Endoscopic cordectomy. A proposal for a classification by the Working Committee, European Laryngological Society.

The European Laryngological Society is proposing a classification of different laryngeal endoscopic cordectomies in order to ensure better definitions of post-operative results. We chose to keep the word "cordectomy" even for partial resections because it is the term most often used in the surgical literature. The classification comprises eight types of cordectomies: a subepithelial cordectomy (type I), which is resection of the epithelium; a subligamental cordectomy (type II), which is a resection of the epithelium, Reinke's space and vocal ligament; transmuscular cordectomy (type III), which proceeds through the vocalis muscle; total cordectomy (type IV); extended cordectomy, which encompasses the contralateral vocal fold and the anterior commissure (type Va); extended cordectomy, which includes the arytenoid (type Vb); extended cordectomy, which encompasses the subglottis (type Vc); and extended cordectomy, which includes the ventricle (type Vd). Indications for performing those cordectomies may vary from surgeon to surgeon. The operations are classified according to the surgical approach used and the degree of resection in order to facilitate use of the classification in daily practice. Each surgical procedure ensures that a specimen is available for histopathological examination.

Management of Zenker's diverticulum and postlaryngectomy pseudodiverticulum with the CO2 laser.

Dysphagia is a common symptom and can be caused by anterior pharyngeal (pseudodiverticulum after laryngectomy) and posterior pharyngeal (Zenker's) diverticula. The only treatment is surgical. The experience with an endoscopic treatment, especially with the CO(2) laser, is limited. Between 1984 and 1996, 81 patients with dysphagia were treated endoscopically with the CO(2) laser at the Department of Otorhinolaryngology-Head and Neck Surgery, University of Kiel. In 70 patients the swallowing disorder was caused by a hypopharyngeal diverticulum, and in 11 patients it was caused by a pseudodiverticulum after laryngectomy. In the Zenker's group, more than 90% of the patients were treated successfully. Eight of 11 patients with pseudodiverticula were without symptoms, and in the remaining 3 patients dysphagia was improved after laser therapy. The excision technique was superior to the incision procedures. The rate of postoperative complications was generally low. The microendoscopic approach with the CO(2) laser is a recommendable method for the treatment of Zenker's diverticulum and pseudodiverticulum in the postlaryngectomy patient. The surgical technique with the CO(2) laser at low power settings is a less invasive, quick, relatively safe, and effective procedure requiring only short hospitalization.

Transoral carbon dioxide laser resection of supraglottic carcinoma.

Between 1981 and 1994, 34 patients with squamous cell carcinoma of the supraglottis were treated by transoral carbon dioxide laser resection, 12 of them palliatively. Additional treatment included neck dissection in 21 patients and radiotherapy in 24 patients. The 3-year overall survival was 62%, and the actuarial survival 80%. The overall survival for T1 and T2 tumors was 71%, and that for T3 and T4 tumors was 47%. The overall 3-year survival for the early stages, I and II, was 88%, and that for the advanced stages, III and IV, was 50%. These results are comparable to the outcome after conventional open partial resection. Given the significantly lower morbidity (only 7 patients required tracheostomy), we do not observe an age limit anymore. The transoral method can be recommended as curative treatment in T1 and T2 tumors and in selected T3 and T4 tumors in concert with neck dissection and/or radiotherapy. In patients with advanced inoperable tumors, laser surgery is an excellent alternative to tracheostomy and palliative radiotherapy. Prerequisites for successful application of the transoral carbon dioxide laser resection are adequate resection techniques.

New insights into the pathomechanism of postintubation arytenoid subluxation.

BACKGROUND: Impaired movement of the cricoarytenoid joint with hoarseness and immobility of the vocal ligament can occur as a consequence of endotracheal intubation. The biomechanics and pathomechanism of cricoarytenoid subluxation have not been demonstrated to date. METHODS: The present study attempts to simulate the trauma that has been associated with arytenoid cartilage subluxation in intubation trials on 37 unfixed larynges in cadavers from persons aged 25 to 89 years. Larynges were intubated or extubated according to former conceptions of arytenoid subluxation, which assume that the arytenoid tip enters the lumen of the tracheal tube, or that a deflection of the arytenoid occurs during withdrawal of the endotracheal tube with the cuff of the tube only partially deflated. Also, manual attempts were carried out to subluxate the arytenoid cartilage. Subsequently after dissecting the left and right cricoarytenoid joint from each larynx, the morphologic changes induced experimentally were analyzed using gross microscopic and histologic methods. RESULTS: Within the scope of the experiment, it proved impossible to produce any subluxation of a cricoarytenoid joint. Histologic analysis revealed injuries of synovial folds, joint-surface impressions of the articular cartilage, and fractures in the area of the subchondral bone in some joints. CONCLUSIONS: Based on the morphologic results, it was concluded that intubation trauma of the cricoarytenoid joint does not cause subluxation per se, but rather that formation of a hemarthros or fractures of the joint bodies lead to fixation of the joint surfaces in an abnormal position. Subsequent ankylosis may occur.

[Clinical and molecular biology studies of respiratory papillomatosis]. / Klinische und molekularbiologische Untersuchungen zur respiratorischen Papillomatose.

BACKGROUND: Recurrent laryngeal papillomatosis is a benign neoplastic disease which is probably caused by but at least associated with the human papillomavirus. It can be of significant importance for the affected patients because of its recurrent clinical course. A great variety of therapeutic measures has been described including the surgical removal either with conventional instruments or using the laser. Development of malignancies from papillomas have been reported. PATIENTS: The clinical courses of all 95 patients who have been treated for laryngeal papillomatosis since 1960 were analysed retrospectively. The two most common forms of treatment, surgical removal either conventionally or with the use of the laser, were compared. "Hot start" polymerase chain reaction and Southern blot hybridization were used to detect HPV DNA. The case reports of all patients developing cancer of the larynx are included. RESULTS: Laryngeal papillomatosis is a disease of all ages, more often first diagnosed in the first and fourth decade. Puberty had no effect on the clinical course. The different forms of treatment did not affect the rate of recurrence. However, the rate of complications such as tracheostomy and glottic webs was significantly reduced after laser surgery. Since the introduction of this new form of therapy no more tracheostomies had to be performed on these patients. HPV DNA was found in four of five samples (HPV 6:3, HPV 11:1). Squamous cell carcinoma subsequently developed in four cases, three of which occurred almost simultaneously and were therefore not included. CONCLUSION: The term juvenile laryngeal papillomatosis should be replaced by recurrent respiratory papillomatosis. One could then distinguish according to the age of onset, i.e., in children below the age of 16 years and in adolescents and adults older than 15 years. The occurrence of squamous cell carcinomas in patients previously treated for papillomas underlines the need for repeated histological studies. The surgical treatment remains the mainstay in the management of laryngeal papillomatosis. The laser surgical technique is superior to conventional removal. Using the at present most sensitive and specific methods HPV DNA can be detected in a large percentage of laryngeal papillomas.

[Clinical and molecular biology studies of laryngeal papillomatosis]. / Klinische und molekularbiologische Untersuchungen zur laryngealen Papillomatose.

BACKGROUND: Recurrent laryngeal papillomatosis is a benign neoplastic disease which is probably caused by but at least associated with the Human Papilloma Virus. It can be of significant importance for the affected patients because of its recurrent clinical course. A wide variety of therapeutic measures have been described including the surgical removal either with conventional instruments or laser. Malignancies developing from papillomas have been reported. PATIENTS: The clinical courses of all 95 patients who have been treated for laryngeal papillomatosis since 1960 were analysed retrospectively. The two most common forms of treatment, surgical removal either conventionally or with the use of the laser, were compared. "Hot-start" polymerase chain reaction and Southern blot hybridization were used to detect HPV-DNA. The case reports of all patients developing cancer of the larynx are included. RESULTS: Laryngeal papillomatosis is a disease of all ages, more often first diagnosed before age 10 or after age 30. Puberty had no effect on the clinical course. However, the rate of complications such as tracheostomy and glottic webs was significantly reduced after laser surgery. HPV-DNA was found in 10 of 11 samples. Squamous cell carcinoma subsequently developed in four cases, three of which occurred almost simultaneously and were therefore not included. CONCLUSION: The term juvenile laryngeal papillomatosis should be replaced by recurrent respiratory papillomatosis. The occurrence of squamous cell carcinomas in patients previously treated for papillomas underlines the need for repeated histological studies. The surgical treatment remains the mainstay in the management of laryngeal papillomatosis. The laser surgical technique is superior to conventional removal. Using the most sensitive and specific methods presently available, HPV-DNA can be detected in a large percentage of laryngeal papillomas.

Endoscopic resections of glottic and supraglottic carcinomas with the CO2 laser.

Clinical experiences with transoral CO2 laser resections of glottic and supraglottic carcinomas are presented. 47 patients with variously sized supraglottic tumors and 114 patients with early glottic cancers were treated at the University of Kiel from 1979 to 1993. Although 10 patients with glottic tumors developed recurrences, curative treatment was possible with either repeat laser surgery (3 cases), irradiation (3 cases) or salvage laryngectomy (3 cases). One patient refused further treatment. Among the 30 patients with supraglottic lesions treated for cure 18 are currently alive and free of disease. 6 patients died with no evidence of disease, 2 patients died from secondary malignancies and 3 patients succumbed to their tumors. Present findings justify routine use of laser resections of laryngeal neoplasms, although patients must still be carefully selected for treatment.