Hiltrud Glanz

Autofluorescence Endoscopy in the Diagnosis of Early Laryngeal Cancer and Its Precursor Lesions

Objectives Because early detection and preoperative assessment of laryngeal cancer and its precursor lesions are essential for curative and function‐preserving surgical treatment, autofluorescence endoscopy has been developed to gain more information about the biologic character of these lesions. The aim of the present study is to investigate a high, representative number of patients and to evaluate the diagnostic potential and the limitations of this method.

Clinical and morphological aspects of laryngeal cysts

To our knowledge only a few defined studies have been carried out on laryngeal cysts. These cysts represent a mixed group of benign laryngeal lesions that can cause diagnostic and therapeutic difficulties. The aim of this study was to characterize their histological structure and localizations in the larynx as well as to discuss theories about their genesis. Between 1973 and 1996, 342 laryngeal cysts were treated at Phillips University of Marburg, while from 1990 to 1996, 74 were treated at Justus Liebig University of Giessen. In all, 416 laryngeal cysts were treated by endolaryngeal microsurgery. All clinical charts were reviewed retrospectively and surgical specimens examined histomorphologically. Findings showed that 58.2% of the laryngeal cysts were located in the glottic area and 18.3% in the ventricular folds. The remainder were located on the aryepiglottic fold (2.2%) and interarythenoid region (0.7%). Two congenital cysts were also treated. Approximately 56% of the laryngeal cysts were lined by squamous cell epithelium, 37% by respiratory epithelium and 7% by oncocytic epithelium. In general, the laryngeal cysts were found to be a collection of inhomogenous lesions from different histogenetic origins with diverse symptoms related to their site and size. On the basis of our investigations, a new classification was established concerning the genesis and development of laryngeal cysts by subdividing cysts into congenital cysts, retention cysts, and inclusion cysts.

CLINICAL VALUE OF OPTICAL COHERENCE TOMOGRAPHY IN LARYNGOLOGY

Optical coherence tomography (OCT) is a new, noninvasive imaging technology for the evaluation of superficial lesions. The objective of this study is to evaluate microlaryngoscopy in combination with OCT compared with microlaryngoscopy alone (ie, without OCT) in supplying a specific diagnosis, predicting invasive tumor growth and epithelial dysplasia in the larynx.

Compact Endoscopy of the Larynx

In order to improve preoperative assessment of suspected precancerous and cancerous lesions of the larynx, we examined 83 patients by compact endoscopy (combination of autofluorescence and contact endoscopy) during microlaryngoscopy in a pilot study. The intraoperative findings were related to histopathologic examination. Cancerous laryngeal mucosa was illuminated during autofluorescence endoscopy by use of blue filtered light (D-light AF system) for optical demarcation of the lesion. After staining the mucosa with methylene blue (1%), we performed contact endoscopy. During autofluorescence examination of the endolaryngeal mucosa, the appearance of precancerous and cancerous lesions varied between opaque light areas and darker reddish areas. By contact endoscopy, it was possible to observe the cells, nuclei, and cytoplasm, as well as different degrees of abnormality. Histopathologic findings of 83 patients revealed laryngeal dysplasia (grade I in 29 patients, grade II in 15, and grade III or carcinoma in situ in 8) and laryngeal cancer (31 patients). In 73 cases (88%), the findings of compact endoscopy corresponded to those of histopathology. In 5 cases, epithelial lesions were overestimated because of inflammation and scarring, and 5 cases were underestimated because of hyperkeratotic thickening of the mucosa covering basal epithelial layers with focal dysplasia of grades II and III, carcinoma in situ, and microinvasive cancer. We conclude that compact endoscopy enables the laryngologist to assess laryngeal cancer and its preceding lesions more accurately during microlaryngoscopy.

Significance of Autofluorescence for the Optical Demarcation of Field Cancerisation in the Upper Aerodigestive Tract

BACKGROUND Second primaries in the upper aerodigestive tract (UADT) are increasingly related to bad prognosis. So early detection of small cancer foci is required to improve the survival rate. Here, autofluorescence (AF) might become useful as in vivo biochemical changes of cancer metabolism can be shown by fluorescence. MATERIAL For more exact data on AF in cancerous lesions 32 cancer specimens of the UADT and 57 specimens of normal oral mucosa as a control group were examined by using autofluorescent microscopy and spectroscopy, the tissue being activated with light at 365 nm wavelength. Video-controlled in vivo fluorescence examinations in field cancerisation of the UADT were also investigated and compared with pathohistological findings. RESULTS The intensity of AF of the connective tissue was observed to increase at the tumour border. Contrary to results in the literature, no homogeneous fluorescence gradient could be proved between marginal epithelium and the tumour itself. The brightly shining submucosal elastic fibres allowed fluorescent spectroscopic detection of the tumour margins in vitro in 71%. Even small precancerous lesions were traced in vivo mainly by keratinization when using the autofluorescence diagnostic imaging system. CONCLUSIONS Our examination proved a multi-factorial genesis of autofluorescence with strong inter-individual variations. Preliminary clinical examination showed that this method can be applied as an additional tool for early detection of cancerous lesions in the UADT.

Inverted Papilloma of the Nasal Cavity and Paranasal Sinuses: Clinical Data, Surgical Strategy and Recurrence Rates

Background: In the last decade inverted papillomas of the nasal cavity and paranasal sinuses have been observed in increasing numbers, and treatment modalities have ranged from extensive open radical procedures to microinvasive endonasal surgical excision. Objective: To establish criteria for selecting patients for open osteoplastic or endonasal surgery according to clearly defined pathological and clinical data. Material and method: In a retrospective study, clinical data of 55 patients treated surgically in the University ENT Clinic Giessen from 1991 to 1998 were analysed. In 33 patients (60%) endonasal excision of the papillomas was carried out and in 22 (40%) osteoplastic lateral rhinotomy or maxillotomy were performed. All histological specimens were revised. Patients were followed up and endoscopically examined until 31 March 1999. Results: In 22 patients, tumours involving the frontal sinus, maxillary sinus, parts of the frontal skull base and anterior ethmoid, and the orbit were operated on using open osteoplastic procedures, with 4 (18%) recurrences observed. Tumours excised endonasally showed the same recurrence rate: 6 out of 33 (18%). These tumours were smaller in size and localized in the nasal cavity, the middle and posterior parts of the ethmoid involving the sphenoid, and the medio-posterior wall of the maxillary sinus. The functional outcome was excellent for all patients; two patients developed a mucocele. Cancerization was observed in three cases. Conclusions: In select cases the endonasal microsurgical approach to inverted papillomas has the same good results concerning function and tumour control as osteoplastic open rhinotomy. This method should still be preferred in tumours localized in the frontal sinus, anterior ethmoid, anterior, caudal and lateral parts of the maxillary sinus and beyond the sinuses.BACKGROUND In the last decade inverted papillomas of the nasal cavity and paranasal sinuses have been observed in increasing numbers, and treatment modalities have ranged from extensive open radical procedures to microinvasive endonasal surgical excision. OBJECTIVE To establish criteria for selecting patients for open osteoplastic or endonasal surgery according to clearly defined pathological and clinical data. MATERIAL AND METHOD In a retrospective study, clinical data of 55 patients treated surgically in the University ENT Clinic Giessen from 1991 to 1998 were analysed. In 33 patients (60%) endonasal excision of the papillomas was carried out and in 22 (40%) osteoplastic lateral rhinotomy or maxillotomy were performed. All histological specimens were revised. Patients were followed up and endoscopically examined until 31 March 1999. RESULTS In 22 patients, tumours involving the frontal sinus, maxillary sinus, parts of the frontal skull base and anterior ethmoid, and the orbit were operated on using open osteoplastic procedures, with 4 (18%) recurrences observed. Tumours excised endonasally showed the same recurrence rate: 6 out of 33 (18%). These tumours were smaller in size and localized in the nasal cavity, the middle and posterior parts of the ethmoid involving the sphenoid, and the medio-posterior wall of the maxillary sinus. The functional outcome was excellent for all patients; two patients developed a mucocele. Cancerization was observed in three cases. CONCLUSIONS In select cases the endonasal microsurgical approach to inverted papillomas has the same good results concerning function and tumour control as osteoplastic open rhinotomy. This method should still be preferred in tumours localized in the frontal sinus, anterior ethmoid. anterior. caudal and lateral parts of the maxillary sinus and beyond the sinuses.

Endoscopic high-frequency ultrasound of the larynx.

Abstract Over the last few years the development of new high-frequency ultrasound equipment has improved the application and resolution of endoluminal ultrasound. Following our in vitro study on the anatomical basis of endolaryngeal high-frequency ultrasound we present the preliminary results of our sonographic examinations during microlaryngoscopy in order to characterize clinical applications. For the present study 38 patients underwent endolaryngeal ultrasound examinations. Laryngeal pathology included vocal fold polyps, laryngeal cysts, chronic laryngitis, Reinke’s edema, epithelial dysplasia and cancer. The ultrasound examination was performed during microlaryngoscopy in a standardized pattern. A newly developed ultrasound apparatus was utilized with 10 MHz and 20 MHz catheters. Site, size and depth of the laryngeal lesion were evaluated. In 23 examinations of laryngeal carcinomas tumor size and infiltration could be measured and involvement of the thyroid cartilage or anterior commissure could be visualized. The exact extension of laryngeal cysts could also be seen. Ultrasound added no additional information to the endoscopic impression of the other laryngeal lesions. Present findings suggest that endoluminal high-frequency ultrasound might supplement microlaryngoscopy in the assessment of certain laryngeal lesions, especially for the evaluation of the size and infiltration of laryngeal tumors and to perform a more accurate preoperative staging without using computed tomography or magnetic resonance imaging.

Investigating quality of life and coping resources after laryngectomy

Abstract Surgical procedures and in particular laryngectomy can become a life-saving treatment for patients with laryngeal or hypopharyngeal cancer, but can result in permanent damage. Clinical observation suggests that patients vary considerably in their ways of dealing with this new situation and in their ability to cope. The aim of our interdisciplinary group was to investigate the quality of life of laryngectomy patients and learn about their perceptions, situation and coping mechanisms. The development of an appropriate study design and a measurement strategy is presented. We investigated 29 laryngectomized patients who had joined the local self-help group. The patients were free from tumour disease and were mostly married with children, retired from work and had not graduated from high school. Assessment of the quality of life was performed with the European Organization for Research on Treatment of Cancer questionnaires QLQ-C30 and H+N35 and additional open questions. Analysis of the acquired data showed that family support was judged most important for overcoming the problems of disease and treatment. Deficits in this area were highly correlated with a low overall quality of life. Financial problems resulted because of the high percentage of retirement before or after therapy. We suggest that perioperative support taking these facts into consideration can result in an improved coping process. Further prospective studies are needed to reveal the effect of such measures.

Endolaryngeal high-frequency ultrasound.

Abstract High-frequency ultrasound can provide high-resolution imaging for diagnosing diseases of the head and neck. Over the last few years, a virtual technical evolution has led to the development of small and flexible ultrasound transducers with even greater anatomic resolution. The aim of the present study was to evaluate the efficacy of this new technique for imaging normal and altered anatomical structures of the endolarynx. Specially developed high-resolution, real-time ultrasound transducers (10 and 20 MHz) placed on the tip of endoluminal catheters were inserted into 20 autopsied larynges and five laryngectomy specimens. In a standardized examination process the endolarynx was analyzed in a real-time mode. Using this technique, exact 360° cross sections of the larynx were obtained, demonstrating that it was possible to image the structures of the endolarynx with ultrasonography. Depending on the frequency used, all anatomical structures could be visualized up to a depth of 2 cm. In laryngeal cancer the depth of tumor as well as its relationship to the laryngeal framework could be clearly recognized. These findings suggest that this new endoluminal sonographic procedure represents a potentially important diagnostic tool in the assessment of laryngeal carcinoma.

Technique of Optical Coherence Tomography of the Larynx During Microlaryngoscopy

Optical coherence tomography (OCT) is a new, noninvasive imaging technology for the evaluation of superficial lesions. Because of a penetrating depth of a few millimeters and an ultrahigh tissue resolution, it qualifies for use in the larynx and might in the near future play an important role in the pre‐, intra‐, and postoperative investigation of early laryngeal cancer and its precursor lesions. Especially directed to otolaryngologists, this paper describes the technique of in vivo OCT imaging of the larynx in detail during microlaryngoscopy and supplies a number of personal hints.