Herbert H. Dedo

Treatment of carcinoma of the vocal cord a review of 20 years experience.

At the University of California, San Francisco, 323 patients were treated for carcinoma of the vocal cord between January 1956 and December 1975. Patients with early T1 or T2 lesions were treated with radiotherapy or conservative surgery. Patients with T3 or T4 lesions were treated with total laryngectomy, radiation alone, or combined therapy. Of the 247 patients treated with definitive radiotherapy, initial control of the primary lesion was achieved in 100% of T1S, 80% of T1, 52% of T2, and 50% of T3 and T4 lesions. Surgical salvage of radiation failures was 86%, giving ultimate control rates in this group of 100% for T1S, 97% for T1, 91% for T2 and 64% for T3 and T4. Involvement of the anterior commissure did not significantly affect local control or survival rates of the irradiated patients. Voice quality was satisfactory in 95% of controlled patients. Surgery alone was used as the primary treatment modality in 63 patients, with ultimate local control achieved in 75% of T1S, 83% of T1, 85% of T2, 81% of T3 and T4 lesions. Planned combined therapy was successful in 9/13 patients in whom it was used. The overall 3 and 5 year actuarial survival rates were 84% and 77% respectively; corresponding determinate survival rates were 90% and 86%.

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.

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 swallows 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.

Prevention of major and minor fistulae after laryngectomy.

Every Head and Neck surgeon has special techniques which he uses to get maximum rates of five‐year survival and minimum fistula formation, especially major fistula and carotid rupture. The literature reflects a wide variation in the rate of fistula formation. We reviewed the senior authors prior 78 total laryngectomies and noted a fistula rate of 10.3% (6.4% minor fistulae and 3.9% major fistulae). We also reviewed contributing factors and discuss surgical techniques designed to minimize fistula formation.

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.

Spastic dysphonia: A patient profile of 200 cases*

A comprehensive case history profile of spastic dysphonia patients was established, using 200 patients matched to 200 controls. The case histories and epidemiologic profiles for male and female patients revealed few dissimilarities. Likewise, intergroup (patients-controls) health history profiles differed in only a few specific instances. The data suggest non-psychogenic, non-behavioral causation of spastic dysphonia; however, neither a definitive cluster or clusters of events at onset nor any unequivocal epidemiologic factor was accountable for spastic dysphonia. Short of qualified improvement with voice therapy in some patients, no form of treatment other than recurrent laryngeal nerve section was shown to be of any significant help for the patient population sampled.

Problems with surgical (RLN section) treatment of spastic dysphonia

For over a century spastic dysphoria — a disorder of phonation — remained enigmatic and highly resistant to treatment. Recurrent laryngeal nerve surgery provides patients with elimination of their spastic dysphonia symptoms. Maintenance of long‐term surgical results has been a problem in some cases. Management of this problem and of problems in the diagnosis and treatment of patients with spastic dysphonia are discussed. The observations and conclusions are based on almost 300 patients examined and/or treated for this disorder.

The mucoperiosteal flap in frontal sinus surgery. (the sewall-boyden-mcnaught operation.)†‡

The problem with the Lynch operation for frontal sinus disease is the high incidence of failures (30 percent) due to the closure of the nasofrontal communication. It seems to us that the use of permanent (Dacron, described as recently as 1972) or temporary (Portex) indwelling tubes to preserve this communication is unreasonable when there is available an operation that requires no gadgets. This is the mucoperiosteal flap operation. This has several advantages over the osteoplastic flap‐fat obliteration procedure. It is performed through a Killian‐type incision through which surgical treatment of the ethmoid and sphenoid sinuses can also be done (not possible with the osteoplastic approach). It is less formidable and not deforming, and there is no concern about the possibility of developing secondary mucoceles. The incidence of failures is extremely low. The probable reason that it is not used more is that it is not well known.

Cranial neuropathies in sinus disease

To study the problem of cranial neuropathies in sinus disease the in‐patient experience at the University of California, San Francisco, and San Francisco General Hospitals was reviewed. The incidence of cranial nerve involvement in acute and chronic sinus inflammations was low (8 percent and 4 percent respectively). The incidence in neoplastic disease of the sinuses was considerably higher (32 percent). Cranial neuropathies occurred in inflammatory disease more frequently when associated with mucopyocele, mucormycosis, and orbital cellulitis. In both inflammatory and neoplastic disease, when cranial nerve deficits occurred, there was a high predelication for sphenoid sinus involvement. Several instructive case histories are included. The important anatomy of the cavernous sinus region and of the orbital apex as it pertains to this problem is 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.