Dynamic 320-slice CT larynx for detection and management of idiopathic bilateral vocal cord paralysis.

Idiopathic bilateral vocal cord paralysis (VCP) is a rare and difficult condition often undiagnosed and frequently confused with asthma and other respiratory conditions. Accurate diagnosis is crucial since 80% of cases patients require surgical intervention, such as tracheostomy or laser surgery, to relieve symptoms. The "gold standard" for diagnosing VCP has been laryngoscopy. In this case study, we demonstrate for the first time that idiopathic bilateral VCP can be accurately diagnosed by means of a novel noninvasive methodology: dynamic volume 320-slice computed tomography larynx. Three-dimensional reconstruction of laryngeal motion during the breathing cycle permitted functional assessment of the larynx showing absence of vocal cord movements. The new methodology may be valuable for noninvasive diagnosis of vocal cord movement disorders before and for follow-up after surgery.

Factors leading to the use of alternate treatment modalities following transoral laser excision of T1 and T2 glottic squamous cell carcinoma.

BACKGROUND: CO(2) transoral laser surgery and radiotherapy are both recognized as acceptable treatments for early glottic squamous cell carcinoma (SCC) with similar rates of cure. The reasons why some of the patients in our series undergoing laser resection as their primary modality of treatment subsequently underwent radiotherapy or chemoradiotherapy will be discussed. METHODS: Retrospective study between January 2003 and August 2010 of all T1 and T2 glottic SCCs treated with laser resection at a major tertiary centre. Tis lesions were excluded. A review of the cases in which primary control with laser resection was not achieved was undertaken. Failure was defined as patients treated initially with laser resection who subsequently received radiotherapy, combined chemoradiotherapy or open surgery for the same tumour. Factors leading to failure were analysed, including tumour location, histology, stage and patient factors. RESULTS: Thirty-one patients were identified, with the majority (27) having T1 disease. Mean number of laser excisions per patient was 1.7. Local control rate was 71% with laser alone. One patient had nodal recurrence with no primary recurrence. Mean follow-up was 32 months. Of the nine patients in whom local control was not achieved with laser alone, all had tumour at or crossing the anterior commissure. Four patients were deemed potentially curable with further excision but chose radiotherapy. Two patients were deemed appropriate for radiotherapy and chemoradiotherapy. Three patients had loco-regional recurrence and underwent laryngectomy. All had anterior commissure involvement. CONCLUSION: Transoral laser excision is a safe, function-preserving treatment of early glottic SCC. Anterior commissure involvement was the major factor for potential failure with laser resection in T1 and T2 glottic tumours.

Abnormal vocal cord function in difficult-to-treat asthma.

RATIONALE: Upper airway dysfunction may complicate asthma but has been largely ignored as an etiological factor. Diagnosis using endoscopic evaluation of vocal cord function is difficult to quantify, with limited clinical application. OBJECTIVES: A novel imaging technique, dynamic 320-slice computerized tomography (CT), was used to examine laryngeal behavior in healthy individuals and individuals with asthma. METHODS: Vocal cord movement was imaged using 320-slice CT larynx. Healthy volunteers were studied to develop and validate an analysis algorithm for quantification of normal vocal cord function. Further studies were then conducted in 46 patients with difficult-to-treat asthma. MEASUREMENTS AND MAIN RESULTS: Vocal cord movement was quantified over the breathing cycle by CT using the ratio of vocal cord diameter to tracheal diameter. Normal limits were calculated, validated, and applied to evaluate difficult-to-treat asthma. Vocal cord movement was abnormal with excessive narrowing in 23 of 46 (50%) patients with asthma and severe in 9 (19%) patients (abnormal > 50% of inspiration or expiration time). Imaging also revealed that laryngeal dysfunction characterized the movement abnormality rather than isolated vocal cord dysfunction. CONCLUSIONS: Noninvasive quantification of laryngeal movement was achieved using CT larynx. Significant numbers of patients with difficult-to-treat asthma had excessive narrowing of the vocal cords. This new approach has identified frequent upper airway dysfunction in asthma with potential implications for disease control and treatment.

Larynx preservation with primary non-surgical treatment for loco-regionally advanced larynx cancer.

INTRODUCTION: The objective of this paper was to review the results of primary non-surgical treatment with the aim of larynx preservation for loco-regionally advanced larynx cancer (LALC). METHODS: All patients with LALC presenting between January 2002 and December 2006 who were selected for primary non-surgical treatment were included in this study. RESULTS: There were 60 patients, 48% with stage III and 52% with stage IV disease. The median follow-up of living patients was 41 months. Larynx preservation with local disease control was achieved in 83% and 77% of patients at 3 and 5 years, respectively. Failure-free survival at 3 and 5 years was 66% and 59%, respectively, and overall survival was 67% and 45%, respectively. All patients with larynx preservation had a functional voice. Two patients became feeding tube dependant. Thirty-nine percent of all deaths were unrelated to LALC. CONCLUSIONS: Primary non-surgical treatment achieves high rates of larynx preservation with a low rate of severe complications but overall survival remains disappointing.

Endoscopic stapling of pharyngeal pouch: a 10-year review of single versus multiple staple rows.

OBJECTIVE: To compare the outcomes obtained in patients undergoing endoscopic stapling of pharyngeal pouches with single versus multiple rows of staples. STUDY DESIGN: A retrospective, 10-year review. SUBJECTS AND METHODS: Review of medical records in 38 patients who underwent endoscopic pharyngeal pouch repair. RESULTS: Patients who underwent stapling with multiple rows had a higher postoperative leak rate than patients who were stapled with a single row (36% vs 0%, P < 0.05). Patients with multiple rows also had a more prolonged length of stay and a slower return to both clear fluids and solid diet (P < 0.05). There was no difference in recurrence rate or patient satisfaction between the two groups. CONCLUSION: The technique of endoscopic pharyngeal pouch stapling has the potential to achieve excellent results. The application of more than one row of staples may be necessary to divide the common wall. However, in our series this is associated with a significantly increased risk of esophageal or pouch perforation. Care should be taken during the placement of multiple rows of staples.

Frozen section for parotid surgery: should it become routine?

BACKGROUND: The role of fine-needle aspiration (FNA) in salivary gland lesions as a preoperative diagnosis has always been under scrutiny. Several studies have shown that frozen section (FS) is accurate for pathological diagnosis and decision-making during the surgery. This study has been carried out to assess the accuracy of FNA and FS in parotid surgeries. METHODS: All parotid lesions removed between July 1998 and June 2003 by the Department of Otolaryngology, Head and Neck unit at Monash Medical Centre were reviewed. FNA, FS and definitive pathology were collected and discrepancies were identified. RESULTS: Eighty-five parotid tumours had been removed. Thirty-three were malignant in which squamous cell carcinoma was the most common. FS was able to differentiate benign tumours from malignant with 100% accuracy (30 cases). FS was able to alter the surgical decisions in six cases. FNA had been carried out in 62 cases, with sensitivity and specificity of 77.2 and 90%, respectively. CONCLUSION: Frozen section in parotid surgery is accurate, inexpensive and may add important information that alters management and improves the outcome. The use of FS routinely in parotid surgery is recommended.