Vincent Bachy

Outcomes following transoral robotic surgery: Supraglottic laryngectomy.

To describe a single center outcomes following transoral robotic surgery for supraglottic laryngectomy (TORS–SL).

Transoral robotic surgery total laryngectomy

has been reported with feasibility trials andpromising initial data. The combination of the two proce-dures, supraglottic and hypopharyngeal TORS resection,can be adapted to perform a TORS total laryngectomy(TORS-TL). In the past, TORS-TL has been met with skep-tical criticism as to its ultimate clinical benefit. Conversely,the authors suggest that the minimally invasive TORSapproach offers significant benefits toward improvingpatient recuperation and the avoidance of substantial post-operative morbidity. However, such benefits can only bedemonstrated following repeated clinical experience. It isthe purpose of this report to describe the surgical protocolutilized by the authors to encourage further application andstudy of this promising surgical advancement.

Transoral robotic surgery (TORS) with the Medrobotics Flex™ System: first surgical application on humans.

Head and neck surgery can be fraught with difficulties in accessing the pharynx and larynx. Minimally invasive surgery has developed with the recent advances in technology. Currently, we have a variety of high-definition multichannel videoendoscopes and robots in our armamentarium. We present our experience in a new robotic surgical system—’The Medrobotics Flex™ System’ at our tertiary referral unit. We aimed to assess the safety, functionality and ease of use of this new device in this prospective study. Thus far, this is the first study in live human subjects who have undergone surgery for the following conditions: (1) obstructive sleep apnoea involving the base of tongue, the tonsil and the velum; (2) vocal fold polyp; (3) carcinoma of the lateral edge of the tongue. There were no complications in our series and the system provided good visualisation and access to these subsites without compromising safety or success. In summary, we found the Medrobotics Flex™ System to have certain other advantages including ease of set up and use besides being reliable and safe.

Vocal fold scars: current concepts and future directions. Consensus report of the phonosurgery committee of the European laryngological society

Scarring of the vocal folds leads to a deterioration of the highly complex micro-structure with consecutively impaired vibratory pattern and glottic insufficiency. The resulting dysphonia is predominantly characterized by a reduced vocal capacity. Despite the considerable progress in understanding of the underlying pathophysiology, the treatment of scarred vocal folds is still an unresolved chapter in laryngology and phonosurgery. Essential for a successful treatment is an individual, multi-dimensional concept that comprises the whole armamentarium of surgical and non-surgical (i.p. voice therapy) modalities. An ideal approach would be to soften the scar, because the reduced pliability and consequently the increased vibratory rigidity impede the easiness of vibration. The chosen phonosurgical method is determined by the main clinical feature: Medialization techniques for the treatment of glottic gap, or epithelium freeing techniques for improvement of vibration characteristics often combined with injection augmentation or implantation. In severe cases, buccal mucosa grafting can be an option. New developments, include treatment with anxiolytic lasers, laser technology with ultrafine excision/ablation properties avoiding coagulation (Picosecond infrared laser, PIRL), or techniques of tissue engineering. However, despite the promising results by in vitro experiments, animal studies and first clinical trials, the step into clinical routine application has yet to be taken.

Laryngeal Advanced Retractor System A New Retractor for Transoral Robotic Surgery

Currently, applications for transoral robotic surgery (TORS) in the treatment of oropharyngolaryngeal tumors are being explored. Early results indicate that TORS may provide advantages over traditional surgery in the areas of organ preservation, development of functional recovery, and improvement in oncologic outcomes. Multiple small case series have been published in the literature describing the learning curve required for the successful application of TORS techniques. One advantage of TORS—after the technical learning curve has been passed—is a reduction in the overall surgical time. However, despite this reduction in surgical time, the time needed for the initial exposure of the surgical site, as well as additional time for retractor repositioning, does not diminish significantly with surgeon experience. On the basis of these findings and our own operative experience with existing systems, we determined that the exposure for TORS may be difficult because the retractors available were not optimally designed. Therefore, we developed a new instrument for exposure—the Laryngeal Advanced Retractor System (LARS; Fentex, Tuttlingen, Germany)—to make exposure for TORS more readily accessible. This report presents our experience with the new retractor from the first 5 patients in whom it was used.

The Effect of Voice Rest on the Outcome of Phonosurgery for Benign Laryngeal Lesions: Preliminary Results of a Prospective Randomized Study

Objectives: According to the literature, voice rest following phonosurgery, as recommended in clinical practice, varies between 3 and 7 days. However, up until now, no randomized trials have been published comparing voice rest of short versus long duration. Methods: This is an ongoing prospective randomized study, comparing strict voice rest of 5 versus 10 days on the voice following phonosurgery. Thirty-one elective patients operated on for benign laryngeal lesions were randomized. They completed pre- and postoperative assessments, including perceptual voice quality (Grade, Roughness, Breathiness, Asthenia, Strain, Instability scale), Voice Handicap Index total score, and voice analysis with both acoustic and aerodynamic measurements. Additional factors such as smoking, vocal abuse, reflux, and preoperative speech therapy were also taken into account. Results: Sixteen patients were randomized to follow 5 days’ voice rest and 15 patients were randomized to 10 days’ voice rest. Statistical analysis showed no significant differences in pre- or postoperative measurements between the 2 groups. However, multilinear regression analysis for the effect of voice rest duration on postoperative values showed a significant improvement in maximum phonation time (MPT) with 10 days’ voice rest. Conclusions: Preliminary results show a benefit of prolonged voice rest (10 days’ duration) on MPT.

Response to letter to Editor: “The clinical course of recurrent respiratory papillomatosis after the use of cidofovir is influenced by multiple factors” by Michel R. M. San Giorgi et al.

We would like to thank Prof F. G. Dikkers and his team from the Department of Otorhinolaryngology, Head and Neck Surgery, University Medical Center Groningen, The Netherlands, for their comments [1] and interests in our paper [2]. We have found a lot of interest on your papers [3] and about HPV typing in all patients. As you stated: ‘‘Younger patients with HPV11 and older patients with HPV6 experience a worse clinical course of RRP’’. In our study, typing is different for all the cases, but Hpv 16 has been excluded. In our network, some labs do not propose the typing of HPV 6 or 11. As you reported in another study [4], ‘‘Gastroesophageal reflux disease and asthma negatively influence the course of RRP’’. In our series, patients had no special comorbidities. We are used to give PPI in the postop care of all our patients after microsurgery to prevent influence of reflux on healing whatever the lesion: polyp and cysts. Anyway cidofovir is only efficient against the virus. We also believe that ‘‘the younger the age of onset, the worse the clinical course of the disease will be’’ [1]. In our study, we have excluded young patients (JORRP), and all our cases were young adults (AORRP). All the patients developed the disease in adulthood. We are used to inject the cidofovir for all our cases. In young adults, we started immediately giving the drug; we believe that the disease is less aggressive than in children, and that combining cidofovir and surgical ablation, the disease could be controlled after a few procedures, what is much more difficult to accomplish in children [2]. Many cases were treated elsewhere without cidofovir that made the difference (83.9 % complete response). The combination of Digital scanning CO2 laser ablation and Cidofovir can lead to a complete remission in young adults affected by laryngeal RRP, showing safety and great efficacy after few intralesional applications, mean of 4.2 (1–14), and decreasing the rate of surgery. Some cases are years old followed-up (38.7 % of cases) and some others months old (58 % of cases). This is a series statiscally treated. Concluding, we do believe that cidofovir made the difference.

La chirurgie robotique en cancérologie ORL

RésuméLa chirurgie robotique en cancérologie ORL est une discipline récente et en évolution constante. La prise en charge thérapeutique des cancers ORL passe actuellement par une stratégie non chirurgicale dite de préservation d’organe. La chirurgie quand elle est retenue peut être en première intention ou dans le cadre d’une chirurgie de rattrapage. Elle s’effectue par voie transcutanée ou transorale, et dans ce cas l’apport du robot est souligné. Nous passerons en revue les acquis actuels publiés pour faire le point avec notre expérience sur les indications actuelles de ce mode opératoire, les avantages, les inconvénients, les développements futurs ainsi que les attentes de l’utilisateur avisé.AbstractTransoral robotic surgery (TORS) in Head and Neck oncology is a recent technical option with continued refinements. The management of head and neck cancer is currently based on organ preservation strategy. Surgery when required can be a first-line or as part of a salvage surgery. It is performed by open neck approach or transorally. In the case of a transoral surgery, the contribution of the robot is outlined. In this article, we have reviewed the existing published data and based on our expertise provided to the reader the evidence about the role of TORS for head and neck cancer, current indications for this procedure, advantages, disadvantages future developments as well as the user’s expectations.

Clinical Thermal Effects of Flexible Fiber CO2 Laser

Objective: To date no clinical investigations have reported on the coagulation effects of flexible fiber CO2 laser delivery to head and neck tissue, the results of which have a direct impact for the progression of transoral laser microsurgery. The objective of the present study was to investigate the histopathologic thermal effects of a flexible fiber CO2 laser delivery system. Method: A prospective histopathologic analysis of 15 consecutive transoral laser microsurgery specimens using the same CO2 fiber system were subjected to dedicated histopathologic analyses. Repeated coagulation depth measurements of 2 independent clinical pathologists were averaged. Specimens were stratified into lymphoid or epitheloid groups for further comparison. Results: The mean coagulation depth across all specimens was 81.53 um (SD, 38.73; range, 15.00-360.34). Although the mean coagulation depth in lymphoid tissues (mean, 75.38 um; SD, 15.91) was elevated over the mean depth of epitheloid tissues (mean, 90.74 um; SD, 31.21), there was no significant difference (P = .11). Conclusion: With an average coagulation depth of 81.53 um the flexible fiber thermal effect compares favorably to tissue effect of line-of-sight lasers. Epitheloid and lymphoid tissues displayed equivalent coagulative effects. To our knowledge, this is the first clinical description of flexible CO2 laser delivery thermal effects of tissues of the head and neck.