CO(2) laser treatment in 244 patients with respiratory papillomas.

OBJECTIVE: Respiratory papillomas (RP) tend to recur and the difficulty in eradicating the disease makes their treatment frustrating. Meticulous CO(2) laser excisions every 2 months has been the most effective treatment to date. This article analyzes the results of this plan in 244 patients with RP in the nose, nasopharynx, pharynx, hypopharynx, larynx, trachea, lung parenchyma, and skin. METHODS: Two hundred forty-four patients with recurrent RP were treated by the senior author with CO(2) laser excisions and, in some cases, podophyllum and alpha interferon. Demographics, initial distribution of papillomas, number of operations performed on each patient, and current results were evaluated. RESULTS: Careful laser excisions of RPs every 2 months achieved "remission" of disease (no visible RP on indirect or often direct laryngoscopy 2 mo after last removal) in 37% of patients, "clearance" of the disease process (no RP clinically apparent for 3 y after last removal) in 6%, and "cure" (no clinical recurrence for 5 y after last removal) in 17%. Juvenile-onset RP tends to follow a more aggressive course than adult-onset RP. Four patients (1.6%) developed malignant transformation of their papillomas. Except for ones in lung parenchyma, RP in areas other than the true vocal cords tend to be cleared faster because aggressive removal does not cause hoarseness. Lung parenchyma RPs are eventually fatal because of pulmonary failure from abscesses and cysts resulting from a lack of effective treatment. CONCLUSION: Frequent and meticulously performed CO(2) laser excisions can achieve significant voice and airway improvement, and some clinical "cures." However, effective antiviral medicines and/or immunologic agents are needed to achieve true cures with elimination of all human papilloma virus 6 and 11 viruses.

Transnasal mucosal flap rotation technique for repair of posterior choanal atresia.

PURPOSE: To describe improved surgical treatment for posterior choanal atresia (PCA) by creating mucosal flaps with the aid of operating microscope, CO(2) laser, self-retaining nasal retractor, and stenting with a flat polytetrafluoroethylene (Teflon) keel. MATERIALS AND METHODS: Retrospective study of 19 patients with PCA, their ages ranging from 6 days to 4 years 4 months at the time of first repair, representing a total of 32 PCA repairs. Four patients had unilateral PCA, and one did not return for follow-up and could not be located. A transnasal microscopic approach uses a myringotomy knife or CO(2) laser to create an anterior mucosal flap; the CO(2) laser is also used to remove any bone plate and to create the posterior flap. The flaps then are rotated into position and are kept separated by a flat Teflon keel instead of a traditional round stent to avoid pressure necrosis. When a stable epithelialized opening (2 x 2 to 3 x 4 mm) is created, it is enlarged by subsequent staged transnasal CO(2) laser submucosal scar excisions with preservation of the overlying mucosa. This creates rotation or sliding flaps to speed healing and prevents circumferential scar contraction. RESULTS: Eighteen patients were re-examined after periods of 3 months to more than 5 years from when their first epithelialized orifice was created with nasal endoscopy to measure the final orifice size. All 18 patients had clinically adequate-to-good bilateral nasal airways at the latest follow-up with an average orifice size of 3 x 5 mm and a range of 2 x 2 to 4 x 10 mm. This "same day surgery" technique with staged procedures provides similar or better patency rates than a single transpalatal approach but with less surgical morbidity. It has a much lower restenosis rate than the transnasal puncture or PCA excision with prolonged round tube stenting and multiple dilation technique.

Frontoethmoidectomy with Sewall-Boyden reconstruction: indications, technique, and philosophy.

The Sewall-Boyden flap, as used to reconstruct a frontal recess after frontoethmoidectomy, is conceptually similar to the endoscopic Lothrop procedure for surgical access to the frontal sinus. The operative technique, indications, and philosophy are presented in this article.

Idiopathic progressive subglottic stenosis: findings and treatment in 52 patients.

Rarely, patients develop severe idiopathic subglottic stenosis. In 34 years, we have observed this disorder in 52 patients. All but 1 of the patients were female--a finding that suggests a hormonal cause. Without treatment, the airway progressively narrows--in some cases, until the patient requires tracheotomy. Laser submucosal resection and rotation mucosal flaps open and stabilize the airway and provide effective palliation. However, unlike traumatic subglottic stenosis, which has been cured with this technique, the idiopathic form causes submucosal fibrosis that regenerates spontaneously. Thus, treatment helps, but does not cure, the patient. The characteristic pathological finding is of submucosal dense fibrotic tissue with evidence of chronic inflammation. The clinical findings and treatment are here discussed.

Frontoethmoidectomy with Sewall-Boyden reconstruction: alive and well, a 25-year experience.

Recent controversies in the rhinologic literature regarding surgical management of the frontal sinus center around relatively new techniques using endoscopic intranasal approaches. Few authors have addressed the concept of frontal "duct" reconstitution, relying instead upon variations of the stenting concept, which fail at least 30% of the time. Some oral presentations and discussions in the past have gone so far as to say that external frontoethmoidectomy is an antiquated operation with few indications. One reason for its recent disfavor concerns the reported high rate of postoperative naso-frontal drainage track stenosis leading to recurrent disease. The senior author has a 25-year experience with a frontal recess reconstruction technique known as the Sewall-Boyden flap. This technique, coupled with the frontoethmoidectomy approach, has been effective with a low failure rate in 41 cases. This article serves to remind sinus surgeons of a safe, effective technique for establishing a drainage track from the frontal sinus: external fronto-ethmoidectomy with Sewall-Boyden flap reconstruction.

The OOPS procedure (operation on placental support): in utero airway management of the fetus with prenatally diagnosed tracheal obstruction.

Tracheal obstruction of the newborn caused by cervical masses such as teratomas and cystic hygromas can result in a profound hypoxic insult and even death, owing to an inability to establish an adequate airway after birth. Prenatal sonographic diagnosis of these congenital anomalies permits (1) anticipation of an airway problem at the time of delivery and (2) formulation of an algorithm for airway management while oxygen delivery to the baby is maintained through the placental circulation. This is the report of a fetus in whom a large anterior cervical cystic hygroma was detected by prenatal ultrasonography. A multidisciplinary management team was assembled, and an algorithm for airway management was developed. Elective cesarean delivery of the fetal head and thorax, under conditions of uterine tocolysis, permitted a controlled evaluation of the airway and endotracheal intubation while oxygen supply to the infant was maintained through the placenta. The baby remained intubated, and 2 days later underwent subtotal excision of the cervical cystic hygroma. Pharmacological maintenance of the feto-placental circulation after hysterotomy is an invaluable adjunct to airway management of the neonate with prenatally diagnosed tracheal obstruction.

Cricopharyngeal myotomy: indications and technique.

Available diagnostic tests evaluating cricopharyngeal dysmotility are expensive, uncomfortable, and unreliable for predicting the results of cricopharyngeal myotomy. Cricopharyngeal myotomy should be performed as a diagnostic test when a patient has "block" dysphagia (in which the food bolus stops rather than the swallow's being painful) localized to the cricoid level, and when no cancer is seen on esophagram. An effective surgical technique relies on the muscular distention provided by the inflated balloon cuff of a large endotracheal tube, and requires cutting the muscle fibers of the upper esophagus, the cricopharyngeus, and the hypopharynx in the posterior midline from a point 1 cm below the cricoid cartilage to the level of the thyrohyoid membrane. The cricopharyngeal limits are indistinct until the muscle fibers have been cut. Bougies, esophagoscopes, and cuffless endotracheal tubes insufficiently distend these muscle fibers. A "peanut" sponge in a Kelly clamp is used to identify and separate the last muscle fibers from the mucosa so they can be divided. These techniques minimize the risks of esophageal perforation and incomplete muscular transection. Our experience performing 54 cricopharyngeal myotomies is reported.

Injection and removal of Teflon for unilateral vocal cord paralysis.

For over 70 years, reinnervation attempts have been unsuccessful in restoring motion to paralyzed vocal cords, in spite of occasional claims to the contrary. Fortunately, the major defect of unilateral vocal cord paralysis, a soft and breathy voice, can be eliminated if the edge of the paralyzed vocal cord is moved to the midline. This permits the mobile vocal cord to adduct and therefore to vibrate firmly against the edge of the paralyzed vocal cord during phonation, eliminating the air leak between the vocal cords. Teflon injection of the paralyzed vocal cord does this effectively. It is accomplished most easily and reliably via indirect laryngoscopy under local anesthesia, so the effect on the voice can be monitored during the injection. Teflon can be easily removed from the vocal cord via direct laryngoscopy. The disadvantages of trying to medialize the edge of a paralyzed vocal cord via a window in the thyroid cartilage (laryngeal framework surgery) will be discussed.

Recurrent laryngeal nerve section for spastic dysphonia: 5- to 14-year preliminary results in the first 300 patients.

This presentation compares the preoperative voice recordings and the latest follow-up voice recordings, made 5 to 14 years postoperatively, of the first 300 patients with various degrees of spastic dysphonia whom we treated with recurrent laryngeal nerve (RLN) sections from 1975 to 1982. Voice therapy was usually given afterward and in some patients, when necessary, "fine tuning" surgery was performed later. The 243 patients who could be located were asked to answer a questionnaire regarding their voice production and communication abilities, and to make a voice recording. The preoperative and long-term postoperative voice recordings were analyzed by means of perceptual voice evaluation and acoustic analysis of the voice spectra. Fifteen percent developed recurrence of mild to moderate spasticity 6 to 24 months after the RLN section. This was curable with laser vocal cord thinning via direct laryngoscopy. Eighty-two percent of patients had little or no voice spasticity 5 to 14 years after their RLN section. The experimental alternative of injecting botulin directly into the vocal cord to temporarily paralyze it is discussed.

The endoscopic Teflon keel for posterior and total glottic stenosis.

Most cases of posterior commissure stenosis today result from endotracheal intubation. The problem has been very difficult to repair. Posterior commissure stenosis has been treated by repeated dilations, which do not work, and reconstructive measures by means of laryngofissure to excise the scar followed by the placement of round stents alone or round stents in combination with mucosal or skin grafts. This treatment also fails frequently. Some, but not all, cases have been cured with laser surgery via microdirect laryngoscopy. An endoscopically placed Teflon keel has been useful in the treatment of posterior glottic and total glottic stenosis when laser surgery is not feasible. Nine patients with posterior glottic stenosis, two of whom initially had total glottic stenosis, have undergone placement of the posterior commissure Teflon keel. Six patients had resolution of the stenosis and were decannulated. One required an arytenoidectomy for a fixed cricoarytenoid joint before successful decannulation. Two patients had marked improvement of their laryngeal airway with this approach, but have not yet been decannulated because of fixed cricoarytenoid joints.

Randomized surgical adjuvant trial of interferon alfa-n1 in recurrent papillomatosis.

Sixty-six patients with recurrent respiratory papillomatosis of juvenile onset were treated for six months with interferon alfa-n1 (Wellferon) in a randomized crossover trial. Half received interferon alfa-n1 intramuscularly at a dosage of 5 megaunits per square meter daily for 28 days and then thrice weekly for five months, followed by six months of observation. The other half were observed for six months and then treated. Operations were performed every two months to assess disease extent by a scale developed for this purpose. The score for the patients during the first observation period was stable. There was a statistically significant lowering of score in patients receiving interferon alfa-n1 during both periods of drug administration. Eight of 57 patients with assessable airway disease achieved complete remission, as did one additional patient with disease limited to the nasopharynx. No patients achieved complete remission during six months of observation alone. This difference was statistically significant. Patients without tracheostomy were significantly more likely to achieve remission than those with a tracheostomy. The patients who were observed after discontinuation of the drug therapy showed a significant rise in score within four months. Symptoms of toxicity included transient fever, fatigue, nausea, and headache. Elevations in serum aspartate aminotransferase levels occurred in 64% of the patients. There was an inverse correlation between age and the ability to tolerate the medication. The dose studied may be close to the maximum tolerated dose. It appears that interferon alfa-n1 as an adjuvant to routine surgical management is effective in slowing the growth of respiratory papillomas.

CO2 laser treatment of oral leukoplakia.

Treatment of oral leukoplakia has been disappointing with the available treatment modalities, because of inaccurate removal and an approximate 30% to 35% rate of recurrence. The CO2 laser has provided a promising new approach in the management of these lesions with very low morbidity and improved control. Twenty-nine patients were treated with the CO2 laser for 38 extensive (from 1 x 1 cm to 6 x 8 cm) intraoral leukoplakic lesions, 28 for cure and one for palliation. Microscopically the lesions varied from hyperkeratosis to carcinoma in situ. Follow-up of these patients ranges from 3 to 10 years, with an average of 5 years. An initial recurrence rate of 10.8% (4/37) was observed, and a 3-year local control rate of 97% after one to two procedures. A malignant transformation rate of 2.6% was encountered. Excellent wound healing and few complications were observed with this treatment approach. Surgical technique and results are reported supporting the advantages of the CO2 laser over conventional modes of treatment in the management of oral leukoplakia.

The recurrent laryngeal nerve in spastic dysphonia. A light and electron microscopic study.

Sections of right or left recurrent laryngeal nerve (RLN), removed from patients with spastic dysphonia (SD) at the time of surgery, were studied using light and electron microscopy and were compared with control RLNs. In both groups, small, medium and large-sized myelinated nerve fibres were found in the RLN. Furthermore, numerous unmyelinated axons intermingled with the myelinated fibres were detected in the control group as well as in SD specimens. Slight morphometric differences were also found between the two groups, but these cannot explain the causation of spastic dysphonia.

Carbon dioxide laser resection of superficial oral carcinoma: indications, technique, and results.

A retrospective medical record review was done of 51 consecutive patients with 56 biopsy-proven squamous cell carcinomas of the oral cavity and oropharynx treated for cure by one of the authors (H.H.D.) using the carbon dioxide laser via microdirect pharyngoscopy. All 51 patients were followed for at least 3 years unless they died, and 27 were followed for 5 years. The tumors treated were superficial, accessible lesions without bone involvement or clinically apparent metastases. Eighteen patients had had irradiation or surgery at the same site, so were having salvage CO2 laser surgery. Indications and technique are discussed. Local recurrence and disease control rates were comparable to those of conventional local surgical excision at 3 and 5 years. Complication rate was low. Carbon dioxide laser resection with microscopic control is, we propose, an excellent modality for transoral excision of carefully selected lesions, and it offers increased precision, better visualization, minimal bleeding, and decreased postoperative morbidity compared to other surgical techniques.

Rhabdomyosarcoma of the soft palate in three patients with follow-up of longer than ten years.

Rhabdomyosarcoma of the head and neck is a rare childhood neoplasm. Most occur in the orbit, which accounts for the scarcity of papers on modern techniques of treatment of soft palate rhabdomyosarcomas. Only 30 cases of soft palate rhabdomyosarcoma have been reported in recent years and none had long-term follow-up periods (greater than 10 yr). This study reports three cases of pediatric soft palate rhabdomyosarcomas treated with surgery, radiotherapy (two of three), and chemotherapy. The complications that occurred in one patient are discussed.