Laser cordotomy versus radiotherapy: an objective cost analysis.

This study presents a cost analysis of and comparison between laser cordotomy and external beam irradiation for the treatment of early glottic carcinoma. It compares the curative results of the two modalities from data of a retrospective study at my institution and a literature review of published cure rates. It also reviews the results of objective voice assessments in cases representing both treatments. The findings of this study indicate that the cure rates are equivalent and that voice quality obtained after laser cordotomy is comparable to that obtained after irradiation, yet the total cost of external beam radiotherapy is significantly higher than that of laser surgery. Hence, the findings of this study provide strong support for initially treating early glottic tumors with laser surgery.

Vocal cord injection with autogenous fat: a long-term magnetic resonance imaging evaluation.

Since 1987, the senior author has injected autogenous fat into paralyzed or atrophic vocal cords as an alternative to alloplastic substances for vocal cord augmentation and medialization. To determine the fate of the injected autogenous fat, the injected vocal cords of 10 patients were evaluated by laryngeal magnetic resonance imaging (MRI) in the sagittal, coronal, and axial planes. Imaging studies were performed as early as 17 hours after surgery to as long as 31 months after fat injection. In 9 patients, identification of a fat signal within the previously injected vocal cords was observed (including the 31-month postoperative follow-up). In 1 patient, no fat signal was identified 13 months after surgery, but the vocal cord was noted to have a bulging, enlarged contour. The results of this imaging study provide further evidence that autogenous fat, which has not been damaged during harvesting or microinjection, can survive transplantation into the vocal cord. The bulk of the vocal cord is maintained by microlipocytes and fibrous connective tissue, both of which replace the damaged fat cells that are gradually being reabsorbed.

Malignant oncocytoma of the lacrimal sac: ultrastructure and immunocytochemistry.

Malignant oncocytoma of the lacrimal sac is a rare tumor. A third example is presented here. In addition to oncocytes, tumor acini also harbored a few mucin cells and myoepithelial cells. The presence of immunoreactive lactoferrin and secretory piece suggested a resemblance to parotid acinic cell carcinomas. The difference was marked by a compact acinar structure and myoepithelial cell differentiation in the oncocytoma.

Modified neoglottis reconstruction following total laryngectomy: long-term follow-up and results.

In 1978 a surgical procedure was developed to create a neoglottis from the upper tracheal rings to facilitate speech rehabilitation in patients who had undergone total laryngectomy for carcinoma of the larynx. To date, 45 such procedures have been performed and results indicate rapid postoperative speech rehabilitation in nearly all patients, good long-term speech results, and low morbidity. This procedure has served as a very successful alternative to the more frequently used tracheoesophageal puncture (TEP) and prosthetic valve technique.

Factors influencing functional outcome in supraglottic laryngectomy.

BACKGROUND: The relationship between preoperative pulmonary function tests (PFTs) and postoperative aspiration and deglutition complications in supraglottic laryngectomy (SL) has not been adequately analyzed. The effects of numerous other variables are either controversial or have not been studied. METHODS: A retrospective chart review was performed on 46 SL patients, analyzing preoperative PFTs and arterial blood gases, demographic factors, stage of disease, extended resections, cricopharyngeal myotomy, hyoid preservation, neck dissection, and postoperative radiotherapy with regards to aspiration and deglutition problems. RESULTS: Eighteen (39%) patients had no problems, 15 (33%) had moderate problems, and 13 (28%) had severe problems; of these, 39 (85%) were ultimately successful with no further swallowing dysfunction, whereas seven (15%) suffered intractable aspiration difficulties. Decreasing FEV1/FVC was significantly correlated with a poorer outcome, as was a greater number of pack-years of smoking. The effect of FEV1/FVC was shown to be independent from pack-years, whereas the converse was not clearly demonstrated. Extensions of the standard procedure did not correlate significantly with increased problems. CONCLUSIONS: An FEV1/FVC less than 50% signifies a greater risk for severe aspiration and deglutition complications, although it must be regarded as one factor among many in determining operability. With careful attention to reconstruction, extensions of the standard SL procedure can be safely performed.

Sulcus vocalis in laryngeal cancer: a histopathologic study.

The incidental finding of sulcus vocalis in surgical specimens of patients with laryngeal cancer prompted this review. Sulcus deformities were histologically identified in 28 (48%) of 58 whole-mount coronal serial-sectioned laryngeal specimens procured from laryngeal cancer patients. The lesions were analyzed, described, and graded. A control group of 20 larynges, obtained from autopsies of patients without known laryngeal pathology, were similarly processed, and whole-mount histologic sections were studied. Four of these specimens (20%) also demonstrated sulcus deformities. In the control group, the shape and location of the sulci were similar, but the lesions were smaller than in the cancer group. The sulcus lesions revealed chronic inflammation of the subepithelial tissues with vascular ingrowth and fibrosis of the superficial lamina propria (Reinke's space); in the cancer group the sulcus was usually on the opposite vocal fold, where irritation from the tumor might be anticipated. Although the etiology of the sulci remains controversial, these findings suggest that irritation and inflammation might play a role in the pathogenesis of sulcus vocalis.

Dedifferentiated chondrosarcoma of the larynx with regional and distant metastases.

Chondrosarcoma of the larynx is an unusual tumor, with only approximately 200 cases having been reported. This tumor is relatively nonaggressive and tends to remain localized in the larynx. Two cases with aggressive clinical behavior manifested by regional or distant metastasis are presented. In the first case, cervical node metastasis appeared 6 months after total laryngectomy. A dedifferentiated chondrosarcoma was identified by pathologic examination. In the other case, clavicular metastasis developed 7 years after initial local excision. Despite additional treatments, the patient later developed cervical node, lung, and vertebral metastasis. Transformation from low-grade to dedifferentiated chondrosarcoma was verified by pathologic examination. We believe this case to be the first reported laryngeal chondrosarcoma with bone metastasis. A review of the literature regarding regional and/or distant metastasis of laryngeal chondrosarcoma, including the present observations, reveals a total of 20 cases. In all cases, tumor grade has been directly correlated with the development of metastasis.

Clinical underestimation of laryngeal cancer. Predictive indicators.

OBJECTIVE: To evaluate the accuracy of clinical staging of advanced laryngeal cancer and to morphologically analyze the underestimated cases. DESIGN: We conducted a retrospective histopathologic study of larynges from patients who had had total laryngectomy and were seen over a 21-year period. SETTING: Academic tertiary referral medical center. PARTICIPANTS: Forty-one patients had clinically staged T3 laryngeal cancer and 16 patients had T4 cancer. INTERVENTION: Patients all underwent wide-field total laryngectomy. All larynges were processed as whole-organ serial sections in the coronal plane. OUTCOME MEASURE: The incidence of clinically underestimated laryngeal cancer. During this investigation, it became obvious that predictive indicators of thyroid cartilage involvement could be established. RESULTS: Clinical underestimation had been made in approximately 50% of all T3 laryngeal cancer cases. The extent of the cartilage involvement in the underestimated group was characterized by microinvasion without penetration; approximately 90% of the cartilage involvement affected the thyroid notch and adjacent area. We established five objective indicators of thyroid cartilage involvement: (1) extensive cartilage ossification (risk for cartilage involvement, 73%); (2) glottic fixation (54%); (3) transglottic cancer (74%); (4) tumor length longer than the entire vocal fold length or longer than 2 cm (66%); and (5) extensive involvement of the anterior commissure (67%). CONCLUSIONS: Clinical underestimation of T4 laryngeal cancer was high because thyroid cartilage involvement was not accurately diagnosed. We believe our indicators of thyroid cartilage involvement will provide objective guidelines for laryngeal cancer staging and will contribute to more reliable clinical cancer-staging decisions.

Laser cordectomy or radiotherapy: cure rates, communication, and cost.

Health care costs have risen dramatically in recent years. Cost-containment strategies have become necessary to ensure that adequate medical care is accessible to all who need it. These strategies include choosing the least costly of several treatment modalities with equal efficacy. Radiotherapy has been considered by some as the treatment of choice for early glottic tumors. Rationale for this is based on two major assumptions: that cure rates are equal for radiotherapy and surgery, and that voice preservation and quality is superior with radiotherapy. Implicit in these assumptions is the idea that cost of therapy should not be a factor in selecting an alternative. This study presents a literature review of cure rates for laser cordectomy and radiotherapy for T1 glottic cancers. An objective voice analysis was performed on 14 patients with T1 glottic cancers treated with laser cordectomy and the results were compared to a group of 20 patients treated with radiotherapy for similar early tumors. Finally, the average total cost of each modality was calculated and compared. Our findings indicate that: (1) cure rates are equivalent; (2) voice quality after laser cordectomy is as good as that noted after radiotherapy; and (3) total cost of therapy is much less for laser cordectomy than for radiotherapy. We advocate laser cordectomy rather than radiotherapy for most early glottic tumors.

Vocal cord augmentation with autogenous fat.

Since 1987, the authors have used a new technique for the augmentation and medialization of the paralyzed vocal cord. Eleven patients with paralyzed vocal cords and one patient with a surgical defect of the vocal cord have been treated with intracordal injections of autogenous fat harvested by suction from the abdominal wall. Treatment efficacy was evaluated by both subjective and objective (videostroboscopic) analyses. Patient follow-up has ranged from 5 to 42 months. All patients showed significant improvement in voice characteristics. Marked reduction in air flow and increased vocal intensity were observed. Correction of glottic insufficiency has been lasting, indicating that the implanted fat cells are viable. At this time, there has been no evidence of loss of vocal cord substance. The natural qualities of autogenous fat appear to make it an excellent alternative to Teflon or collagen. The fat is readily available, and easily harvested and injected. A larger patient population and longer follow-up periods will help determine if these initial findings are consistent.

A modified neoglottis procedure: update and analysis.

In recent years, various techniques have been introduced for construction of an epithelium-lined shunt between the trachea and the esophagus or hypopharynx. We described a rigid neoglottis in a preliminary report of 12 cases in which the upper tracheal rings were used to construct the epithelium-lined tract. This study reports the cases of 22 additional patients and offers an in-depth analysis of additional demographics, complications, and long-term speech results that quantify the vocal characteristics of neoglottic speakers. Results indicate rapid postoperative speech rehabilitation in nearly all patients, good long-term speech results (mean followup, 52 months), and low morbidity. There was a low incidence of local recurrence and stenosis, and 26 of 34 patients had either no aspiration or occasional asymptomatic aspiration of small amounts of liquid. This modified neoglottis procedure should be considered for patients who need voice restoration after laryngectomy.

Primary irradiation, surgery or combined therapy in squamous cell carcinoma of the larynx. A comparison of treatment results from two centers.

We compared two groups of patients with squamous cell carcinoma of the larynx. Group 1 consisted of 483 patients treated from 1958 through 1978. Primary surgery was selected in 41% pre- or postoperative radiation therapy in 16% and primary radiation therapy in 43%. Group 2 consisted of 247 patients treated from 1978 through 1983. Primary surgery was selected in only 1.6%, pre- or postoperative radiation therapy in 23%, and primary radiation therapy, with surgery in reserve for residual or recurrent carcinoma, in 76%. Although the results were comparable for patients with early stage tumors in the two groups, significantly higher local-regional tumor control rates and corrected survival rates were recorded for patients with advanced tumors in group 2. More patients survived with a cancer-free functional larynx, the surgical salvage rates were higher, the complication rates and the death rates lower in group 2 compared to group 1.

Variables contributing to distress in male cardiac patients.

Fifty-five male subjects attending a cardiology clinic were examined using a structured interview keyed to a 12-item Hamilton Anxiety Scale (HAS). Sixty-five percent scored in the range of moderate to severe distress with highest mean scores on the following subscales: anxious mood, tension, insomnia, muscular complaints, and global behavioral distress. Two-way analysis of variance revealed the following factors to be significantly associated with higher total HAS scores: greater number of medical diagnoses (P = .007), taking more medications (P = .001), history of psychiatric treatment (P = .007), being declared disabled (P = .002), and living with others (P = .025). Each of these variables might contribute to greater psychological or physical discomfort, increased medical utilization, and difficulty with cardiac rehabilitation. The complexity of psychosocial factors in determining distress is addressed, since subjects living with others scored higher than those who were socially isolated (HAS mean score = 17.9 +/- 8 vs 10.7 +/- 5.5, respectively, P = .025).

An objective assessment of voice production after radiation therapy for stage I squamous cell carcinoma of the glottis.

Radiation therapy has been the primary treatment for early glottic carcinoma, especially when restoration of normal voice is essential; yet objective evidence of the status of vocal function after treatment is lacking. The purpose of this study was to assess vocal characteristics of patients with glottic carcinoma after they had undergone radiation therapy. Twenty males, who had previously been treated with external beam irradiation for T1N0M0 squamous cell carcinoma with no subsequent evidence of recurrence, volunteered for this study. Laryngovideostroboscopic, acoustic, aerodynamic, and perceptual measures of vocal function were used to determine the characteristics of voice production. Acoustic indices were compared to those of a normal group of 30 age-matched volunteers, and the other measures were compared to established values reported in the literature. On acoustic analysis, the study group was characterized by significantly worse voice production than their counterparts. A high degree of intersubject variability was noted that could not be accounted for in terms of variables in treatment and medical history. The aerodynamic, spectral, and video-stroboscopic findings correlated well; this indicated a poor vibratory source, characterized by diffuse stiffness. Further work is necessary in order to compare vocal function after endoscopic laser and conventional conservative excision.

Coronal sections of larynges from radiation-therapy failures: a clinical-pathologic study.

Serial coronal sections of 89 wide-field laryngectomies were examined. Twenty were specimens obtained from laryngectomies to treat patients for whom primary radiation therapy failed to cure early laryngeal cancer. These specimens were compared to 69 specimens from laryngectomies for T3 and T4 laryngeal cancers. The irradiation-failure group showed a significantly greater invasion of cartilage and extension into subglottic areas. The extension of tumors along blood vessels and mucous glands appeared to contribute to the spread of tumors in the irradiation-failure group. These findings have implications for the surgical management of irradiation failures in the treatment of laryngeal cancers.

An epidemiologic study of oral cancer in a statewide network.

A case-control study was conducted to investigate the risks of male and female oral, oropharyngeal, and hypopharyngeal cancer associated with poor oral health, mouthwash use, occupation, histories of tobacco and alcohol use, and other factors. Data were collected from all newly diagnosed patients entered into the Wisconsin Head and Neck Cancer Network over an 18-month period (N = 623). The prevalence of painful or ill-fitting dentures was significantly higher among males and females with oral cavity cancer. Relative risks for painful dentures were 5.97 (males) and 1.60 (females); for ill-fitting dentures, the relative risks were 3.15 (males) and 2.15 (females). For males, high relative risks of oropharyngeal cancer were also found to be associated with these indicators of poor dentition. Other indicators of poor oral health, including toothbrushing frequency and prevalence of broken teeth, were not associated with oral cancer. Mouthwash use was not found to carry a risk of oral cavity, oropharyngeal, or hypopharyngeal cancer. The risks of upper aerodigestive cancers with smoking and alcohol were confirmed for males, and lifetime use patterns were explored. Notable sex differences in exposure to alcohol and tobacco were found. There was little evidence that past alcohol use was related to female oral cancer.

Spontaneous remission in diffuse large cell lymphoma.

A case of spontaneous remission in a Stage IIA diffuse large cell lymphoma is presented. Review of the literature suggests that whereas spontaneous regressions are a well-recognized phenomenon in indolent lymphomas, it is extremely rare in lymphomas of aggressive histologic subtype.

Significance of apparent intratympanic meningiomas.

Meningioma is the most common tumor of the central nervous system, but it has only been reported in 79 patients to involve the temporal bone. The 4 cases presented here show striking clinical similarity to a subgroup of 20 meningiomas reported to be entirely intratympanic; however, in each instance the extent, origin, and potential of the disease was not initially evident. Precise histopathologic diagnosis may be aided by electron microscopy. Current concepts of embryology lend credence to the possible role of arachnoid endothelial cells in the pathogenesis of intratympanic meningioma. An advanced intracranial meningioma may be overshadowed by the hearing loss, tinnitus, and otalgia calling attention to an intratympanic component. The clinician should remain suspicious of intracranial disease even after excision of an apparently well circumscribed intratemporal lesion. Progressive sensorineural hearing loss and persistent otalgia portend recurrent or intracranial disease. Follow-up for at least 10 years with judicious use of CT scans is suggested.

The eleventh nerve in radical neck surgery.

The greatest morbidity associated with the radical neck dissection has been the "shoulder syndrome" due to the sacrifice of the spinal accessory nerve. Despite the fact that the XIth nerve can be spared by a careful dissection of the postcervical triangle, to do so remains a controversial issue. The 125 radical neck dissections performed at the University of Wisconsin Clinical Science Center from 1970 through 1975 were carefully evaluated to determine the incidence of recurrent tumor in the operated-on neck. In 60 cases the spinal accessory nerve was resected with the neck specimen, and in 65 cases the nerve was preserved. A second study was then undertaken involving 245 neck dissections performed from 1975-1978 in the Wisconsin Head and neck Cancer Control Network Hospitals. In 69 instances the spinal accessory nerve was spared. The total number of neck dissections (370 cases) from both studies were analyzed. The overall rate for recurrent tumor in the neck with the classical neck dissection was 12%. When the spinal accessory nerve was spared, the recurrent rate was 6%. On the basis of these observations we propose that the classical neck dissection can be modified to preserve the spinal accessory nerve without jeopardizing the chances for a cure in elective neck dissections and selected therapeutic neck dissections.

Vocal rehabilitation after laryngectomy.

A technique was developed to create a neoglottis from the upper tracheal rings to facilitate vocal rehabilitation after laryngectomy. Useful speech developed in 11 (85%) of 13 patients in whom this technique was performed. Concurrent radical neck dissection was performed in four patients and did not have any adverse effect on development of speech. Failure to acquire satisfactory speech occurred in two patients; one of these patients is having difficulty mastering the technique despite the fact that the shunt is patent. There was one wound breakdown with fistula formation. As with other tracheoesophageal shunt procedures, careful long-term follow-up studies will be necessary before any final conclusions can be drawn.