal lymphoma. The MR images showed a homogeneous mass in the right supraglottic larynx extending to the true vocal cord through the paraglottic space, of which signal intensity was intermediate both on T1- and T2-weighted images. The tumor was moderately enhanced and preserved mucosal layers were demonstrated as hyperintense bands on gadolinium-enhanced fat-suppressed T1-weighted images. Primary laryngeal lymphoma should be included in the differential diagnosis for a homogeneous solid mass in the supraglottic submucosal area.

Aged↗

PubMed2007

Surgical treatment of exercise-induced laryngeal dysfunction.

A method for combined ergo-spirometry and continuous laryngeal inspection during exercise, entitled continuous laryngoscopy exercise test (CLE-test) has been developed in order to study airway obstruction at the laryngeal level during exercise. The aim of the study was to apply the CLE-test on patients experiencing respiratory distress during exercise in order to reveal the usefulness of the CLE-test both as a diagnostic tool in the selection of patients for surgery and in evaluation of treatment effects postoperatively. Until now, 81 patients with a history of exercise-induced stridor have undergone the CLE-test. Ten of these patients were selected for surgical treatment based on the severity of symptoms and their motivation for treatment. All ten patients underwent endoscopic supraglottoplasty (ES), with laser incision in both aryepiglottic folds anterior to the cuneiform cartilages and removal of the mucosa around the top of the tubercles. Each patient was examined by the CLE-test before and 3 months after surgery. Eight patients felt subjectively that their breathing capacity during exercise was improved. When pre- and postoperative ergo-spirometry evaluations were compared, increased peak oxygen consumption was observed in four out of ten patients and better maximal minute ventilation in seven out of ten. Postoperative evaluation of the laryngeal images showed less prominent aryepiglottic folds. The typical adduction of the supraglottic structures concomitant with inspiratory stridor found preoperatively was not present in any of the patients during exercise postoperatively. The ES procedure is an efficient surgical treatment for exercise-induced laryngeal supraglottic obstruction and the CLE-test eases the selection of patients for surgery and facilitates the evaluation of treatment effects.

Adolescent↗

PubMed1999

Prognostic significance of histopathological parameters in cancer of the larynx.

In this study we investigated the prognostic significance of differentiation, the mode of tumor invasion to surrounding tissues, the microscopic appearance of tumor, peritumoral lymphocytic infiltration and cartilage involvement according to disease-free survival, and the recurrence and presence of cervical lymph node metastasis in cancer of the larynx. Only the mode of tumor invasion to surrounding tissues was significantly related to survival (P < 0.05). The patients with "well-defined margin" tumors survive significantly longer than those with "groups of cells, no distinct margin." Patients with supraglottic tumors and a mode of invasion other than "well-defined margin" have a significantly higher risk of recurrence (P < 0.05) and therefore require adjuvant therapy. Patients with poorly differentiated, cartilage invading, ulcerative supraglottic tumors, and patients with glottic tumors having diffusely infiltrating margins, certainly need elective neck dissection (P < 0.05). According to the multivariant analysis, none of the factors significantly affect disease-free survival independently (P > 0.15). According to multiple logistic regression and cox regression analysis, in decreasing order of significance, the mode of invasion, microscopic tumor appearance and lymphocytic infiltration significantly affect the recurrence and time between surgery and the development of recurrence independently (P < 0.15).

Adult↗

PubMed1999

The value of CT scans in improving laryngoscopy in patients with laryngeal cancer.

This retrospective study assessed the value of computed tomography (CT) scan with contrast in improving the staging accuracy of indirect and direct laryngoscopy. We compared the preoperative staging obtained by the two latter procedures with postoperative histopathological findings in 187 patients operated on for laryngeal cancer. Of these cancers, 98 were supraglottic, 82 glottic and 7 subglottic in origin. The staging accuracy of laryngoscopy was 51.3% and CT was 70.1%. When the two procedures were combined, the staging accuracy was 80.2%. The accuracy of the CT increased from glottic to supraglottic to subglottic tumors, although the accuracy of laryngoscopy decreased in the same direction. Laryngoscopy alone tended to understage larger tumors (pT3 and pT4), whereas CT underestimated the smaller ones (pT1 and pT2). Our data suggest that in order to plan the best treatment both laryngoscopy and CT should be used in making the diagnosis.

Adult↗

PubMed1999

Changing trends in the occurrence and subsite distribution of laryngeal cancer in Finland.

Cancer of the larynx represents worldwide approximately 1-2% of all cancers and generally occurs predominantly in males. Based upon many reports, the age-adjusted incidence of laryngeal cancer has been rising in recent years, especially among women. Squamous cell carcinomas arising in the glottic region are the most common of all laryngeal cancers and more prevalent than the supraglottic ones. Subglottic disease is still rare. The Finnish Head and Neck Oncology Group evaluated the present occurrence of laryngeal cancer by site and gender in Finland. The annual age-standardized incidence of laryngeal cancer is 3.2 per 100,000 for men and 0.3 per 100,000 for women. The proportion of females in the five university centers reviewed was 5%. During the 30-year time period from the early 1960s to the 1990s there has been a significant decrease in the laryngeal cancer incidence rates for males, but no change for females. Finland thus seems to be the only Western country with clearly declining occurrence rates in recent decades. In the same time period a clear decrease in the incidence of bronchial cancer has occurred in males and an increase in females. The results also show that in all five university hospital districts glottic cancer became more common (50-68%) in the late 1980s and 1990s, which is opposite to the situation in the 1960s when supraglottic localizations (65%) dominated in Finland.

Adult↗

PubMed2002

Laryngopharyngeal dysmotility in multiple sclerosis.

This study investigated the swallowing physiology of 13 patients [age 27-69 years (mean = 45 years)] with multiple sclerosis (MS) who had Kurtzke Extended Disability Status Scale (EDSS) scores ranging from 2 to 9 (mean = 6) and who complained of difficulty swallowing. Videofluoroscopic recordings of the patients' calibrated liquid and paste bolus swallows were analyzed and compared with published normative data. Results showed that swallowing physiology was disordered in the 13 MS patients with severity level ranging from mild to severe. Eleven patients had primary pharyngeal dysphagia. 1 patient had primary laryngeal dysphagia, and 1 patient had primary oral dysphagia. Laryngeal dysmotility, the predominant anterior pharyngeal segment dysfunction, was evidenced in all 13 patients with MS. They displayed significantly longer-than-normal pharyngeal delay times, shorter-than-normal time intervals from onset of laryngeal excursion to return to rest. and longer-than-normal time intervals between airway closure at the arytenoid to epiglottic base and upper esophageal sphincter opening. Pharyngeal constrictor dysmotility, the predominant posterior pharyngeal segment dysfunction, was observed in 11 of the 13 MS patients. A significant relationship was found between the severity of the MS patients' functional swallowing impairment and posterior pharyngeal segment dysfunction. Material penetrated the supraglottic airway of 9 patients with 1 patient aspirating. A significant relationship was observed between supraglottic penetration and brainstem dysfunction. No significant relationship was found between severity of dysphagia and neurological disability as measured by EDSS scores or neurological impairment as measured by Functional System (FS) scores. Disturbed neuromotor sequencing of laryngeal events and a progression in neuromotor weakening of the pharyngeal constrictors were suggested from the findings.

Adult↗

PubMed2002

Early laryngeal cancer.

For early-stage laryngeal cancer, both surgery and radiotherapy are effective treatment modalities, offering a high rate of local control and cure for this select group of patients. The probability of obtaining local control for early glottic cancer is similar when comparing the results of radiation therapy, cordectomy, and hemilaryngectomy. Radiation therapy has been the treatment of choice for all previously untreated T1 and T2 vocal cord cancers at our institution. We currently treat most patients with irradiation and consider transoral laser excision for the small subset of patients with well-defined T1 tumors that are limited to the mid-third of the cord. In this area, excision will not significantly diminish voice quality. Stage I and stage II supraglottic cancers may be treated with either radiation therapy alone or with a supraglottic laryngectomy with bilateral selective neck dissections (levels II-IV). In experienced hands, transoral laser excision also is an acceptable alternative for selected lesions. Overall, approximately 80% of patients at our institution are treated initially by irradiation.

Health Behavior↗

PubMed1999

Conservation laryngeal surgery.

Conservation laryngeal surgery is an increasingly available alternative for treatment of laryngeal cancer. In addition to the traditional techniques of vertical partial laryngectomy (hemilaryngectomy) and supraglottic laryngectomy, new techniques are now in practice that extend the indications to a far greater number of patients. The carbon dioxide laser is used to resect both glottic and supraglottic cancers. This procedure is best applied to early stage I and stage II cancers. Reports indicate superior functional outcome to open surgical procedures, with shorter hospital duration, less morbidity, and equivalent survival rates. The supracricoid partial laryngectomy is becoming increasingly popular for intermediate extent tumors. This novel procedure allows resection of transglottic tumors and tumors with vocal cord paralysis while preserving the patient's speech and swallowing and avoiding a permanent tracheal stoma.

Carbon Dioxide↗