Open partial horizontal laryngectomies: a proposal for classification by the working committee on nomenclature of the European Laryngological Society.

We present herein the proposal of the European Laryngological Society working committee on nomenclature for a systematic classification of open partial horizontal laryngectomies (OPHL). This is based on the cranio-caudal extent of laryngeal structures resected, instead of a number of different and heterogeneous variables present in existing nomenclatures, usually referring to eponyms, types of pexy, or inferior limit of resection. According to the proposed classification system, we have defined three types of OPHLs: Type I (formerly defined horizontal supraglottic laryngectomy), Type II (previously called supracricoid laryngectomy), and Type III (also named supratracheal laryngectomy). Use of suffixes "a" and "b" in Type II and III OPHLs reflects sparing or not of the suprahyoid epiglottis. Various extensions to one arytenoid, base of tongue, piriform sinus, and crico-arytenoid unit are indicated by abbreviations (ARY, BOT, PIR, and CAU, respectively). Our proposal is not intended to give a comprehensive algorithm of application of different OPHLs to specific clinical situations, but to serve as the basis for obtaining a common language among the head and neck surgical community. We therefore intend to present this classification system as a simple and intuitive teaching instrument, and a tool to be able to compare surgical series with each other and with non-surgical data.

[Recent advances in the treatment of laryngeal and hypopharyngeal carcinoma]. / Aktuelle Therapieoptionen bei Larynx- und Hypopharynxkarzinomen.

The prognosis of squamous epithelial cell carcinoma of the upper aerodigestive tract has improved considerably in the last 30 years. Patients presenting with stage I or II disease are treated with surgery or radiation therapy with curative intent. Although the efficacy is comparable between the two methods, surgery is usually preferred so that the side effects and late toxic effects of radiation can be avoided. For the treatment of advanced stages of disease, surgery, radiotherapy, chemotherapy and immunotherapy are usually combined. The introduction of concurrent administration of chemotherapy and radiotherapy (chemoradiotherapy) has been a major advancement. This has resulted in local control and survival rates comparable to those seen following radical surgery and postoperative radiotherapy, but with preservation of the larynx in most patients. However, recent epidemiological observations have shown declining survival rates in laryngeal cancer patients, raising concern about uncritical and too frequent use of this approach. The rationale for choosing treatment options for patients with laryngeal and hypopharyngeal carcinoma is discussed.

Single modality and multimodality treatment of nasal and paranasal sinuses cancer: a single institution experience of 229 patients.

AIMS: To assess the single and multimodal treatment results and prognostic factors for sinonasal carcinoma. METHODS: Overall survival (OS), disease-specific survival (DSS), local control (LC), and disease-free survival (DFS) in 229 patients with sinonasal carcinoma treated from 1967 to 2003 were calculated. Prognostic factors were univariately and multivariately analyzed. The median follow-up period for survivors was 126 months. RESULTS: 32% of the patients were operated only, 47% underwent multimodal therapy, and 20% were treated without operation. The 5-year OS rate was 41%, and the DSS rate was 51%. The LC rate was 64%, and the DFS rate was 34%. Prognostic for DSS were M status (p<0.001), UICC stage (p<0.001), T classification (p=0.001), N status (p=0.002), intracranial tumor infiltration (p=0.008), infiltration of the pterygopalatine fossa (p=0.02), infiltration of the skull base (p=0.021), infiltration of the orbita (p=0.041), and the type of therapy (p<0.001): The 5-year DSS rate was 63% for patients operated only, 56% for all operated patients, 46% for patients undergoing surgery and radiotherapy, but only 21% for patients treated with radiotherapy+/-chemotherapy. Multivariate analysis revealed that T classification (p=0.042), N classification (p=0.035), M classification (p=0.007), UICC stage (p=0.038), and type of therapy (p=0.038) were independent prognostic factors for DSS. CONCLUSIONS: Radical surgery is recommended for stage I/II sinonasal carcinomas. Stage III/IV carcinomas still have a poor prognosis, but multimodal treatment seems to favor the outcome.

Intensified hyperfractionated accelerated radiotherapy limits the additional benefit of simultaneous chemotherapy--results of a multicentric randomized German trial in advanced head-and-neck cancer.

PURPOSE: To demonstrate the efficacy of radiochemotherapy (RCT) as the first choice of treatment for advanced unresectable head-and-neck cancer. To prove an expected benefit of simultaneously given chemotherapy, a two-arm randomized study with hyperfractionated accelerated radiochemotherapy (HF-ACC-RCT) vs. hyperfractionated accelerated radiotherapy (HF-ACC-RT) was initiated. The primary endpoint was 1-year survival with local control (SLC). METHODS AND MATERIALS: Patients with Stage III and IV (UICC) unresectable oro- and hypopharyngeal carcinomas were randomized for HF-ACC-RCT with 2 cycles of 5-FU (600 mg/m(2)/day)/carboplatinum (70 mg/m(2)) on days 1--5 and 29--33 (arm A) or HF-ACC-RT alone (arm B). In both arms, there was a second randomization for testing the effect of prophylactically given G-CSF (263 microg, days 15--19) on mucosal toxicity. Total RT dose in both arms was 69.9 Gy in 38 days, with a concomitant boost regimen (weeks 1--3: 1.8 Gy/day, weeks 4 and 5: b.i.d. RT with 1.8 Gy/1.5 Gy). Between July 1995 and May 1999, 263 patients were randomized (median age 56 years; 96% Stage IV tumors, 4% Stage III tumors). RESULTS: This analysis is based on 240 patients: 113 patients with RCT and 127 patients with RT, qualified for protocol and starting treatment. There were 178 oropharyngeal and 62 hypopharyngeal carcinomas. Treatment was tolerable in both arms, with a higher mucosal toxicity after RCT. Restaging showed comparable nonsignificant different CR + PR rates of 92.4% after RCT and 87.9% after RT (p = 0.29). After a median observed time of 22.3 months, l- and 2-year local-regional control (LRC) rates were 69% and 51% after RCT and 58% and 45% after RT (p = 0.14). There was a significantly better 1-year SLC after RCT (58%) compared with RT (44%, p = 0.05). Patients with oropharyngeal carcinomas showed significantly better SLC after RCT (60%) vs. RT (40%, p = 0.01); the smaller group of hypopharyngeal carcinomas had no statistical benefit of RCT (p = 0.84). For both tumor locations, prophylactically given G-CSF was a poor prognostic factor (Cox regression), and resulted in reduced LRC (log-rank test: +/- G-CSF, p = 0.0072). CONCLUSION: With accelerated radiotherapy, the efficiency of simultaneously given chemotherapy may be not as high as expected when compared to standard fractionated RT. Oropharyngeal carcinomas showed better LRC after HF-ACC-RCT vs. HF-ACC-RT; hypopharyngeal carcinomas did not. Prophylactic G-CSF resulted in an unexpected reduced local control and should be given in radiotherapy regimen only with strong hematologic indication.

Emergency stenting of malignant obstruction of the upper airways: long-term follow-up with two types of silicone prostheses.

OBJECTIVE: We evaluated the long-term prognosis of stents placed on an emergency basis in the trachea and its bifurcation for malignant stenosis. METHODS: We retrospectively analyzed all bronchologic treatments of obstructing airway lesions from January 1993 to December 1995. RESULTS: We report on 10 patients with severe malignant "mixed-type" obstruction of the proximal trachea or distal trachea plus both main-stem bronchi. They had far-advanced inoperable tumor (esophageal cancer: n = 4; lung cancer: n = 3; recurrent laryngeal, uvula, and thyroid cancer: n = 1 each). Emergency treatment consisted of a dilating bougie maneuver followed by the insertion of a large one-way (n = 4) or Y-shaped silicone prosthesis (n = 6). After the intervention, there was a long-lasting clinical improvement. Median survival from stent insertion was 8 months for all patients irrespective of tumor type; it was 5 months for patients with lung carcinoma and 8 months for those with esophageal cancer. The results are in accordance with other studies using different therapeutic modalities. Stent exchange was necessary in five patients. Main reasons were continuing tumor growth beyond the proximal and distal boundaries and recurrent productive bronchial infection. Patients died of pneumonia (n = 4), pulmonary lymphatic spread (n = 1), cardiac failure (n = 2), and fatal hemorrhage (n = 1). As of December 1995, three patients were still alive 2, 5, and 8 months after implantation. CONCLUSIONS: As evidenced by clinical efficiency and length of palliation, endoscopic placement of silicone-based one-way and bifurcational prostheses in far-advanced tumor of the central airways is technically feasible and ethically justifiable.

Clinical and laboratory evaluation of a new thin-walled self-expanding tracheobronchial silicone stent: progress and pitfalls.

BACKGROUND: Although widely established in the management of malignant airway lesions, currently available tracheobronchial prostheses made of silicone have their drawbacks resulting from rigidity and wall thickness. Therefore we present clinical follow-up data obtained with a novel thin-walled expandable prototype silicone airway stent (Polyflex stent, Willy Rüsch AG, Kernen, Germany) in 19 patients. METHODS: Seventeen of 19 patients had tracheobronchial complications of infiltrating cancer: five had respiratory-digestive fistulas, 14 had mixed-type obstructions (mucosal infiltration plus extrinsic compression), and two had diffuse tracheal hemorrhages from the tumor surface (three patients had more than one complication). Two of 19 patients had benign postintubation stricture and malacia. Overall, 33 stents were implanted either simultaneously or in a consecutive manner. Scanning electron microscopy was performed both on prototype stents and on other available silicone stents for comparison. RESULTS: The treatment improved the patients' clinical condition substantially. The mechanical properties of the new prosthesis were excellent. Important stent-associated side effects were early mucus retention (n = 7), infolding of the inner silicone layer (n = 2), and stent dislodgment (n = 2). As of February 1997, 10 patients have died of causes unrelated to stent placement. Seven patients with malignant airway disease are still alive from 2 weeks up to 7 months after initial treatment. Scanning electron microscopy of explanted and unused prototypes suggested that an extremely ragged luminal microstructure may contribute to the firm adhesion of secretory material and that technical smoothing of the surface avoids such complications. CONCLUSIONS: The novel self-expandable silicone airway stent may be a promising addition to commonly used stent types. Short-term and medium-term management of fistulas, tumor surface bleeding, and strictures (malignant and benign) is satisfactory. Scanning electron microscopy of stents provides information on peculiar features of microstructure and material that may be of use in clinical research and technical innovation.

Atresia of the trachea following repeated percutaneous dilational tracheotomy.

Percutaneous dilational tracheotomy (PDT) and conventional tracheostomy are still competing methods to provide an airway for intensive care patients requiring assisted ventilation. Tracheal stenosis is a late complication for any tracheostomy and long-term intubation. However, late complications in PDT have not been extensively studied. This article is the first to report on total atresia of the subglottic larynx and cervical trachea after PDT. The dimension of the lesion is visualized by three-dimensional reconstructed CT scan. The etiology of this condition is discussed.

Hypothyroidism after therapy for larynx and pharynx carcinoma.

Early detection of local and regional recurrence is the main goal during follow-up of patients with larynx and pharynx cancer. Hypothyroidism occurring in those patients stays frequently undiagnosed as screening for hypothyroidism is not part of the routine follow-up. This study was performed to assess the prevalence of hypothyroidism in these patients. We included 120 patients (106 male, 14 female) with larynx or pharynx cancer treated more than 2 months earlier (mean = 41 months) in the study. Cancer treatment consisted of either surgery (n = 44), radiotherapy (n = 15), or surgery combined with postoperative radiotherapy (n = 61). In all patients, thyroid function studies (thyrotropin [TSH], free triiodothyronine [FT3], and free thyroxine [FT4]) were performed. Twenty-six of all patients (22%) were hypothyroid; in two patients hypothyroidism was diagnosed postoperatively and these two patients were on replacement therapy with thyroid hormones. The highest rate of hypothyroidism (34%) was present in patients treated with surgery combined with radiotherapy, whereas among patients treated with surgery only 7% were hypothyroid (p < 0.001). There was no difference in the duration of follow-up between therapy and inclusion in the study between those two groups. Two of 15 patients treated only with radiotherapy were diagnosed hypothyroid, but in this group the latency was shorter (p < 0.05). The results indicate that thyroid function studies should be routinely performed in the follow-up of head and neck cancer patients, especially if radiotherapy was part of the treatment.

Prognostic significance of Ki-67 (MIB1), PCNA and p53 in cancer of the oropharynx and oral cavity.

Up to now results concerning the prognostic value of tumor proliferation markers in squamous cell head and neck carcinoma have been equivocal. Beside biological reasons, different treatment modalities are hypothetically responsible for contradictory findings. The aim of this study was to investigate the relationship between proliferative capacity, represented by the immunohistochemical labeling index of proliferation markers Ki-67, PCNA and p53 status, and treatment failure in a matched-pair study design of recurrent and non-recurrent carcinoma initially treated with primary surgery combined with curative post-operative radiation. From a group of 239 patients with T1-T3 carcinoma of the oropharynx or oral cavity, 28 patients with recurrent disease were selected and matched with 28 patients with non-recurrent disease regarding stage and location of tumor as well as age and therapy. All patients received primary surgery combined with post-operative radiation. Immunohistochemistry determined the p53 status and the PCNA and MIB1 (Ki-67) labeling index. The Ki-67 labeling index was significantly (p=0.032) higher in tumors from patients suffering from treatment failure (mean=59. 1%) than in non-failures (mean=50.5%). Carcinoma with a Ki-67 (MIB1) labeling index above the median (53.7%) of the general study population showed a mean time to relapse of 45 months (n=25), whereas mean time-to-relapse was 61.7 months for those cases (n=31) below the median of the general study population (p=0.029). The PCNA labeling index did not correlate significantly with tumor recurrence (mean=50.2% for treatment failures, 45% for non-failures, p=0.31), nor with time-to-relapse (p=0.26). Forty-six percent of tumors showed p53 over-expression. However, there was no significant correlation between p53 over-expression and tumor recurrence or time-to-relapse. We present the largest series of oropharyngeal and oral cavity carcinoma investigated by immunohistochemistry in a controlled study. We conclude that a high Ki-67 labeling index is an indicator for treatment failure in these patients. Like other investigations for different head and neck subsites, we found no relationship between p53 or PCNA status and tumor prognosis. Our data, obtained from a group of patients treated with a combination of surgery and post-operative irradiation, show that for squamous cell carcinoma of the oropharynx and oral cavity the detection of Ki-67 is an unfavorable prognostic factor.

Transoral CO2 laser for surgical management of glottic carcinoma in situ.

OBJECTIVES/HYPOTHESIS: In carcinoma in situ (CIS) tumors malignant cells have not penetrated the basement membrane and therefore have no metastatic potential. Treatment strategies of CIS are topics of ongoing discussion. The aim of this study was to evaluate long-term results of CO2 laser therapy in laryngeal CIS. METHODS: From 1986 to 1995, 29 patients with glottic CIS with a minimum follow-up of 2 years were treated initially with transoral CO2 laser surgery and were included is this series. RESULTS: A complete removal of the tumor was possible with superficial laser cordectomy in 21 patients and with subligamental laser cordectomy in 8 cases. There was no tumor-related death in this series. Repeated laser resections were performed in four patients for local recurrences. No patient required total laryngectomy or radiotherapy during a follow-up ranging from 25 to 143 months. CONCLUSIONS: Local control rates presented in this study are superior to those previously reported with conventional surgery and similar to those after radiotherapy. The ultimate rate of larynx preservation was seven times higher than reported after radiotherapy. Our results add further support to the observation that laser surgery is the best treatment option for CIS of the larynx. Based on the material of this study, recommended treatment for CIS is CO2 laser resection in combination with a meticulous follow-up for early recognition of local recurrence.

Transoral laser resection with staged discontinuous neck dissection for oral cavity and oropharynx squamous cell carcinoma.

Transoral laser resection of oral cavity and oropharynx squamous cell carcinoma (OOSCC) is a widely accepted approach in the absence of cervical lymph node metastases. This study investigated the results of transoral laser surgery and discontinuous neck dissection (ND) for OOSCC with clinically obvious or suspected cervical node metastases. One hundred seventeen patients with infiltrating oral carcinoma were treated for cure with transoral resection of the primary and staged ND. Twenty-nine primaries were classified as T1, 50 as T2, 35 as T3, and 3 as T4. Lymph node metastases were identified in the ND specimen of 36 patients. All patients were followed for a minimum of 3 years unless they died. Estimated tumor-related survival after 5 years is 81% for stage I and II disease of the oral cavity, 86% for stage I and II disease of the oropharynx, 73% for stage III disease of the oral cavity, 65% for stage III disease of the oropharynx, and 21% for stage IV disease of the oral cavity and the oropharynx. Local and regional control of cancer was achieved in 72 (62%) of the 117 patients. Forty-five local and regional recurrences were diagnosed during the follow-up period. Two patients died of distant metastases with no evidence of local or regional recurrence. The combination of transoral laser resection and staged ND for the treatment of OOSCC seems to offer satisfactory cure rates for a selected group of patients. These two minor surgical interventions cause less morbidity than commando-type surgery and lead to low perioperative mortality and morbidity.

Ki-67 (MIB1), p53, and Lewis-X (LeuM1) as prognostic factors of recurrence in T1 and T2 laryngeal carcinoma.

OBJECTIVES: Recently published data suggest a prognostic value of immunohistochemical proliferation markers for limited laryngeal carcinoma. Previous studies have reported contrasting findings on this issue. In this context, different treatment modalities may be responsible for contradictory findings. To study the relationship between proliferative activity--expressed by the immunohistochemical labeling index of proliferation-associated markers Ki-67 (MIB1), Lewis-X (LeuM1), and proliferating cell nuclear antigen (PCNA) and by p53 status--and treatment failure in a matched-pair study on recurrent and nonrecurrent T1 and T2 glottic carcinoma having received primary transoral laser surgery. METHODS: Twenty-one patients with tumor recurrence were randomly selected and matched with 26 patients with nonrecurrent disease regarding histopathological grading and age. MIB1 staining was used to determine the Ki-67 labeling index, and LeuM1 staining for detecting the Lewis-X antigen; immunohistochemistry determined the p53 status and PCNA labeling index. RESULTS: The Ki-67 labeling index was significantly (P = .001) higher in tumors from patients who had treatment failure (mean = 20.02%) than in patients who did not fail treatment ("nonfailures") (mean = 9.95%). Carcinoma with a Ki-67 (MIB1) labeling index above the median (15%) of the general study population showed a mean time to relapse of 23 months (n = 21), compared with 50 months for cases (n = 26) below the median (P = .016). PCNA labeling index correlated less impressively with tumor recurrence (mean = 28.59% for treatment failures, mean = 21.75% for nonfailures, P = .022). Positive detection of the Lewis-X antigen was significantly associated with recurrence (P = .015) and time to relapse (P = .006). Status of p53 was not a significant prognostic factor. CONCLUSION: The Ki-67 (MIB1) labeling index may be associated with early relapse of limited laryngeal carcinoma treated with transoral laser surgery. Since the prognostic relevance of Ki-67 seems to be different for radiological and surgical concepts of treatment, Ki-67 might become useful as criterion of therapy selection. The Lewis-X antigen, for the first time used on laryngeal carcinoma, seems to be a strong prognostic marker deserving further investigations.

Measuring in situ central airway resistance in patients with laryngotracheal stenosis.

OBJECTIVES: To evaluate a newly developed bronchoscopic technique for the assessment of intratracheal pressures. STUDY DESIGN: In situ measurement of central airway resistance in 20 consecutive spontaneously breathing subjects. Thirteen patients had benign glottic or subglottic stenosis. Seven patients without central airway disease served as normal control subjects. METHODS: A pressure catheter was introduced into the trachea via the working channel. The pressure swing was measured upstream and downstream of the stenosis. Central airflow was monitored simultaneously using a commercial pneumotachograph attached to a mouthpiece. Data acquisition frequency was 500 Hz. Prestenotic and poststenotic inspiratory and expiratory resistances could be calculated and displayed from the raw data off-line. RESULTS: Inspiratory and expiratory resistances measured in mid-trachea or below the stenosis (subglottic) were 0.36 +/- 0.13 and 0.35 +/- 0.13 kPa.s/L for the control subjects (C), 1.11 +/- 0.47 and 0.65 +/- 0.26 kPa.s/L for patients who did not need to be operated on (NOOP), 7.11 +/- 7.19 and 3.35 +/- 2.25 kPa.s/L respectively for those who required surgical correction (OP). Supraglottic inspiratory and expiratory resistances for C were 0.22 +/- 0.09 and 0.25 +/- 0.06 kPa.s/L, for NOOP 0.15 +/- 0.10 and 0.14 +/- 0.11 kPa.s/L, and for OP 0.26 +/- 0.13 and 0.24 +/- 0.07 kPa.s/L respectively. The cut-off point for surgical correction was estimated to be > 2.5 kPa.s/L of inspiratory resistance. Concurrent expiratory values showed a considerable overlap between OP and NOOP. No correlation could be established between local resistance values and dyspnea score. CONCLUSIONS: In situ subglottic flow-pressure tracing in spontaneously breathing patients who present with benign obstruction of the upper airways is well tolerated and may help to identify patients who need surgical correction.

Bone density measurements of the paranasal sinuses on plastinated whole-organ sections: anatomic data to prevent complications in endoscopic sinus surgery.

OBJECTIVE/HYPOTHESIS: Although anatomic data regarding the gross anatomy of the paranasal sinuses are available, severe complications of endonasal sinus surgery (ESS) are frequently reported. To understand and to avoid these complications, density of bony walls of the paranasal sinuses were studied in this report. Special attention was given to the analysis of the bone density in regions where minor and major complications occur in ESS. METHODS: Thirty cadaver heads were embedded in epoxy resin. The plastic blocks were sectioned with a diamond-coated wire saw into 1.0-mm thick, parallel slices in axial, coronal, and sagittal planes for 10 specimens each. The slices were x-rayed and scanned with a computerized image analyzing system. For each specimen the bone density in 12 regions of interest was measured. RESULTS: Besides the macroscopic examination of the plastinated specimens, a bone density analysis based on x-ray films is presented. Lowest bone density was found at the lateral wall of the sphenoid sinus (3.31 +/- 0.99 mm aluminum [Al]); highest density was measured at the roof of the sphenoid sinus (12.91 +/- 1.75 mm Al). Overall bone density in female specimens was 0.41 mm Al (mean) lower than in male specimens. CONCLUSIONS: This study is the first to use plastinated whole-organ serial sections and bone density images for the analysis of potential complications in ESS. The illustration of regions with minor and major bone density of the paranasal sinuses and the ethmoid floor as presented in this study may help the novice sinus surgeon to minimize the risks of ESS and to avoid severe complications.

Hyoid bone malformation confirmed by 3-dimensional computed tomography.

We describe the case of a young woman with pain on turning her head attributable to a malformation of the hyoid bone. Diagnosis was established using spiral computed tomography with the patient's neck in the position of greatest discomfort and with 3-dimensional reconstruction of the hyoid bone. Prior conventional radiography and magnetic resonance imaging did not aid in finding a diagnosis. After surgical removal of both greater cornua of the hyoid bone there was a complete relief of symptoms.

Cricoid cartilage necrosis after arytenoidectomy in a previously irradiated larynx.

Several open and endoscopic surgical techniques are available to provide an adequate airway for patients with bilateral vocal cord paralysis. Transoral laser arytenoidectomy has repeatedly been reported to be a reliable and effective minimally invasive procedure for airway restoration. To our knowledge, there have been no previous reports of serious complications, other than poor vocal results, aspiration, and failed decannulation in individual patients, that have resulted from this intervention. We report a case in which arytenoidectomy led to severe complications and death. Prior irradiation is suspected to be a causative factor. To prevent such an outcome, we believe that operative settings should be chosen that avoid deep thermal injury of the laryngeal framework.

Prognostic value of laryngeal electromyography in vocal fold paralysis.

OBJECTIVE: To analyze the value of electromyography in predicting recovery from acute neurogenic vocal fold paralysis. STUDY DESIGN: Prospective case series. SETTING: University-based hospital of otorhinolaryngology-head and neck surgery. PATIENTS: Ninety-eight patients (56 women, with a mean age of 62.2 years; 42 men, with a mean age of 39.8 years) with 111 paralyzed vocal folds. The causes were varied, with thyroid surgery (53 cases) and idiopathic palsy (18 cases) being the predominant factors. INTERVENTION: Prognostication was based on electromyography performed no earlier than 14 days after onset of palsy. Findings were classified as neurapraxy, axonotmesis, and neurotmesis. Prognosis is inherent in this classification, since neurapraxy is presumed to resolve completely within 8 to 12 weeks, whereas axonotmesis is most likely to be followed by impaired vocal fold mobility. MAIN OUTCOME MEASURES: Vocal fold mobility after 6 months. RESULTS: In 102 vocal folds, some palsy of various degree persisted after 6 months. Free mobility of the paralyzed vocal fold was restored in 9 cases. By means of laryngeal electromyography, defective recovery, defined as absence of completely free vocal fold mobility, was predicted correctly in 94.4% of cases (68/72). For complete recovery, prognosis was accurate in only 12.8% of cases (5/39). CONCLUSIONS: The detection of neural degeneration by laryngeal electromyography allows the prediction of poor functional outcome with sufficient reliability in an early phase of the disease process. Conversely, the absence of signs of degeneration does not imply that complete recovery is to be expected.

Endoscopic laser resection of supraglottic carcinoma.

Forty-six patients with infiltrating supraglottic carcinoma were treated prospectively for cure between 1986 and 1992 with transoral laser resection of the primary. Nine primaries were classified as T1, and 37 as T2. Thirty-three had staged unilateral or bilateral neck dissections, and 16 had postoperative radiotherapy. All patients were followed up for 2 to 8 years unless they died. Of the 46 patients, 33 are alive without disease, 8 died with disease, and 5 died of intercurrent disease. Among the 8 patients who died with disease, 4 had uncontrollable local or regional recurrences, and 4 had distant metastases but were free of local or regional recurrence. Calculated overall survival was 59% and adjusted survival was 72% after 5 years. Four patients had tracheostomies perioperatively, and 2 required temporary postoperative tracheostomies. The remaining 40 patients needed no artificial airway other than orotracheal intubation for the endolaryngeal intervention. Thirty-seven patients relearned undisturbed deglutition within 2 weeks from surgery, and 4, within 4 weeks. However, 5 (10.9%) patients failed to relearn swallowing and consecutively underwent "completion" total laryngectomy. Among them were the two patients who had previously had unsuccessful surgical or radiologic treatment of their primaries and the patient with a history of oral cavity carcinoma. This study confirms that transoral laser resection can effectively control early supraglottic carcinoma. Tracheostomies are not routinely required, and phonatory function is not compromised. However, transoral laser resection could not steadily preserve undisturbed deglutition in the patients included in this study. Patients with histories of unsuccessful attempts of other larynx-sparing therapeutic modalities or of previous major head and neck interventions were not successfully managed with transoral laser resection in this series. Criteria for patient selection remain to be established.

Phonatory results after laser surgery for glottic carcinoma.

OBJECTIVE: To identify the influence of type and extent of surgery on postoperative voice parameters after endoscopic laser resection for glottic carcinoma. SETTING AND DESIGN: A multidisciplinary university-based head and neck cancer center. Objective and subjective measures of voice were correlated with type and extent of surgery following a standardized classification in a prospective study including 80 patients. SUBJECTS AND METHOD: The postoperative mechanism of phonation was assessed by videostroboscopy 6 months after surgery at the earliest. A phonetogram was produced, and its area was calculated (relative phonetogram (RP)) in relation to a gender-different normal phonetogram. Two speech therapists (ST) and a trained otolaryngologist (TO) rated each voice independently for communication ability in a grade from 1 (poor) to 5 (near normal). RESULTS: After simple cordectomy the means were as follows: RP = 24.8%, TO = 3.26, and ST = 3.33. When the anterior commissure was completely preserved, mean results were better (RP = 34%, TO = 3.92, ST = 3.83). Results were worse after extended cordectomy (RP = 14.7%, TO = 2.82, ST = 3.00) and transglottic resection (RP = 13.7%, TO = 2.30, ST = 2.86) but were similar within these two groups. The parameters RP TO, and ST do not differ significantly between the group who had speech therapy after surgery (n = 33) and the group who did not (n = 47). Voice production at glottic level yields better results for every parameter than supraglottic substitute phonation. The amount of tissue removed was less significant. CONCLUSION: Postoperative phonatory results correlate with the postoperative mechanism of phonation. There is no linear correlation with the amount of tissue removed. Comparison of similar types of resection preservation of the anterior commissure plays a key role. From the data in this study, there is no evidence for a significant benefit from speech therapy. The parameter RP is an effective and relatively simple parameter to complete auditory voice assessment.