Use of the buccal fat [corrected] pad for vocal cord augmentation.

CONCLUSION: We performed therapeutically successful intracordal injection of autologous fat harvested from the buccal fat pad. OBJECTIVE: Autologous fat has been used increasingly for intracordal injection as vocal rehabilitation in patients with deficient glottal closure. Adipose tissues used have been harvested mostly from the lower abdomen. However, patients differ considerably in the amount of fat available from the lower abdomen, and it is often difficult to obtain sufficient fat in patients with a low body mass index (BMI). Moreover, the scar visible after harvesting can be cosmetically undesirable. As an alternative, we evaluated harvesting of the buccal fat pad, as in plastic surgery. PATIENTS AND METHODS: From January to December 2005, intracordal buccal fat injection was performed for 10 patients, who were subsequently followed up for over 6 months. Buccal mucosa was incised under general anesthesia to expose and harvest the buccal fat pad. This fat was cut into small pieces and injected into the vocal cord. Maximum phonation time and glottal aerodynamics were evaluated pre- and postoperatively. Glottal closure and mucosal vibration were examined stroboscopically. RESULTS: Except in one patient, no postoperative complications such as swelling or infection followed either harvesting or injection. After injection, phonation showed notable improvement that was maintained throughout follow-up.

[Use of the buccal fat pad for vocal fold injection].

In recent years, autologous fat has been increasingly used for intracordal injection as a means of vocal rehabilitation in patients with deficient glottal closure, and the dipose tissue used has for the most part been harvested from the lower abdomen. However, patients differ considerably in the amount of fat available in the lower abdomen, and obtaining sufficient fat is often difficult in patents with a low body mass index (BMI). To overcome this problem we tried adopting a method that uses the buccal fat pad, as practiced in plastic surgery. The details of the method and the postoperative course are reported. The intracordal fat injection method for buccal fat pad tissue was performed in 10 cases during the 1-year from January 2005 to December 2005, and the patients' postoperative course was carefully monitored for more than 6 months after surgery. With the exception of one case, no signs of complications, such as swelling, infection, etc., were seen at the site of fat collection or in the vocal cord after the operation. Phonation was markedly improved after the injection, and the improvement was maintained throughout the observation period. Treatment of unilateral recurrent nerve paralysis by intracordal injection of autologous fat harvested from the buccal fat pad was successful.

Adipose tissue formation in response to basic fibroblast growth factor.

CONCLUSION: Formation of new fat cells may occur in injected adipose tissue in response to basic fibroblast growth factor (bFGF). OBJECTIVE: In an effort to prevent loss of fat volume and generation of additional adipose tissue after intracordal injection of autologous fat, the effects of injecting fat together with basic fibroblast growth factor bFGF were evaluated. MATERIALS AND METHODS: Models of bilateral recurrent laryngeal nerve paralysis were prepared using 12 beagle dogs. Autologous fat was injected into one vocal cord, and a mixture of autologous fat with bFGF, gelatin microspheres, and collagen sponge was injected into the other. Histologic reactions were examined over time. RESULTS: In vocal cords where autologous fat was injected together with bFGF, fusiform immature adipocytes were found in the injected fat at 8 weeks after injection. The volume of the injected fat was maintained almost completely even at 24 weeks after injection. Vocal cords where only autologous fat was injected showed a marked decrease in volume of injected fat over time.

Autologous fat augmentation of the vocal fold with basic fibroblast growth factor: Computed tomographic assessment of fat tissue survival after augmentation.

CONCLUSION: The volume of fat tissue loss after vocal fold augmentation can be decreased when augmentation is performed with addition of basic fibroblast growth factor (b-FGF). OBJECTIVES: The effectiveness of augmentation is easily decreased due to absorption. Canine experiments have confirmed that the decreased effectiveness caused by absorption after augmentation can be reduced by administering low-concentration b-FGF. Clinical application was trialed after acquiring approval from the institutional clinical review committee. METHOD: Autologous fat tissue with b-FGF was injected into the vocal folds in cases of unilateral vocal cord paralysis. This study compared fat tissue survival after injection by assessing images from computed tomography (CT). RESULTS: Assessments using CT revealed that the decrease in volume of injected fat tissue was smaller in cases treated using b-FGF than in cases using the conventional method. No severe complications were encountered using this method.

Voice quality after laser surgery or radiotherapy for T1a glottic carcinoma.

OBJECTIVE: To compare the effect on phonation of radiotherapy and endoscopic laser surgery for stage T1a glottic squamous cell carcinoma. STUDY DESIGN: Retrospective. METHODS: Patients treated for stage T1a glottic carcinoma from August 1994 to March 2000 and who had been followed for at least 1 year were candidates. Eight patients who underwent radiotherapy and 22 who underwent laser surgery were enrolled. Indirect laryngoscopy and stroboscopic examination were performed, and voice quality was analyzed using standard parameters. RESULTS: Maximum phonation time, average airflow rate, sound pressure level, and average fundamental frequency during unconditional phonation were similar after laser surgery and radiotherapy. However, compared with normal men who were 50 years of age or older, the average fundamental frequency was higher after laser surgery. CONCLUSIONS: Contrary to some reports, the voice quality is minimally affected by laser surgery for T1a glottic carcinoma, and outcome is similar to radiotherapy. The average fundamental frequency is higher than normal after laser surgery, but the effect on the quality of life was trivial.

Intralaryngeal application of a miniaturized ultrasonic probe.

We developed a method for performing intralaryngeal ultrasonography. Normal larynges were obtained from 10 cadavers and examined using an intraluminal ultrasonic tomography apparatus connected to a radial scanning 20 MHz miniaturized probe. The larynx was placed in a bath filled with physiologic saline. and the probe was inserted through the forceps channel of the fiberscope (6 mm diameter). A horizontal ultrasonic image of the vocal fold was obtained. Histologic sections of the larynx were compared with the ultrasonic images. The mucosa in the membranous region of the vocal fold was comprised of three layers ultrasonographically. The epithelium and superficial layer of the lamina propria were visualized as a high echo (hyperechoic) region, the intermediate layer of the lamina propria was visualized as a low echo (hypoechoic) region and the deep layer of the lamina propria was seen as a hyperechoic region. The vocal fold structure can be visualized by intralaryngeal ultrasonography using the filling method. This method may be clinically useful for the detection of tumors involving the vocal folds.

Direction of lateral traction in Ejnell's technique: an experimental study and case report of bilateral vocal cord paralysis.

In order to develop the method of laterofixation of the vocal cord (Ejnell's method) in cases of bilateral vocal cord paralysis, six autopsy specimens of normal larynx were obtained. We inserted traction sutures under conditions of direct visualization and studied the relationship between the direction of the traction exerted by the suture and subsequent enlargement of the glottis. When the vocal cord was pulled perpendicular to the thyroid cartilage wing, the mean glottal area was 106.2% of its area before traction. When the vocal cord was pulled perpendicular to the median line of the glottis, the mean glottal area was 112.7% of its area before traction. The latter angle of traction therefore produced more efficient enlargement of the glottis (p < 0.05; paired t-test). Based on an anatomic study of cadaveric laryngeal regions, a formula was developed to predict at which point the needle should be placed in order to produce optimal results using Ejnell's technique. Further clinical studies will be carried out in patients to test the validity of this formula.

Use of freeze-dried autologous fascia to augment the vocal fold: an experimental study in dogs.

This study assessed the practicality of using autologous freeze-dried fascia to augment the vocal fold. Freeze-dried autologous fascia was injected into the vocal fold and skin of dogs in order to monitor sequential histological changes. Fascia lata was harvested from six adult dogs. After freeze-drying, minced fascia suspended in hyaluronic acid was injected subcutaneously into the abdominal wall and directly into the vocal fold. The specimens were extracted 3 weeks after injection and studied histologically. Freeze-drying destroyed all cellular components but did not affect the collagen fibers, which are the major components of fascia. There was no evidence of degeneration, necrosis or infection. Fibroblastic infiltration was seen in the fascia injected into the vocal fold, but the fascia remained as an unencapsulated mass at the site of injection. This study demonstrates that freeze-drying does not compromise the collagen in fascia and that the injection of freeze-dried collagen is well tolerated. Freeze-dried fascia is a promising new augmentation material.

Autologous fat augmentation of the vocal folds.

Autologous fat augmentation of the vocal folds has become widely adopted as a means of vocal rehabilitation in patients with deficient glottal closure. In general, the injection method using autologous tissues has no problems regarding safety issues such as infection of unknown cause, but the period of continuous effect is not constant because absorption may occur after injection. In 99 cases during the 8-years from August 2003 to April 2011. The details of postoperative course were reported. In a cases, maximum phonation time was improved.

Buccal fat augmentation for insufficient neoglottal closure after supracricoid laryngectomy with cricohyoidoepiglottopexy.

OBJECTIVE: Supracricoid laryngectomy with Cricohyoidoepiglottopexy (SCL-CHEP) is a functional organ preservation surgery for laryngeal cancers. Post-operative laryngeal function is generally promising. Some patients, however, cannot attain satisfactory functional results because of an excessively wide neoglottis resulting in an insufficient neoglottal closure. Autologous buccal fat augmentation was conducted to correct the insufficiency. PATIENTS AND METHODS: Two patients underwent intervention. Under general anesthesia, autologous fat was harvested from the buccal fat pad. Fat tissue was injected into the widest plane of the neoglottis under direct laryngoscopy; a navigation system was incorporated to identify the responsible site. Acoustic, aerodynamic, and perceptual analyses along with videofluoroscopic swallowing study and screening questionnaires were used for functional evaluation. RESULTS: A total of 0.8ml (Case 1) and 0.7ml (Case 2) of fat tissues were injected into the submucosal space of the responsible sites. Both patients experienced functional improvement subjectively after augmentation; psychological parameters for voice and swallowing also improved. CONCLUSIONS: Buccal fat augmentation to correct insufficient neoglottal closure after SCL-CHEP was technically feasible. A navigation system was helpful for confirmation. Fat absorption occurred and one third of the volume remained at 3 and 6 months. Although, vocal measurements remained unchanged, psychological parameters for voice and swallowing improved.

Comparison of fat tissues used in intracordal autologous fat injection.

CONCLUSIONS: The buccal fat pad appears to be more useful as a source of fat tissues in intracordal fat injection than the abdominal fat tissues used previously. However, further studies are required to confirm this point. OBJECTIVES: Fat tissues used in vocal fold augmentation surgery have primarily been harvested from the subcutaneous region of the lower abdomen. It is often difficult to obtain sufficient fat tissue for injection due to the physical features of the individual patient. We have thus adopted a method using fat tissue from the buccal fat pad, which is already used in other plastic surgeries. METHODS: This was a retrospective study. We evaluated and compared the histological characteristics of fat cells and the condition of vocal folds after injection of fat tissue extracted from the subcutaneous region of the lower abdomen and from the buccal fat pad. RESULTS: Buccal fat cells were relatively smaller than abdominal fat cells and were not influenced by body mass index (BMI), showing less individual differences according to the physical features of the patient. Numbers of vascular endothelial cells tended to be higher in buccal fat tissues. The percentage of cases showing continuous effects for more than 6 months was slightly higher in cases using buccal fat.

Intracordal injection technique: materials and injection site.

OBJECTIVE: Various materials have been used for intracordal injection to treat deficiencies in glottal closure. However, specific injection sites and materials are desirable for various conditions. Here, we reviewed injection sites and materials. METHODS: By considering the characteristics of injection materials used in Japan to date as well as the normal structure of the vocal cord, we have determined injection materials and sites suitable for different type of disease. RESULTS: Collagen obtained commercially for injection consists mainly of type I collagen, as does autologous fascia. When this material is injected into the superficial layer of the lamina propria mucosae of the vocal cord, the wave motion of the mucosa during phonation is disturbed. This material therefore should be injected deeper into the lamina propria. Indications for collagen injection include unilateral recurrent laryngeal nerve paralysis. Even when injected into the lamina propria, fat tissue does not disturb mucosal wave motion, and is useful for treating vocal cord atrophy or sulcus vocalis. CONCLUSION: When intracordal injection is used in vocal rehabilitation, material and site should be selected, based on the cause of glottal dysfunction.

Concurrent chemoradiotherapy with low-dose cisplatin plus 5-fluorouracil for the treatment of patients with unresectable head and neck cancer.

OBJECTIVE: The purpose of this study was to determine the efficacy of concurrent chemoradiotherapy using conventional radiotherapy combined with low-dose daily 5-fluorouracil (5FU) and cisplatin (CDDP) for the locally unresectable head and neck cancer patients. PATIENTS AND METHODS: From September 1996 through December 2000, we carried out a phase II study of concurrent chemoradiotherapy with low-dose CDDP plus 5FU for the treatment of patients with unresectable squamous cell carcinoma of the head and neck. Chemoradiotherapy consisted of irradiation with 1.6-2.0 Gy/day for 5 days per week up to a total dose 68 Gy and CDDP 3 mg/m2 by intravenous infusion over 1 h plus 5FU 150 mg/m2 by intravenous infusion over 24 h per day for 5 days per week. RESULTS: Ninety percent of the patients had stage IV disease, including 65% of patients with T4 disease. Thirty-three patients (83%) received the full treatment as planned; 39 (98%) received full-dose radiotherapy and 33 (83%) full-dose chemotherapy. Of the 40 patients evaluable for response, 20 (50%) achieved complete response (CR) and 12 (30%) partial response with an overall response rate of 80%. Among the 20 CR patients, 15 underwent endoscopic blind biopsies and 4 had positive lesions. The most frequently observed toxicity was mucositis. Ten patients developed grade III mucositis, and 3 patients required enteral nutritional support through a feeding tube. Grade III leukopenia, anemia and thrombocytopenia were observed in 28, 25 and 20% of the patients, respectively. The median duration of follow-up at the time of analysis was 18 months. The median survival time was 23 months. The responders survived longer (34 months) than the nonresponders (4 months; p < 0.05). CONCLUSION: This regimen is safe and efficacious in the treatment of patients with advanced unresectable head and neck cancer.

Feasibility of sentinel lymph node radiolocalization in neck node-negative oral squamous cell carcinoma patients.

We examined the reliability of the use of lymphoscintigraphy (LS) and a hand-held gamma probe (GP) to identify the sentinel lymph node (SLN), and sequentially determined the feasibility of SLN radiolocalization in clinical neck node-negative oral squamous cell carcinoma (SCC) patients. A radiolabel with the unfiltered (99m)Tc tin colloid was injected submucosally around the primary site followed by LS at 2-hour intervals. Preoperative localization was performed with GP. After en bloc removal of the regional lymphatics, histopathologic results for the nodes were compared with the SLN radiolocalization. The LS and GP counts were well correlated, and there was concordance between SLN and neck node status in 7 of 8 cases (87.5%). We thus considered that our concept in this study was valid in determining the necessity for neck dissection for those node-negative oral SCC patients.