Submucosal neoplasms of the laryngeal introitus.

BACKGROUND: The differential diagnosis of endolaryngeal mesenchymal neoplasms includes a wide spectrum of benign and malignant pathologies, which have been rarely photo-documented and assessed as a group. METHODS: Non-epithelial neoplasms of the endolarynx seen at our centre from 2002 to 2011 (n = 38; 36 treated at our institution) were retrospectively reviewed, with attention to clinical presentation, radiographic imaging, operative management, histology, and pre- and post-operative endoscopy. Submucosal squamous cell carcinomas, mucosal cysts, amyloid and Teflon granulomas were excluded. RESULTS: Twenty-three of a total of 36 patients underwent definitive endoscopic surgical treatment. Supraglottic pathologies included lymphoma, lipoma, neuroendocrine carcinoma, lymphangioma, oncocytoma, haemangioma, synovial cell sarcoma and benign spindle cell neoplasm. Transglottic pathologies included synovial cell sarcoma and granular cell tumour. Glottic pathologies included granular cell tumour, osteoma, rhabdomyoma, rhabdomycosarcoma and myofibroblastic sarcoma. Subglottic pathologies included chondrosarcoma, neurofibroma, adenoid cystic carcinoma and vascular malformation. CONCLUSION: The site of origin, degree of malignant behaviour and sensitivity to adjuvant treatment determined the course of surgical management, i.e. endolaryngeal versus transcervical, and limited removal versus wider resection.

Value and utility of 532 nanometre pulsed potassium-titanyl-phosphate laser in endoscopic laryngeal surgery.

OBJECTIVES: Recently, the 532 nm pulsed potassium-titanyl-phosphate laser has emerged as an effective angiolytic laser for treating mucosal lesions of the larynx in the operating theatre and clinic. We sought to assess the current impact of potassium-titanyl-phosphate laser on our laryngeal surgery practice. STUDY DESIGN: Retrospective review of 710 patients undergoing endoscopic laryngeal surgery over a one-year period. METHODS: Medical records of the endoscopic laryngeal procedures were reviewed; 386/710 had been performed in the clinic and 324/710 in the operating theatre under general anaesthesia. Indications for the procedures were classified by pathology. RESULTS: Pulsed potassium-titanyl-phosphate laser was used in 209/386 clinic procedures. The indications for these procedures were: dysplasia (114/209 procedures), papillomatosis (89/209), varices or ectasia (three of 209), and 'other' (three of 209). Pulsed potassium-titanyl-phosphate laser was used in 178/324 operating theatre endoscopic laryngeal procedures. The indications for these procedures were: cancer (54/178 procedures), dysplasia (52/178), papillomatosis (38/178), varices or ectasia (13/178), polyps (six of 178), nodules (six of 178), stenosis (five of 178), granulation (three of 178), and amyloid (one of 178). CONCLUSIONS: Due to its versatility, the 532 nm pulsed potassium-titanyl-phosphate laser is our most commonly utilised instrument for performing endoscopic laryngeal surgery.

Stroboscopic assessment of vocal fold keratosis and glottic cancer.

Disruption of the normal viscoelastic properties of the superficial lamina propria (SLP) results in aberrant vocal fold vibration and mucosal wave propagation. Therefore, an investigation was performed to determine whether stroboscopy is a reliable method for 1) differentiating invasive glottic carcinoma from intraepithelial atypia or 2) determining the depth of cancer invasion. An analysis was done on the preoperative vocal fold vibration characteristics of 62 keratotic (intraepithelial, 45; cancer, 17) lesions that were subsequently resected by means of microlaryngoscopy. Histopathology and intraoperative mapping were used to specify the depth of invasion. A panel of 4 blinded judges was used to assess the amplitude of vocal fold vibration and the magnitude of mucosal wave activity in the region of the lesion from videostroboscopic recordings. The final comparative data set comprised only those ratings that achieved at least 75% interjudge agreement. Of the 28 intraepithelial lesions that could be reliably evaluated for amplitude of vocal fold vibration, only 2 were normal, with the amplitude reduced in 24 and absent in 2. Of the 30 intraepithelial lesions in which mucosal wave activity could be reliably assessed, only 2 were normal, with the wave reduced in 24 and absent in 4. Furthermore, amplitude of vocal fold vibration and magnitude of mucosal wave propagation were absent in 2 of 4 carcinomas in which the depth of microinvasion did not reach the vocal ligament. According to the findings herein, reduced amplitude of vocal fold vibration and/or mucosal wave propagation associated with keratosis did not reliably predict the presence of cancer or the depth of cancer invasion into the laminae propriae. However, the presence of a flexible mucosal wave probably indicates that there is not extensive vocal ligament invasion. Reductions in the amplitude of vocal fold vibration and in mucosal wave magnitude were usually noted in intraepithelial atypia, despite the fact that there was no invasion into the SLP. The reduced epithelial pliability could be due to bulky keratosis and/or alteration of the SLP occurring as a result of inflammation or fibrovascular scarring.

Phonomicrosurgery I: principles and equipment.

Phonomicrosurgery arose from 19th century endolaryngeal surgery, which was done through a natural passage and was one of the earliest forms of minimally invasive procedural interventions. The evolution and growth of laryngology as a specialty is inextricably connected to the development of endoscopic laryngeal surgery. Phonomicrosurgical techniques have evolved in the last decade of the 20th century as a group of procedures that are guided by physiologic principles of vocal fold oscillation so as to improve vocal outcome. The anatomic premise of these techniques is to maximally preserve the vocal fold's layered microstructure, epithelium, and lamina propria. Phonomicrosurgery has acquired increasing importance because a dependable voice has become a necessity in our communication-based society.

The evolution of the assessment and treatment of paralytic dysphonia.

Vocal fold paralysis has been an omnipresent disorder throughout the annals of laryngologic history since the origin of the specialty in 1858. The attendant complexity of laryngoscopic presentation, physiologic dysfunction, and surgical rehabilitation have led to a rich heritage of scientific investigations that can be traced through the past 140 years. The following historical summary provides the reader with a working knowledge of past experiences that connect to current initiatives and portend future progress.

New procedures for paralytic dysphonia: adduction arytenopexy, Goretex medialization laryngoplasty, and cricothyroid subluxation.

Laryngoplastic phonosurgery has evolved to be a dominant treatment modality for paralytic dysphonia. The postoperative vocal outcome from the combined use of adduction arytenopexy, Goretex medialization laryngoplasty, and cricothyroid subluxation is such that most patients will have a normal phonation time and more than two octaves of dynamic range with minimal acoustic perturbation. With the addition of the adduction arytenopexy and cricothyroid subluxation procedures to the armamentarium of the phonosurgeon, all parameters for static reconstruction of the paralyzed vocal fold have been addressed.

Endolaryngeal microsurgery at the anterior glottal commissure: controversies and observations.

There are a number of tenets regarding endolaryngeal microsurgical management of disease that involves and/or encroaches upon the anterior glottal commissure (AGC). They include avoidance of 1) bilateral epithelial incisions near the AGC, 2) removal of papillomatosis in the AGC, and 3) resection of bilateral keratosis with atypia or carcinoma at the AGC. During the last 6 years, 115 patients underwent microsurgical management of disease at the AGC: carcinoma in 20 (T1 in 15 and T2 in 5), keratosis in 41, papillomatosis in 20, and polypoid corditis (Reinke's edema) in 34. No patients with polypoid corditis developed a synechia or web. All cancers were successfully resected en bloc; 1 of the 20 patients developed a microscopic local failure that was successfully re-resected endoscopically. Eleven of the 20 cancers required excision of part of the supraglottis to establish adequate exposure for the glottic cancer resection. Eight of 15 patients with bilateral keratosis underwent staged resections. Fourteen of 15 patients with bilateral papillomatosis required staged resections. Twelve of the total 115 patients presented with a web secondary to prior microsurgery, and 3 developed a new, clinically insignificant web. The complications of management of disease in or near the AGC described by other authors were not noted in this series. This success was primarily the result of improved exposure in the AGC, which was achieved by use of larger and better-designed laryngoscopes and by resection of supraglottic tissue as necessary. Positioning these prototype laryngoscopes was facilitated by the use of elevated-vector suspension and external counterpressure.

Phonomicrosurgical management of vocal fold polyps: the subepithelial microflap resection technique.

Vocal fold polyps are typically caused by acute and chronic trauma to the microvasculature of the superficial lamina propria (SLP). Shearing stresses that are induced by hyperfunctional glottal sound production lead to bleeding into the SLP and malformed neo-vascularized masses. Because the primary process does not involve the epithelium, the authors designed a technique to resect hemorrhagic polyps by epithelial cordotomy with partial or complete preservation of the vocal fold epithelium. This approach is different from the traditional microsurgical resection of hemorrhagic polyps by amputation with or without the carbon dioxide laser. Forty patients who underwent microlaryngoscopic resection of hemorrhagic polyps from 1996 through 1998 were reviewed retrospectively. Thirty-six of the 40 procedures were by epithelial cordotomy and subepithelial removal of the polyp contents. Sixteen of 36 were assisted by a subepithelial infusion of saline and epinephrine, and all were 3 mm to 6 mm. Four of 40 polyps were amputated; all of these were less than 3 mm and were pedicled on a narrow base. Cold instruments were used exclusively in all 40 patients. Postoperative laryngeal stroboscopy within 2 weeks revealed improved mucosal wave propagation and improved glottal closure in all 33 patients in whom postoperative strobovideolaryngoscopy was available. The epithelial cordotomy technique was introduced to minimize disturbance of normal SLP and epithelium. Despite the hemorrhagic nature of these lesions, cold instruments could be used exclusively with facility due to careful microdissection between the polyp and the residual normal SLP and the enhanced hemostasis provided by the subepithelial infusion of saline and epinephrine. The rapid return to improved glottal function is the result of this ultra tissue-sparing technique.

Cricothyroid subluxation: a new innovation for enhancing the voice with laryngoplastic phonosurgery.

Laryngoplastic phonosurgery has evolved to become a dominant treatment modality for paralytic dysphonia. Current surgical procedures have addressed primarily the position of the musculomembranous vocal fold and the arytenoid in the axial and vertical planes. However. dynamic range capabilities and vocal flexibility have been limited secondary to the flaccid, denervated vocal fold tissue. Therefore. a new procedure was conceived to enhance the acoustic vocal outcome from operations that reposition the vocal edge. Cricothyroid (CT) subluxation was designed as a technique to increase the distance between the cricoarytenoid joint and the insertion of the anterior commissure ligament. Cricothyroid subluxation was done without complication in 9 patients who underwent combined adduction arytenopexy and medialization laryngoplasty, and in 4 patients with medialization laryngoplasty alone. Postoperative stroboscopic assessment was done in all of the 13 patients, while complete analysis of vocal function was available in 10 of the 13 patients; this revealed improvement (as a group) on almost all objective measures over the preoperative state. All patients who underwent CT subluxation had a normal maximum frequency range (pitch variation of more than 2 octaves), as compared with 22% of a prior similar cohort of patients who did not undergo CT subluxation. All patients who underwent CT subluxation had normal glottal airflow and a normal noise-to-harmonics ratio. Cricothyroid subluxation is a relatively easily adjustable procedure that increases the length and viscoelastic tension of the denervated vocal fold. The modified biomechanical properties resulted in improved vocal outcome in all of our patients, which was most remarkable in terms of maximal range capabilities. Cricothyroid subluxation enhanced the postoperative voice of patients regardless of whether they required medialization laryngoplasty alone or whether they also required adduction arytenopexy.

Universal modular glottiscope system: the evolution of a century of design and technique for direct laryngoscopy.

Since Kirstein introduced formal direct examination (autoscopy) of the glottis in 1895, a great number of laryngoscopes have been produced to view the vocal folds; however, none have had universal appeal. The primary goals for the designs have been to optimize exposure and to facilitate instrumentation of the glottis. An analysis of more than 50 laryngoscopes was done to assess key design characteristics that would ideally be present in a laryngoscope for optimally viewing the musculomembranous vocal folds. The Pro/Engineer and Pro/Mechanica computer programs were used to model the universal modular glottiscope. This new laryngoscope comprises a plurality of specially designed examining tubes that are bivalved proximally to improve utilization of hand instrumentation, and form a single tube distally to achieve internal distention of the supraglottal tissues. The distal lumen has an arcuate isosceles-triangular conformation to optimally expose the glottis. The base of the tube is detachable for the difficult intubation or the placement of bronchoscopes. The examining tubes vary in size and dimension to accommodate the diversity of human anatomy. The tubes are easily attachable to and detachable from an ergodynamically designed universal handle that can be joined to fulcrum laryngoscope holders or suspension gallows. The universal modular glottiscope evolved from the selective integration of optimal 20th-century design modifications of Kirstein's original autoscope. This new laryngoscope is ideally suited for phonomicrosurgery as well as for difficult intubation.

Analysis of the forces and position required for direct laryngoscopic exposure of the anterior vocal folds.

The sniffing position is traditionally considered optimal for direct laryngoscopic examination of the vocal folds. This study examined head and neck positions associated with ideal exposure of the anterior glottal commissure with a variety of laryngoscopes. A prospective investigation was done in 20 patients by comparing the force required to expose the anterior vocal folds by utilizing 3 head and neck positions with 3 different-sized tubular laryngoscopes. The completeness of anterior glottal exposure was rated and the force required to achieve this exposure was measured with a strain gauge. Three positions relating the atlanto-occipital and cervicothoracic vertebrae were analyzed: 1) extension-extension. 2) sniffing: extension-flexion, and 3) flexion-flexion. Head and neck position and laryngoscope size were both statistically significant factors for achieving complete anterior vocal fold exposure. Regardless of the laryngoscope, the number of patients in whom complete exposure could be achieved increased gradually when the position was changed from extension-extension to extension-flexion to flexion-flexion. Complete exposure was inversely related to larger laryngoscope size. According to the data herein, the flexion-flexion position provides the best glottal exposure for endotracheal intubation in those patients who are anatomically predisposed to difficulty in direct examination of the glottis. Because this places the laryngoscope lumen in a vertical position, this position is inappropriate for microlaryngoscopy. The study reinforced the concept that the sniffing position is the optimal position for microlaryngoscopy because it enables the use of the largest-lumened laryngoscope. This facilitates ideal exposure of the anterior vocal folds, which is necessary for phonomicrosurgery.

Phonomicrosurgical resection of glottal papillomatosis.

Controlled debulking has been the surgical approach to treat laryngeal papillomatosis for over a century despite dramatic improvements in surgical technology. It is commonplace to leave disease in the glottis at the end of the procedure (eg, in the anterior commissure) because of complications associated with attempted complete removal. This study examined the recurrence patterns of adult glottal papillomatosis after phonomicrosurgical microflap resection. Between 1990 and 1995, 22 patients underwent phonomicrosurgical resection of glottal papillomatosis. Six patients had not undergone previous microlaryngeal surgery and 16 patients had had prior procedures. All patients underwent resection of all visible papillomatosis, and this frequently required staged resections. The subepithelial infusion technique was used to facilitate the resection in most cases. No patient who underwent resection for primary disease had a recurrence. Ten of 16 (62%) patients who presented with recurrent disease did not have a recurrence after microflap resection. Follow up on all patients was at least 2 years. This preliminary report suggests that recently developed phonomicrosurgical microflap resection techniques can eradicate adult glottal papillomatosis in some cases, and that resection of papillomatosis appears to be preferable to conventional debulking and/or ablation techniques.

Ectasias and varices of the vocal fold: clearing the striking zone.

Vascular malformations such as ectasias and varices (Es and Vs) are frequently encountered in patients who present with recurrent vocal fold hemorrhage and/or other traumatic vocal fold lesions. This study examined Es and Vs with regard to their anatomic presentation, phonomicrosurgical management, and treatment outcome. Forty-two patients (39 of them singers) were treated for a total of 87 Es and Vs: 67 of 87 (77%) were on the superior surface of the vocal fold and 20 of 87 (23%) were on the medial surface of the vocal fold. Eighty-three percent were located in the middle musculomembranous region (the striking zone), where the greatest aerodynamically induced shearing stresses occur during phonation. Treatment was performed with carbon dioxide laser cauterization (13 patients), or a new technique utilizing cold instrument excision by means of epithelial cordotomies (23 patients), while a combined approach was employed in 6 patients. Comparisons of preoperative and postoperative stroboscopy revealed improvement or no significant change in all patients in whom the cold instrument technique was used, and increased epithelial stiffness was noted in 4 of 19 patients in whom the carbon dioxide laser was used. Clearing the striking zone appears to have halted further hemorrhages by removing the the fragile Es and Vs from this injury-prone region of the vocal fold. Interpretations of stroboscopic examinations were directed at providing new insights into the biomechanical forces of vocal fold vibration that probably contribute to the genesis of Es and Vs in the vocal folds.

Adduction arytenopexy: a new procedure for paralytic dysphonia with implications for implant medialization.

Arytenoid adduction was designed to enhance posterior glottal closure in patients with paralytic dysphonia by reproducing lateral cricoarytenoid muscle function. However this procedure can exaggerate normal medial rotation of the vocal process, because the agonist-antagonist function of the interarytenoid, lateral thyroarytenoid, and posterior cricoarytenoid muscles is not simulated. Therefore, a new adduction procedure (adduction arytenopexy) was devised to affix the arytenoid on the cricoid facet in a more optimal position for glottal sound production. The adduction arytenopexy procedure was designed on fresh cadavers. In this technique, the lateral aspect of the cricoarytenoid joint is opened widely and the body of the arytenoid is manually medialized along the cricoid facet. A specially designed single suture is then placed through the posterior cricoid and the body or the muscular process of the arytenoid to achieve 2-point fixation. This draws the arytenoid posteriorly, superiorly, and medially for precise positioning. The arytenoid is rocked internally on the cricoid facet, and suture tension is adjusted appropriately to simulate normal cricoarytenoid adduction. In the first study, the adduction arytenopexy was compared with the classic arytenoid adduction in 10 fresh cadaver larynges. The new arytenopexy procedure resulted in an average increase of 2.1 mm (p < .01) in the length of the musculomembranous vocal fold, whereas the classic arytenoid adduction did not reveal a significant change in length. Additionally, the adduction arytenopexy resulted in a consistently higher vocal fold and a more normally contoured arytenoid than the classic adduction procedure. The second study consisted of a clinical trial in which 12 patients, who presented with a widely patent posterior glottis, underwent adduction arytenopexy in conjunction with implant medialization. The procedure was successful in all patients, and there were minimal complications. In the third study, preoperative and postoperative vocal assessment measures (stroboscopic, aerodynamic, acoustic, and perceptual) were analyzed in 9 of the 12 patients. The most striking preoperative stroboscopic observation was that 8 of the 9 patients presented with an aperiodic vibrational flutter during phonation due to severe valvular incompetence. Postoperatively, all patients developed complete closure of the glottal chink and effective entrained oscillation of the vocal folds. This visual improvement in function was commensurate with comparable changes in most of the other objective and subjective measures of vocal function. The new adduction arytenopexy procedure closely simulates the biomechanics underlying normal glottal closure and cricoarytenoid adduction. In turn, complex implant design shapes are not necessary to achieve proper alignment of the arytenoid and the vocal fold. Because the arytenoid is properly positioned prior to the medialization, implants can be sized more precisely and are unencumbered by an anterior thyroid lamina suture. These procedural innovations resulted in enhanced entrained oscillation of the glottal valve and, in turn, improved laryngeal sound production.

Soft-palate reconstruction with a "SCARF" superior-constrictor advancement-rotation flap.

Reconstruction of hemi-soft-palate defects after tumor resection is usually done by means of a regional flap, free-tissue transfer or a prosthesis. These options vary in complexity and have a number of shortcomings. A local myomucosal flap was designed that employs a superior-constrictor advancement-rotation flap (SCARF) to achieve circumferential closure of the velopharynx and to re-establish its valvular sphincteric function. Ten patients underwent a SCARF reconstruction of the velopharynx after 35% to 65% of the soft palate was resected. All patients re-established normal velopharyngeal function without significant phonatory or deglutitive disability. Two patients did require a second-stage reinforcement of the suture line after partial dehiscence. The SCARF reconstruction of the soft palate is simple, fast, and reliable and there is no significant donor site morbidity. Patients resume oral intake earlier than standard reconstructive approaches. The SCARF can be done transorally, which allows for primary resection and discontinuous neck dissection. These factors facilitate short hospitalization and effective use of resources.

Assessment of vocal function using simultaneous aerodynamic and calibrated videostroboscopic measures.

Despite many attempts to model how vocal fold movements relate to the aerodynamic forces acting on them during phonation, there have been few simultaneous measurements of glottal area and transglottal air pressures and flows. A novel system is described that combines endoscopic measurement of glottal area with aerodynamic flow and pressure measures made during phonation. Results from bench top model tests and from one human subject are presented. For both tests, an aerodynamic model of airflow through a constriction was used to predict the area of the constriction (glottis), and these predictions were compared with endoscopic measurements. The results showed good correlation between predicted and observed areas; however, for small constrictions (<0.025 cm2), whether artificial or glottal, the errors in estimating areas with either optical or aerodynamic methods increase significantly. These results suggest that this measurement system has the potential to enhance the assessment of vocal function.

Outcomes of atypical symptoms attributed to gastroesophageal reflux treated by laparoscopic fundoplication.

BACKGROUND: The introduction of laparoscopic fundoplication (LF) has lowered the threshold for operation in patients with symptoms attributed to gastroesophageal reflux. We sought to determine whether the outcomes in patients referred for atypical symptoms (pulmonary, pharyngolaryngeal, and pain syndromes) were as good as those referred for correction of heartburn and regurgitation (typical symptoms). METHODS: Thirty-five of 150 consecutive patients undergoing LF with a minimum of 12 months of follow-up were referred primarily for correction of atypical symptoms. A standard preoperative evaluation included endoscopy, manometry, upper gastrointestinal contrast radiography, and 24-hour pH probe testing (33 of 35 patients with atypical symptoms). Patients completed a symptom questionnaire administered by a study nurse before the operation and 3 and 12 months after the operation. Symptoms were scored from 0 to 10. RESULTS: Heartburn was relieved by LF in 93% of patients, whereas only 56% of patients had relief of atypical symptoms. Furthermore, the degree of improvement in typical symptoms was greater than that seen for atypical symptoms as measured by the 0 to 10-symptom rating score (improvement in typical symptoms = 6.2 vs improvement in atypical symptoms = 4.4 [p = 0.01]). The response rate for laryngeal, pulmonary, and epigastric/chest pain symptoms was 78%, 58%, and 48%, respectively. Analysis of factors associated with relief of atypical symptoms revealed that response to a preoperative trial of omeprazole or H2-blockers was significantly associated with successful surgical outcome (p = 0.03). Six of seven patients with laryngeal symptoms who had acid reflux above the cricopharyngeal level shown by dual-probe pH testing had relief of the symptoms after LF. Manometric findings (amplitude of esophageal body contractions, propagation of contractions, and lower esophageal sphincter resting pressure) neither predicted nor correlated with relief of atypical symptoms after the operation. CONCLUSIONS: Relief of atypical symptoms attributed to gastroesophageal reflux by LF is less satisfactory and more difficult to predict than relief of heartburn and regurgitation. The only useful preoperative predictors of relief of atypical symptoms in this study were the response to pharmacologic acid suppression and dual-probe pH testing (only in patients with laryngeal symptoms).

Chevalier Jackson's contributions to direct laryngoscopy.

Chevalier Jackson championed rigid endoscopy of the upper aerodigestive tract and facilitated its development and popularity at the beginning of the 20th century. He realized that endoscopy and open surgery are inextricably linked for effective management of diseases of the upper air and food passages. Toward this end, Jackson contributed a number of important innovations to direct laryngoscopy, while developing a unique mastery of the technique. Ultimately, he combined this endoscopic proficiency with open surgical techniques.