Transoral laser microsurgery in advanced carcinomas of larynx and pharynx

Introduction and objectivesThere are several types of treatment for advanced squamous cell carcinomas of the pharynx and larynx. However, both open surgery and chemoradiation protocols have failed to improve control and survival. There is a tendency toward conservative treatment without worsening oncological outcomes. The objective of this study was to describe the effectiveness of organ-preserving CO₂ laser microsurgery for treating advanced carcinomas of the larynx and pharynx.Material and methodA retrospective review of 63 patients undergoing CO₂ laser microsurgery for the treatment of squamous cell carcinomas of the pharynx and larynx in advanced stages (stages III and IV) was performed. Tumour distribution was 14 patients with a tumour at the base of the tongue, 16 with a pyriform sinus tumour, 29 with a supraglottic tumour and 4 with a glottic tumour. Mean follow-up was 51 months.ResultsThirty-five percent of patients (23) had recurrences. The recurrence rate was 28% for base of tongue tumours, 50% for hypopharyngeal tumours, 27% for supraglottic tumours and 75% for glottic tumours. The 5-year disease-specific survival rate was 73.3% for all locations, with a range from 90% for supraglottic tumours up to 50% for glottic tumours. Thirty-four percent of patients had some type of complication after surgery. The most frequent complication was local bleeding (17%).ConclusionTransoral CO₂ laser microsurgery is an alternative for the treatment of carcinomas of the pharynx and larynx in advanced stages. Its oncological results are equivalent to other treatment modalities and its morbidity is lower.     

Endoskopische Krebsnachsorge im oberen Aero-Digestiv-Trakt

Summary Between 1975 and 1980, at the ENT Department of the University Hospital of Erlangen, more than 900 patients were treated for malignant lesions in mouth, pharynx and larnyx. About 40% of these lesions were laryngeal carcinomas.Long range after-care serves to ensure early recognition of residual, recurrent or second carcinomas. It rises particular demands with respect to organization and methods. Prerequisite is a good cooperation between patient and doctor. A tumour register in connection with a precise patient-summoning system, permits expedient patient follow-up at regular intervals.The ENT examination always includes endoscopy of the nose, pharynx and larynx in the awake patient. In addition to the routine photographic (and video-) documentation, a cytological swab is always obtained from the area of primary tumour manifestation. All visible proliferations are subject to a thorough cytological and histological (biopsy) investigation, irrespective of size or clinical significance. In the case of changes produced by irradiation or surgery, which can be difficult to evaluate, a different methodical approach may sometimes be required.Provided that the patient is properly instructed and is willing to cooperate, this standardized concept enables the detection of recurrences at an early stage — in particular in the larynx — and to ensure improved treatment with respect both to the functional result and the subsequent prognosis.     

窄带成像技术在咽喉肿瘤诊治中的应用

咽喉部恶性肿瘤是一种临床发病率低,发现时已到晚期,五年生存率低的一种疾病。对于如何提高咽喉部恶性肿瘤的早期发现这一问题,严重困扰着耳鼻喉科医师。目前咽喉部最常用的检查是白光电子喉镜。随着窄带电子喉镜(NBI)的出现,通过观察咽喉部黏膜及黏膜下毛细血管袢的形态,相对于普通白光电子喉镜,为早期发现咽喉部恶性肿瘤提供了可能性,同时在术中应用做到微创治疗及术后随访均起到重大作用。现就从NBI的起源原理,在咽喉恶性肿瘤中的应用优点、难点、临床应用发展前景等方面综述NBI技术在咽喉恶性肿瘤疾病中的应用。     

A new video laryngo-pharyngoscope with shape-holding coiled tube and surgical forceps: A preliminary study

Objectives

We developed a new video laryngo-pharyngoscope with a shape-holding coiled tube and examined its effectiveness in some patients.

Methods

The video laryngo-pharyngoscope is designed to inspect the pharynx and larynx transorally and to perform surgical manipulations. The scope consists of a coiled tube, a grip with trigger connected to the forceps and a CCD Camera with a battery. The stainless coiled tube of the scope is flexible but shape-holding, so that its shape can be changed by hand with the characteristic that the new orientation remains invariable during both inspection and operation in the pharynx and larynx. After a local anesthesia, the operator holds the scope in one hand and pulls the patient's tongue by the other hand. The operator then inserted the scope transorally while monitoring video images that were wirelessly transferred to the display to ensure that the forceps has reached the area of interest and treated lesions successfully.

Results

Using the scope, we successfully examined the upper airway lesions and removed foreign bodies from the pharynx and performed both resection of a benign tumor and taking a biopsy of a malignant tumor from the pharynx and larynx. But, we could hardly remove vocal fold polyps because of the structural limitation of the scope.

Conclusions

We demonstrated that the new video laryngo-pharyngoscope can be used safely and successfully in the inspection and removal of lesions in the oropharynx and supraglottic area of the larynx and will be a useful tool for minimally invasive office-based surgery.     

Importance of whole body skeletal scintigraphy within the scope of staging of neoplasms in the ENT area]

Concerning malignant tumours of the oral cavity, pharynx and larynx, bone metastases are in general rarely seen. For the specification to which patients the whole body bone scintigraphy as detection method should be applied, the findings of 370 patients were analysed retrospectively. In respect of primary staging, bone metastases could be found by scintigraphy in only 1.4% of the patients. On the other hand, there was a detection rate of 12% during the further course of the disease, especially in case of clinical symptoms pointing at spreading metastases or in tumour recurrences. Nevertheless, positive scan findings which were not due to metastases could be found in both groups with equal frequency (12 and 13%, respectively). Therefore the routine performance of whole body bone scintigraphy as a screening method does not seem to be useful in the primary staging of cancer of the mouth, pharynx and larynx. Contrary to this, in the follow-up of these tumours bone scanning proves to be a valuable and sensitive method for detecting skeletal metastases.     

Entering the pharynx in total laryngectomy

In performing total laryngectomy for carcinoma of the larynx, the pharynx should be entered at sites away from the tumour. When the tumour is supraglottic in location, the entry should be through the lateral pharyngeal wall; and when the tumour is located in the postcricoid area, entry above the hyoid bone is preferred.     

Złośliwe i niezłośliwe guzy chrzęstne krtani

Introduction

Cartilaginous tumours of the larynx are rare. They usually involve cricoid cartilage, less frequently thyroid cartilage and other cartilages. The most significant clinical manifestations are hoarseness, dyspnea, dysphagia or a neck mass. On physical examination, tumour is found as a bulge with intact mucosa or a tumour situated in a part of the larynx also with fixation. CT scanning is the mainstay of radiographic imaging. The histopathologic diagnosis is made after the surgical excision. Prognosis for survival is good. The recurrences occur very often, also with malignant transformation and require laryngectomy.

Material

We presented 11 patients (including symptoms, involved cartilage, laryngoscopy examination, histopathologic diagnosis, treatment and the follow-up).

Results

6 patients manifested hoarseness, 5 dyspnea, 3 dysphagia, 1 neck mass as the first symptom. In laryngoscopy a tumour with intact mucosa was situated in subglottis – 5 patients, in supraglottis – 2 patients and in half of the larynx with fixation – 4 patients. The majority of tumours involved the cricoid cartilage – in 9 cases, the rest arytenoid and epiglottic cartilage. The histopathology diagnosis were given after surgery, only in one case after biopsy. There were 7 patients with chondrosarcoma and four with chondroma. We did not observe lymph node or distant metastases. All patients were treated surgically. Follow-up of patients with chondrosarcoma were 5 to 17 years without recurrence. However, two recurrences of chondroma appeared to be chondrosarcomas and required laryngectomy.     

Laryngeal chondrosarcoma diagnosed by core-needle biopsy

We report a case of chondrosarcoma of the larynx, diagnosed by a percutaneous core-needle biopsy (CNB). Cartilaginous tumors of the larynx are usually diagnosed by biopsy with direct laryngomicroscopy under general anesthesia. However, patients find it difficult to undergo a biopsy under general anesthesia, for physical, economic, and social reasons. Instead, we can readily detect and sample tumors of the larynx using ultrasound under local anesthesia with reduced stress. Concerning needle-puncture biopsies, including fine-needle aspiration cytology (FNAC) and CNB, some studies have reported needle track dissemination, a possible complication in patients with malignant tumors. Thus, in the head and neck region, we generally use FNAC for biopsies, not CNB. However, it can be difficult to diagnose bone tumors by cytology alone. Regarding primary bone tumors, only one study has reported needle track dissemination by CNB, in osteosarcoma of the femur. Additionally, this complication has not been reported before with chondrosarcoma anywhere in the body. To our knowledge, this is the first report concerning chondrosarcoma of the larynx diagnosed by percutaneous CNB. We recommend CNB as a useful and safe diagnostic technique for primary bone tumors in the head and neck region.     

Correlation of clinical, radiologic, and histopathologic findings in laryngeal, hypopharyngeal, and oropharyngeal cancer

The correct staging of the tumors has important consequences in the planning of the treatment in the patients with cancer of larynx, hypopharynx and oropharynx. The objective of this paper is to study the correlation of the clinical, radiologic and pathologic staging with the purpose to evaluate if the computed tomography (CT) is effective in the diagnostic of the stage in the different tumoral findings. We did a retrospective study in 34 patients with pharynx and larynx cancer in the "Hospital Universitario Príncipe de Asturias" between the years 1994-1998. The method was: 1. Clinical history and ENT examination. 2. Head and neck CT. 3. Direct laryngoscopy and biopsy. 4. Surgical treatment and posterior pathologic staging of the removed specimen. The lesions were studied according the TNM-UICC classification with the T and N stage. The first thing to do was the clinical stage then the radiologic stage and at last compare it with the pathologic stage after surgical removal. The results are presented in percentages and confirm that the clinical and radiologic combined information improve the correlation between clinical and pathologic staging in the cancer of larynx, hypopharynx and oropharynx.     

Endoscopic needle biopsy in larynx and pharynx. A simple method for the histological diagnosis of tumours (author's transl)

The needle-biopsy taken in the pharynx and larynx is a simple and reliable procedure for the histological diagnosis of submucosal tumours. It can be performed either in local anaesthesia using the zoom-endoscope by v.Stuckrad or during microlaryngoscopy under general anesthesia. This method however does neither replace the single biopsy of exophytic tumours nor the microlaryngoscopic excision of suspicious, precancerous lesions.     

脱细胞真皮基质黏膜组织补片在咽部修复中的应用

目的 探讨脱细胞真皮基质黏膜组织补片（acellular dermal matrix，ADM）在咽部的修复作用。方法 2003年6月—2004年12月对18例患者行口咽、喉咽癌切除术，其中4例肿瘤原发于口咽和喉咽后壁，保留喉功能切除肿瘤，用ADM重建口咽和喉咽后壁；3例肿瘤原发一侧梨状窝侧壁和咽后壁，声带活动正常的，保留喉功能行咽后壁或侧壁切除术，将ADM缝在椎前筋膜和咽侧壁上关闭咽腔，用保留的胸锁乳突肌加固；对11例肿瘤累及颈段食管，声带活动受限及固定者，行喉全切除或喉咽全切除术，将ADM缝在椎前筋膜上重建喉咽后壁，用胸大肌肌皮瓣重建喉咽前壁和侧壁，重建密闭腔道。术后全部患者进行放射治疗，放疗剂量60～70Gy。结果 18例患者术后未发生排异反应，无咽瘘，创面均黏膜化。2例患者切口皮下感染，经换药后伤口愈合。所有患者均可经口进食。7例保留喉的患者恢复了喉功能，拔除气管套管，但其中3例进食流质时有轻度误咽。术后随访12～30个月，中位随访时间为19．38个月，补片移植区无排异反应、瘢痕和挛缩。随访18月以上11例，其中3例肿瘤复发，1例再次手术后健在，2例死于全身转移。结论 ADM来源方便，组织相容性好，厚薄适宜，手术操作简便，可联合胸大肌肌皮瓣或其他颈部组织修复咽部环周缺损，是一种新的安全有效的修复材料。     

NBI flexible laryngoscopy targeted tissue sampling in head and neck cancer patients with difficult airways

Direct suspension laryngoscopic biopsy of neoplasms in larynx, oropharynx, and hypopharynx was an arduous procedure in patients with a history of head and neck cancer and difficult airways. This preliminary study was aimed to report the efficacy and safety of a narrow band imaging-guided biopsy of this category by flexible laryngoscopy. This is a retrospective chart review study conducted in setting of tertiary referral centre. Nineteen consecutive head and neck cancer patients with difficulty in general anesthesia and rigid endoscopic approach due to trismus, craniofacial deformities, and/or limited neck extension after cancer therapy were referred for endoscopic biopsy of their suspicious lesions in larynx, hypopharynx, or parts of oropharynx. Following topical anesthesia, a flexible laryngoscope was introduced through the nose into the pharynx. Under narrow band imaging magnified view, the specified tumor foci were biopsied in an office-based setting. All of the lesions were reached and biopsied to obtain sufficient tissue samples. The procedure took <20 min in every case. Twelve of the 19 pathologic examinations disclosed the malignancies at the first biopsy, and another underwent a second biopsy to prove cancer recurrence. The other six patients with benign lesions received further follow-up for at least 6 months and showed no recurrence. There were no complications associated with the technique. This study introduced that flexible laryngoscopy with narrow band imaging has the advantages of nimbleness, precision, and minimal morbidity. This combined technique may be a safe and promising method for tissue sampling of suspicious recurrence in head and neck cancer patients with difficult airways.     

Radiation‐induced cancers of the pharynx and larynx: a study of five clinical cases

Radiation‐induced cancers of the pharynx and larynx: a study of five clinical cases Radiation‐induced cancer, a rare clinical entity, is often difficult to diagnose and manage. This study reports a series of five cases of radiocarcinogenesis of the pharynx and/or larynx that developed after external radiotherapy. The primary lesion was diagnosed at a mean age of 50 years (±12.9) and the radiation‐induced cancer at a mean age of 59 years (±13.1), giving a latent period of 9 years (±3.7). Analysis of gammagraphic records indicated that four of the patients had developed a secondary tumour in the penumbra of irradiation fields. In these zones, the delivered dose was between 20 and 80% of the prescribed dose, corresponding to an estimated cumulative mean dose of 14.1–56.3 Gy. These results are compared with data in the literature to determine the diagnostic criteria for radiation‐induced cancer, possible predisposition (genetic or acquired) and the dose effect.     

Endoskopische Grobnadelbiopsie in Rachen und Kehlkopf

Summary The needle-biopsy taken in the pharynx and larynx is a simple and reliable procedure for the histological diagnosis of submucosal tumours. It can be performed either in local anaesthesia using the zoom-endoscope by v. Stuckrad or during microlaryngoscopy under general anaesthesie. This method however does neither replace the single biopsy of exophtic tumours nor the microlaryngoscopic excision of suspicious, precancerous lesions.     

咽喉鳞状细胞癌患者外周血T淋巴细胞亚群和NK细胞活性研究

目的:研究咽喉癌患者外周血T淋巴细胞亚群分布和NK细胞活性及其意义。方法:应用流式细胞仪检测123例咽喉癌患者及36例正常志愿者空腹外周静脉血淋巴细胞亚群和NK细胞活性。结果:咽喉癌患者外周血总T淋巴细胞百分比低于正常人(P<0.05),辅助T淋巴细胞百分比略低于正常人(P>0.05),抑制T淋巴细胞百分比高于正常人(P<0.01),辅助/抑制T淋巴细胞比值低于正常人(P<0.05)。外周血总B淋巴细胞咽喉癌患者略低于正常人(P>0.05),活化T细胞正常人略低于咽喉癌患者(P>0.05),NK细胞活性比较咽喉癌患者低于正常人(P<0.01)。Ⅰ～Ⅱ期外周血总T淋巴细胞略低于Ⅲ～Ⅳ期患者(P>0.05),Ⅰ～Ⅱ期辅助T淋巴细胞含量略高于Ⅲ～Ⅳ期患者(P>0.05),Ⅰ～Ⅱ期抑制T淋巴细胞比值低于Ⅲ～Ⅳ期患者(P<0.01),Ⅰ～Ⅱ期辅助/抑制T淋巴细胞比值高于Ⅲ～Ⅳ期患者(P<0.01)。Ⅰ～Ⅱ期外周血总B淋巴细胞相对值高于Ⅲ～Ⅳ期患者(P<0.05),活化T细胞在Ⅰ～Ⅱ期和Ⅲ～Ⅳ期患者变化不大(P>0.05);Ⅰ～Ⅱ期外周血NK细胞比值略高于Ⅲ～Ⅳ期患者(P>0.05)。结论:咽喉癌患者存在免疫功能紊乱或低...     

Destructive tumours of the larynx mimicking osteosarcoma: two cases of osteoblastoma with organ-saving resection and follow-up

Osteoblastoma of the larynx is an extremely rare type of locally progressive and destructive tumour which is mimicking osteosarcoma radiologically and histologically. Since prognostic and therapeutic strategies for benign osteoblastoma differ from the more common osteosarcoma of the larynx, a meticulous pre-operative histological diagnosis is required to avoid over-therapy. We report about two patients with osteoblastoma of the larynx with organ-saving resection and long-period follow-up without tumour recurrence. A review of the literature detected five further osteoblastomas of the larynx, all in elderly men, like our observations. This situation is quite different from the usual osteoblastomas of bone, which occur in young adults of both sexes equally.     

Combined use of histopathology with touch smear cytology in biopsies of the larynx

The aim of this prospective study is to evaluate the effectiveness of combined use of histopathology with cytology in biopsies of the larynx. Biopsies taken for this purpose are studied by using two different methods and the results are evaluated. One hundred and thirty-five patients with suspected malignant laryngeal lesions were examined by direct microlaryngoscopy for primary diagnosis. Each lesion was biopsied first. Subsequently touch smear cytology was obtained from the biopsies. In all cases, cytologic slides (one or two per biopsy) were screened and compared to corresponding biopsies. Lesions were categorized as benign, laryngeal intraepithelial neoplasia and malignant. Results obtained were compared with surgical samples obtained from patients who have undergone surgery. In other cases, where surgery was not applied, results of the follow-up were evaluated. In larynx biopsies the results for histopathology were as follows: sensitivity 93.9%, specificity 100% and accuracy 96.3%. The results for cytology were as follows: sensitivity 82.5%, specificity 94.5% and accuracy 87.4%. A comparison of cytologic evaluation versus histopathologic evaluation in laryngeal biopsies reveals that histopathology is superior. According to the study results, in 88.9% (120/135) of the cases the agreement between cytological and histopathological results was found. In two other cases (1.5%) cytologic evaluation contributed to the histopathologic diagnosis.     

咽喉部尖锐湿疣的诊断方法探讨

目的：探讨咽喉部尖锐湿疣的诊断方法。方法：通过病史与临床分析，并应用病理组织学、免疫组化染色和ＰＣＲ等方法检测致病原。结果：正确诊断了６例咽喉部尖锐湿疣。结论：病史、临床表现、病理组织学检查、ＨＰＶ－Ａｇ免疫组化染色和ＰＣＲ检测组织中ＨＰＶ相结合，是目前诊断咽喉部尖锐湿疣的有效方法。     

咽喉部淋巴瘤的临床分析

目的分析咽喉部淋巴瘤的临床特征,提高咽喉部淋巴瘤的临床检出率。方法回顾性分析16例咽喉部淋巴瘤患者的临床资料。结果咽喉部淋巴瘤临床症状主要为咽喉部疼痛（14例）,咽喉部异物感（12例）,部分患者伴声嘶（6例）,发热、乏力、盗汗（5例）,呼吸困难（2例）,及痰中带血（1例）。16例患者均经电子喉镜下活检病理证实：NK/T细胞淋巴瘤11例,B细胞淋巴瘤5例。结论咽喉部淋巴瘤的临床症状无特异性,电子喉镜下病变的表现有一定的特殊性,电子喉镜检查有利于早期发现并且可以在电子喉镜引导下嵌取病变组织,结合病理结果进行疾病的诊断,减少误诊及漏诊。     

Rupture of supra-aortic neck arteries due to lesions caused by tracheal tubes

Haemorrhages from the common carotid or innominate artery caused by tracheal tubes are rare but dramatic complications of head and neck surgery. Patients with metal tracheostomy cannulas or patients in the phase of wound healing after radical tumour resections of the pharynx and larynx run a greater risk. Following extensive tumour resections and radiation of the upper respiratory and digestive tracts in 680 patients, acute bleeding of the larger neck arteries occurred in 18 patients. In four of these cases, fistulae developed in the innominate or common carotid artery. These ruptures were caused by both plastic and metal tracheal tubes.