Laser scanning microscopy of the human larynx mucosa: a preliminary, ex vivo study

OBJECTIVE: Laser scanning microscopy (LSM) supplies in vivo information from epithelia up to depths between 0.1 to 0.5 mm. The aim of this ex vivo prospective pilot study was to investigate the potential use of LSM for the diagnosis of laryngeal cancer and its precursors. METHODS: Forty-three larynx specimens of 26 patients (age 35-61 years, mean age 51.9+/-9.5 years; 7 women and 19 men) with laryngeal lesions were investigated with LSM. The LSM findings were compared with histopathologic sections. The following criteria were used for characterization of cancerous lesions: enlarged nuclei, enlarged cells with variable shapes, cluster of cells, increased nucleus/cytoplasm ratio, irregular cell architecture, and loss of cellular junctions characterized by lack of visualization of the cell membrane. RESULTS: LSM enables the visualization of epithelium up to the basement membrane, Reincke space, the subepithelial vessels, and the fibers of the subepithelial space. In contrast to the squamous epithelium, the respiratory epithelium bears kinocilia. The beat of the cilia and the directed mucous transport can be observed ex vivo. With the use of the presented malignancy criteria, a sensitivity of 72.7% and a specificity of 82.9% for differentiation of dysplasia and benign laryngeal lesions from cancer were reached. CONCLUSIONS: LSM in an ex vivo manner supplies microscopic images up to the subepithelial space. LSM could represent a new technology in laryngology to visualize larynx epithelia. In the next step, in vivo LSM will be applied to evaluate laryngeal lesion in vivo.     

喉结核临床表现及喉内镜观察

目的探讨现今喉结核的临床表现及喉内镜下的病变特点。方法回顾性分析1994年以来经病理确诊的36例喉结核患者的临床资料。结果患者年龄19-78岁，中位年龄39，5岁；声嘶为主要症状（83．3％）。纤维喉镜下见病变多累及声带、室带，病变形态以肉芽样或结节样增殖性病变为主；动态喉镜下见病变声带黏膜波及振动消失或减弱；24例喉部多部位病灶者中79，2％（19／24）并发活动性肺结核，12例喉部单一病灶者中75．0％（9／12）肺部正常。全部患者均行系统抗结核治疗，除失访10例外，其余26例均治愈。结论当今喉结核的局部症状不典型，全身症状不明显；可以发生于无肺结核者，其病变可累及喉部多处，以声带、室带多见。     

电声门图与声学测试技术在病理性嗓音诊断中的运用

目的：探讨电声门图(EGG)和声学测试参数值与嗓音疾病诊断的相关性。方法：采用EGG及声学测试两种检测方法对207例正常人和296例喉部疾病患者进行测试。运用Dr．Speech 3．0软件，计算出嗓音声学分析参数，并对数据进行统计学分析。结果：声带息肉和声带小结患者的振幅微扰(shimmer)和频率微扰(jitter)变化率相近，但shimmer的敏感度较jitter更高。声带息肉、声带小结、喉鳞状细胞癌与对照组相比，习惯基频、jitter和shimmer增大，谐噪比减小。喉鳞状细胞癌患者接触幂值高于对照组，接触率与之比较差异无统计学意义。结论：EGG和声学测试参数值及波形的变化可为喉部疾病的诊断提供客观的量化指标。     

In vivo diagnosis of epithelial changes of the oropharynx using confocal microscopy

BACKGROUND: Confocal laser scanning microscopy enables the visualization of the anterior regions of the oropharynx mucosa. The specific aim of this investigation was to evaluate whether this in vivo tool supplies essential information for the surgeon prior to operation or not. PATIENTS AND METHODS: The laser scanning microscope HRT II and Rostock Cornea Module were used in this in vivo study. To obtain comparable images, the specifications of this tool used for all investigations were maintained (63 x water immersion objective lens). The investigations were performed on 9 patients with tongue cancer with primary tumor site and stage I (AJCC) and on 12 patients with head and neck cancer who underwent radiochemotherapy (RCT). Data from 21 patients were compared to those of healthy subjects. RESULTS: The following parameters can be detected using LSM: nuclear density, nuclear size, nucleus/cytoplasm relation, number of nuclei, regularity of cell layers, morphology of cells of a cell layer, and occurrence of cellular junctions. In regard to these parameters, dysplastic and cancerous lesions reveal significant differences compared to healthy tissue of the oropharynx. After RCT several epithelial changes were found, such as keratosis, mild dysplasia, increased vascularization and more cell edema and necrosis. CONCLUSIONS: Consistent differences exist between LSM findings of healthy subjects and those of patients with dysplastic, keratotic and cancerous lesions. Both strong hyperplasia and leukoplakia prevent a visualization of the basement cell layer in the oropharynx. The combination of LSM technology and endoscopy and following further investigations are needed for evaluation of LSM technology in the field of otorhinolaryngology.     

Mucoepidermoid cancer of the larynx. Case report and review of the literature]

Mucoepidermoid carcinoma (MEC) is classified among the salivary gland tumours and is most commonly found in the parotid gland. It rarely occurs in the larynx. There have been only 87 cases of laryngeal MEC reported in the literature. We report on an MEC of the vocal cord in a 75-year-old man, with a thickened right vocal cord without any loss of movement. The initial diagnosis was squamous cell carcinoma. One year after radiotherapy a tumour recurrence developed. Because the patient refused to laryngectomise, a tumour resection with the CO2 laser was performed twice. To date, the patient has been free from disease for more than five years. The true incidence of this type of neoplasm could be higher than is believed because of its frequent misdiagnosis as squamous cell carcinoma.     

Pathological and clinical assessment of polypoid hypertrophy of the vocal cords

Polypoid hypertrophy of mucosa of the vocal cord is the most common non-neoplastic disease of the larynx. This hypertrophy has a form of simple polyp of vocal cord or polypoid hypertrophy of the whole length of one or both vocal cords. In most cases a course of the disease is typical. In a few cases we can observe changes in polyp epithelium, i.e. hyperplasia or even dysplasia. Clinical and histological analysis of 809 patients treated because of laryngeal polyps (by Kleinsasser microsurgical procedure) within the period of 1981-1995 at ENT Clinic in Gdańsk was made. Sex and age of the patients, macroscopic picture of the disease as well as treatment and results were assessed. Special attention was paid to the problem of polyp epithelium rebuilding. In a few cases, polyp of the vocal cord should be assessed as praecancerous state.     

The own experience with complications narrowing the glottis as a result of microsurgical procedures

Proceeding rules in the larynx narrowing scars were presented. The clinical material consisted of patients with bilateral vocal cord paralysis, oedema Reincke and early stages of laryngeal carcinoma who underwent laser microsurgery of the larynx. The attention was paid to prophylaxis relating to the surgical procedure and perioperative care. The possibility of the silastic sheet insertion into the glottis was introduced as a way of treatment in recurrent scars.     

Autofluorescence endoscopy in the diagnosis of early laryngeal cancer and its precursor lesions

OBJECTIVES: Because early detection and preoperative assessment of laryngeal cancer and its precursor lesions are essential for curative and function-preserving surgical treatment, autofluorescence endoscopy has been developed to gain more information about the biologic character of these lesions. The aim of the present study is to investigate a high, representative number of patients and to evaluate the diagnostic potential and the limitations of this method. METHODS: In a prospective study, 127 patients were investigated during microlaryngoscopy. A total of 111 patients were suspected of having precancerous or cancerous lesions, 12 had benign lesions, and 4 patients had normal epithelium. Autofluorescence was induced by filtered blue light (380-460 nm) of a xenon short arc lamp and processed by a CCD camera system (D-light-AF system; Storz, Tuttlingen, Germany). Autofluorescence endoscopic images were immediately assessed for diagnosis, correlated to the dysplasia grading system and compared with the histopathologic findings. RESULTS: Normal laryngeal mucosa displayed a typical green fluorescence signal. Moderate and high epithelial dysplasia, carcinoma in situ, and invasive carcinoma showed a diminished green fluorescence. False-negative results (n = 2) were the result of extreme hyperkeratosis. False positive cases (n = 8) either showed mild dysplasia with inflammatory reactions or scarring of the vocal folds. In 105 of 111 cases (94.6%), we found concordant results (sensitivity, 97.3%; specificity, 83.8%). CONCLUSION: Autofluorescence endoscopy facilitates the detection and delineation of precancerous lesions, carcinoma in situ, and microinvasive cancer of the larynx more accurately than clinical observation alone. Scarring, marked hyperkeratosis, and inflammation can limit the predictive value of the method.     

声门上型喉癌声带不同活动情况组织病理学分析

目的 :探讨声门上型喉癌声带不同活动情况下的组织病理学特点 ,为喉部分切除术提供理论依据。方法 :84例声门上型喉癌喉切除标本 ,经火棉胶包埋 ,制成连续切片 ,苏木精 伊红染色 ,光学显微镜下观察。结果 :声带固定 2 6例中杓状软骨、声门旁间隙下区以及两者同时受侵率分别为 4 6 .2 %、15 .4 %、38.5 % ;声带活动受限 30例中杓状软骨、声门旁间隙下区以及两者同时受侵率分别为 4 6 .7%、6 .7%、13.3% ;声带活动良好 2 8例中杓状软骨及声门旁间隙下区无受侵。声带固定、声带活动受限、声带活动良好 3组之间杓状软骨及声门旁间隙下区的受侵率差异有统计学意义 (P <0 .0 5 ) ;侵犯声门旁间隙下区的肿瘤均侵犯了喉室 ,声带活动受限及声带固定者中 ,肿瘤组织侵犯声门旁间隙下区占侵犯喉室比例分别为 4 0 .0 % (6 / 15 )、73.7% (14 / 19) ,两者之间差异有统计学意义 (P <0 .0 5 )。结论 :肿瘤侵犯杓状软骨及声门旁间隙下区是声门上型喉癌引起声带活动受限或固定的主要原因 ,观察声带活动及喉室的受侵情况 ,可为喉部分切除术提供参考依据。     

Institutional and comprehensive review of laryngeal leukoplakia

OBJECTIVES: The nature and interpretation of vocal fold leukoplakia has been limited by small study sizes. The present study reviewed institutional data and the published literature to better characterize vocal fold leukoplakia. METHODS: At our institution, the histopathology, age, and malignant conversion rates of 136 patients (208 biopsies) with vocal fold leukoplakia from 1990 to 2005 were reviewed. RESULTS: No dysplasia (ND), mild and/or moderate dysplasia (MM), and severe dysplasia and/or squamous cell carcinoma in situ (SS) was identified in, respectively, 110 of 208 (53%), 38 of 208 (18%), and 31 of 208 (15%) biopsies. After 30 months (range, 1 to 134 months), malignant transformation was observed in 8 patients on subsequent biopsies. Additionally, a literature search was performed from 1960 to 2005 for the medical subject headings (MeSH) premalignant laryngeal lesions, laryngeal dysplasia, laryngeal leukoplakia, vocal cord dysplasia, and hyperkeratosis of the larynx. Fifteen reports were included for review. When these were combined with our institutional data, 1,173 of 2,188 biopsies (53.6%) revealed ND. Mild and/or moderate dysplasia and SS were present in 717 of 2,140 (33.5%) and 375 of 2,471 (15.2%) biopsies, respectively. Squamous cell carcinoma developed in 52 of 1,388 (3.7%), 83 of 824 (10.1%), and 56 of 310 (18.1%) patients whose initial biopsies demonstrated ND, MM, or SS. CONCLUSIONS: More than half of the reported leukoplakia lesions with biopsies showed ND. However, even lesions characterized as ND were associated with an increased risk of development of squamous cell carcinoma. Importantly, the risk of developing malignancy appears to correlate with the severity of dysplasia present on initial biopsy. Because clinical examination does not accurately predict the risk of malignancy, future studies, including genomic evaluation of this lesion, may be necessary to further characterize its biologic behavior.     

早期喉癌与声带癌前病变的诊断和微创治疗

目的 对早期喉癌和癌前病变的临床诊断和病理诊断标准及微创伤治疗后的临床效果进行总结和探讨。方法 临床诊断并经病理证实的３２例早期声门癌（Ｔ１ＮｏＭｏ）及２０例癌前病变在显微支撑喉镜下接受粘膜剥脱及声带切除与微波处理微创伤治疗。结果 经３年随访,２６例早期癌术后未见异常,３例复发,２例再次行剥脱术。２０例声带癌前病变分为声带白斑、轻度不典型增生、中度不典型增生、生度不典型增生。手术剥脱后经３年随访无     

bcl-2和bax基因在喉鳞状细胞癌细胞周期各时相的表达及其意义

OBJECTIVE: To detect the expression of bcl-2 and bax in each phase of cell cycle in laryngeal carcinoma, and explore the relationship between the expression of bcl-2 and bax in each phase of the cell cycle and the occurrence, development and prognosis in the carcinoma of larynx. METHODS: The immunohistochemical method, TUNEL technique and flowcytometry (FCM) parameter analyses were combined to detect the apoptosis and the expression of bcl-2 and bax in each phase of the cell cycle in 15 polyps of vocal cord and 387 laryngeal carcinomas. RESULTS: Total bcl-2 expression and bcl-2 expression in G0G1 stage in laryngeal carcinoma was significantly higher than that in polyp of vocal cord. In contrast, the total bax expression and the bax expression in each phase of cell cycle in laryngeal carcinoma were all lower than that in polyp of vocal cord. The total apoptosis index in laryngeal carcinoma was obviously lower than that in polyp of vocal cord, and this phenomenon was mainly caused by the decrease of the apoptosis in G0G1 phase. The bcl-2, bax expression and the apoptosis wasn't notably related to clinical stage, clinical type and T grade. In poor-differentiated squamous carcinoma, the bcl-2 expression in S and G2M phase was obviously higher than that in well-differentiated and the moderate-differentiated squamous carcinoma. The total apoptosis index, the apoptosis in S phase and the apoptosis in G2M phase were obviously enhanced both in the group of recurrence and in the patients who died in 5 years after the operation, in the same samples, the significant increasing of bcl-2 expression in S and G2M phase was detected. CONCLUSIONS: The significant decreasing of the apoptosis in G0G1 phase caused by high expression of bcl-2 was an important affair in the initial stage of laryngeal carcinoma. Accompanying the significant increasing of the total apoptosis index, the apoptosis in S phase and the apoptosis in G2M phase could be regard as an indicator that the cancer of larynx was malignant with poor prognosis and need adjuvant therapy. The decreasing of bax expression may play a role in the occurrence of laryngeal carcinoma.     

胸舌骨肌瓣或舌骨-胸舌骨肌瓣用于垂直喉部分切除术后声带重建

目的：探讨垂直喉部分切除术后改善发声，恢复喉功能的修复手段，以提高喉癌患者术后的生存质量。方法：垂直喉部分切除术后，用患侧甲状软骨外膜修复上半喉腔缺损，取健侧胸舌骨肌瓣（或舌骨－胸舌骨肌瓣）修复下半喉腔缺损并重建声带。结果：修复的新喉腔呈三角形，重建的声带具有一定的张力并参与发声，恰似一侧居于正中位麻痹的声带，发声时由健侧声带代偿运动与新声带前2／3相互靠近。93．4％的患者发声近乎正常或自觉发声质量较术前明显好转。结论：垂直喉部分切除术后采用患侧甲状软骨外膜和健侧胸舌骨肌瓣（或舌骨－胸舌骨肌瓣）修复缺损并重建声带，方法简单，取材方便，创伤小，效果满意，可作为垂直喉部分切除术后声带重建的首选方法。     

The role of laser microsurgery in the treatment of laryngeal cancer

PURPOSE OF REVIEW: Transoral laser microsurgery has developed in recent years into a surgical method that combines a minimally invasive approach with the surgical precision of laser and microscope. The outcomes of laser microsurgical treatment of laryngeal carcinomas are reviewed and compared with the results of competitive standard procedures. RECENT FINDINGS: Laser microsurgery is widely acknowledged to have advantages in the treatment of early glottic carcinoma. In the treatment of glottic carcinoma causing impaired mobility or fixation of the vocal cord the role of laser surgery has not yet been definitively assessed. Based on published results, primary laser therapy can achieve local tumor control with a functional residual larynx in approximately 70-80% of cases. In patients with early or moderately advanced supraglottic carcinoma, laser microsurgery is comparable to open supraglottic laryngectomy in terms of local control and survival. With regard to organ preservation, laser microsurgery is comparable to open supraglottic laryngectomy but superior to radiotherapy. Microsurgery can preserve functionally important structures, allowing for early swallowing rehabilitation while avoiding tracheotomy. SUMMARY: This review elucidates the role of laser microsurgical partial resections of the larynx in comparison with other treatment modalities.     

Laryngeal synkinesis: its significance to the laryngologist

Basic research and surgical cases have shown that the injured recurrent laryngeal nerve (RLN) may regenerate axons to the larynx that inappropriately innervate both vocal cord adductors and abductors. Innervation of vocal cord adductor muscles by those axons that depolarize during inspiration is particularly devastating to laryngeal function, since it produces medial vocal cord movement during inspiration. Many patients thought to have clinical bilateral vocal cord paralysis can be found to have synkinesis on at least one side. This will make the glottic airway smaller, particularly during inspiration, than would true paralysis of all the intrinsic laryngeal muscles. Patients with bilateral vocal cord paralysis should undergo laryngeal electromyography. If inspiratory innervation of the adductor muscles is present, simple reinnervation of the posterior cricoarytenoid muscle will fail. The adductor muscles also must be denervated by transection of the adductor division of the regenerated RLN.     

Diomed-25半导体激光手术治疗早期声门癌疗效观察

目的：观察激光治疗早期声门癌的临床效果。方法：采用Diomed-25半导体激光器对18例早期声门癌患者进行手术治疗，其中7例在局麻下进行．10例在全麻下进行，1例患者局麻下难以配合，全麻支撑喉镜下前联合暴露困难，遂行喉裂开后以激光切除肿瘤。结果：术后随访3～5年，局部复发3例，其中2例为T1b患者，病变侵犯前联合，1例为T2病变。18例中，失访1例(按死亡计算)，3年生存率为100．0％(18/18)，5年生存率为90．9％(10／11)。除2例肿瘤复发行全喉切除外，余16例均保留了喉发声功能。结论：半导体激光手术治疗早期声门癌，疗效确切，喉功能保留好，并发症发生率低，有临床应用价值。     

Return of vocal cord movement: an independent predictor of response to nonsurgical management of laryngeal cancers

OBJECTIVE: To determine whether return of vocal cord function after treatment of T2b/T3 laryngeal carcinoma is an independent prognostic factor for locoregional recurrence. STUDY DESIGN: A retrospective review of patients treated with radiation +/- chemotherapy between 2000 and 2005 for T2 with vocal cord paresis and T3 laryngeal carcinoma was conducted. METHODS: Only those patients obtained from the tumor registry with pre-and posttreatment video stroboscopies were included. Patients' charts were reviewed for local and regional recurrence after treatment. Fisher's exact test was used to determine significant association between recurrence and possible risk factors. RESULTS: Fourteen patients met the inclusion criterion. Six patients had T2 lesions with vocal cord paresis, and eight patients had T3 lesions. Fifty percent of patients with T2 and 75% of patients with T3 lesions had return of vocal cord function after treatment. Five of 14 patients did not have return of vocal cord function, and of these, 100% had locoregional recurrence. Of the nine patients who had return of vocal cord movement, none of the patients had recurrence. The proportion of recurrence was significantly higher for those whose vocal function did not return compared with the patients whose vocal function returned (100% vs. 0%, P < .01). CONCLUSION: The immobile vocal cord is associated with a worse prognosis and is therefore factored into the American Joint Commission on Cancer staging for laryngeal tumors. We show that vocal cord immobility is an independent prognostic factor of recurrence even after treatment and can predict treatment failure in T2 and T3 lesions of the larynx.     

Combined use of endoscopic CO2 laser excision of a marginal laryngeal tumor, radical neck dissection, and perioperative laterofixation of the opposite vocal cord

We report the use of endoscopic laser excision of a marginal laryngeal tumor, radical neck dissection, and laterofixation of a paralyzed vocal cord in a 66-year-old man who had an early-stage right supraglottic endolaryngeal tumor and ipsilateral neck metastasis. He had a left vocal cord paralysis after a left pneumonectomy that was performed 5 years previously. The primary laryngeal tumor was excised by endoscopic CO₂ laser resection, and a simultaneous radical neck dissection was carried out. Postoperatively, severe inspiratory dyspnea developed because of the surgical intervention on the right side causing moderate laryngeal edema and limited movement of the right vocal cord in addition to the paralyzed left side. An endolaryngeal laterofixation of the paralyzed left vocal cord was performed to provide the patient with an adequate airway instead of tracheostomy. This patient had a ¶2 years’ follow-up without recurrence of tumor. In the meantime movement of the right vocal cord has returned, so that the patient’s voice was socially acceptable and he has a functioning larynx.     

早期喉癌与声带癌前病变的诊断和微创治疗

目的　对早期喉癌和癌前病变的临床诊断和病理诊断标准及微创伤治疗后的临床效果进行总结和探讨。方法　临床诊断并经病理证实的 3 2例早期声门癌 (T1N0 M0 )及 2 0例癌前病变在显微支撑喉镜下接受粘膜剥脱及声带切除与微波处理微创伤治疗。结果　经 3年随访 ,2 6例早期癌术后未见异常 ,3例复发 ,2例再次行剥脱术。 2 0例声带癌前病变分为声带白斑、轻度不典型增生、中度不典型增生、重度不典型增生。手术剥脱后经 3年随访无一例转为恶性。结论　①早期喉癌和癌前病变的临床鉴别诊断非常重要 ,常常几种病理形态共存 ,过小的活检组织有漏诊之虞 ,采用剥脱手术 ,即是确切诊断的方法又是有效治疗的措施 ,并能恢复正常发音功能 ;②对于声带活动稍有减弱的声带肿瘤 ,其减弱原因可能与肿瘤重力压迫有关 ,不应放弃粘膜剥脱的微创性治疗 ;③手术后患者的密切随访是至关重要的