Potential role of transoral laser surgery for larynx carcinoma.

BACKGROUND AND OBJECTIVE: The treatment of larynx carcinoma is not settled to date. This prospective study evaluates the potential role of transoral laser surgery (TLS) for larynx carcinoma in a large series of unselected patients from a single institution. MATERIALS AND METHODS: A total of 504 consecutive patients with previously untreated carcinoma of the larynx were seen from 1986-1994. Their treatment modalities and results were prospectively evaluated. RESULTS: TLS was used in 290 patients (58%), total laryngectomy in 130 (26%), conventional partial laryngectomies in 31 (6%), and radiotherapy in 34 (7%). Nineteen (4%) had no curative treatment. Uncorrected actuarial survival for all patients with glottic carcinoma stages I and II treated with laser surgery (n = 202) was 80.2%, cause specific survival 96.7%, and local control 85.8%. Uncorrected actuarial survival for all patients with supraglottic carcinoma stages I and II treated with laser surgery (n = 40) was 49.0%, cause specific survival 78.6%, and local control 87.3%. CONCLUSION: TLS was the most important single treatment modality in this large series of unselected patients. It is a safe and time- and cost-effective alternative to radiotherapy for early stage larynx carcinoma.

[Voice quality after partial laser laryngectomy]. / Stimmstatus nach Laser-Kehlkopfteilresektion.

BACKGROUND: We conducted a prospective study to investigate voice quality after transoral endolaryngeal laser surgery in terms of ability to communicate effectively. Eighty patients with T1 or T2 glottic carcinoma were enrolled in the study. The main objective was to identify the influence of type and extent of surgery on postoperative voice parameters after endoscopic laser surgery. MATERIAL AND METHODS: The postoperative mechanism of phonation was assessed by videostroboscopy six months after surgery at the earliest. A phonetogram was produced and its area calculated (relative phonetogram, RP) in relation to a gender-specific normal phonetogram. A speech therapist (ST) and a trained otolaryngologist (TO) rated each voice independently for communication ability in a grade from 1 (poor) to 6 (near normal). RESULTS: After simple cordectomy the mean values were as follows: RP = 24.8%, TO = 3.26, ST = 3.33. When the anterior commissure was completely preserved mean results were better (RP = 34%, TO = 3.92, ST = 3.83). Results were worse following extended cordectomy (RP = 14.7%, TO = 2.82, ST = 3.00) and transglottic resection (RP = 13.7%, TO = 2.30, ST = 2.86), but similar within these two groups. The parameters RP, TO, and ST do not differ significantly between the group who had speech therapy after surgery (N = 33) and the group who did not (N = 47). Voice production at glottic level yields better results for every parameter than supraglottic substitute phonation. The amount of tissue removed was less significant. CONCLUSION: We conclude that postoperative phonatory results correlate with the postoperative mechanism of phonation. There is no linear correlation with the amount of tissue removed. Comparing similar types of resection preservation of the anterior commissure plays a key role. From the data in this study there is no evidence of a significant benefit from speech therapy. The parameter RP is an effective and relatively simple parameter to complete auditive voice assessment.

[Endolaryngeal surgical procedures in glottis expansion in bilateral recurrent nerve paralysis]. / Endolaryngeale Operationsverfahren zur Glottiserweiterung bei beidseitiger Rekurrenslähmung.

OBJECTIVE: Subtotal cordectomy and posterior cordectomy have repeatedly been recommended as surgical interventions restoring the airway, for the treatment of bilateral vocal cord paralysis. The objective of this study was to assess the effectiveness of transoral laser cordectomy and posterior cordectomy as compared to laser arytenoidectomy and to compare the respiratory and phonatory results of these minimally invasive procedures. MATERIAL AND METHODS: Forty patients with bilateral vocal cord paralysis were included in a prospective study and operated upon to improve their laryngeal airways. Twenty-two patients had cordectomy, 13 had arytenoidectomy, and 5 had posterior cordectomy. Lung function tests and voice analysis were obtained preoperatively and postoperatively. Subclinical aspiration was determined by endoscopic evaluation of the larynx during deglutition. The results were compared to determine the relative effectiveness of the three surgical methods. RESULTS: Flow volume spirograms documented equally improved flow rates in both groups. Final voice evaluation revealed maximum phonation time. Peak sound pressure levels and frequency range were reduced in all 28 patients, but phonatory results varied considerably in each group. Subclinical aspiration was noticed in 5 out of 10 patients after arytenoidectomy, but in none of 18 patients after cordectomy. Four previously tracheotomised patients were decannulated within 2 weeks after surgery, while the other 24 patients had no perioperative tracheotomies. CONCLUSION: Transoral laser cordectomy and arytenoidectomy are equally effective and reliable in the management of the restricted airway. Cordectomy and posterior cordectomy offer the advantage of uncompromised deglutition after surgery. Although no clinically relevant aspiration occurred in any of the patients, cordectomy should be considered as the method of choice in patients for whom subclinical aspiration could be potentially harmful due to coexisting pulmonary or cardiac disease. Phonatory outcome is not predictable with both surgical procedures. Subtotal cordectomy and posterior cordectomy are easier and faster to perform, and subclinical aspiration is not encountered with these procedures.

[Nosocomial infections in head and neck surgery. 1]. / Nosokomiale Infektionen in der Kopf- und Halschirurgie Teil 1: Uberblick.

Hospital-acquired or nosocomial infections are infections that are neither present nor incubating at the time of admission. They must become manifest by 48 h after admission. They raise significantly the morbidity, mortality, and economic burden of the underlying disease. Nosocomial infections occur in 2.5-9.5% of all hospitalizations. They are mainly found in intensive care units and surgical wards. Urinary tract infections are the most frequent, followed by wound infections, pneumonia, infections of the skin and mucosa, bloodstream infections and others. The major pathogens causing nosocomial infections are Staphylococcus aureus, Escherichia coli, enterococcus and Pseudomonas. Methicillin-resistant pathogens must be considered. In Germany the direct costs of excessive hospital stays exceed 3 billion DM annually. Preventive measures reduce current nosocomial infections. The CDC suggest that these measures include a trained hospital epidemiologist, an infection control nurse, an active surveillance program and data feedback to surgeons about their wound infection rates.

[Nosocomial infections in head and neck surgery. 2. A prospective study]. / Nosokomiale Infektionen in der Kopf- und Halschirurgie. Teil 2: Eine prospektive Untersuchung.

Nosocomial infections are defined as infections that occur during hospitalization but were not present at admission. Nosocomial infections have been found to occur in 6% of all hospitalizations and are present mainly in intensive care units and surgical wards. These infections extend the time of hospitalization and therefore increase the cost of care. Between July and December 1993, all nosocomial infections occurring in 304 patients of the surgical ward of the University ENT Department, Cologne, were recorded prospectively. These were classified into wound, implant, urinary tract, respiratory, skin or mucosal infections, nosocomial bacteremias and gastrointestinal infections. The overall prevalence of nosocomial infections was 15.4%. Of these, 9.2% were postoperative wound infections, 2.6% respiratory infections, and 2.3% infections of the skin and mucosa. The incidence of urinary tract infections was 0.7%, while bacteremias occurred in 0.3%. No implant or gastrointestinal infections occurred. Microbial analysis demonstrated 9 gram-positive and 15 gram-negative bacterial and 8 candidal infections. Nineteen cultures were negative. Among the bacteria cultured three were methicillin-resistant. The time of hospitalization was extended from a normal average of 9.52 days to 25.7 days. The distinct risk of a nosocomial infection in the treatment of hospitalized patients requires and accurate documentation of all acquired infections. Determination of the source of infection, the method of spread and microbial analysis including the spectrum of organism resistance is necessary in order to decrease the infection rate and to prevent establishment of a nosocomial infection. These requirements at the least are an important part of quality control in the surgical disciplines.

[Peak flow measurement in patients with laryngeal and tracheal stenoses. A simple and valuable spirometric method]. / Die Peak-flow-Messung bei Patienten mit Kehlkopf- und Trachealstenosen. Eine einfache und aussagekräftige spirometrische Untersuchungsmethode.

Body plethysmographic and spirometric indices can be used for routine examinations of obstructive lesions of the larynx and upper trachea. Total resistance, forced expiratory volume in 1 sec (FEV1) and the S-shaped flow-pressure loop can show clinically significant extrathoracic stenoses. We have now also measured peak inspiratory flow (PIF) and peak expiratory flow (PEF) with a peak flow meter. Easy handling was compared with good reliability of the measurements and possible detection of laryngeal lesions. Extrathoracic stenoses caused turbulent flow, with a flow-dependent increase in total resistance (Rtot). This resistance increased only with severe stenoses, while mild stenoses were often not detected. Peak expiratory flow reacted earlier than did peak inspiratory flow and seemed to be the most reliable parameter for detecting an extrathoracic stenosis. Testing was easy to perform and was usually reproducible. Patients with additional peripheral obstructive stenoses required a more specific examination.

Cordectomy versus arytenoidectomy in the management of bilateral vocal cord paralysis.

Our objective was to assess the effectiveness of transoral laser cordectomy and laser arytenoidectomy and to compare the results with a view to respiratory and phonatory function and deglutition. Twenty-eight patients with bilateral vocal cord paralysis were included in a prospective study. Eighteen patients had cordectomy, and 10, arytenoidectomy. Lung function tests and voice analysis were performed preoperatively and postoperatively. Subclinical aspiration was determined by endoscopic evaluation of the larynx during deglutition. The results were compared to determine the relative effectiveness of both surgical methods. Flow volume spirograms documented equally improved flow rates in both groups. The final voice evaluation revealed that maximum phonation time, peak sound pressure levels, and frequency range were reduced in all 28 patients, but the phonatory results varied considerably in each group. Subclinical aspiration was noticed in 5 of 10 patients after arytenoidectomy, but in none of 18 patients after cordectomy. Four of 6 previously tracheostomized patients were decannulated within 2 weeks after surgery, while the other 22 patients had no perioperative tracheostomies. We conclude that transoral laser cordectomy and arytenoidectomy are equally effective and reliable in the management of the restricted airway. Phonatory outcome is not predictable with either surgical procedure. Cordectomy is easier and faster to perform, and subclinical aspiration is not encountered with this procedure.

[Cisplatin/5-FU versus carboplatin/5-FU. 5 year follow-up]. / Cisplatin/5-FU versus carboplatin/5-FU. Fünfjahresergebnisse.

Between March 1986 and October 1987, 73 patients with advanced squamous cell carcinomas of the head and neck underwent initial chemotherapy before surgery and/or radiotherapy. Chemotherapy consisted of three courses of carboplatin/5-FU or cisplatin/5-FU. Pretreatment tumor states, remission rates and ages of the patients were comparable. Carboplatin as a modification of cisplatin showed significantly less gastrointestinal nerval and ototoxic side effects. After five years of followup, 30% of the patients treated with carboplatin and 33% of the cisplatinum group were alive and clinically free of disease. In contrast, 97% of all patients treated with sequential chemoradiotherapy have died. The data fails to support a "downstaging" of disease. These results document that the only prognostic factor for long-term survival is histologically complete resection of tumor. Further studies must compare the influence of prior chemotherapy and surgery, both followed by conventional fractionated radiotherapy in resectable tumors. Findings show that induction chemotherapy should not be used for unresectable tumors or for sequential chemo-radiotherapy. The use of carboplatin is preferred since oncological efficiency is comparable while side-effects are significantly less.