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.

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 CO2 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.

[Laser diverticulotomy in hypopharyngeal diverticulum (Zenker's diverticulum)]. / Laserdivertikkulotomi ved hypopharynxdivertikkel (zenkers divertikkel).

From 1992 until 1995 the Ear, Nose and Throat Department at the National Hospital investigated 29 patients and completed treatment of 28 patients with a hypopharyngeal diverticulum. A myotomy of the cricopharyngeal muscle was performed endoscopically using CO2 laser. One patient developed mediastinitis as a result of perforation during initial hypopharyngoscopy. Most of the patients reported improvement of the dysphagia. The advantages of this method are a shortened stay in hospital and less morbidity. In addition, the operation can be performed in elderly patients with other complicating diseases. This paper describes the surgical technique and the results.

[Laser surgery of laryngeal cancer (T1 glottis). New therapeutic alternative]. / Laserkirurgi ved larynxcancer (T1a glottis). Nytt behandlingsalternativ.

The standard treatment for patients with T1a vocal cord cancer has been radiotherapy. From October 1995 selected patients have undergone laser surgery and up until March 1997 we had treated 16 patients. The results so far have been satisfactory with only one recurrence. Some of the patients have experienced a slight to moderate degree of hoarseness postoperatively. Laser treatment is more cost-effective than radiotherapy and in larger series the incidence of residual disease and recurrence seems to be equal to or even better than when following radiotherapy. The procedure demands considerable skill with laser surgery of the larynx and should be limited to 1-2 surgeons at two hospitals in this country where the annual incidence of T1a glottic cancers is approximately 30.

[Botulinum toxin. A new therapeutic alternative in spastic dysphonia (laryngeal abductor dystonia)]. / Botulinumtoksin. Et nytt behandlingsalternativ ved spastisk dysfoni (laryngeal adduktordystoni).

Laryngeal dystonia is a condition characterized by involuntary spasms of the laryngeal muscles. In most patients this involves the adductor laryngeal muscles (adductor laryngeal dystonia). Treatment with a variety of therapies, including speech therapy and pharmacotherapy, have led to minimal improvement. Injections of botulinum-toxin (Botox) bilaterally into the vocalis muscles is a new treatment for adductor laryngeal dystonia. Since May 1991 we have treated 23 patients with adductor laryngeal dystonia with botulinum-toxin. In 74% of the patients the voice improved within 24-72 hours, and effect lasted for 2-14 months (average four months). Most of the patients got a breathy voice and a mild sensation of dysphagia during the first week after the injection.

Recurrent nerve/ansa cervicalis nerve anastomosis: a treatment alternative in unilateral recurrent nerve paralysis.

Sectioning of the right recurrent nerve was done in 5 mongrel dogs under general anaesthesia. The distal stump was anastomosed with the ansa cervicalis nerve branch to the sternothyroid muscle. Three to 5 months later the vocal cord movements during light and very light anaesthesia were videorecorded. Under light anaesthesia contraction and medial bulging of the reinnervated right vocal cord occurred in 4 of the dogs. Under very light anaesthesia there was also some adduction of the right vocal cord in these 4 dogs. The right recurrent nerve was then sectioned proximally to the anastomosis and stimulated electrically. In all 5 dogs we observed that electrical stimulation produced a strong adduction of the right vocal cord. Histochemistry of the right vocal and posterior cricoarytenoid muscles showed that reinnervation had taken place. The study indicates that in cases of unilateral vocal cord paralysis an anastomosis between the ansa cervalalis and the recurrent nerve will result in improved phonatory function of the affected vocal cord.

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.

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.

The human posterior cricoarytenoid (PCA) muscle and diaphragm. A histochemical comparison as a basis for reinnervation attempts.

PCA (posterior cricoarytenoid) muscles and biopsies from the SCM (sterno-cleidomastoid) muscles as well as the diaphragm were serially sectioned and incubated for myofibrillar ATPase and selected metabolic enzymes. The three main fibre types were present in all muscles, although some PCA muscles seemed to lack IIB fibres. The mean fibre type pattern of the PCA muscle was 57% type I, 36% type IIA and 7% type IIB, as compared with 42% type I, 42% type IIA and 16% type IIB in the diaphragm. All fibre types of the PCA muscle and the diaphragm were significantly more oxidative and less glycolytic than the corresponding SCM muscle fibres. Most striking was the finding of high 3-HBDH activity in the PCA and diaphragm muscle fibres, especially in type I.

Functional results after experimental reinnervation of the posterior cricoarytenoid muscle in dogs.

The purpose of the present investigation was to test and compare three different types of experimental posterior cricoarytenoid (PCA) muscle reinnervation. Dogs were subjected to reinnervation by the recurrent nerve itself (self-reinnervation) (n = 6), by the ansa cervicalis nerve (n = 5) or by the phrenic nerve (n = 5). In all but three of the self-reinnervation cases the adductor branch of the nerve was cut and ligated. Three to seven months postoperatively--depending upon the experimental approach--the animals were anesthetized and the function of the vocal cords was tested, visually evaluated and photographed. In the self--reinnervated larynges there were no observable movements on the reinnervated side during quiet inspiration, while during forced inspiration there were small but inconsistent movements. In the larynges reinnervated by the ansa cervicalis nerve no movements could be observed on the reinnervated side during either quiet or forced respiration. In four out of five larynges reinnervated by the phrenic nerve there were larger excursions on the reinnervated side as compared to the normal side during quiet respiration. During forced inspiration the excursions increased on both sides, but relatively more on the normal side. In all experiments indirect electrical stimulation gave large excursions on the experimental side indicating successful reinnervation. It is concluded that the phrenic nerve appears to be the best alternative if reinnervation of the PCA muscle in paralyzed larynges is attempted.

A histochemical evaluation of experimentally reinnervated canine laryngeal muscles.

Sixteen dogs underwent different types of experimental reinnervation procedures of the posterior cricoarytenoid (PCA) muscle - reinnervation by the recurrent nerve itself (self-reinnervation) (n = 6), by the ansa cervicalis nerve (n = 5) or by the phrenic nerve (n = 5). After functional evaluation the normal left and the reinnervated right PCA muscles were removed for histochemical analysis. Cryostat sections were incubated for actomyosin ATPase, NADH-TR and alpha-GPDH. All muscles showed microscopical evidence of successful reinnervation. There was a slight change in the muscle fiber type composition in the reinnervated muscle as compared to the normal side. Incubations for the NADH-TR and alpha-GPDH showed less staining intensity in the reinnervated muscles. The histochemical differences between normal and reinnervated muscles were small, however, and probably of minor importance with regard to the function of the muscles.

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.

Parathyroid gland transplantation after total thyroidectomy with pharyngolaryngoesophagectomy.

Surgical treatment of extensive hypopharyngeal carcinoma often includes total thyroidectomy together with resection of the primary disease. The risk of removing or damaging the parathyroid glands is considerable; this may render the patient permanently hypoparathyroid with all the problems of management. These patients must be on lifelong supplementation and at times, due to failure to take the medication, hypocalcemic crises are precipitated. To avoid this problem, we have been identifying the parathyroid glands intraoperatively and, after pathological confirmation, have transplanted them to the forearm. Three patients who underwent this procedure are presented. All are normocalcemic without supplementation and parathyroid hormone assays on serum from the transplanted forearm show significantly elevated levels.

The natural history of otosclerosis. A correlation of the volume and activity of the otosclerotic lesion with age.

Two-hundred and fifty years after Valsalva's discovery that fixation of the stapes could be a cause of deafness, there is still a lack of knowledge about the etiology and pathogenesis of otosclerosis. The purpose of this study was to obtain more information about the natural history of this disease by correlating the volumes and activity of otosclerotic lesions within the temporal bone to the patient's age and sex. Fifty temporal bones from 33 patients (19 females and 14 males) with otosclerotic lesions were reviewed microscopically. The degrees of activity of these foci were assessed and, using a computer based technique known as "digitizing", the volumes of each otosclerotic lesion were calculated. The results of this study indicate that there is no statistical difference in volumes between males and females. From the results obtained, it is suggested that there appear to be two growth patterns of the otosclerotic lesion: one pattern grows for a very short period and then becomes dormant or inactive. The other type of otosclerosis shows a continuing growth and progression throughout life.

Adult recurrent multiple laryngeal papilloma: laser management and socioeconomic effects.

Results of laser treatment of 15 adults with multiple recurrent laryngeal papilloma are reviewed. The pathology in all cases was benign and typical of juvenile recurrent papilloma. The laser is a precise tool in their therapy but is not curative. In 8 patients where complete remission has been achieved, the mean number of laser treatments was 5.3. The social and economic effects of papilloma and their treatment are discussed, from the standpoint of multiple hospitalization, threatened loss of employment, lack of promotion caused by poor voice, and handicap at home.

Ludwig's angina following dental extraction as a cause of necrotizing mediastinitis.

A fatal case of Ludwig's angina is reported in which penicillin was used as the sole antibiotic. Bacteroides melanogenicus resistant by virtue of production of Beta-lactamase was present. It is suggested that a combination of penicillin and an antibiotic effective against anaerobes such as metronidazole is the most appropriate initial chemotherapy pending confirmation from the bacteriology laboratory.

Head and neck manifestations of mycobacteria in the absence of pulmonary disease.

Mycobacterial infections, once relatively rare in North America have recently shown an upsurge with the influx of Asian and African immigrants. The infections are usually due to M. tuberculosis and present with pulmonary symptoms. However, an uncommon presentation is that of a mass in the head and neck region without any pulmonary manifestations. Although these infections are usually secondary to invasion by "atypical" mycobacteria, unusual presentations due to mycobacterium tuberculosis have been noted. Case reports depicting the very rare presentations of M. tuberculosis in the thyroglossal duct cyst, parotid, and submandibular lymph node are described. A very unusual case of atypical mycobacteria in the larynx is noted and cervical adenitis is also included. The initial subtle presentation emphasizes the importance of mycobacteria in the differential diagnosis of lesions in the head and neck region.