Ramon A. Franco

585-NM Pulsed Dye Laser Treatment of Glottal Dysplasia

Management of glottal dysplasia can be difficult and often results in a suboptimal treatment outcome. The surgeon and patient must cooperatively balance decisions regarding the effects of possible malignancy, vocal dysfunction, and recurrences leading to multiple use of general anesthetics. A pilot study was done in 57 cases (36 patients and 97 vocal folds) without complication to evaluate the effectiveness of a 585-nm pulsed dye laser (PDL; 450-μs pulse width, 19 to 76-J/cm2 fluence, 1- to 2-mm spot size) in the treatment of vocal fold keratosis. Forty of the 57 cases had bilateral treatment. Phonomicrosurgical resection was done in 35 of the 57 cases after PDL treatment. Of this group, 10 cases were found to have hyperplasia, 21 dysplasia, 4 carcinoma in situ, and 1 carcinoma. One patient had phonomicrosurgical resection before PDL treatment. In 21 of the 57 cases, the disease was irradiated without resection (4 unilateral lesions and 17 bilateral lesions). Approximately 80% of the patients in this series had a greater than 70% reduction in the size of the lesion with the use of the PDL irrespective of whether they underwent resection. Clinical observation revealed no new anterior commissure web formation despite bilateral anterior commissure treatment in 28 of the 57 cases. The PDL enhanced the epithelial excision by improving hemostasis and by creating an optimal dissection plane between the basement membrane and the underlying superficial lamina propria. In this initial trial, the PDL provided relatively safe and effective treatment for glottal dysplasia. Analysis of patterns of recurrence will require longer follow-up.

Voice and treatment outcome from phonosurgical management of early glottic cancer.

Phonosurgical management of early glottic cancer has evolved considerably, but objective vocal outcome data are sparse. A prospective clinical trial was done on 32 patients with unilateral cancer (T1a in 28 and T2a in 4) who underwent ultranarrow-margin resection; 15 had resection superficial to the vocal ligament, and 17 deep to it. The subepithelial infusion technique facilitated selection of these patients for the appropriate procedure. All are cancer-free without radiotherapy or open surgery. Involvement of the anterior commissure (22/32) or the vocal process (15/32) of the arytenoid cartilage did not influence local control. Nine of 17 patients had resection of paraglottic musculature, and all underwent medialization reconstruction by lipoinjection and/or Gore-Tex laryngoplasty. Eight of the 17 had resections deep to the vocal ligament, but without vocalis muscle, and 1 of the 8 underwent medialization. Posttreatment vocal function measures were obtained for all patients. A clear majority of the patients displayed normal values for average fundamental frequency (72%) during connected speech, and normal noise-to-harmonics ratio (75%) and average glottal airflow (91%) measures during sustained vowels. Smaller majorities of patients displayed normal values for average sound pressure level (SPL; 59%) during connected speech and for maximum ranges for fundamental frequency (56%) and SPL (59%). Fewer than half of the patients displayed normal values for sustained vowel measures of jitter (45%), shimmer (22%), and maximum phonation time (34%). Almost all patients had elevated subglottal pressures and reduced values for the ratio of SPL to subglottal pressure (vocal efficiency). There were significant improvements in a majority of patients for most vocal function measures after medialization reconstruction. Normal or near-normal conversation-level voices were achieved in most cases, regardless of the disease depth, by utilization of a spectrum of resection and reconstruction options. These favorable results are based on establishing aerodynamic glottal competency and preserving the layered microstructure of noncancerous glottal tissue.

Phonosurgical reconstruction of early glottic cancer

INTRODUCTION Fraenkel reported the first successful transoral (mirror-guided) treatment of an early-stage vocal fold cancer in 1886. After Kirstein popularized direct laryngoscopy (1895) and Killian established the advantages of suspension laryngoscopy (1912), Lynch published the first series of direct laryngoscopic early-stage glottic cancer resections (1920). The role of laryngoscopic treatment of early-stage glottic cancer expanded with the introduction of the surgical microscope by Scalco et al. in 1960. During the last quarter of the 20 century, there were two critical, simultaneous, and initially independent surgical advancements. The carbon dioxide (CO2) laser was introduced to surgical oncology by Jako, Strong, and Vaughan, and laryngoplastic phonosurgery was championed by Isshiki et al. Phonosurgical management of early-stage glottic cancer is an interdependent convergence of emerging resection and reconstruction techniques, which is a general philosophy underlying evolving concepts in surgical oncology. If a glottic cancer resection requires excision of vocal musculature, the resulting neocord is usually concave, which leads to aerodynamic insufficiency during phonatory adduction of the arytenoids. Voice restoration is based on re-establishing glottal competency by means of augmentation of the paraglottic space or medialization of the excavated musculomembranous vocal fold, or both. This can be accomplished by means of transoral lipoinjection or transcervical medialization laryngoplasty, or both. If Broyles’ ligament is resected, a laryngofissure and anterior commissure (AC) laryngoplasty may be necessary to close a keyhole aperture.

Genetic evidence for an association of the TOR1A locus with segmental/focal dystonia

Polymorphisms in the TOR1A/TOR1B region have been implicated as being associated with primary focal and segmental dystonia. In a cohort of subjects with either focal or segmental dystonia affecting the face, larynx, neck, or arm, we report a strong association of a single nucleotide polymorphism (SNP), the deletion allele at the Mtdel SNP (rs3842225), and protection from focal dystonia. In contrast, we did not find an association of either allele at the D216H SNP (rs1801968) with focal or segmental dystonia in the same cohort.

In-office laryngeal surgery with the 585-nm pulsed dye laser.

Purpose of reviewTo describe the current support in the literature for in-office surgery using the 585-nm pulsed dye laser. Recent findingsThere are substantial cost savings (US

Development and Validation of a High-Fidelity Porcine Laryngeal Surgical Simulator

5000) and patient comfort when in-office surgery is performed with the pulsed dye laser. The pulsed dye laser can be used in the office and operating room to activate aminolevulinic acid for photodynamic treatment of recalcitrant laryngeal keratosis, with long-term eradication of keratosis without the prolonged photosensitivity of previous photodynamic agents. The site of the cleavage plane created in the true vocal fold mucosa has now been elucidated. SummaryThe 585-nm pulsed dye laser allows safe, medically effective and cost-effective in-office surgery for a host of laryngeal lesions such as papillomatosis, keratosis, Reinkes edema, granulomas and other vascular lesions. The pulsed dye laser can activate aminolevulinic acid for laryngeal photodynamic therapy. Of the lasers currently in use it has the longest track record of safety and, to the satisfaction of many, continues in service at 23 centers around the world.

Voice Outcomes After Endoscopic Injection Laryngoplasty with Hyaluronic luronic Acid Stabilized Gel

Objective Design and validate a laryngeal surgical simulator to teach phonomicrosurgical techniques. Study Design Device development and prospective validation. Setting Tertiary medical center. Subjects and Methods A novel laryngeal fixation device and custom laryngoscope were produced for use with ex vivo porcine larynx specimens. Vocal fold lesions such as nodules and keratotic lesions were simulated with silicone injections and epithelial markings. A prospective validation using postsimulation surveys, global rating scales, and procedure-specific checklists was performed with a group of 15 medical students, otolaryngology residents, fellows, and attending laryngologists. Three procedures were performed: vocal fold augmentation, excision of a simulated vocal fold nodule, and excision of a simulated vocal fold keratosis. Results Participants overwhelmingly agreed that the simulator provided a realistic dissection experience that taught skills that would transfer to real operating scenarios. Expert performance was statistically superior to novice performance for excision of simulated vocal fold nodules and keratotic lesions, while no difference was observed for injection laryngoplasty. Conclusion The ability to learn and rehearse surgical procedures in a safe environment is invaluable, particularly for delicate and highly technical phonomicrosurgical operations. We have developed a high-fidelity laryngeal surgical simulator complete with pathological lesions such as nodules and keratoses to teach these procedures. A prospective study demonstrated validity of our global rating scale and checklist assessments for vocal fold nodule and keratosis excision procedures, allowing them to be confidently incorporated into phonomicrosurgical training programs for surgeons of all levels of expertise.

Photochemical repair of vocal fold microflap defects.

OBJECTIVE A variety of materials as well as approaches have been used to treat glottic insufficiency, but the ideal procedure has yet to be determined. The goal of this study was evaluate the safety and efficacy of cross-linked hyaluronic acid (Restylane) for office-based injection laryngoplasty for the treatment of vocal fold (VF) immobility. STUDY DESIGN Retrospective chart review. METHODS Twenty-seven patients were with diagnosed VF immobility. Twenty-five received Restylane VF injections in the office setting via percutaneous, trans-thyrohyoid injection with distal chip endoscopic guidance. Two patients received injections using suspension microlaryngoscopy under general anesthesia. Voice outcomes were followed using the Voice-Related Quality of Life Survey and the Voice Outcome Survey. RESULTS Four patients were lost to follow-up immediately after injection. 20 of 23 patients (87%) reported subjective improvement in voice. Analysis of subjective surveys from nine patients revealed a trend toward improvement of V-RQOL from 34 to 23 (P = 0.083) but did not reach significance. After compilation of all VOS questions, 69% of all follow-up responses noted improvement of symptoms, 24% were unchanged and 7% were worse. CONCLUSIONS Office-based injection laryngoplasty with Restylane appears to be a safe procedure that improves vocal function in patients with glottal insufficiency due to impaired VF mobility. Further studies are required to quantify the benefits and to compare the effects with other injectable materials.

Aminolevulinic acid 585 nm pulsed dye laser photodynamic treatment of laryngeal keratosis with atypia

To bond vocal fold flaps using a sutureless, nonthermal laser‐assisted method combining visible light and photosensitizing dyes to produce collagen crosslinks.

Double-bend needle modification for transthyrohyoid vocal fold injection.

Objective To evaluate the safety and efficacy of aminolevulinic acid photodynamic therapy (ALA-PDT) with the 585 nmpulsed dye laser. Methods A 5-year prospective study was performed with 12 male patients with keratosis. Twenty percent ALA was sprayed into the larynx and activated with the 585 nm pulsed dye laser (PDL). Of the 12 patients, four were not included (one lost to follow-up, two developed cancer, one papillomatosis), which reduced the number to eight. Twenty-eight procedures were performed in these eight patients; 18 (64%) procedures were performed in the clinic setting. Results There was a 78% reduction (range, 10% to 100%) in the keratosis. No major side effects were noted. Mean follow-up was 34.5 months (range, 12 to 50 months). There were no statistical differences between the outpatient and operating room treatments. Conclusions ALA-PDL PDT is effective and safe in treating laryngeal keratosis in the awake clinic setting and reduces morbidity without sacrificing treatment efficacy.