Comparative cost analysis of hemilaryngectomy and irradiation for early glottic carcinoma.

The cost of hemilaryngectomy (15 patients) was compared to that of radiation treatment (18 patients) in epidermoid carcinoma confined to the true vocal cord with normal mobility (T1N0). An average of $3,495 was saved if radiation therapy was chosen; savings in terms of working hours were also substantial. We maintain that, if different treatment methods yield the same cure rate and quality of life, then cost should be the next strong consideration in choosing a particular treatment method.

Voice rehabilitation following blunt trauma to the larynx.

Two case reports illustrate different ways for restoration of quality of the voice. In both instances the vocal cords were displaced by trauma and restored by surgical correction.

Functional restoration for recurrent laryngeal paralysis: an experimental study.

The purpose of this investigation was to exclude abductor disturbance and to maintain phonation during recurrent laryngeal nerve paralysis through a new surgical design. This new method consists of implantation of the ansa hypoglossi and sternothyroid muscle pedicle which has been shown to provide sufficient abductor function in a recent publication, and the selective severance of the abductor branch after neurorrhaphy of the recurrent laryngeal which is shown to be a sufficient adductor function in another study. The recovery of sufficient abductor function during inspiration and dyspnea was 67% and 89% of adductor function with phonation. However, after cutting an adductor nerve branch of the recurrent laryngeal nerve in cases of insufficient abduction, the vocal cord on the operated-on side regained abduction during inspiration. The effect of the ansa hypoglossi and sternothyroid muscle pedicle is also discussed.

Reconstruction of laryngeal function for recurrent laryngeal nerve paralysis: historical view, advancement of latest investigations and a preliminary experiment.

Historical investigations of the functional restoration for recurrent laryngeal nerve paralysis are reviewed and some advancement in recent studies are introduced. A preliminary experiment is reported in which the ansa hypoglossi and the sternothyroid muscle pedicle was implanted into the denervated posterior cricoarytenoid muscle in dogs. From these experiments we have concluded that the ansa hypoglossi and sternothyroid muscle pedicle, which has been shown to transmit efferent inspiratory bursts, is capable of restoring function to the paralyzed posterior cricoarytenoid muscle in some dogs.

Stomal recurrences: a clinicopathological analysis and protocol for future management.

From 1965 to 1975, 452 total laryngectomies were performed at the Washington University Medical Center, St. Louis, Mo. During this period, 33 stomal recurrences were diagnosed. These are clinicopathologically analyzed with regard to tumor size, site, histopathology and original surgical procedure. An association with transglottic tumors, emergency tracheotomy and, surprisingly, hemilaryngectomy is noted. Three theories of etiology are discussed. Since treatment to date is disappointing, several proposed methods of prophylaxis are presented. These include emergency laryngectomy, recurrent laryngeal lymphatic dissection and postoperative radiotherapy. The role of wide local excision and mediastinal dissection is also examined. Based upon the analysis and the proposed methods of prophylaxis, a protocol is suggested for the future management of this dreaded complication.

Health care costs of laryngeal surgery.

The total costs of various laryngeal surgeries were considered from initial visit through one year postoperatively. For the four most widely used procedures, average costs were: laryngoscopy with biopsy, $1,000.00; hemilaryngectomy, $5,035.00; total laryngectomy $6,010.00; and supraglottic laryngectomy and neck dissection, $12,096.00. Most ancillary service charges decrease as length of hospitalization increases except for pharmacy and respiratory therapy. Physicians whose decisions affect health care should also take cognizance of health care costs.

Panel discussion: the management of advanced laryngotracheal stenosis. Use of the hyoid graft for treatment of laryngotracheal stenosis.

The most common cause of laryngotracheal stenosis is trauma. The stenotic area may involve the larynx, subglottis, or trachea. A hyoid bone graft has been used in 22 cases for reconstruction of the stenotic area. The hyoid graft may be used with other concomitant laryngeal procedures. A vascularized sternohyoid--hyoid graft has been used in somes cases. Of the 22 cases all but 3 have been successful. The advantages of the hyoid graft are: 1. Firm graft to maintain the architecture of the lumen. 2. Accessibility in the same operating field. 3. Patient's own graft material decreases immune rejection possibility. 4. The vascularized pedicle graft decreases possibility of hyoid resorption.

Maxillary sinus carcinoma.

Primary site control, anatomical site of failure, survival, and complications of treatment were determined in a retrospective review of primary maxillary sinus carcinoma. Sixty-one patients were treated by radiation followed by surgery and 35 by radiation alone. Primary tumor control was achieved in 69% of patients receiving combined treatment, 14% of patients treated with radiation alone, and 49% of all patients. Neck nodes were the initial site of tumor recurrence in 20% of patients treated with combined treatment. distant metastases were the first site of tumor recurrence in 8% of patients. Local control did not differ with histological type. Virtually all epidermoid and undifferentiated carcinoma recurrences occurred within 2 years, but 27% of adenocarcinomas recurred after 2 years.

Neurorrhaphy of the recurrent laryngeal nerve.

The authors have experimentally performed neurorrhaphy and its modifications and nerve grafting with end-to-end anastomosis of the recurrent laryngeal nerve in dogs. Recovery of a neurorrhaphy of the recurrent laryngeal nerve resulted in the bizarre and spasmodic movement of the vocal cords. These effects were recorded by means of electromyography and 16 mm cinematography to demonstrate restoration of nerve muscle function and vocal cord movements. From these results, it was concluded that these single modes were not adequate for restoration of laryngeal function, however, some specific attention is given to a few trophic changes of the affected muscles after a period of ten months postoperative.

Immediate facial rehabilitation in poor prognosis tumor patients.

Effective rehabilitation of facial paralysis in the poor prognosis tumor patient is best accomplished by the judicious and individualized use of that combination of static or static and dynamic procedures which will correct the major deformities present immediately and with minimal morbidity. This approach may be taken at the time of tumor ablation or later when the effects of paralysis become distressingly evident. In the rare patient whose disease is controlled, additonal dynamic rehabilitative efforts may be considered subsequently.

Laryngeal radiation after hemilaryngectomy.

Laryngeal radiation was administered to 30 patients after hemilaryngectomy for true vocal cord carcinoma at Washington University Medical Center during the years 1957-1976. Twelve patients were irradiated at the time of gross recurrence and 5/12 (42%) of these patients had recurrence of their disease after radiation. Eighteen patients were irradiated immediately after hemilaryngectomy because positive margins were seen in the hemilaryngectomy specimen and 5/18 (28%) of these had recurrence. All but 1 recurrence occurred within 13 months following radiation. Total laryngectomy salvaged an additional 3 patients for ultimate cancer control in 23/30 (77%). This high dose laryngeal irradiation was well tolerated. A major complication occurred in 1 patient (3%) and consisted of permanent laryngeal edema necessitating tracheostomy but permitting useful speech. Mild complications occurred in 5 patients.

Hemilaryngectomy for verrucous carcinoma of the glottis.

Seven patients with verrucous carcinoma of the glottis treated by hemilaryngectomy are analyzed. The diagnostic criteria for this tumor are reviewed. Close cooperation between the clinician and pathologist is necessary for the correct diagnosis. The controversy regarding radiation therapy is discussed. Hemilaryngectomy is concluded to be a successful surgical modality for limited verrucous carcinoma of the larynx.

Surgical management of bilateral vocal cord paralysis.

Fifty-five patients with bilateral abductor paralysis of the vocal cords were managed surgically from 1957 to 1973. Initially, unilateral arytenoidectomy or arytenoidopexy was employed. If this was not satisfactory, a contralateral arytenoidectomy was performed 6 to 12 months later. If the patient's airway was still inadequate, then open unilateral submucous resection of the vocal cord was accomplished. Initial management was successful in 62 patient (34/55) of patients, and 50 to 55 patients (91 percent) were eventually decannulated. Failure of the arytenoidectomy appeared to be related to traumatic etiology of the bilateral paralysis presence of previous treatment, and technical problems of the procedure itself.

A comparison of therapeutic modalities of glomus tumors in the temporal bone.

Seventy-seven patients with glomus tumors involving the temporal bone were treated by surgery, irradiation, and combined therapy. The therapeutic success rate for the surgery group was 91 percent for glomus tympanicum and 78 percent for glomus jugulare tumors. The success rate for radiation therapy was 30% in glomus jugulare tumors. Patients with extensive lesions treated by combined therapy had a therapeutic success rate of 60 percent. The clinical response of glomus jugulare tumors to radiation therapy was 65 percent. Surgery appears to be the best method for eradication of the tumors; however, with large extensive lesions, combined therapy offers a better prognosis than either modality alone.

Floor of mouth cancer: patient selection and treatment results.

Retrospective review of 126 primarily treated floor of mouth (FOM) cancers was done to study patient selection and to search for more optimum treatment strategies. Small surface lesions were treated by local excision (LE); small lesions invading FOM without lymph nodes were treated by radiation alone (RA), while larger lesions and those with palpable nodes were treated by preoperative irradiation and surgery (R + S). Ultimate control of the FOM cancer and nodes was achieved for 100% of the LE, 71% of the RA, and 75% of the R + S patients. The majority of primary tumor and nodal recurrences developed by 15 months and 35% of the failures were salvaged by additional treatment. Change in treatment strategies are suggested for surface lesions because of a poor rate of initial tumor control (43%), for patients treated by RA because of a high rate of complications (41%), and for patients without palpable lymph nodes who can be successfully treated by elective neck irradiation.

Treatment of epidermoid and undifferentiated carcinomas from occult primaries presenting in cervical lymph nodes.

We treated 83 patients with epidermoid or undifferentiated carcinoma in cervical neck nodes without an obvious primary at our institution between 1964 and 1979. All patients received radiotherapy and 29 patients had radical neck dissection (RND) or total excisional biopsy (TEB) as well. Actuarial survival was 38% at 5 years for the entire group and 25% at 10 years. Fifty-four patients with neck control had significantly better survival (p = .0001) at 5 and 10 years than those whose neck was uncontrolled. Factors associated with improved neck control were initial size of the neck mass and the addition of surgery (RND or TEB). Analysis of failures showed that 50% of patients failed only in the primary or neck and 50% developed distant metastases. Tumor was the major cause of death. We recommend more aggressive treatment with both XRT and neck dissection in patients with large resectable neck masses to prevent regrowth of tumor in the neck.

Flap reconstruction in patients with head and neck cancer: techniques and results.

Patients who are treated by surgery, radiotherapy, or any combination thereof may suffer from complications in wound healing or tumor recurrence which necessitate reconstruction of repair utilizing tissue brought in from other parts of the body. The majority of patients, who required flap reconstruction for primary repair or for a complication of their surgery, had their primary lesion in the supraglottic larynx or inferior hypopharynx. More than two-thirds of the flaps elevated were for fistula repair. Five year survival in this group of patients was lower than in those patients with uncomplicated postoperative courses, although the quality of life for the survivors in both groups was not significantly different.

Malignant fibrous histiocytoma of the head and neck.

Eight cases, the largest series of malignant fibrous histiocytomas of the head and neck to date, are reported. In over one-half of the cases, the initial problems encountered in the case made the true diagnosis misleading. For correct diagnosis multiple biopsies may be required. The diagnosis is further confirmed by the clinical behavior of the tumor and its site, size, and depth of involvement. Four specific histopathologic variants are described. Wide surgical excision is the preferrred treatment. The potential role of adjunctive irradiation should be considered.

Hemilaryngectomy for T3 (fixed cord) epidermoid carcinoma of larynx.

This clinicopathologic study was undertaken to determine whether true vocal cord fixation produced by epidermoid carcinoma is an absolute contra-indication to treatment by hemilaryngectomy. In a consecutive series of 114 hemilaryngectomies performed at McMillan Hospital (1960-1967) for previously untreated epidermoid carcinoma, 18 patients had fixation of the involved true vocal cord. Each hemilaryngectomy specimen (serial step sections in the longitudinal plane) was re-examined to ascertain the cause of vocal cord fixation; the adequacy of margin; and the presence of blood vessel, nerve sheath and cartilage invasion. Clinical follow-up on each patient was current through December, 1972 (5-12 years postop). All of these cases were seen initially by one of the authors (J.H.O.). Serial sections revealed that true vocal cord fixation was caused by muscle invasion in 14 of the 18 patients. "Positive margins" were present in eight patients but no immediate treatment was given. Two of these patients developed biopsy proven local recurrences, and both were cured with Co60 irradiation. Among the 18 patients with T3 epidermoid carcinoma treated by hemilaryngectomy: a. Three local recurrences developed, all in the anterior commissure. Two were cured with irradiation. The third had a laryngectomy but died from persistent cancer. b. Two patients developed cervical metastases (without local recurrence), and one was salvaged with radical neck dissection. c. Four patients died of other causes, cancer free, three to five years postoperatively. Of the 14 determinant patients, two patients died of cancer. Twelve (85 percent) were alive and free of cancer five years postoperatively. Two had received full course irradiation; one had a radical neck dissection, and all 12 had a functioning larynx. When Ogura's patients are added to the reports of other hemilaryngectomies performed despite true vocal cord fixation (Leroux-Robert [1950] 18/24, Kirchner, Som [1971] 13/19), a determinant salvage rate of 78 percent can be expected. True vocal cord fixation is generally caused by invasion of the vocalis muscle and thus may be well encompassed by a hemilaryngectomy. The precise anatomical limits of the lesion should dictate the type of surgery required for cure.

Voice preservation in treatment of carcinoma of the pyriform sinus.

A retrospective analysis of 175 patients having a histopathologic diagnosis of epidermoid carcinoma of the pyriform sinus presenting between January 1, 1964 and December 31, 1973 was undertaken to establish the effectiveness of conservation surgery in preserving voice. Patients were treated by three separate methods: 1. preoperative radiation therapy, partial laryngopharyngectomy and radical neck dissection (PLP and RND) (N = 85); 2. preoperative radiation therapy, total laryngopharyngectomy and radical neck dissection (TLP and RND), (N = 57); and 3. palliation, which consisted of palliative radiation therapy alone or combinations of radiation therapy and chemotherapy or palliative surgery (N = 33). Of the 85 patients treated with the expectation of cancer cure and voice preservation (PLP and RND), 44 or 52% actually had their voice preserved. Of course, in none of the patients treated by TLP and RND was voice preserved, but 2 of the 33 patients treated palliatively retained ability to speak. Overall, 46 of 175 patients (26%) with carcinoma of the pyriform sinus were afforded voice preservation. The ability to preserve voice is correlated with stage and an analysis of operative complications is presented.