CT-scan prediction of thyroid cartilage invasion for early laryngeal squamous cell carcinoma.

Treatment choice for laryngeal cancer may be influenced by the diagnosis of thyroid cartilage invasion on preoperative computed tomography (CT). Our objective was to determine the predictive value of CT for thyroid cartilage invasion in early- to mid-stage laryngeal cancer. Retrospective study (1992-2008) of laryngeal squamous cell carcinoma treated with open partial laryngectomy and resection of at least part of the thyroid cartilage. Previous laser surgery, radiation therapy, chemotherapy and second primaries were excluded. CT prediction of thyroid cartilage invasion was determined by specialized radiologists. Tumor characteristics and pathologic thyroid cartilage invasion were compared to the radiologic assessment. 236 patients were treated by vertical (20 %), supracricoid (67 %) or supraglottic partial laryngectomy (13 %) for tumors staged cT1 (26 %), cT2 (55 %), and cT3 (19 %). The thyroid cartilage was invaded on pathology in 19 cases (8 %). CT's sensitivity was 10.5 %, specificity 94 %, positive predictive value 13 %, and negative predictive value 92 %. CT correctly predicted thyroid cartilage invasion in only two cases for an overall accuracy of 87 %. Among the false-positive CT's, tumors involving the anterior commissure were significantly over-represented (61.5 % vs. 27 %, p = .004). Tumors with decreased vocal fold (VF) mobility were significantly over-represented in the group of false-negatives (41 vs. 13 %, p = .0035). Preoperative CT was not effective in predicting thyroid cartilage invasion in these early- to mid-stage lesions, overestimating cartilage invasion for AC lesions and underestimating invasion for lesions with decreased VF mobility.

Is open surgery for head and neck cancers truly declining?

In the past two decades, major modifications in the way we treat head and neck cancers, due to advances in technology and medical oncology, have led to a decline in the use of open surgery as first-line treatment of cancers arising from several primary tumor sites. The incidence of tobacco- and alcohol-related squamous cell carcinoma of the pharynx and larynx has been steadily decreasing, with a rise in the incidence of human papillomavirus-related oropharyngeal tumors and the use of minimally invasive endoscopic surgery and non-surgical treatment modalities has increased in the treatment of all of these tumors. However, open surgery remains the initial definitive treatment modality for other tumors, including tumors of the skin, oral cavity, sinonasal cavities and skull base, salivary glands, thyroid and sarcomas. Selected group of nasal, paranasal, base of the skull and thyroid tumors are also candidates for minimally invasive procedures. For some indications, the rate of open surgery has actually increased in the past decade, with an increase in the incidence of oral cavity, thyroid and skin cancer, an increase in the number of neck dissections performed, and an increase in salvage surgery and free flap reconstruction. The use of minimally invasive, technology-based surgery-with the use of lasers, operating microscopes, endoscopes, robots and image guidance-has increased. Technology, epidemiology and advances in other domains such as tissue engineering and allotransplantations may further change the domains of competencies for future head and neck surgeons.

Long-term acoustic comparison of thyroplasty versus autologous fat injection.

OBJECTIVES: Medialization by thyroplasty or intracordal autologous fat injection provides voice improvement in patients with unilateral vocal fold paralysis. Thyroplasty is considered a "permanent" medialization, whereas fat injection is considered "temporary" because of reabsorption. The objective of this study was to compare the evolution of acoustic parameters for these procedures over 1 year and to evaluate the results of fat injection at 2 years. METHODS: From 1994 to 1998, 46 consecutive patients (17 women and 29 men) were treated exclusively by intracordal injection of autologous fat, and then from 1999 to 2002, 48 consecutive patients (19 women and 29 men) were treated with the Montgomery Thyroplasty Implant System or Gore-Tex thyroplasty. Each patient's voice was prospectively recorded before operation and at 1,3, 12, and 24 months after operation. Six patients (13%) in the injection group underwent a second injection, and 1 patient (2%) in the thyroplasty group underwent revision surgery. Jitter, shimmer, and noise-to-harmonics ratio (NHR) were calculated for a 1000-ms midvowel segment of the vowel /a/. RESULTS: One month after operation, jitter, shimmer, and NHR were significantly improved in both groups (Wilcoxon's test, p < 0.05 in all cases). Jitter and shimmer did not change significantly between 1 and 3 months or between 1 and 12 months (p > 0.05). The NHR had improved at 12 months in both groups (injection, p = 0.0004; thyroplasty, p = 0.0178) and at 24 months in the injection group (p = 0.0076). No significant difference was noted between the two techniques before operation or at 1, 3, or 12 months after operation (Mann-Whitney test, p > 0.05). Jitter and shimmer had not changed significantly after 24 months in either group. At 24 months, there was no difference in acoustic parameters between the two treatment groups. CONCLUSIONS: The two techniques provided comparable objective acoustic voice improvement. At 2 years, autologous fat injection provides long-term acoustic voice improvement comparable to that of thyroplasty, but it has a higher rate of revision surgery.

Cardiac metastasis after squamous cell carcinoma of the base of tongue.

OBJECTIVES: Metastases to the heart are rare. We report a case of squamous cell carcinoma of the base of tongue secondarily complicated with cardiac metastasis 6 months after surgical treatment resulted in successful local control. METHODS: The lesion was found using computerized axial tomography in a patient with minimal cardiologic symptoms. RESULTS: The patient died shortly due to complications of his metastatic disease. No curative treatment was possible. CONCLUSIONS: Cardiac metastasis should be suspected when new cardiovascular symptoms are observed in patients with a history of head and neck neoplasm. The prognosis of the condition typically is inevitably fatal.

Prognostic value of tumor-infiltrating CD4+ T-cell subpopulations in head and neck cancers.

PURPOSE: CD4(+) T cells play a central role in initiating and maintaining anticancer immune responses. However, regulatory CD4(+)CD25(+) T cells which express Foxp3 have also been shown to inhibit antitumor effector T cells. In view of these heterogeneous CD4(+) T-cell populations, this study was designed to determine the prognostic value of various tumor-infiltrating CD4(+) T-cell populations in head and neck squamous cell carcinoma. EXPERIMENTAL DESIGN: Eighty-four newly diagnosed untreated patients with histologically proven primary head and neck squamous cell carcinoma were included in this study. Double or triple immunofluorescence staining was done to assess and quantify the activated CD4(+)CD69(+) T cells, regulatory CD4(+)Foxp3(+) T cells, and mixed CD4(+)CD25(+) T cells comprising both activated and regulatory T cells. RESULTS: On univariate analysis, high levels of tumor-infiltrating CD4(+)CD69(+) T cells were correlated with both better locoregional control (P = 0.01) and longer survival (P = 0.01). Infiltration by regulatory Foxp3(+)CD4(+) T cells was positively associated with a better locoregional control of the tumor. Multivariate analysis showed that the only significant prognostic factors related to locoregional control were T stage (P = 0.02) and CD4(+)Foxp3(+) T-cell infiltration of the tumor (P = 0.02). In the Cox multivariate analysis, only two variables influenced overall survival probability: T stage (P = 0.036) and CD4(+)CD69(+) T-cell infiltration (P = 0.017). CONCLUSION: This study shows that tumor-infiltrating activated CD4(+)CD69(+) T cells are associated with a good prognosis in head and neck squamous cell carcinoma. In addition, regulatory Foxp3(+)CD4(+) T cells are positively correlated with locoregional control may be through down-regulation of harmful inflammatory reaction, which could favor tumor progression.

Preservation of the marginal mandibular branch of the facial nerve using a plexus block nerve stimulator.

Preserving the marginal mandibular branch of the facial nerve is essential in submandibular neck dissection to avert disfiguring complications. Despite the high incidence of postoperative palsy, old-fashioned techniques of nerve identification remain widespread. The use of disposable plexus block nerve stimulators as a safe and accurate method to localize the nerve intraoperatively is suggested herein. Such devices are significantly more affordable and user-friendly than larger facial nerve monitoring devices, which are rather favored for those procedures more extensively jeopardizing the branches of the facial nerve. In this report, disposable stimulators led to successful identification of the nerve in 100% of 25 patients between 2003 and 2005, with no postoperative paralysis. In addition, stimulation devices are constantly gaining in reliability and safety, and the number of surgical fields supporting their use is expanding. Therefore, their routine use for surgery on the submandibular area is recommended by the authors.

Early-stage glottic cancer: oncological results and margins in laser cordectomy.

OBJECTIVES: To assess local control of early-stage glottic cancer by laser cordectomy in comparison with previously published external partial laryngectomy series and to determine the relevance of histological margins in glottic cancers excised with laser cordectomy. DESIGN: Retrospective review of laser cordectomy for carcinoma in situ (Tis) and stage T1 glottic cancer from January 1991 to January 2004. SETTING: University hospital. PATIENTS: Fifty-two patients with Tis or T1 glottic cancer. INTERVENTION: Endoscopic laser cordectomy, classified using the system proposed by the European Laryngeal Society Working Committee. MAIN OUTCOME MEASURES: Local control after initial surgery and after salvage compared with a published historical control group, according to the type of cordectomy performed and the histological margins of the removed specimen. RESULTS: Sixteen patients with Tis, 30 with T1a tumors, and 6 with T1b tumors were followed up for an average of 38 months. Type I cordectomy was the most common procedure used to treat Tis, and type II and type III were the most common for treating T1a and T1b tumors. Of 6 recurrences, 4 were treated with laser cordectomy and 2 were treated with external partial laryngectomy. The rate of laryngeal preservation was 100%. There were 3 recurrences despite histologically clear margins. Three (17%) of 18 patients with suspicious margins developed recurrences. The rate of local control with single intervention (46 [89%] of 52) was lower than with partial external laryngectomy. However, 46 (89%) of 52 patients ultimately had less tissue removed by laser than would have been removed by external partial laryngectomy. CONCLUSIONS: Laser cordectomy provides excellent local control and laryngeal preservation. Close follow-up of patients with positive or suspicious margins is an alternative to further routine treatment.

Fundamental frequency histograms measured by electroglottography during speech: a pilot study for standardization.

This study was designed to develop a database for the electroglottographic measurement of fundamental frequency (Fo) in normal subjects in running speech, for reference in the diagnosis and follow-up of dysphonic patients. A prospective pilot study included 20 healthy male volunteers without laryngeal disorder. Electroglottographic recordings of speaking Fo during connected speech (French) were obtained from two texts with different prosodic content. Fo histograms were sensitive to the variation of speaking Fo between both texts. Graphic representation of the range and distribution of the Fo of the speaker were designed as normalized Fo histograms with plot lines at 5th and 95th percentiles. Less than 5% variability of Fo histograms was recorded when recording more than 15 subjects. This pilot study designed a graphic display of standardized electroglottographic Fo measurements during the physiological condition of connected speech. As the degree of Fo variability depends on the phonetic contents of the text and on the language spoken, a separate histogram for normal subjects needs to be developed in each country or at least for each voice laboratory, with a standard, previously chosen text.

Clinical review: Current concepts in the management of unilateral recurrent laryngeal nerve paralysis after thyroid surgery.

OBJECTIVE: This study was designed to provide an update on the pathophysiological concepts and patient management in a common complication of thyroid surgery, unilateral recurrent laryngeal nerve paralysis (URLNP). METHOD: Recent publications in physiology and head and neck surgery were reviewed. RESULTS: Even for experienced surgeons, URLNP may occur after thyroid surgery, especially for thyroid cancer and in case of reoperation. URLNP is frequently well tolerated but may be life threatening by inducing aspiration pneumonia. Permanent URLNP may decrease quality of life by decreasing voice quality and increasing vocal effort. Spontaneous recovery of vocal function, with or without full recovery of vocal fold motion, may occur due to spontaneous axonal regrowth or other neurological phenomena. In the last decade, several surgical techniques have been developed to treat aspiration and poor voice quality due to URLNP by medialization of the paralyzed vocal fold. These techniques are simple, have a low complication rate, and are highly efficient in eliminating aspiration and improving voice quality and quality of life. CONCLUSIONS: The voice and swallowing handicap caused by URLNP may be efficiently treated by safe and simple techniques. The possibility to improve the quality of life should be proposed to all patients with symptomatic URLNP.

Laryngeal aerodynamics after vocal fold augmentation with autologous fat vs thyroplasty in the same patient.

OBJECTIVE: To analyze laryngeal aerodynamics in the same patient in 4 different circumstances: before the onset of unilateral vocal fold paralysis (UVFP), after the onset of UVFP, and after 2 types of surgical vocal fold medialization techniques to compare the results of surgery with the measurements made in that same patient when his larynx was healthy (before paralysis). DESIGN: Prospective self-paired study of 1 male patient. Measurements were taken before iatrogenic UVFP (of the patient's healthy larynx), 1 week after the onset of iatrogenic UVFP (thoracic surgery), 3 days after vocal fold medialization with autologous fat, and 2 months after polytetrafluoroethylene thyroplasty. SETTING: University hospital. MAIN OUTCOME MEASURE: Phonatory airflow and intraoral pressure. RESULTS: Airflow and intraoral pressure increased after the onset of UVFP. Airflow decreased to preparalytic values after both types of vocal fold medialization. Intraoral pressure decreased after fat injection but increased after thyroplasty, despite the favorable effects of this treatment on laryngeal resistance and vocal efficiency compared with preparalytic values. CONCLUSIONS: Our study demonstrates the variability of intraoral pressure as an indirect measure of subglottal pressure after vocal fold medialization in UVFP, due to as yet unknown factors. Phonatory airflow, laryngeal resistance, and vocal efficiency seem to be more reliable indicators of aerodynamic results after vocal fold medialization.

Phonetic effects of paralytic dysphonia.

OBJECTIVES: This study was performed to determine whether and how unilateral vocal fold paralysis (UVFP) affects the production and perception of voiced stop consonants as compared with unvoiced stops, and to analyze the phonetic effects of UVFP on the voicing feature. METHODS: Phonetic constructs pronounced by 7 male patients with UVFP and 5 normal male subjects were recorded. The 432 speech tokens consisted of intervocalic, prevocalic, and postvocalic stop consonants (/p/, /t/, /k/, /b/, /d/, /g/) in the vowel contexts /a/ and /i/. Perceptual consonant identification testing was performed with 5 voice and speech professionals as listeners. The type and frequency of errors made in consonant identification were analyzed. Spectrographic analysis was used to analyze acoustic cues. RESULTS: The rate of correct consonant identification was significantly lower for tokens pronounced by patients with UVFP (77.3% versus 97.6%, p = .0001) because of incorrect identification of the voiced consonants, frequently perceived as their unvoiced homologues. Confusion between dental and alveolar place of articulation for unvoiced stops was also noted. CONCLUSIONS: Unilateral vocal fold paralysis alters the voiced-unvoiced stop consonant distinction and the dental-palatal stop consonant distinction in an experimental nonspeech context. This finding implies the existence of a phonetic handicap for patients with UVFP. Further studies should determine the effects of UVFP on global speech intelligibility.

Contemporary Surgical Management of Early Glottic Cancer.

For early-stage T1-T2 glottic squamous cell carcinoma, transoral laser microsurgery (TLM) is the main surgical modality, with rates of local control and laryngeal preservation ranging from 85% to 100% and low morbidity. For extensive lesions, open conservation laryngeal surgery may enable wider resections than TLM but at costs of longer hospital stay and higher postoperative morbidity. Surgery provides results that are comparable to nonsurgical treatment options while reserving radiation therapy for recurrences or second primary cancers, particularly in younger patients. In the future, transoral robot-assisted surgery may enable more extensive transoral resections than laser alone, decreasing further the indications for open surgery.

Voice Outcomes of Transoral Laser Microsurgery of the Larynx.

Transoral laser microsurgery (TLM) is the mainstay in the treatment of early (TisT1T2) glottic cancer. Current knowledge concerning voice quality and voice-related quality of life in patients treated using TLM is based on small cohort studies using various instruments to evaluate these functional results. The bulk of the literature indicates that subjective and objective measurements of voice quality can return to normal or almost normal values after TLM, generally after 6 to 12 months and particularly after cordectomy types I, II, and III.

Variability of electroglottographic glottal closed quotients: necessity of standardization to obtain normative values.

OBJECTIVE: To demonstrate the variability of electroglottographic measurements of the glottal closed quotient (GCQ) in normal subjects by the calculation method used, fundamental frequency, and intensity. DESIGN: Prospective study. SETTING: Tertiary university-based referral center. SUBJECTS: Twenty healthy male volunteers without laryngeal disorder. Three successive sustained productions of the vowel /a/ were performed by each subject. Electroglottographic recordings of GCQ were obtained using the criterion level method, which defines an approximate duration of glottal closure and opening. Glottal closed quotient values were calculated based on criterion levels ranging from 10% to 40%. MAIN OUTCOME MEASURES: The extent of correlation between GCQ variation and the mean fundamental frequency and intensity. RESULTS: As the criterion level increased, a decrease in the mean GCQ was recorded, which was significant with a 10% criterion level increase, up to a critical level of 25%. A significant positive correlation was found between GCQ and the variables of fundamental frequency and intensity. CONCLUSIONS: This study demonstrated significant effects of the criterion level used, fundamental frequency, and intensity in the determination of normative values of GCQ. Normative values can only be assessed through the standardization of one criterion level reached by consensus.

Acoustic analysis of autologous fat injection versus thyroplasty in the same patient.

We objectively measured the acoustic effects of treatment of unilateral vocal fold paralysis by injection of autologous fat and by polytetrafluoroethylene thyroplasty, in the same patient. To our knowledge, this is the first report comparing the two techniques by using the patient's normal voice as the control. The voice of a male patient was recorded before and after onset of unilateral vocal fold paralysis, after treatment with autologous fat, and after polytetrafluoroethylene thyroplasty. Acoustic analysis was performed on a long-term average spectrum of text and on the MDVP (Kay Elemetrics) evaluation of the vowel /a/. Jitter and shimmer were not normalized, but they improved to a greater extent after fat injection. The cepstral peak prominence, spectral skewness, and long-term average spectrum returned to preparalytic values after both treatments, but improved to a greater extent after fat injection. This study showed that both techniques can return the voice to preparalytic values. Spectral measurements best reflected the voice improvement. Further prospective studies in a larger number of patients will be necessary to confirm these results and to determine the long-term objective voice outcome obtained with these techniques.

Thyroid cartilage invasion in early-stage squamous cell carcinoma involving the anterior commissure.

BACKGROUND: Anterior commissure (AC) carcinoma is in close proximity to the thyroid cartilage. Our objective was to evaluate risk factors for thyroid cartilage invasion. METHODS: This was a retrospective study of tumors involving the AC treated by open surgery. Tumor stage, extensions, vocal fold (VF) mobility, CT scan, and pathologic cartilage status were recorded. RESULTS: Ninety-four patients with clinical T (cT) classifications cT1b (44%), cT2 (50%), and cT3 (6%) were included. The incidence of thyroid cartilage invasion was 8.5%, significantly related to VF mobility, with invasion in 31% versus 5% with normal mobility (p = .002). Sensitivity, specificity, and positive and negative predictive values for decreased VF mobility were 50%, 90%, 31%, and 95%, respectively. After a median follow-up of 49 months, there was no difference in local control between tumors with or without cartilage invasion. CONCLUSIONS: For these tumors involving the AC, VF mobility was the only significant factor related to thyroid cartilage invasion and should be taken into consideration when planning surgery.

Evidence-based review of treatment options for patients with glottic cancer.

Evidence-based medicine integrates the best available data in decision making, with the goal of minimizing physicians' and patients' subjectivity. In 2006, the American Society of Clinical Oncology edited clinical practice guidelines for the use of larynx preservation strategies. The objective of this review was to evaluate the current levels of evidence for glottic squamous cell carcinoma. Current guidelines for early stage glottic cancer are based on low-level evidence. Conservation surgery (open or transoral) and radiation therapy are all valid options for T1 and selected T2 lesions. For advanced lesions, surgery and combined chemotherapy and radiation are options. High-level evidence favors combined chemotherapy and radiation therapy or altered fractionation radiation therapy as nonsurgical strategies for organ preservation, compared with radiation therapy alone. The optimal combination of chemotherapy, targeted therapy, and radiation therapy remains to be demonstrated, however, and for high-volume tumors, total laryngectomy may still be warranted.

Organ preservation surgery for laryngeal squamous cell carcinoma: low incidence of thyroid cartilage invasion.

OBJECTIVES/HYPOTHESIS: Determine the incidence and risk factors for thyroid cartilage invasion in early and midstage laryngeal cancer. STUDY DESIGN: Retrospective review. METHODS: A retrospective review was carried out of tumors treated by open surgery with at least partial resection of thyroid cartilage from 1992 to 2008. Preoperative laser, radiation therapy, or chemotherapy were excluded. Tumor stage, anterior commissure involvement, vocal fold (VF) mobility, computed tomography (CT) scan, and pathological cartilage status were recorded. RESULTS: Three hundred fifty-eight patients were treated for tumors staged cT1 (32%), cT2 (53%), and cT3 (15%) by vertical (26%), supracricoid (62%), or supraglottic partial laryngectomy (12%). The thyroid cartilage was invaded in 8.9% of cases. Abnormal VF mobility was significantly related to thyroid cartilage invasion (Fisher exact test, P = .0002). Neither anterior commissure involvement nor CT scan were related to cartilage invasion. CONCLUSIONS: Thyroid cartilage invasion was rare but increased if VF mobility was impaired. This has implications for transoral resection, which unlike open surgery avoids unnecessary cartilage resection.