Kjell Brøndbo

Epidemiological aspects of recurrent respiratory papillomatosis: a population-based study.

The incidence of genital infections, cervical cancer, and oropharyngeal cancer induced by human papillomaviruses (HPV) is increasing in Western countries. Primarily, this study was conducted to estimate the incidence rate of recurrent respiratory papillomatosis (RRP) in juveniles and adults in two Norwegian subpopulations for each year between 1987 and 2009. The secondary objective of the study was to investigate whether there are trends in the incidence rates of RRP in the study period similar to what we have seen for HPV‐related cancer.

Laser surgery of T1a glottic carcinomas; significance of resection margins

Since 1995 patients with T1a glottic carcinomas have been treated with laser surgery at the Department of Otorhinolaryngology, Rikshospitalet in Oslo. During this period we have in many cases noticed an inconsistency between the clinical outcome and the histopathological report describing that the resection margins were not free. We wanted to investigate this discrepancy, and the charts with the histopathological reports of 171 patients treated between 1995 and 2005 have been reviewed. Seventeen patients (10%) experienced a recurrence of the initial disease and were treated by repeated laser surgery, radiotherapy, or radiotherapy and laryngectomy. Two patients (1%) had died from the disease. In 36% of the cases (62 patients) the histopathological report indicated “not free” or “probably not free” resection margins. The discrepancy between the histopathological reports and the clinical outcome reflects the pathologist’s difficulty in orienting and determining resection margins in laser-resected specimens. Because of the low number of recurrences or metastases, the verdict of a violated resection margin should probably not be crucial for further treatment. The surgeon’s peroperative judgement may be trusted, however, with very close follow-up in order to detect early recurrences.

Exercise-induced laryngochalasia: an imitator of exercise-induced bronchospasm.

BACKGROUND Patients with exercise-induced laryngochalasia present with dyspnea and stridor during exercise. Symptoms are due to a subtotal occlusion of the larynx resulting from mucosal edema from the aryepiglottic folds being drawn into the endolarynx. METHODS We report on three patients with exercise-induced bronchospasm, refractory to standard therapy. RESULTS Spirometry with flow-volume loops revealed truncation of the inspiratory limb. Abnormal movement of the arytenoid region was visualized on laryngoscopy. A diagnosis of exercise-induced laryngochalasia was made. CONCLUSIONS Evaluation of laryngeal motion in patients with refractory exercise-induced bronchospasm is important. Surgical correction with laser laryngoplasty is effective in carefully selected cases.

Recurrent respiratory papillomatosis: HPV genotypes and risk of high-grade laryngeal neoplasia.

Patients with recurrent respiratory papillomatosis (RRP) in Norway treated between 1987 and 2009 were recruited to this cohort study. They were followed from disease onset and data recorded until January 2012. Here, we describe the distribution of human papillomavirus (HPV) genotypes, the prevalence of multiple HPV infections, and the risk of high-grade laryngeal neoplasia and respiratory tract invasive carcinoma in a large cohort of patients with RRP. We also examined whether HPV genotype, gender, age or clinical course are risk factors for this development. Clinical records and histological specimens were reviewed. Using formalin-fixed paraffin-embedded biopsies, HPV genotyping were performed by quantitative polymerase chain reaction assays identifying 15 HPV types. HPV-negative specimens were analyzed by metagenomic sequencing. Paraffin blocks were available in 224/238 patients. The DNA quality was approved in 221/224 cases. HPV DNA was detected in 207/221 patients and all were HPV 6 or HPV 11 positive, comprising HPV 6 in 133/207, HPV 11 in 40/207 cases and HPV 6/11 in 15/207 cases. Co-infection with one or two high-risk HPV types together with HPV 6 or HPV 11 was present in 19/207 patients. Metagenomic sequencing of 14 HPV-negative specimens revealed HPV 8 in one case. In total, 39/221 patients developed high-grade laryngeal neoplasia. 8/221 patients developed carcinoma of the respiratory tract (six patients with laryngeal carcinoma and two patients with lung carcinoma). High-grade laryngeal neoplasias were found more frequently in HPV-negative versus HPV-positive patients, (RR = 2.35, 95% CI 1.1, 4.99), as well as respiratory tract carcinomas (RR = 48, 95% CI 10.72, 214.91). In summary, the majority of RRP were associated with HPV 6 and/or 11. HPV-negative RRP biopsies occurred more frequently in adult-onset patients, and were associated with an increased risk of laryngeal neoplasia and carcinoma in the respiratory tract.

Laser resection of T1a glottic carcinomas: results and postoperative voice quality

Objectives—To calculate recurrence, mortality and complication rates and evaluate postoperative voice quality after laser resection of T1a glottic carcinoma. Material and Methods—Since 1995 we have treated 118 patients with a T1a glottic carcinoma with laser surgery. In order to evaluate postoperative voice quality, patients who were alive and free of recurrence were sent the Voice Handicap Index (VHI) questionnaire containing 30 questions concerning how their voice affects their daily life physically, emotionally and socially. Results—Twelve patients (10%) had a local recurrence and received further treatment, either a second laser treatment, radiotherapy or a total laryngectomy. One patient (0.84%) died due to the laryngeal cancer. Ninety-nine patients were sent the VHI questionnaire and 94 of the completed questionnaires were included in the study and analyzed. The mean total score was 13.2, with mean subscores of 6.5 (physical), 4.1 (functional) and 2.5 (emotional). Conclusions—The results indicate that these patients as a group do not consider that their voice has a negative impact on their daily life. Good surgical technique is essential to obtain a good functional result. The laser strength should be kept low and the surgical margins small in order to minimize scarring and vocal cord stiffness.

Treatment of Cricopharyngeal Dysfunction by Endoscopic Laser Myotomy

Cricopharyngeal dysfunction may be caused by a central or peripheral nerve disease, a muscular disease, previous neck surgery or it may be idiopathic. The treatment may be a myotomy of the cricopharyngeal muscle carried out externally or endoscopically. Since 1995 we have treated 17 patients with endoscopic myotomy of the cricopharyngeal muscle with the CO 2 laser. Anamnesis was the basis for the diagnosis and we obtained further information from videoradiographs of the upper gastrointestinal tract and from manometry. There were no immediate or late complications from the surgery. Three patients died from other diseases, the remaining 14 patients were sent a follow-up questionnaire and asked to grade their complaints pre- and postoperatively and to answer questions about their weight. All patients except one stated that their swallowing abilities had improved since the surgery and more than half of the patients had gained weight. A low rate of complications and postoperative morbidity, combined with good functional results, indicate that endoscopic laser myotomy should be recommended for treatment of cricopharyngeal dysfunction.

The Histochemistry of the Posterior Cricoarytenoid (PCA) Muscle in the Dog, Compared with the Diaphragm, the Sternothyroid and the Sternomastoid Muscle

The canine posterior cricoarytenoid (PCA) muscle was compared histochemically with pieces of the diaphragm (Dia), an infrahyoid muscle (the sternothyroid, ST), and with a reference skeletal muscle (the sternomastoid, SM) taken from the same animal. The muscle fibre type composition in the PCA, Dia and ST differed very little and showed a slight type II preponderance. In the SM there was a strong type II preponderance. A subgrouping of the type II muscle fibres could not be carried out in any of the muscles. The oxidative activity was greater in the PCA than in the other three muscles and greater in type I than in type II fibres for all muscles except the Dia. In the Dia, some type I fibres had a larger cross-sectional area and showed a greater oxidative activity and contained less glycogen than the rest of the type I fibres in the muscle. These fibres seemed to represent a separate subgroup of type I fibres possibly serving quiet respiration.

Paradoxical vocal cord movement in newborn and congenital idiopathic vocal cord paralysis: two of a kind?

The second most common cause of stridor reported in the newborn is bilateral vocal cord paralysis (BVCP) and one-third of the cases have been categorized as idiopathic. During the last year four children with stridor since birth were referred to our department for examination. Videotaped flexible laryngoscopy, carried out with the patient awake or under general anaesthesia with a spontanous respiration, revealed instead of abduction of the vocal cords during inspiration, rather an active adductory movement. Consequently instead of BVCP, we made the diagnosis paradoxical vocal cord movement (PVCM). One of the twins required a tracheostomy, the three other patients have been observed without the need of further treatment. No previous publications have described PVCM in newborn. However, our observations and video recordings clearly show that the stridor in our four patients is due to PVCM. This is possibly the same condition as earlier reported as congenital, idiopathic BVCP where incoordinated vocal cord movement or dyskinesia has been a part of the laryngoscopic findings. The mechanism behind PVCM in this age group or site of lesion is unclear.

Experimental Laryngeal Reinnervation by Phrenic Nerve Implantation into the Posterior Cricoarytenoid Muscle

Under general anaesthesia, 5 dogs underwent sectioning of the right recurrent nerve followed by implantation of the phrenic nerve into the posterior cricoarytenoid (PCA) muscle. Some 6-7 months later the dogs were sacrificed after registration of vocal cord motility. Still photographs and movie film of the larynx were taken during quiet and forced respiration and at electrical stimulation of the implanted phrenic nerve. The PCA and vocal muscles were removed for histochemical studies. We found practically no abductory movement of the vocal cord on the reinnervated side, either during quiet or forced respiration. During forced inspiration there was, however, a slight medial bowing of the right vocal cord. At electrical stimulation there was a sphincteric movement of the entire larynx. Histochemistry showed a reinnervation picture of both the PCA and the vocal muscles on the experimental side. The conclusion drawn from this study is that axonal escape, probably from the implantation site, results in an unwanted reinnervation of laryngeal adductor muscles, which neutralize the abducting effect of the PCA muscle during inspiration. This method therefore does not seem to be suitable as a treatment alternative for bilateral recurrent nerve paralysis.

Risk of recurrence in laryngeal cancer

A cohort study was undertaken to analyze the risk of recurrence among 1616 patients with primary squamous cell carcinoma of the larynx from 1983 to 2010 at a single, tertiary academic center in Oslo, Norway. The cohort was followed from the date of diagnosis to September 2011. Competing risk regression analysis assessed the association between various risk factors and the risk of recurrence, where death was considered a competing event. Recurrence was observed in 368 patients (23%) during the study period. The majority (71%) of recurrences involved the location of the primary tumor. The overall risk of recurrence during the first three years after initiating treatment was 20.5%. Increased risk of recurrence was observed in patients with supraglottic cancer, younger patients, those with T2–T3 tumors and in patients treated in the earlier part of the study period. Significant factors for recurrence in glottic carcinomas were age, treatment in the earlier part of the study and T-status, whereas age was a significant factor in supraglottic cancer. N-status appeared less significant. In conclusion, follow-up of laryngeal squamous cell carcinoma should place particular emphasis on the site of the primary tumor, younger patients, cases of supraglottic cancer and T2-T4 primary tumors, especially during the first three years after treatment. More studies are needed to assess the impact of surgical versus non-surgical treatment, and eventually the significance of recurrence, for disease-specific and overall survival in cases of advanced laryngeal squamous cell carcinoma.