Motor features of voluntary cough following partial laryngectomy for glottal carcinoma.

BACKGROUND: Aspiration and respiratory tract infections are commonly observed in patients following conservative laryngeal surgery such as supracricoid laryngectomy with cricohyoidopexy (CHP). Since laryngeal closure is important for cough effectiveness, we hypothesised that CHP reduced cough intensity by affecting the cough motor pattern. METHODS: In ten male patients with laryngeal cancer eligible for CHP, we assessed the intensity of maximum voluntary cough (MVC) prior to and 2 months after surgery. Cough intensity was indexed in terms of both the peak amplitude of the integrated electromyographic activity of abdominal muscles (IEMGp) and the ratio of IEMGp to the duration of the expiratory ramp during cough (TEC), i.e. the rate of rise of IEMG activity (IEMGp/ TEC). For each cough effort, the duration of the compressive phase (CP), the cough peak flow (CPF), the time elapsed from the onset of cough to CPF (TTP) and their ratio, i.e. the volume acceleration (VA), were also evaluated. RESULTS: CHP did not affect IEMG-related variables; in contrast, it reduced (p < 0.01) CPF, CP and lengthened (p < 0.05) TTP values. In consequence, cough VA values after CHP were consistently lower than in control condition. CONCLUSIONS: Supracricoid laryngectomy with CHP alters the intensity of voluntary cough as indexed by flow-related variables. This may reduce cough efficiency and facilitate the onset and/or persistence of chest infections (Tab. 2, Fig. 1, Ref. 22).

Nasal polyposis: microsurgical ethmoidectomy and interruption of autonomic innervation vs conventional surgery.

Nasal polyposis is an invalidating disease which develops through chronic inflammation which leads to tissue oedema and eventually polyps. Treatment is aimed at eliminating polyps, resolving rhinitis symptoms, re-establishing nasal breathing and olfaction and preventing recurrence. The pathogenesis can be explained, in part, by degranulation of mast cells and release of mediators attracting eosinophils which, in turn, can cause tissue damage and oedema. Neurovascular reflexes and factors related to the complex anatomy of ethmoidal labyrinth may be responsible for the onset and persistence of oedema. This would offer a rationale to treatments modifying ethmoid anatomy and blocking neurovascular reflexes in the management of nasal polyposis. The advent of microsurgery and of diagnostic and operative endoscopy has led, over the last twenty years, to earlier detection and to less traumatic and more precise surgical treatment of nasal polyps. With these techniques resection of parasympathetic innervation is also possible, which is in keeping with the proposed rationale and cannot be easily achieved by conventional surgery. To evaluate the impact of this resection on the management of nasal polyposis a review of data has been made in a series of patients with diagnosis of nasal polyposis established by clinical examination, resistant to pharmacological therapy and treated between 1983 and 1998 at the Oto-Neuro-Ophthalmology Department of Florence University (Italy). Patients were treated by conventional surgery (386 cases), by microsurgery without resection of the parasympathetic component of the vidian nerve (97 cases), or by microsurgery with resection of this latter component (94 cases). The rate of recurrence and of major post-operative complications, respectively, were: 39.9% and 4.4% for patients treated by conventional surgery; 37.1% and 6.2% with microsurgery without resection of parasympathetic innervation; and 25.5% and 2.1% with resection of this innervation. The difference in recurrence rate between the three groups was significant (p < 0.05). The average disease-free interval was 45.7 months with conventional surgery and 53.5 months with microsurgery (regardless of resection of innervation). Results show that microsurgery for nasal polyposis together with resection of parasympathetic innervation improves results compared to those with conventional surgery and does not cause an increase in post-operative complications.

TNM glottic: role of the vocal muscle, arytenoid cartilage, and inferior paraglottic space in impaired vocal cord mobility (T2). An embryological and clinical study.

The TNM classification is unsatisfactory regarding the impaired mobility of the vocal cord and/or the arytenoid. The authors have studied the intrinsic laryngeal musculature, with particular attention to the medial thyroarytenoid muscle, the lateral thyroarytenoid muscle, and the inferior paraglottic space. The study was conducted on serial sections of 4 embryonal and 9 fetal larynges at different stages of development. The embryological observations showed that the lateral and medial thyroarytenoid muscles have different maturation times and probably different functions: phonatory and sphincteric. The authors have found that the inferior paraglottic space is situated between these 2 muscles. It would represent a path of diffusion for glottic cancer and play a central role in impaired vocal cord and/or arytenoid mobility, according to the degree of diffusion. Embryological observations have suggested the existence of laryngeal morphofunctional units belonging to the subsites of the glottic region and related to tumoral spreading.

Colocalization of tumor necrosis factor-alpha and nitric oxide-synthase immunoreactivity in mast cell granules of nasal mucosa.

We have demonstrated, with immunohistochemical techniques, the colocalization of tumour necrosis factor-alpha (TNF alpha) with a constitutive neuronal isoform of nitric oxide-synthase (NOS) in granules of the majority (52.77%) of the mast cells (MCs) of healthy human nasal mucosa. Very few cells were positive for NOS alone (2.54%). Some cells were positive for TNF alpha alone (16.73%) or negative for both antigens (18%). Since dim degranulation occurs in MCs of healthy nasal mucosa at any time, we propose that low concentrations of TNF alpha and NOS secreted by these cells are involved not only in the regulation of homeostasis of normal human nasal mucosa, but also in the survival and function of MCs themselves.

Carcinoma of the anterior commissure of the larynx: II. Proposal of a new staging system.

On the basis of embryology and clinical experience, we have defined here an anterior commissure (AC) subsite of the human larynx and have addressed the issue as to whether the degree of involvement of this subsite is related to the outcome of glottic cancer, in terms of local control within 5 years of therapy. Retrospective analysis of 534 patients included 1) classification of patients according to the TNM, 2) actuarial evaluation of the outcome, 3) reclassification of patients according to the involvement of the AC subsite, and 4) reevaluation of the outcome according to this latter classification. The results showed that the outcome was not well correlated with TNM classification, whereas patients with progressively heavier involvement of the AC subsite had a progressively worse outcome. On the basis of these data, we suggest that TNM classification of cancer involving the AC be implemented by and AC classification, in order to better forecast the prognosis and design specific conservative surgery.

Carcinoma of the anterior commissure of the larynx: I. Embryological and anatomic considerations.

In this study we attempt to define the organization of the anterior region of the adult larynx, on the basis of its development. For this purpose, we have studied the development of the anterior commissure region on serial sections of human larynges from embryos, fetuses, and adults. Our findings indicate that all the structures of this region derive from a single median mesenchymal band, first evident at 7 to 8 weeks of gestation, between the lateral laminae of the thyroid cartilage. This band of mesenchyme gives rise to all the structures along the midline of the thyroid cartilage and immediately beyond, including the intermediate lamina of the thyroid cartilage, the median process, and the connective tissue that connects the latter with the conoid ligament. We provide, for the first time, evidence that Broyles' ligament (commissural tendon) derives from the dorsal part of the median process and becomes intimately connected with the surrounding structures, including the insertion fibers of the vocal muscles, from early in development. On the basis of this finding we identify an independent anterior commissure region in the adult larynx, which comprises the intermediate lamina, Broyles' ligament, the connective tissue between the Broyles' and conoid ligaments, and the insertion fibers of the vocal muscles. The interpretation of all these structures as a unified region can explain the peculiar progression pathways and evolution of commissural and cordo-commissural tumors.

Does the epithelium play a central role in the immune function of rhinopharyngeal tonsils? An immunocytochemical and ultrastructural study.

Enlarged adenoids from 10 children with chronic rhinitis and otitis media with effusion have been studied immunocytochemically and ultrastructurally, to better define the possible role of the epithelium and the dendritic accessory cells in the immune activation of lymphoid cells, and provide further insight into the pathogenesis of the disease. The presence within the columnar epithelium of lymphocytes positive for CD8 antigen, and which electron microscopically have been found frequently apposed to degenerating epithelial cells suggests that the latter cells are targets for cytotoxic activity of intraepithelial lymphocytes, rather than being engaged in antigen presentation. Furthermore, the finding of typical dendritic accessory cells, recognized by their typical immunophenotypic and ultrastructural features, in the lamina propria, indicates that antigen presentation is more likely exerted by dendritic accessory cells. This is further supported by the fact that these cells express major histocompatibility (MHC) class II molecules, which are needed for antigen presentation, whereas epithelial cells do not. A possible relationship between epithelial damage and the pathogenesis of adenoidal enlargement is discussed.

Glottic cancer involving anterior commissure: surgery vs radiotherapy.

A retrospective review of 182 patients with glottic cancer involving the anterior commissure (AC) is presented. Of these, 123 patients were first treated with conservative surgery and 59 underwent radiotherapy. Patients were staged according to the AJCC system and by the modality of neoplastic involvement of AC (pure AC cancer, glottic cancer involving AC up to the midline, and beyond the midline). Our results indicate a higher rate of local control and of specific-disease survival in the group of patients first treated with surgery than those treated with radiotherapy (86% vs 74% and 97.5% vs 84%, respectively) (p less than 0.05). For pure AC cancers, our results show better local control with primary radiotherapy than with conservation surgery (82% vs 76.5%), but surgical failures have been more successfully salvaged than have radiotherapy recurrences (ultimate local control, 97.5% vs 82%, respectively). These data suggest that the treatment of choice for AC cancers is conservation surgery, particularly frontolateral laryngectomy.

[Tumors of the lateral parapharyngeal space. Our case series]. / I tumori dello spazio parafaringeo laterale. Nostra casistica.

After a review of the literature, the authors present 20 cases of parapharyngeal tumors which were operated on over the past 13 years at the ENT Clinic of the University of Florence. Although diagnosis is generally made quite late, great improvement has been achieved with the new "imaging" techniques. New and better information has made it possible to choose the most suitable surgical approach. In such cases neoplasm is most frequently observed in young adults; they prove benign in most cases and are of varying oncotypes--most often of a salivary gland or neurogenic origin. Diagnosis is performed by a CT scanner with an intravenous contrast medium and by angiography of the carotid artery. More recently CT sialography and MRI have also been used. The surgical technique (transoral, transcervical, transparotid and transmandibular excision, alone or combined) was chosen according to localization, size and vascularity. Follow-up data show a high incidence of recovery (85%) with acceptable functional results.

Interdigitating cells in the peritumoral infiltrate of laryngeal carcinomas: an immunocytochemical and ultrastructural study.

Interdigitating cells (IDCs) have been found in the peritumoral infiltrate of 18 patients with squamous cell carcinoma of the larynx. These cells have a dendritic shape and are characterized by the expression of S-100 protein and CD1a antigens. By electron microscopy, these cells are seen to establish intimate contacts with the apposed lymphocytes, which sometimes show signs of functional activation and proliferation. These findings indicate that IDCs may play a role in setting up a T-cell immune reaction against neoplastic cells, which may influence the biological behaviour and/or local growth of the tumour. Moreover, monocytes and cells with intermediate features between monocytes and IDCs are also found in the peritumoral infiltrate, thus suggesting that IDCs differentiate in situ from monocytic precursors, possibly under the influence of either tumour-derived factors or the local lymphoid microenvironment.

Fibre size in the left and right recurrent laryngeal nerves (RLNs) in the man.

Some morphological data of the right and left human RLNs were evaluated with the aim of verifying possible differences in the fibre composition of the two nerves. The following parameters were evaluated in the right and left RLNs of five human cases: 1) the maximum diameter of the fibres; 2) the axon diameter and area; 3) the myelin sheath area obtained substracting the axon area from the total area of each fibre. The obtained data were plotted on histograms for each case: moreover, histograms of all fibres of both left and right nerves of all five cases were made. The results show that the values of the maximum diameter of the fibres and of the myelin sheath area are always greater in a statistically significant way in the left RLNs than in the right RLNs. On the other hand the axon diameter is nearly the same in the nerves of both sides. These data suggest that the greater calibre of the myelin sheath in the fibres of the left inferior laryngeal nerve can be responsible of the faster conduction speed in this nerve. This fact might explain the simultaneous arrival of the impulses to the laryngeal muscles of the two sides in spite to the different length of the two nerves.

[Contralateral metastasis in patients with cancer of the larynx and the hypopharynx. Analysis and critical review of our caseload]. / Le metastasi controlaterali in pazienti con cancro laringeo ed ipofaringeo. Analisi e revisione critica della nostra casistica.

Cancers of the hypopharynx (pyriform fossa, post-cricoid area and posterior wall) and larynx show a high tendency to invade the cervical lymph nodes. Such nodal extension is a well known prognostic factor. In general, those lesions that are in well-lateralized primary sites (pyriform sinus, aryepiglottic fold...) tend to metastasize to the ipsilateral side of the neck. This concept, however, is fraught with exceptions; any lesion, especially with ipsilateral metastases, creates a risk for contralateral node involvement. The present study is based on a retrospective review of 450 clinical records of patients affected by well-lateralized laryngeal (301 pt.) and hypopharyngeal (149 pt.) carcinomas. The incidence of contralateral metastases was analyzed for this group; 25 out of 310 patients with laryngeal cancer (8.3%) and 20 out of 149 with hypopharyngeal cancer (13.4%) showed metastatic involvement of the contralateral neck. In patients with laterally oriented primary lesions, the initial appearance of cervical adenopathy is rarely contralateral since contralaterality is almost a manifestation of bilaterality of metastases. A contralateral disease is rarely possible even if the homolateral neck has been surgically treated. This is because of shunted lymph flow through the submental and submandibular lymphatics. Isolated contralateral disease was only found in 4 patients (1.3%): such data do not suggest any systematic, elective treatment of the contralateral neck NO in patients with unilateral laryngeal and hypopharyngeal cancers.

Vidian nerve resection, histamine turnover and mucosal mast cell function in patients with chronic hypertrophic non-allergic rhinitis.

Parasympathetic innervation of the respiratory tract of nasal mucosa plays an important role in the pathogenesis of chronic hypertrophic non-allergic rhinitis (C.H.N.A.R.), the vidian nerve providing the main parasympathetic nerve supply to respiratory mucosa. The present study investigates the effect of vidian nerve resection in 22 patient with intractable C.H.N.A.R. on histamine content and formation and on the number of mast cells and their degranulation in the respiratory tract. Samples were taken from respiratory mucosa for histamine and histidine-decarboxylase assay, and for microscopic observations for mast cell density and degranulation index, before and 12-24 months after vidian nerve resection. Neurectomy of the vidian nerve completely cured the clinical symptomatology, evaluated by rhinoreomanometry, and also significantly decreased both the high histamine levels and histidine-decarboxylase activity in patients with C.H.N.A.R. The density and degranulation index of mast cells were also significantly lower after surgery. These data suggest a relationship between cholinergic activity and the secretory response of mast cells and indicates a correlation between the parasympathetic nerve supply and chronic hyperthrophic non-allergic rhinitis. The significant reduction in mast cell density, histamine levels and histidine-decarboxylase activity also lends support to the hypothesis that the parasympathetic nerve supply plays a role in the regulation of mast cell histamine.

Histamine release from nasal mucosal mast cells in patients with chronic hypertrophic non-allergic rhinitis, after parasympathetic nerve stimulation.

The vidian nerve provides the main parasympathetic nerve supply to nasal respiratory and maxillary sinus mucosa, and its electrical stimulation causes apparent secretory and vasodilatatory effects in animals. The present investigation was carried out in 8 patients with chronic hypertrophic non-allergic rhinitis (C.H.N.A.R.) undergoing therapeutic vidian nerve resection. The vidian nerve was electrically stimulated before the resection. Samples were taken from nasal sinus mucosa for histamine determination and microscopical observation before and after the stimulation period. Vidian nerve stimulation causes a significant decrease in histamine content and mast cell density in the mucosa sample, differentially influenced by eserine and atropine pretreatment.

Stimulation and resection of Vidian nerve in patients with chronic hypertrophic non-allergic rhinitis: effect on histamine content in nasal mucosa.

Parasympathetic innervation of nasal mucosa plays an important role in the pathogenesis of chronic hypertrophic non-allergic rhinitis (C.H.N.A.R.). The present study investigated the effect of Vidian nerve stimulation and resection on the histamine contents and on the morphological pattern in mucosal samples of patients with C.H.N.A.R. Vidian nerve stimulation determines a significant decrease in histamine content in the samples examined; microscopical observations showed significant variations in the glandular, stromal and vascular components. The changes indicate an enhanced secretory activity, intensive vasodilatation and active degranulation of mast cells, which were significantly decreased in number in the samples obtained after 90 sec of stimulation. The neurectomy of the Vidian nerve resolves quite completely the clinical symptomatology and in parallel decreases the mucosal histamine contents, which are increased in patients with C.H.N.A.R. before the operation in comparison with the normal controls.

Vidian nerve resection in chronic hypertrophic non allergic rhinitis: effects on histamine content, number and rate of degranulation processes of mast cells in nasal mucosa.

The effects of Vidian nerve resection on the histamine content, number and rate of degranulation processes of mast cells in the respiratory tract of the nasal mucosa in patients with intractable chronic hypertrophic non-allergic rhinitis (CHNAR) have been investigated at various times after surgery. Preliminary data are also presented on the effects of Vidian nerve stimulation on the same parameters. The Vidian nerve was stimulated during surgery before resection. After neurotomy the histamine content was significantly lower than before but the values became less low with the passing of time. The number of mast cells per microscopic field and their degranulation index were significantly lower after surgery than before it. Stimulation determines a significant reduction in the number of mast cells per microscopic field and a parallel reduction in histamine content. These data establish a relationship between cholinergic activity and secretory response of mast cells and demonstrate a role of the parasympathetic nerve supply in the pathogenesis of CHNAR. The great reduction in the number of mast cells and histamine content also suggests that the parasympathetic nerve supply could play a role in the regulation of histamine synthesis and uptake.