M. Stuart Strong

Predictive Factors of Success or Failure in the Endoscopic Management of Laryngeal and Tracheal Stenosis

Stenosis of the larynx and/or trachea presents perplexing problems. No one technique has proved totally satisfactory in the management of all varieties of stenosis. Recent reports have described the successful use of the CO2 laser in the endoscopic management of stenosis of the larynx and trachea. Failures of this technique need emphasis to assure appropriate selection of therapeutic method. Retrospectively, 49 cases of laryngeal stenosis, 6 cases of tracheal stenosis and 5 cases of combined laryngeal and tracheal stenosis were studied (total 60 patients) following treatment at the Boston University Affiliated Hospitals. Follow-up ranged from 1 to 8 years. Multiple procedures were required in 35 laryngeal patients. Of the laryngeal patients 39 were successfully managed (average number of procedures in successful cases 2.18). Of 11 tracheal patients with combined laryngeal and tracheal procedures, 3 were successfully managed (average number of procedures in successful cases 6). Failures in laryngeal stenosis included four patients in whom an adequate airway was not established though voice was present while maintaining tracheostomies. Thirteen patients failing endoscopic management required open surgery with good result. Factors associated with poor result or failure include circumferential scarring with cicatricial contracture, scarring wider than 1 cm in vertical dimension, tracheomalacia and loss of cartilage, previous history of severe bacterial infection associated with tracheostomy, and posterior laryngeal inlet scarring with arytenoid fixation. In these circumstances, multiple procedures, more extensive alternative open surgical techniques, or maintenance of tracheostomy were necessary. In successful cases only three or fewer procedures on average were required. The factors associated with failure or success of endoscopic methods in the management of laryngotracheal stenosis, including use of the CO2 laser and soft Silastic stents, are analyzed.

LASER SURGERY IN OTOLARYNGOLOGY: INTERACTION OF CO2 LASER AND SOFT TISSUE*

The sequence of histological change induced by CO2 laser irradiation was discussed in terms of two factors: the physiomechanical factor and the physiochemical factor. At sufficiently high heat energy levels, the immediate findings are characterized by crater formation resulting from rapid vaporization of the water and ejection of the solid component. In the immediate vicinity of the crater edge, the maximum tissue temperature rise is 65 degrees C above the 32 degrees C ambient tissue temperature and it decreases to the primary tissue temperature within a distance of 2 mm. The healing process of CO2 laser induced lesions proceeds with minimal delay. The lymphatic and vascular channels are occluded in the marginal area of coagulation resulting in a marked hemostatic effect. This sealing effect increases the margin of safety in preventing possible dissemination of tumor cells. By selecting the appropriate power, time, and focus cone angle, precise destruction of preselected areas of tissue can be achieved with an extraordinary hemostatic effect without damaging the underlying tissue. These advantages are especially helpful in function-preserving surgery.

Recurrent Respiratory Papillomatosis Management with the CO2 Laser

Recurrent respiratory papillomatosis is most common in childhood but it affects all age groups; it represents a diathesis of the aerodigestive tract so that lesions may develop at various sites — the nares, lips, pharynx, nasopharynx, larynx, tracheobronchial tree, and the lungs. Ablation of all visible papillomas with the surgical laser achieved remissions in approximately one-third of patients for one year or more; since relapses may occasionally occur 2 to 20 years later, cure can never be assumed. At the present time, management is directed towards total ablation of all visible papilloma consistent with preservation of the airway and voice; reduction of the tumor burden to minimal proportions is thought to allow the maximum opportunity for remission. As the host-papilloma relationship is unraveled, it may be possible in the future to provoke an immune response so that remissions can be predicted and produced consistently.

Induction chemotherapy in advanced squamous head and neck carcinoma with high-dose cis-platinum and bleomycin infusion.

Forty patients with advanced head and neck cancer were treated with combined Cis‐platinum‐Bleomycin chemotherapy. Cis‐diammine dichloroplatinum (DDP) 120 mg/m2 iv was given after prehydration, with mannitol diuresis on Day 1. On Day 3, an initial loading dose of Bleomycin 15 mg/m2 was given by rapid iv push followed by continuous 24 hour intravenous infusion of Bleomycin 15 mg/m2 Day 3 through Day 10. DDP 120 mg/m2 iv was administered again on Day 22. The patients were evaluated for tumor response and resectability between Day 29 to Day 35. Of 39 patients who were evaluable, there were 8 complete responses or CR (20%) and 22 partial responses or PR (56%), for a major response rate of 76%. Nineteen patients had surgery (14 patients whose lesions were initially inoperable and 5 patients who were initially operable). Chemotherapy toxicity in 40 patients included alopecia (40), vomiting (39), mucositis (11), skin rash (10), fever (17), weight loss of more than 5 lbs. (25), WBC less than 3,000 (2), platelets less than 100,000 (1), peak serum creatinine of 2 mg% (3), severe‐hearing loss (1), hypersensitivity reaction (2). Surgical complication in 19 patients were pharyngocutaneous fistulae (2), wound dehiscence (1), meningitis and brain abscess (1). There was one death secondary to nephrotoxicity. This particular combination chemotherapy when given as initial treatment, appears very effective in reduction of tumor bulk. Long‐term follow‐up and randomization is necessary to determine effect upon survival.

Laser excision of carcinoma of the larynx

The CO2 surgical laser and microscope assembly have been used to excise carefully selected T1 carcinomas of the membranous portions of the cord. Healing has been prompt and return of function satisfactory.

Excisional biopsy in the selective management of T1glottic cancer: A three‐year follow‐up study

Transoral excisional biopsy has been used in the evaluation and management of 103 Tl glottic cancers. A 3‐year follow‐up on these patients indicates that excisional biopsy unequivocally established the diagnosis and stage of the disease and that it is adequate treatment for micro and mini squamous cell cancers of the glottis in which the margins of excision are clear.

Laser surgery in the aerodigestive tract

Summary The conventional management of certain problems in the aerodigestive tract has been either inconvenient or ineffective. Seventy-five cases have been treated with the continuous wave CO 2 laser in an attempt to identify the advantages and limitations of laser surgery. It has been found that the CO 2 laser provides a practical method of tissue ablation or excision which can be carried out with excellent control. The laser beam is directed with a handpiece in the oral cavity, with the surgical microscopic laser attachment in the nose, pharynx, and larynx, and with the endoscope-bronchoscope assembly in the tracheobronchial tree. Laser surgery appears to be most valuable when precise surgery is needed to preserve function.

Patterns of relapse in locally advanced head and neck cancer patients who achieved complete remission after combined modality therapy

Relapse patterns in patients with locally advanced head and neck cancer who achieved complete remission were evaluated. After combined modality therapy with induction chemotherapy followed by surgery and/or radiotherapy, 71 of 103 patients were clinically free of disease. The 5‐year recurrence rate was estimated at 51%, with a 39% local and 26% distant failure rate by 5 years. The factors significantly affecting the relapse patterns were: (1) the site of the primary tumor (those with oral cavity lesions were more likely to fail locally, whereas hypopharynx patients had a higher risk of distant metastases); (2) the type of definitive local treatment (those patients who received surgery and radiotherapy were at lower risk of pure local failure); (3) TN Stage (patients with T4N3 or T3N3 tumor were at higher risk of both local and distant failure); and (4) time to response and presence of oropharyngeal lesions (patients who had a longer period from diagnosis to final complete response [CR] and patients with oropharyngeal primaries were at higher risk for simultaneous local and distant failure). Type of chemotherapy, patient age, tumor differentiation, and response to induction chemotherapy did not significantly influence the patterns of relapse. A combined modality approach with induction chemotherapy, surgery, and/or radiotherapy does not seem to reduce the incidence of distant metastases significantly.

Localized Amyloidosis of the Head and Neck and Upper Aerodigestive and Lower Respiratory Tracts

Seven cases of localized amyloidosis limited to structures of the head and neck and upper aerodigestive and lower respiratory tracts evaluated and treated at Boston University Hospitals in a recent 7-year period were reviewed. Negative Congo red staining of abdominal adipose aspiration biopsy or rectal biopsy specimens established that the amyloidosis was not systemic. Localized amyloidosis occurred in discrete masses in a variety of sites in the aerodigestive tract including the orbit, nasopharynx, lips, floor of mouth, tongue, larynx, and tracheobronchial tree. Five patients required surgical excision because of significant airway obstruction or organic dysfunction. Amyloid deposits completely excised with the carbon dioxide laser have not recurred, though other amyloid masses may appear elsewhere within the same organ or region. Amyloidosis may occur primarily or secondarily to other disease states. Localized amyloidosis has not been chemically identified but is usually defined by the absence of systemic features. While rare, amyloidosis must be recognized and understood by the otolaryngologist head and neck surgeon to allow appropriate diagnostic and therapeutic planning.

Bronchoscopic Carbon Dioxide Laser Surgery

Endotracheal and endobronchial carbon dioxide laser surgery can be carried out using standard ventilating bronchoscopes, a recently developed laser endoscope attachment and a 50W CO2 surgical laser unit. General anesthesia, using nonflammable anesthetics, is delivered through the side arm of the ventilating bronchoscope; the tidal flow of gases keeps the trachea and bronchi free of steam and smoke. The technique has been particularly helpful in the bloodless removal of recurrent papillomas from the trachea and main stem bronchi of ten children with tracheostomies. While three of the patients have gone into remission following laser excision, the method cannot be curative of itself. There were no complications attributable to the carbon dioxide laser surgery, per se, but constant vigilance must be exercised as with all laser surgery. As instrumentation becomes refined the technique will have wider application in the management of tracheobronchial disease.