Subtotal laryngectomy with crico-hyoido-epiglotto-pexy for the treatment of extended glottic carcinomas.

We first described subtotal laryngectomy with crico-hyoido-epiglotto-pexy in 1974. This procedure is a modification of Majer's operation and results in the complete resection of the intact thyroid cartilage. The epiglottic petiole, the false cords, the true cords, and one arytenoid are also excised, along with the paraglottic space. The pharynx is closed by suturing the cricoid to the epiglottis and the hyoid bone. The neoglottis is occluded during deglutition by the epiglottis and the base of tongue, which come into contact with the remaining arytenoid. Postoperative hospitalization lasts approximately 3 weeks, and patients have a strong but deep voice. Between 1972 and 1985, we treated 104 patients with stage T2 and T3 lesions of the glottis using this method. A retrospective analysis showed that the overall survival rate of patients was 86% at 3 years and 75% at 5 years. Five patients experienced local recurrence. Seven patients had recurrences in the neck, and eight developed second primaries. Thirteen patients were lost to follow-up or developed intercurrent disease. Patients with T3NO lesions were treated with unilateral prophylactic neck dissection, and positive nodes were found in 23% of cases. We believe that the high proportion of positive nodes justifies routine prophylactic neck dissection in these patients. Because our operation is associated with good local control (5% recurrence rate), we propose that, for the treatment of extended glottic cancers, it replace transcartilaginous procedures that are associated with much higher recurrence rates.

Subtotal laryngectomy with cricohyoidopexy for supraglottic carcinoma: review of 61 cases.

BACKGROUND: Subtotal laryngectomy with cricohyoidopexy is a functional laryngectomy suitable for treatment of supraglottic carcinomas. This procedure consists of resection of the thyroid cartilage, the paraglottic space, the epiglottis, and the entire pre-epiglottic space. The cricoid cartilage, the hyoid bone, and at least one arytenoid cartilage are spared. METHODS: Between 1973 and 1990, we used subtotal laryngectomy with cricohyoidopexy to treat 61 successive patients with supraglottic carcinomas. The data were collected by a review of patient records. The cancers were stages T1 (2), T2 (41), T3 (14), and T4 (4), according to the 1979 American Joint Committee on Cancer staging criteria. RESULTS: No patient died postoperatively. Forty-nine (80%) were able to eat normally before the 28th day. A follow-up analysis showed survival rates of 83% at 3 years and 79% at 5 years. CONCLUSION: We propose subtotal laryngectomy with cricohyoidopexy for the surgical treatment of supraglottic carcinomas extending to the true vocal cord, the ventricle, and the posterior third of the false vocal cord.

Cricohyoidoepiglottopexy for glottic carcinoma with fixation or impaired motion of the true vocal cord: 5-year oncologic results with 112 patients.

The medical charts and operative files of 112 patients (combined inception cohort) with well to moderately differentiated invasive glottic squamous cell carcinoma presenting fixation (22) or impaired motion (90) of the true vocal cord (TVC) consecutively treated with cricohyoidoepiglottopexy (CHEP) at our institutions from 1972 to 1989 were retrospectively reviewed. A minimum 5-year follow-up was always achieved. The Kaplan-Meier 5-year actuarial survival, local recurrence, nodal recurrence, distant metastasis, and metachronous second primary tumor estimate for the entire group of patients were 84.7%, 5.4%, 6.4%, 1.2%, and 10.8%, respectively. The 5-year absolute and cause-specific survival rates were 85.5% and 94.1% for patients with fixation of the TVC and 81.3% and 96% for patients with impaired motion of the TVC. The 5-year actuarial local control rates for patients with fixation or impaired motion of the TVC were 95.4% and 94.4%, respectively. Local recurrence was statistically more likely in patients with positive margins (p = .007). Nodal recurrence was statistically more likely in patients with local recurrence (p = .005). Permanent tracheostomy related to postoperative laryngeal stenosis was requested in 2 patients. Aspiration-related completion total laryngectomy and/or permanent gastrostomy were never requested. Overall, local control and laryngeal preservation were achieved in 97.3%, and 95.5% of patients, respectively. At our institutions, the change from the conservative treatment modalities of radiotherapy and vertical partial laryngectomy to CHEP has brought about an increase in long-term survival, local control, and laryngeal preservation rates when compared to historical controls using vertical partial laryngectomy or radiotherapy.

Surgical treatment of angiofibromas of the nasopharynx--34 cases.

Between 1966 and 1987 we have treated 34 angiofibromas. The patients were between 9 to 28 years of age (average 16.5 years). The tumour extension was determined formerly by tomography and angiography, but these two methods have been replaced by angioscanning, which give the best results. Nineteen patients were classified stage I, fourteen stage II and one stage III. The surgical approach was transmaxillary in most cases. After tumour resection, two local recurrences were seen and a second operation was necessary to achieve a definitive cure in these patients.

[Neurinoma of the foramen laceratum (author's transl)]. / Les neurinomes du trou déchiré postérieur.

The clinical diagnosis of acoustic neuroma was suggested by the cochleovestibular symptomatology in a young woman who, was found indeed to have a neurinoma of the foramen laceratum. Such masquerading symptoms and signs are frequently reported (in one quarter of the cases) in these tumors, and probably partly explain their rarity, only 59 cases having been described. Tomography of the base of the skull appears as the main investigation leading to a correct diagnosis.

[Is endoscopy of the respiratory-digestive tract under general anesthesia useful in the screening for cancer of the superior respiratory-digestive tract synchronous with lung cancer?]. / L'endoscopie des voies aéro-digestives sous anesthésie générale est-elle utile au dépistage des cancers des voies aéro-digestives supérieures synchrones des cancers bronchiques?

The frequency of lung cancers associated with synchronous head and neck malignancies can be evaluated between 1.5 to 2%. The purpose of our work was to determine if complete endoscopic head and neck examination performed under general anesthesia was superior than clinical head and neck examination for the diagnosis of these synchronous additional tumors. From july 1991 to august 1992, we realised a prospective study on 58 consecutive patients suffering from pulmonary removable lung cancers. All the patients had a clinical head and neck examination during the preoperative period. Immediately before thoracotomy a complete endoscopy of head and neck aerian and digestive tract was performed. During this last examination 18 new macroscopical lesions were discovered in 13 patients: benign lesions (n = 17), oral cavity and laryngeal dysplasia (n = 1). The one gingivolingual sulcus carcinoma, already discovered by the clinical examination, was confirmed. This study suggests that complete head and neck endoscopy is not superior than clinical examination for the diagnosis of synchronous malignancies before lung cancers removal.

[Sphenoidal aspergillosis in a seed-shop keeper]. / Aspergillose sphénoïdale chez une grainetière.

Human infections due to Aspergillosis Fungi are unusual and occur preferentially in defenseless patients. Nonetheless, our patient, a seed-shop owner, was not immuno-depressed and became infected by inhaling or chewing the seeds. Moreover, the aspergillosis was situated in the sphenoidal sinus, which is extremely unusual. In fact, the initial pseudo tumoral and misleading appearance justified a surgical biopsy which revealed a black "truffle" suggestive of aspergillosis and was confirmed by anatomo-pathology.

[Midline congenital fistula of the nose]. / Les fistules congénitales médianes du dos du nez.

Midline congenital fistulae of the nose requires early diagnosis to avoid infectious complications. This dermoid cyst of the nose may have intracranial extension and is the consequence of an anterior neural tube closure abnormality. The authors report 2 cases revealed by ophthalmic complications. Computed tomographic scan or magnetic resonance imaging provides precise information concerning the extent. Surgical treatment is always necessary.

[Use of the PVC, a laryngoscope for difficult intubation]. / Utilisation du PCV, laryngoscope pour intubation difficile.

The PCV (Piquet-Crinquette-Vilette) laryngoscope has been designed for use in difficult endotracheal intubation in the adult. Its blade, 170 mm long, is curved, narrow (12 mm internal diameter) and semicircular in cross-section, like a closed C. An 8 mm endotracheal tube can be pushed through this blade. There is a cold light source. The use of this blade requires a teeth protector. The epiglottis will be lifted directly, and the blade will be moved into the vestibule, stopping short of the vocal cords. The endotracheal tube will then be introduced into the laryngoscope blade which guides it in between the cords. Once the tube has been checked to be within the trachea, the laryngoscope is removed by sliding the blade backwards over the tube. The PCV may be introduced into the mouth either on the right, or on the left, or behind the molar teeth, or between two teeth. It can held with the handle horizontal in case of a prominent sternum. The limits of this tool are a mouth opening of less then 20 mm, and some rare predictable difficulties which require an X-ray assessment to determine the best intubation technique to be used. Of 115 patients with a predicted difficult endotracheal intubation, fifty were intubated with the PCV without any failures. Also, twenty-five patients, out of thirty, were successfully intubated with the PCV after an attempt with a MacIntosh blade had failed. Of these five failures, one was never intubated by any technique whatsoever, two were intubated by fibroscopy and two by the ENT surgeon.

[Laser and glottis excision]. / Laser et exérèse glottique.

The CO2 laser is being used in several department for primary treatment of limited vocal cord carcinoma. The surgical resection is not the same in several department. One speaks of vaporisation, laser excision, cordectomy, deep cordectomy. The purpose of this paper is to definitive 3 types of laser surgery for glottic cancer = partial cordectomy, cordectomy with exposition, enlarged cordectomy. This classification allow to know with precision the importance of the surgical resection in each case.

[Non-chromaffin laryngeal paraganglioma. Clinical and electron microscopical study]. / Les paragangliomes non chromaffines du larynx. Etude clinique et en microscopie électronique

The authors describe the case of a 51 year-old woman presenting with a very large laryngeal paraganglioma in the aryepiglottic fold which had passed through the cricothyroid membrane and invaled the thyroid. A crico-hyoido-pexy enabled the tumour to by completely removed and anatomo-pathological examination showed degeneration. Under electron microscopy, the ultrastructure of the tumour was similar to that of chromaffin paragangliomas. It is three years since this patient was cured.

[Results of the surgical treatment of cancers of the supraglottic area]. / Les résultats du traitement chirurgical des cancers de l'étage sus-glottique.

The authors report a retrospective analysis of the results of surgery in 169 patients with supraglottic cancer referred to the Lille ENT clinic from 1976 to 1985. Partial surgery was performed in 53% of patients versus total laryngectomy in 47%. The 5 year survival rates in the patient groups treated by supraglottic laryngectomy and supracricoid laryngectomy with cricohyoidopexy were similar, 69.4% and 75.2%, respectively. The 5 year survival rate in the patient group treated by total laryngectomy or by total laryngectomy extended to the base of tongue was 62.8%.

[Liposarcoma of the infratemporal fossa. Apropos of a case]. / Liposarcome de la fosse infra-temporale. A propos d'un cas.

The authors report about one female patient with a liposarcoma of the right infratemporal fossa. Such tumors are rare, making up 10 to 12% of all soft-tissue sarcomas. Their occurrence in a cervical site is rare, unlike that in the inguinal region, the retroperitoneum or the lower limbs. Their diagnosis is mainly established by the histopathological study. Computed tomography and magnetic resonance imaging are particularly useful to choose the surgical approach. The technique chosen for this infratemporal tumor was a transmandibular cervical approach. Evolution was favorable, and the patient has currently had no reoccurrence after two years.

[Value of coral implant in the treatment of functional failure after subtotal laryngectomy with crico-hyoid fixation]. / Intérêt de l'implant de corail dans le traitement des échecs fonctionnels après laryngectomie subtotale avec crico-hyoido-pexie.

Subtotal laryngectomy with CHP have prolongated post operative care because aspiration. In 16% of cases a new surgical procedure is necessary. The authors have used a implant of madreporic coral placed in the base of the tongue just behind the hyoid bone to achieve a total closure of the larynx during swallowing. This operation has stopped aspiration in 2 cases very quickly.

[Nasopharyngeal fibroma (author's transl)]. / Le fibrome naso-pharyngien.

The authors report 17 cases nasopharyngeal fibroma treated between 1966 and 1978. Half of the cases developed before the age of 16, the other half occurring between 16 and 28 years. Arteriography was performed in only 8 cases and embolisation in 4 cases with 2 vascular accidents. Surgery was performed in 16 cases (15 Rouge Denker, 1 paralatero nasal). Invasion of the pterygomaxillary fossa was invariably found at operation. Amongst the patients treated by surgery, there was only one local recurrence and reoperation was successful. Finally, one patient with a very large fibroma with invasion of the temporal fossa was successfully treated by radiotherapy at a dose of 4 000 R.

[Subtotal laryngectomy in the treatment of extensive tumors of the larynx]. / La laryngectomie sub-totale dans le traitement des tumeurs étendues du larynx.

The authors assess the possibility to perform subtotal laryngectomy for extensive tumors of the endolarynx. They describe a particular variety of T3/T4 tumor extending anteriorly to the thyroid cartilage or to the pre-epiglottic space. Such tumors do not affect the arytenoid cartilages posteriorly, which makes functional subtotal laryngectomy with CHP or CHEP possible. This surgery was performed in 28 patients from 1972 to 1985, with 20 patients still living after 5 years, ie. 72% of all cases.

[Thyroplasty by external approach with silastic prosthesis in the treatment of laryngeal paralysis]. / Thyroplastie par voie externe avec prothèse en silastic dans le traitement des immobilités laryngées.

From August 1995 to January 1997 8 phonosurgical procedures were performed to correct glottal incompetence. There were 4 men and 4 women, the median age was 42 years. The most common indication for thyroplasty was recurrent or vagal nerve injury (6/8 cases). In 7 cases the paralyzed vocal cord was unilateral and in 1 case bilateral after oesophagectomy. Two patients were previously treated by endoscopic injection without success. The procedure was conducted under general anaesthesia. A window in the thyroid ala was created and silastic implant inserted. This technique was indicated to correct large glottal incompetence or in case of failure after endoscopic treatment. There have been no complications. Improvement of post operative voice was noted. The maximum phonation duration, intensity and objective voice measurements were improved in all cases.

[Epidermoid cysts of the mandible (author's transl)]. / Kystes épidermoïdes du maxillaire inférieur.

The authors present three cases of epidermoid cyst of the mandible, one of which had undergone malignant change. These cysts are rare. They are most often situated at the angle of the jaw and present as a deep swelling of the cheek. The only treatment is excision, the authors advising the external approach which gave them the best results.

[Treatment of bilateral laryngeal abductor paralysis (author's transl)]. / Le traitement des paralysies laryngées bilatérales en fermeture.

The authors report on their treatment of 39 patients with bilateral laryngeal abductor paralysis, observed over a 10-year period. Medical treatment was given in 5 cases, and tracheotomy was performed in 5. Ten patients underwent endoscopic surgery with very good results in 7. Arytenoidopexy was carried out by the extra-laryngeal route in 19 cases with 16 excellent results.

[Laryngectomy with Tucker's epiglottoplasty]. / Laryngectomie avec épiglottoplastie de Tucker.

From 1980 to 1987, 37 patients were operated with a reconstructive anterior frontal laryngectomy including epiglottoplasty such as described by Tucker. These patients presented with epidermoid carcinomas of the glottis. The carcinological results are satisfactory, with a survival rate of 33 of 37 patients at 3 years and 22 of 25 patients at 5 years. However, the control of the paraglottic space still is insufficient after this type of surgery, and we reserve it for the tumors confined to the glottic level, without impairment of mobility. The anterior frontal laryngectomy performed is extensive and frontolateral. It is used for a few of its former indications, as showed by the comparison of the periods before and after 1980.