Value of pre- and intraoperative diagnostic methods in suspected glottic neoplasia.

PURPOSE: To evaluate the individual and combined ability of videostroboscopy (VS), high-speed digital imaging (HSDI), enhanced endoscopy (EE) and saline infusion (SI) to predict neoplasia, defined as glottic precursor lesion (GPL) or T1a glottic cancer, in patients suspected for glottic neoplasia. METHODS: A nationwide prospective cohort study of patients treated by cordectomy for suspected GPL or T1a glottic cancer from August 1st 2016 to October 31st 2018 was conducted in the five Danish University Departments of Head and Neck surgery. Sensitivity, specificity, negative and positive predictive values, and area under Receiver Operating Curves (AUC-ROC) were calculated with 95% confidence intervals with respect to the histological diagnosis. Logistic regression with an imputation model for missing data was applied. RESULTS: 261 patients aged 34-91 years participated; 79 (30.3%) with non-neoplasia (i.e., inflammation, papilloma, hyperkeratosis) and 182 (69.7%) neoplasia, hereof 95 (36.4%) with GPL and 87 (33.3%) with T1a glottic cancer. Data from 188 VS, 60 HSDI, 100 preoperative EE, 209 intraoperative EE, and 234 SI were analyzed. In the complete case analysis the AUC-ROC of each diagnostic test was low, but increased when the tests were combined and especially if the combination included EE. However, multinomial logistic regression with imputation showed significant association (p < 0.05) only between age, male gender, and perpendicular vasculature in intraoperative EE, and the endpoint neoplasia. CONCLUSIONS: Intraoperative EE was the most accurate diagnostic method in detecting neoplasia. The prediction ability of methods applied preoperatively was more limited, but improved when test modalities were combined.

Endoscopic management of airway venous malformations with Nd:YAG laser.

OBJECTIVES: The neodymium:yttrium-aluminum-garnet (Nd:YAG) laser is a powerful tool in treating venous malformations (VMs) involving the upper airway. If left untreated, laryngeal VMs can lead to life-threatening airway obstruction. We aimed to evaluate the efficacy of endoscopic management of laryngeal VMs with the Nd:YAG laser. METHODS: We performed a 12-year retrospective review in a tertiary referral center. Patient records were reviewed for demographics, presenting symptoms, area of involvement, age at first Nd:YAG laser therapy, total number of treatments, time between treatments, and treatment response. RESULTS: Seventeen patients were treated endoscopically with an Nd:YAG laser for laryngeal VMs. The mean age at first treatment was 23.0 years (range, 18 to 45 years). The majority of patients presented with obstructive sleep apnea (58.8%), and 17.5% of patients presented with acute airway obstruction or stridor. The remaining patients presented with minor symptoms, including chronic cough and voice changes. The VMs involved the supraglottis, glottis, or both in 29%, 35%, and 35% of patients, respectively. An average of 4 treatments were required per patient (median, 3.5; range, 1 to 9). The time between treatments increased with each consecutive laser therapy, starting at a mean of 3.8 months between the first and second treatments to 21.7 months between the third and fourth. A marked reduction in VM size and symptom improvement were achieved in each patient after Nd:YAG therapy. Two complications (3%) were encountered among 66 total procedures. CONCLUSIONS: Endoscopic management of VMs using an Nd:YAG laser appears to be both effective and relatively safe. Multiple treatments are often required, but increased time can elapse between consecutive therapies. Use of the Nd:YAG laser for laryngeal VMs helps avoid tracheotomy and open surgical resection.

Total microvessel perimeter per tumor area is a predictor of radiosensitivity in early-stage glottic carcinoma.

PURPOSE: To confirm that total number of microvessels per tumor area (TN/TA) and total microvessel perimeter per tumor area (TP/TA) are predictors for radiosensitivity in early-stage glottic carcinoma. METHODS AND MATERIALS: One hundred twenty consecutive patients with T1-2N0M0 glottic cancer who were treated with radical radiotherapy in three different hospitals in Japan were included in this study. Biopsy specimens from patients were immunostained with anti-CD31 antibody. The TN/TA and TP/TA of each sample were analyzed using a computer-assisted image analysis system. Patients were stratified into high and low groups according to the cut-off values derived from receiver operating characteristic curve analysis. Progression-free survival rates of the different groups were compared. The relationship of microvessel perimeter to vessel maturation was also discussed. RESULTS: Survival analysis showed higher TP/TA to be associated significantly with longer progression-free survival, as compared with the lower-level group (p = 0.031). In multivariate analysis, both TP/TA (p = 0.037) and T stage (p < 0.001) proved to be independent predictive factors. Microvessel perimeter correlated closely with vessel maturity, which suggests that a tumor with high TP/TA contains more functional vessels and as a result contains more oxygenated and radiosensitive cells. CONCLUSION: Assessment of TP/TA in biopsy specimens, using a computer-assisted analysis system, can predict the radiosensitivity of early-stage glottic carcinoma. High TP/TA may be a better indication for radiotherapy than for partial laryngectomy or laser excision.

What is important for ultrasound evaluation of occult metastatic lymph nodes in laryngeal cancer: size, shape, vascularity or cytological findings?

The assessment of the status of the cervical lymph nodes in patients with a squamous cell carcinoma of the head and neck is still one of the most challenging diagnostic problems. We evaluated ultrasonography criteria with respect to their value for comparative determination of occult metastatic lymph nodes in laryngeal carcinoma. A prospective study was performed in 60 patients with laryngeal squamous cell carcinoma without enlarged neck nodes on CT scan. We used recommended sonography criteria for size, shape and vascularity for distinguishing metastatic and nonmetastatic nodes preoperatively and compared them with cytological and histopathological investigations. Fifty-two of 144 lymph nodes were involved with metastasis on histopathological examination. Respective values for ultrasound-guided fine needle aspiration cytology (USg FNAC) showed high sensitivity, specificity, positive and negative predictive values and accuracy (92, 100, 100, 96, and 97%, respectively). The size, shape and vascularity showed significantly lower values of these statistic parameters. USg FNAC is useful for preoperative evaluation of the neck, as the most reliable, inexpensive and easily available method. It is essential for diagnosis, staging and therapy choices.

Anatomical definition of the subglottic region.

BACKGROUND: Due to laryngeal neoplasia, as well as infectious and autoimmune diseases, the subglottic region is of great clinical relevance. However, descriptions of the subglottic structures are inconsistent. The aim of our study was to present a precise analysis of the subglottic region and derive functional and clinical conclusions. METHODS: Histological, histochemical and immunohistochemical investigations as well as scanning electron microscopy were performed and combined with injection techniques applied to the subglottic region of the larynges of 33 body donors. RESULTS: The three-dimensional extensions of the subglottic region were newly defined: the inferior arcuate line of the vocal cord was defined as the cranial border. The lower margin of the cricoid is the caudal border. Craniolaterally, the elastic cone and, further caudally, the cricoid form the border. Therefore, the definition presented comprises heretofore unnamed ventral and dorsal parts of the lower larynx. The subglottic region can be described as cylindrical, becoming smaller in the cranial direction, following the elastic cone. The ventral boundary is formed by the median part of the cricothyroid ligament (ligamentum conicum), the dorsal part by the cricoid cartilage. The walls of the subglottis are divided into three or four layers composed of collagenous and elastic fibres in which seromucous glands are embedded. Subglottic blood vessels including a tight subepithelial capillary plexus were delineated. CONCLUSION: The new definition of the subglottic extensions presented is helpful and essential for precise laryngeal tumour classification. The results indicate that the boundaries are unlikely to counteract tumour progression in the subglottis. Furthermore, the findings suggest that these structures contribute to temperature regulation of breath, protection against inflammation as well as breath frequency and depth-dependent mucus secretion.

Embryological study of the glottic site and clinical implications.

The development of the glottic site, in particular of its ventral area, was studied to better understand the spreading pathways of T1, T2 cancer. Serial sections of larynges from human embryos, fetuses and adults were observed. A dorsal, a ventral and an intermediate compartment were found on the basis of their maturation schedule. A commissure muscle which develops in the anterior one third of the glottic site and wraps the connection system of vocal ligaments was recognized. The inferior paraglottic space, the compartment structures and the localization of superficial and deep blood vessels and of glands in the ventral compartment and the components of Broyles ligament were studied during ontogenesis. The compartments identified here have clinical and oncological relevance. Their detailed knowledge offers a prerequisite for planning and performing compartment conservative surgery in T1, T2 cancer, based on their spreading pathways.

Revascularization of a salvage supraglottic laryngectomy. Preliminary report.

After supraglottic laryngectomy, particularly if there has been a large preoperative dose of radiotherapy, significant ischemia at the suspension anastomosis site may ensue. Neovascularization may play a major role in the healing of this salvage horizontal laryngectomy anastomosis. We have analyzed the process of angiogenesis and neovascularization from a fascial flap in a case of salvage supraglottic laryngectomy.

Vascularized fascia as a transferable bed for experimental laryngeal reconstruction.

Laryngeal defects were reconstructed with a combined vascular flap consisting of lateral thoracic fascia used as a transferable vascular bed. A buccal mucosal graft was fixed on this bed as an internal lining. An autogenous cartilage graft, circumferentially wrapped in vascular connective tissue, was used as external support. The first focus of interest of this experimental study was to investigate the necessity of epithelial lining in the repair of a full-thickness laryngeal wall defect. The second focus of interest was to study reconstruction of the posterior glottis by introducing additional supporting material.

Linfáticos da laringe / Lymphatics of the larynx

Realizamos 147 injeçöes de diferentes corantes e/ou contraste radiopaco, em 77 laringes de cäes a fim de se estudar os linfáticos da submucosa da laringe e suas eventuais vias preferencias de drenagem. Os corantess utilizados (Blue Patent V, Azul da Prússia e Tinta Nankin) e/ou contraste radiopaco (Hypaque) foram previamente injetados em regiöes topográficas selecionadas. O estudo foi realizado em cäes anestesiados ou recém-sacrificados, e em laringes extirpadas. A drenagem linfática foi também estudada em cäes submetidos a ligadura prévia de eferentes linfáticos aos linfonodos cervicais. Em laringes isoladas, o estudo dos linfáticos e suas vias de drenagem foi realizado sob lupa estereoscópica, antes e após a desidrataçäo e diafanizaçäo das peças. O autor descreve os caminhos descritos pelos linfáticos da submucosa da laringe até encontrar as vias de drenagem: via superior, via média e via inferior.

Conservative treatment of infantile subglottic hemangioma with corticosteroids.

Infantile subglottic hemangioma is a rare, potentially fatal cause of airway obstruction. Diagnosis is made by history, neck roentgenograms, and direct laryngoscopy. A regimen of high-dose intravenous steroids in combination with oxygen and a mist tent is the preferred mode of therapy in cases where tracheostomy is not required.

Vasculature of the anterior commissure.

Results of a study of the vasculature of the anterior commissure, part of a larger study of the larynx, are presented. The vasculature of the anterior commissure is dependent on the medial branch of the anteroinferior laryngeal artery. The techniques used, postmortem angiography, dissection, cleared method, microangiography and histological sections, made it possible to follow the course of the artery and determine its configuration. The results reveal separation of the supraglottis and the glottis between the thyroepiglottic ligament and the anterior commissure; the study also establishes that a separation does not exist between the glottis and the subglottis in the anterior larynx. Particular emphasis is placed on ossification of the thyroid cartilage and the relationship between the vascular network of the glottic and subglottic mucosa and the tissues immediately in front of the larynx.

Angiography in laryngeal carcinoma.

Angiography was performed in 8 patients with laryngeal carcinoma. The findings suggest that angiography can provide useful information on deep tumour invasion but further experiences are required before any definite conclusions can be drawn.

Laryngeal microcirculation and pathways of cancer spread.

The microcirculation of the human larynx was studied in cleared anatomic specimens. The distribution of the endolaryngeal blood supply was constant enough to permit naming of the subdivisions of the superior and inferior laryngeal arteries. There was a remarkable correlation between arteriolar and capillary distribution and the laryngeal routes of cancer spread within the larynx. Compartmentalization of the larynx was not apparent. The paraglottic space was filled with blood vessels.

Microfil angiography: a demonstration of the microvasculature of the larynx with reference to tumor spread.

The microvasculature of both the human and monkey larynx is described. The recognized patterns of growth and spread of laryngeal carcinoma are discussed in relation to the microvasculature. The direction of enlargement of these tumors may be influenced by the lines of least resistance created in the tissues by the microvasculature.