Hans-Edmund Eckel

Transoral laser surgery for early glottic carcinoma

Abstract This prospective study evaluates the oncological results of transoral laser surgery (TLS) for glottic carcinoma categorized Tis, T1 and T2 in a large, unselected group of 285 consecutive patients from a university-based referral center that uses transoral laser surgery as the standard approach to these tumors. Patients were treated between 1 January 1987 and 31 December 1996. Thirty-three patients had Tis disease, 174 T1 tumors and 113 T2. Main outcome measures were local control with initial therapy, ultimate local control, regional control, organ preservation, overall survival and cause-specific survival. The 5-year uncorrected actuarial survival for all 285 patients was 71.1%, and cause-specific actuarial survival was 98.7%. Local control with initial treatment was 85.9%, ultimate local control with salvage for local treatment failures 98.5%, and regional control 98.4%. In all, 94.3% had their larynges preserved after 5 years. Although favorable oncological results for early laryngeal carcinoma treated with laser surgery are supported this study, no definitive recommendations can be given for the best single treatment. Partial laryngectomies lead to the highest local control rates reported so far, radiotherapy is believed to preserve voice best and laser surgery is associated with time- and cost-effectiveness, low morbidity, fair local control rates and excellent re-treatment options in case of local failure. All specialists dealing with the treatment of early glottic carcinoma should be able to offer these different treatment modalities to their patients and to deal specifically with each patient’s individual needs and preferences.

Phonatory results after laser surgery for glottic carcinoma

OBJECTIVE: To identify the influence of type and extent of surgery on postoperative voice parameters after endoscopic laser resection for glottic carcinoma. SETTING AND DESIGN: A multidisciplinary university-based head and neck cancer center. Objective and subjective measures of voice were correlated with type and extent of surgery following a standardized classification in a prospective study including 80 patients. SUBJECTS AND METHOD: The postoperative mechanism of phonation was assessed by videostroboscopy 6 months after surgery at the earliest. A phonetogram was produced, and its area was calculated (relative phonetogram [RP]) in relation to a gender-different normal phonetogram. Two speech therapists (ST) and a trained otolaryngologist (TO) rated each voice independently for communication ability in a grade from 1 (poor) to 5 (near normal). RESULTS: After simple cordectomy the means were as follows: RP = 24.8%, TO = 3.26, and ST = 3.33. When the anterior commissure was completely preserved, mean results were better (RP = 34%, TO = 3.92, ST = 3.83). Results were worse after extended cordectomy (RP = 14.7%, TO = 2.82, ST = 3.00) and transglottic resection (RP = 13.7%, TO = 2.30, ST = 2.86) but were similar within these two groups. The parameters RP, TO, and ST do not differ significantly between the group who had speech therapy after surgery (n = 33) and the group who did not (n = 47). Voice production at glottic level yields better results for every parameter than supraglottic substitute phonation. The amount of tissue removed was less significant. CONCLUSION: Postoperative phonatory results correlate with the postoperative mechanism of phonation. There is no linear correlation with the amount of tissue removed. Comparison of similar types of resection preservation of the anterior commissure plays a key role. From the data in this study, there is no evidence for a significant benefit from speech therapy. The parameter RP is an effective and relatively simple parameter to complete auditory voice assessment.

Surgical Voice Rehabilitation after Laser Surgery for Glottic Carcinoma

Transoral laser surgery today is the mainstay of treatment for T1 and T2 glottic carcinoma. The vocal ability remains sufficient in the majority of patients. However, in some cases, a significant glottic gap may persist, leading to poor voice quality. We report a special technique of medialization thyroplasty using autologous cartilage specifically adapted for vocal rehabilitation after laser resection. Six patients with a significant glottic gap following laser surgery were treated. For vocal rehabilitation, a special medialization technique was performed. The superior rim of the thyroid cartilage of the resected side was exposed. A 1 × 2-cm piece of cartilage was harvested and reimplanted into a subperichondrial pouch created on the inner side of the thyroid cartilage. When phonation was optimal, this cartilaginous strut was sutured and/or glued in place. In all 6 cases, the vocal function improved significantly. The dysphonia index (0 = normal, 3 = aphonia), which includes objective parameters as well as expert voice ratings and the patients perception, increased by 1.1 on average (range, 0.4 to 1.6). The results have been lasting. The established medialization techniques are of limited value in a larynx scarred by laser surgery. Injection augmentation is often futile because the tight scar tissue does not lend itself to augmentation. Implantation of nonorganic material may cause problems if revision surgery for tumor recurrence should become necessary or if the implant protrudes into the scarred endolarynx. The technique reported avoids these pitfalls and leads to voice quality improvement comparable to that of established medialization procedures.

Measuring in Situ Central Airway Resistance in Patients With Laryngotracheal Stenosis

Objectives: To evaluate a newly developed bronchoscopic technique for the assessment of intratracheal pressures.

Hoarseness after laryngeal blunt trauma: a differential diagnosis between an injury to the external branch of the superior laryngeal nerve and an arytenoid subluxation. A case report and literature review

Arytenoid subluxation is a well-known cause of hoarseness due to incomplete glottic closure with intact inferior laryngeal nerves after severe laryngeal trauma. We report the case of a young man presenting after laryngeal blunt trauma with hoarseness, easy fatigue during phonation, marked difficulty with his high-pitch and singing voice and decreased phonation time, but intact function of both inferior laryngeal nerves, intact endolaryngeal mucosa sensibility and normal CT scans of the larynx and the neck. Due to the asymmetric anteromedial position of the right arytenoid with incomplete glottic closure, the primary diagnosis was arytenoid subluxation, and the patient was referred for instantaneous relocation therapy. The stroboscopic and electromyographic diagnosis of a unilateral paresis of the external branch of the right superior laryngeal nerve caused the therapy to be changed. Without repositioning, the patient had a total recovery of voice quality when the paresis receded 2 months later. In conclusion, the unilateral paresis of the external branch of the superior laryngeal nerve after laryngeal blunt trauma is reported here for the first time. Although the clinical findings are familiar sequelae of thyroid surgery, they may be misdiagnosed as arytenoid subluxation after laryngeal blunt trauma. Stroboscopy and electromyography permitted the correct diagnosis.

Electrophysiologic investigation of lower cranial nerve diseases by means of magnetically stimulated neuromyography of the larynx

Zoom endoscopic electromyography of the larynx, as introduced in 1979, has contributed greatly to the diagnosis of lower cranial nerve palsies, but in the early stage of a vagus nerve disorder one cannot investigate the nerve conduction from the brain stem to the laryngeal muscles with electrical stimulation. As with the early diagnosis of facial nerve palsies, up to now the intracranial part of the motoric brain nerves could not be stimulated directly. With a new magnetic coil device (Novametrix, Magstim 200) this intracranial stimulation is easily possible in the awake patient with painless magnetic stimuli that induce a muscle action potential into the laryngeal muscles. Hence, an immediate diagnosis is possible. Two coils with mean diameters of 8.5 or 3 cm were used. The stimulator delivered current pulses of peak amplitude up to 5,000 A with rise times of 140 microseconds and 65 microseconds, respectively, that generated peak fields of up to 2 T. In a healthy population, cisternal stimulation of the vagus nerve leads to a muscular response in the vocal muscle after 4 to 6.6 milliseconds (mean 5 milliseconds). Cortical stimulation leads to such a response after 9.5 to 12 milliseconds. Potentials in healthy individuals have been shown to be very uniform. Stimulation in recurrent nerve palsies may show prolongation of these latencies up to 30 milliseconds. The method is limited by the fact that complete neural blocks cannot be overcome by proximal stimulation. We have applied magnetic stimulation to 190 patients with different disorders of the vagus nerve. It allows a differential diagnosis of palsies immediately after their onset, and is thus the first method to make such an early investigation possible.