Endoscopic CO2 Laser Resection Using the Inversion Technique in 22 Combined Laryngoceles.

OBJECTIVE: To demonstrate the feasibility of transoral resection of, even large, combined laryngoceles by endoscopic CO2 laser resection using the inversion technique. METHODS: A retrospective study over a 25-year period of 20 patients with 22 combined laryngoceles. All patients were operated on using the CO2 laser inversion technique. Pre- and postoperative computed tomography (CT)-scans or magnetic resonance (MR) imaging were available in all patients. RESULTS: There were no surgical problems during all procedures. One patient required a tracheotomy pre-operatively due to a compromised airway. All procedures were without intraoperative complications. Postoperatively, there were two complications: one hemorrhage, and one patient developed a granuloma with airway compromise. In two patients, residual disease was detected on postoperative imaging. One of them was re-operated several years later due to the progression of this residual external component of the laryngocele. One patient had a non-significant small internal laryngocele recurrence. The recurrence rate in this series was 2/22 (9.1%). The majority of patients (15/20) could be discharged from the hospital the day after surgery. CONCLUSION: The results of this study show excellent control of combined laryngoceles using the CO2 laser inversion technique, with a short hospital stay and a low rate of complications and recurrence. Even in large combined laryngoceles, CO2 laser excision using the inversion technique should be considered. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:2742-2746, 2023.

Transtracheal Use of the CriCath Cannula in Combination With the Ventrain Device for Prevention of Hypoxic Arrest due to Severe Upper Airway Obstruction: A Case Report.

A patient recently treated with surgery and radiation for oropharyngeal cancer presented with impending hypoxic respiratory and cardiac arrest in a difficult airway scenario. A CriCath cannula in combination with the Ventrain device and its active expiratory ventilation technology enabled oxygenation and ventilation for 60 minutes until a surgical airway was established. This case report is the first to describe the intended use of Ventrain technology in an emergent "can't ventilate-can't intubate" scenario.

Prospective evaluation of voice outcome during the first two years in male patients treated by radiotherapy or laser surgery for T1a glottic carcinoma.

In this prospective cohort study, we assessed voice outcome in patients before and up to 2 years after treatment for early glottic cancer either by radiotherapy or by laser surgery; 106 male patients, treated for T1aN0M0 glottic cancer either by endoscopic laser surgery (n = 67) or by radiotherapy (n = 39), participated in the study. Patients' voices were recorded and analysed pre-treatment and 3, 6, 12 and 24 months post-treatment at their routine visit at the outpatient clinic. Average fundamental frequency (F0), percent jitter, percent shimmer and normalized noise energy (NNE) were determined. After 2 years, local control rate was 95% in the radiotherapy group and 97% in the laser surgery group. Larynx preservation rate was 95% after radiotherapy and 100% after laser surgery. Voice outcome recovers more quickly in patients treated with laser surgery in comparison to radiotherapy: 3 months after laser surgery there is no longer a difference with regard to normal voices except for the fundamental frequency, which remains higher pitched, even in the longer term. For patients treated with radiotherapy it takes longer for jitter, shimmer and NNE to become normal, where jitter remains significantly different from normal voices even after 2 years. According to these results, we believe that laser surgery is the first treatment of choice in the treatment of selected cases of T1a glottic carcinomas with good functional and oncological results.

Long-term efficacy of voice therapy in patients with voice problems after treatment of early glottic cancer.

OBJECTIVE: The purpose of the present pilot study is to investigate whether the beneficial short-term effects of voice therapy in patients with voice problems after treatment of early glottic cancer as reported in our earlier study remain present on the long term. STUDY DESIGN: In this prospective study, 12 patients, selected based on a screening questionnaire about voice problems and randomly assigned for treatment with voice therapy (vs no treatment), were evaluated with a mean of 13 months after finishing voice therapy to evaluate the long-term voice effects. METHODS: Voice assessment consisted of the Voice Handicap Index (VHI) and acoustic analyses (percent jitter, percent shimmer, and noise-to-harmonics ratio). RESULTS: Statistical analysis showed that the beneficial short-term effect on the mean VHI, percent jitter, and shimmer remained stable after more than a year of follow-up. CONCLUSIONS: The present study provides initial evidence that the beneficial effect of voice therapy is not just a short-lived voice improvement but may result in a better voice for a period of at least 1 year. Future long-term randomized controlled trials are needed to confirm our findings.

Endoscopic carbon dioxide laser Zenker's diverticulotomy revisited.

OBJECTIVES: We assessed the efficacy of endoscopic Zenker's diverticulotomy with the carbon dioxide (CO2) laser and Acuspot and compared it with the historical results of using a CO2 laser without Acuspot and electrocautery diverticulotomy. METHODS: Between 1976 and 2005, a total of 229 endoscopic Zenker's diverticulotomies in 189 patients were performed in our institution. Since 1995, micro-endoscopic diverticulotomy with the CO2 laser and Acuspot (MEDCO2A) has been performed in 61 cases. Between 1984 and 1995, micro-endoscopic diverticulotomy with the CO2 laser (MEDCO2) was performed in 113 cases. Before 1984, endoscopic diverticulotomy with electrocautery (EDE) was performed in 55 cases. All patients had radiologically proven Zenker's diverticula. We recorded preoperative and postoperative complaints of dysphagia, the frequency of recurrence in long-term follow-up, postoperative tube feeding, non-oral intake, days of admission, and complications. RESULTS: After operation, dysphagia was absent in 84.6% of MEDCO2A cases, 78.4% of MEDCO2 cases, and 72.0% of EDE cases. Repeat surgery was required in 13.0% of MEDCO2A cases, 19.6% of MEDCO2 cases, and 24.3% of EDE cases. Five patients developed mediastinitis (2 MEDCO2 cases and 3 EDE cases); none died as a consequence. In 1 patient, squamous cell carcinoma was found in the diverticulum. CONCLUSIONS: The technological improvement of the CO2 laser with Acuspot has further increased the efficacy of its use over that of methods previously used in our institution. The results and complications rate are comparable to those reported for endoscopic stapler diverticulotomy in the literature.

Clinical evaluation of a membrane-based voice-producing element for laryngectomized women.

BACKGROUND: A newly developed artificial voice source was clinically evaluated in laryngectomized women for voice quality improvements. The prosthesis was placed in a commercially available, tracheoesophageal shunt valve. METHODS: In 17 subjects, voice-producing element (VPE) prototypes were compared with the subject's regular tracheo-esophageal shunt voice in a randomized cross-over trial. The evaluation was based on aeroacoustic measurements and perceptual analysis. RESULTS: Considerably higher fundamental frequencies were attained with the use of the VPE. The sound pressure level also increased for most subjects. The required driving pressures of the lung and air flow rates were altered, allowing significantly longer phonation times in 1 breath. Accumulation of mucus did not interfere with the proper functioning of the device during these tests. CONCLUSION: A VPE with sound-generating membranes is suitable for providing a substitute voice source for laryngectomized patients, especially patients suggestive of a severely hypotonic or atonic pharyngoesophageal segment who can benefit from a more melodious and louder voice.

Cordectomy by CO2 laser or radiotherapy for small T1a glottic carcinomas: costs, local control, survival, quality of life, and voice quality.

BACKGROUND: The clinical results of radiotherapy and endoscopic cordectomy for T1a glottic carcinoma are reported to be similar, but costs of both treatments may differ. Therefore, we retrospectively evaluated the costs, voice quality, quality of life, and clinical results of both treatments. METHODS: Costs and effects from the first visit up to 2 years of follow-up were calculated, based on chart data of 35 and 54 patients who were treated with curative intent for T1a glottic carcinoma from 1995 to 1999 with radiotherapy and endoscopic cordectomy, respectively. Voice quality and quality of life were evaluated by means of patient questionnaires. RESULTS: Total costs (in Euros) of radiotherapy and CO(2)-laser cordectomy were 8322 euro and 4434 euro, respectively, including the costs of treating possible recurrences. The effects of both treatments were equal, including voice quality and quality of life. CONCLUSIONS: We conclude that endoscopic cordectomy is an efficient alternative for radiotherapy for these patients.

Diagnosis and management of laryngopharyngeal reflux disease.

PURPOSE OF REVIEW: Laryngopharyngeal reflux remains a controversial subject for both diagnosis as well as treatment. Nevertheless, there is increasing clinical and experimental evidence to suggest that it is associated with many nonspecific otolaryngological symptoms. RECENT FINDINGS: Twenty-four hour dual probe pH tests fail to prove or exclude laryngopharyngeal reflux because of insufficient specificity and sensitivity. Therefore, the diagnosis is usually based on a combination of diagnostic signs and symptoms, which cannot be explained by pathology other than laryngopharyngeal reflux. Many signs of laryngopharyngeal reflux, however, are also found in individuals without symptoms. Treatment should consist of high-dose proton-pump inhibitor medication twice daily. SUMMARY: Laryngopharyngeal reflux disease is a diagnosis by exclusion, and resolution of symptoms following a 4-month trial of high-dose proton pump inhibitor twice daily is, for all practical purposes, considered proof of the initial diagnosis. Nonresponse does not exclude the diagnosis of laryngopharyngeal reflux disease, however, since proton-pump inhibitors will only reduce the acid component of the refluxate.

The efficacy of voice therapy in patients after treatment for early glottic carcinoma.

BACKGROUND: After treatment for early glottic carcinoma, a considerable number of patients end up with voice problems that interfere with daily life activities. The objective of this randomized and controlled study was to assess the efficacy of voice therapy in these patients. METHODS: Of 177 patients, 6-120 months after treatment for early glottic carcinoma, 70 patients (40%) suffered from voice impairment based on a 5-item screening questionnaire. Approximately 60% of those 70 patients were not interested in participating in the current study. Twenty-three patients who were willing to participate were assigned randomly either to a voice therapy group (n = 12 patients) or to a control group (n = 11 patients). Multidimensional voice analyses (the self-reported Voice Handicap Index [VHI], acoustic and perceptual voice quality analysis, videolaryngostroboscopy, and the Voice Range Profile) were conducted twice: before and after voice therapy or with 3 months in between for the control group. RESULTS: Statistical analyses of the difference in scores (postmeasurement minus premeasurement) showed significant voice improvement after voice therapy on the total VHI score, percent jitter, and noise-to-harmonics ratio in the voice signal and on the perceptual rating of vocal fry. CONCLUSIONS: Voice therapy proved to be effective in patients who had voice problems after treatment for early glottic carcinoma. Improvement not only was noticed by the patients (VHI) but also was confirmed by objective voice parameters.

A screening questionnaire for voice problems after treatment of early glottic cancer.

PURPOSE: After treatment for early glottic cancer, a considerable number of patients end up with voice problems interfering with daily life activities. A 5-item screening questionnaire was designed for detection of voice impairment. The purpose of this study is to assess psychometric properties of this questionnaire in clinical practice. METHODS AND MATERIALS: The questionnaire was completed by 110 controls without voice complaints and 177 patients after radiotherapy or laser surgery for early glottic cancer. RESULTS: Based on normative data of the controls, a score of 5 or less on at least 1 of the 5 questions was considered to state overall voice impairment. Reliability of the questionnaire proved to be good. Voice impairment was reported in 44% of the patients treated with radiotherapy vs. 29% of the patients treated with endoscopic laser surgery. CONCLUSIONS: The questionnaire proved to be a reliable, valid, and feasible method to detect voice impairment in daily life. The questionnaire is easy to fill in, and interpretation is straightforward. It is useful for both radiation oncologists and otorhinolaryngologists in their follow-up of patients treated for early glottic cancer.

Vocal aging and the impact on daily life: a longitudinal study.

Longitudinal studies on vocal aging are scarce, and information on the impact of age-related voice changes on daily life is lacking. This longitudinal study reports on age-related voice changes and the impact on daily life over a time period of 5 years on 11 healthy male speakers, age ranging from 50 to 81 years. All males completed a questionnaire on vocal performance in daily life, and perceptual and acoustical analyses of vocal quality and analyses of maximum performance tasks of vocal function (voice range profile) were performed. Results showed a significant deterioration of the acoustic voice signal as well as increased ratings on vocal roughness judged by experts after the time period of 5 years. An increase of self-reported voice instability and the tendency to avoid social parties supported these findings. Smoking males had a lower speaking fundamental frequency compared with nonsmoking males, and this seemed reversible for males who stop smoking. This study suggests a normal gradual vocal aging process with clear consequences in daily life, which should be taken into consideration in clinical practice as well as in studies concerning communication in social life.

Health status and voice outcome after treatment for T1a glottic carcinoma.

Radiotherapy as well as endoscopic laser surgery as the most widely used treatment modalities for T1a glottic carcinoma cause minor morbidity and negligible mortality and result in more or less comparable, excellent cure and larynx preservation rates. Therefore, other outcome measures such as voice-related problems and health status are important factors in the choice of treatment for T1a glottic cancer. The present study focuses on voice-related problems in the daily life of patients treated by radiotherapy or endoscopic laser surgery for T1a glottic cancer. Self ratings on health status assessed by means of COOP/WONCA health status charts and voice problems evaluated with a validated voice-specific questionnaire (the Voice Handicap Index) and overall judgment on voice quality were obtained. A total of 102 patients (56 treated by endoscopic laser surgery and 46 treated by radiotherapy) with at least 1-year follow-up were included. Response scores were high: 52 (93%) patients after endoscopic laser surgery versus 40 (87%) patients after radiation therapy completed and returned the questionnaires. A high percentage of patients reported voice problems in daily life: 58% of the patients following radiotherapy and 40% of the patients following endoscopic treatment had abnormal VHI scores. The difference between both treatment modalities proved to be significant. No significant differences were found concerning health status or overall judgment of voice quality. Moderate correlations were found between total VHI score and voice quality judgment and the COOP/WONCA social activities chart. This study reveals that treatment for T1a glottic cancer often does result in voice problems in daily life, negatively influencing patients social activities. Patients selected for endoscopic laser surgery on average report fewer voice-related problems than those who underwent radiotherapy.

Communicative suitability of voice following radiotherapy for T1 glottic carcinoma: testing the reliability of a rating instrument.

The objective of the study was to determine whether a communicative suitability rating instrument could be used in a meaningful way to assess functionality of voice following radiotherapy for T1 glottic cancer. Seventeen naive listeners judged the suitability of voice of a patient group with T1 glottic carcinoma (n = 20) just before treatment, a group of patients (n = 40) after radiotherapy, and a matched control group (n = 20) of normal speakers. Listeners rated suitability on a 10-point scale for 10 speaking situations, which supposedly make different demands. In order to validate scores on communicative suitability, ratings were related to perceptual voice quality evaluations and videolaryngostroboscopic evaluations. Results indicate that the concept of measuring listener judgments of communicative suitability of voice is basically sound. Raters are reliable and can discriminate between groups of normal and pathological voices. Patients with T1 glottic carcinoma (assessed before the start of treatment) have on average the least suitable voices. Following radiotherapy suitability is, on average, improved, but does not approach the suitability of normal voices. Ratings on communicative suitability were clearly related to perceptual voice quality aspects and videolaryngostroboscopic evaluations. A subset of three communicative suitability rating scales is recommended as part of the protocol for evaluating voice outcome after radiotherapy for early glottic cancer, besides perceptual evaluation of voice quality by trained and naive raters, videolaryngostroboscopy, acoustical analyses, and self-ratings of vocal performance.

Cervical necrotizing fasciitis with thoracic extension after total laryngectomy.

Cervical necrotizing fasciitis (CNF) with thoracic extension is rare. It has never been reported in laryngectomized patients. A case of fatal CNF in a laryngectomized patient equipped with a voice prosthesis is presented. Diagnosis and treatment are discussed. CNF with thoracic extension was diagnosed on clinical picture, computed tomography (CT) and biopsies were taken just above the tracheostoma. Antibiotic treatment was started and extensive debridement of the affected tissues performed. A minor extension to the left pleura was considered irresectable. Irradical debridement and the impossibility of administering hyperbaric oxygen therapy caused death within two day after presentation. CNF is a rare disease and to our knowledge, has never been reported after total laryngectomy. This case emphasizes the need for early antibiotic treatment and radical surgical resection of the affected tissues.