Anatomical Study of Two Cricothyroid Approaches to the Cadaver Larynx.

OBJECTIVE: The purpose of this study was to measure the angle and depth at which the vocal folds are accessed via transcutaneous injection through two different approaches through the cricothyroid membrane. METHODS: Twenty-five cadavers preserved with formalin were studied. The larynges were bisected through the thyroid notch, and the skin and soft tissue were removed. A 27-gauge needle was inserted through the cricothyroid membrane, once from just inferior to the thyroid cartilage and once from just superior to the cricoid cartilage, and advanced to the midpoint of the musculomembranous vocal fold (determined as the halfway point from anterior commissure to vocal process), immediately lateral to the vocalis muscle without penetrating the epithelium. The angle of approach was determined after taking multiple measurements with a Castroviejo caliper. The depth of the needle was measured. RESULTS: Ten male and 15 female cadavers were studied. Their average age was 85.5 ± 12.4 years. The mean distance from midline for an injection performed with 0° of lateral angle was 5.7 ± 0.7 mm for the males, which was significantly greater than for females (4.8 ± 0.8 mm, P = 0.012). The insertion angle for the infrathyroid approach was 22.2 ± 6.9°, which was significantly different from the supracricoid angle, which was 33.0 ± 5.2° (P < 0.001). The mean insertion depth of the subthyroid approach was 11.3 ± 1.8 mm (range 8.0-15.5 mm), which was significantly less than the depth for the supracricoid approach (18.2 ± 2.4 mm, range 11.0-22.0 mm, P < 0.001.). The infrathyroid approach angle for males was 26.0 ± 8.5°, which was significantly greater than the angle for females (19.3 ± 3.4°, P = 0.016.). The supracricoid approach angle for males was 37.5 ± 2.4°, which was significantly greater than the angle for females (29.7 ± 4.1°, P < 0.001.). The insertion depth for males was 19.6 ± 1.4 mm, which was significantly greater than that for females (17.2 ± 2.6 mm, P = 0.021). CONCLUSIONS: Comparison of a supracricoid and infrathyroid approach through the cricothyroid membrane to the middle third of the vocal folds demonstrated significant differences in angle of approach. We also identified a significant difference in the angle of entry between male and female larynges in both approaches, as well as an increased depth of insertion required in males for the supracricoid approach.

Serial in-office laser treatment of vocal fold leukoplakia: Disease control and voice outcomes.

OBJECTIVE: Although vocal fold (VF) leukoplakia is commonly treated with in-office laser, there is no data on its long-term effectiveness. This study hypothesizes that VF leukoplakia treated by serial in-office laser results in long-term disease control with maintenance of voice and minimal morbidity. STUDY DESIGN: Retrospective review (2008-2015). METHODS: Forty-six patients with VF leukoplakia treated by in-office KTP (potassium titanyl phosphate) or PDL (pulsed dye laser) were included. Median follow-up from final laser treatment was 19.6 months. Main outcomes included: 1) rate of disease control, 2) percentage of disease regression using ImageJ analysis. Secondary outcomes included vocal assessment using the Voice Handicap Index-10 (VHI-10). RESULTS: Patients underwent a median of 2 (range: 1-6) in-office laser treatments. Time between treatments was median 7.6 months. After final treatment, 19 patients (41.3%) had no disease; two patients (4.3%) progressed to invasive cancer; overall disease regression was median 77.1% (P < 0.001); and VHI-10 score decreased by median 5 (P = 0.037). Thirty-one patients (67.4%) were responders (controlled with in-office treatment only); failures were 13 patients (28.3%) who required operative intervention and two patients (4%) who underwent radiation. Compared to responders, failures demonstrated significantly shorter duration between treatments (median 2.3 vs. 8.9 months, P = 0.038) and significantly less regression (median 49.3% vs. 100%, P = 0.006). CONCLUSION: Serial outpatient KTP or PDL treatment of VF leukoplakia is effective for disease control with minimal morbidity and preservation of voice quality. We suggest that patients requiring repeated in-office treatment every 6 months may benefit from earlier operative intervention; other factors associated with in-office success remain unclear. LEVEL OF EVIDENCE: 4. Laryngoscope, 127:1644-1651, 2017.

Survival Outcomes in Early Stage Laryngeal Cancer.

AIM: To evaluate survival outcomes of radiotherapy versus surgical resection in the treatment of early stage laryngeal cancer. PATIENTS AND METHODS: Data was extracted from the Surveillance, Epidemiology, and End Results 18 Database. The cohort included 5,301 patients diagnosed with stages I and II laryngeal squamous cell carcinoma between 1992 and 2009, treated with either surgical therapy or radiotherapy. RESULTS: Patients who received surgical therapy had better overall survival (OS) than patients who received radiation therapy (p<0.001). The difference in OS between treatment groups remained after stratification by stage (p<0.001 for Stage I; p=0.03 for Stage II) and subsite (p<0.001). On multivariable analysis, the radiotherapy group had worse OS (hazard ratio (HR)=1.29). CONCLUSION: Patients with early-stage laryngeal cancer treated with surgical therapy have better survival outcomes than patients treated with non-surgical therapy.

Infrapopliteal angioplasty for critical limb ischemia: relation of TransAtlantic InterSociety Consensus class to outcome in 176 limbs.

OBJECTIVE: Recent data suggest that percutaneous transluminal angioplasty (PTA) may be appropriate primary therapy for critical limb ischemia (CLI). However, little data are available regarding infrapopliteal angioplasty outcomes based on TransAtlantic InterSociety Consensus (TASC) classification. We report our experience with infrapopliteal angioplasty stratified by TASC lesion classification. METHODS: From February 2004 to March 2007, 176 consecutive limbs (163 patients) underwent infrapopliteal angioplasty for CLI. Stents were placed for lesions refractory to PTA or flow-limiting dissections. Patients were stratified by TASC classification and suitability for bypass grafting. Primary outcome was freedom from restenosis, reintervention, or amputation. Primary patency, freedom from secondary restenosis, limb salvage, reintervention by repeat angioplasty or bypass, and survival were determined. RESULTS: Median age was 73 years (range, 39-94 years). Technical success was 93%. Average follow-up was 10 months (range, 1-41 months). At 1 and 2 years, freedom from restenosis, reintervention, or amputation was 39% and 35%, conventional primary patency was 53% and 51%, and freedom from secondary restenosis and reintervention were 63% and 61%, respectively. Limb salvage was 84% at 1, 2, and 3 years. Within 2 years, 15% underwent bypass and 18% underwent repeat infrapopliteal PTA. Postoperative complications occurred in 9% and intraprocedural complications in 10%. The 30-day mortality was 5% (9 of 181). Overall survival was 81%, 65%, and 54% at 1, 2, and 3 years. TASC D classification predicted diminished technical success (75% D vs 100% A, B, and C; P < .001), primary restenosis, reintervention, or amputation (hazard ratio [HR], 3.4; 95% confidence interval [CI], 2.1-5.5, P < .001), primary patency (HR, 2.2; 95% CI, 1.3-3.9, P < .004), secondary restenosis (HR, 3.2; 95% CI, 1.6-6.4, P = .001), and limb salvage (HR, 2.6; 95% CI, 1.1-6.3, P < .05). Unsuitability for surgical bypass also predicted restenosis, reintervention, or amputation, secondary restenosis, need for repeated angioplasty, and inferior primary patency and limb salvage rates. CONCLUSION: Infrapopliteal angioplasty is a reasonable primary treatment for CLI patients with TASC A, B, or C lesions. Restenosis, reintervention, or amputation was higher in patients who were unsuitable candidates for bypass; however, an attempt at PTA may be indicated as an alternative to primary amputation. Although restenosis, reintervention, or amputation is high after tibial angioplasty for CLI, excellent limb salvage rates may be obtained with careful follow-up and reinterventions when necessary, including bypass in 15%.

A novel function for cadherin 11/osteoblast-cadherin in vascular smooth muscle cells: modulation of cell migration and proliferation.

OBJECTIVE: Intimal hyperplasia is a common cause of vein graft failure in cardiovascular surgery. The molecular basis for intimal hyperplasia remains poorly defined. We have previously identified, by gene chip analysis of vein grafts, increased messenger (mRNA) for the adhesion molecule cadherin 11/osteoblast-cadherin (CDH11). The function of CDH11 in vascular cells is unknown. The aim of the present study is to confirm CDH11 expression in vein grafts and characterize its role in vascular remodeling. METHODS: Cephalic vein interposition grafts were implanted in a canine model and harvested at predetermined time points. CDH11 protein expression was determined by immunohistochemistry. Early passage human coronary artery smooth muscle cells (SMCs) were used for in vitro studies. Real-time polymerase chain reaction was used to assess cellular CDH11 mRNA levels. CDH11 signaling was inhibited by either transfection with silencing RNA targeting CDH11 or with a blocking antibody to CDH11. Cellular migration was evaluated and cellular proliferation was assessed. RESULTS: Expression of CDH11 was increased in medial SMCs of vein grafts recovered at 7, 14, and 30 days after surgery compared with control veins from the same animals. In vitro CDH11 mRNA was up-regulated 1.8 +/- 0.2-fold (P = .003) in SMCs after treatment with tumor necrosis factor-alpha. Cellular migration was attenuated by inhibition of CDH11 both with a blocking antibody (0.67 +/- 0.09; P = .063) and gene knockdown mediated by small interfering RNA (0.67 +/- 0.14; P = .036). SMC proliferation decreased by 3.1-fold (P = .006) in the presence of CDH11-blocking antibody. Knockdown of CDH11 mediated by small interfering RNA resulted in a 1.3-fold (P = .018) decrease in proliferation. CONCLUSIONS: CDH11 is up-regulated in SMC in vivo and in vitro as part of the response to injury. Inhibition of CDH11 decreases SMC migration and proliferation, two pathogenic effectors of intimal hyperplasia.