Powered instrumentation in laryngeal surgery

The endoscopic shaver system employs a motorized handpiece and specially tailored blades that allow access to glottic, subglottic, and tracheal sites. The system and setup is identical to that used in endoscopic sinus surgery except for the blade attachments. This similarity confers a degree of familiarity to the surgeon as well as the operating room staff. The system can be utilized for resection or biopsy of lesions of the upper aero-digestive tract. Endoscopic shaver resection of laryngeal tumors is a safer and more rapid alternative to conventional laser resections. Many of the risks associated with laser resections including inadvertent burn injury and airway fires are avoided. Benign tumors of the larynx, subglottis, and trachea requiring conservative management are especially amenable to this form of therapy. This technique is well suited for resection of papillomas as well as other lesions of the airway. A drawback of this technique is the inadequate assessment of surgical margins that limits its utility in the management of malignancies.     

Use of the KTP-532 Laser in Acoustic Neuroma Surgery

The potassium titanyl phosphate (KTP-532) laser has been applied to otologic surgery with a proven record of both safety and efficacy. The aim of this study was to demonstrate the use, safety, and advantages of laser dissection in the surgical treatment of acoustic neuromas. The authors' experience with 111 patients in whom laser surgery was used in acoustic neuroma is presented, with emphasis on surgical technique employed and facial nerve functional outcome. The method of laser dissection did not result in deleterious neurologic sequelae or laser-specific complications. In addition, laser dissection afforded certain advantages to traditional techniques, especially in larger tumors. The facial nerve functional outcome as assessed by the House-Brackmann grading system revealed that 90.2% of small tumors, 72.2% of medium tumors, and 75.0% of large tumors achieved satisfactory (grades I and II) functional results. These results compare favorably with the literature describing nonlaser dissection techniques. The observations and results reported in this article demonstrate the safety of the KTP-532 laser in the posterior cranial fossa, and specific advantages that this technology may offer to the surgical armamentarium of the neuro-otologist are outlined.     

Laser excision of multiple esophageal lymphangiomas: a case report and review of the literature

Lymphangiomas of the gastrointestinal tract are rare and benign submucosal tumors. We present the first case of multiple lymphangiomas in the cervical esophagus and only the 15th case of an esophageal lymphangioma. A 63-year-old male presented to our clinic with two years of dysphagia and an esophageal mass noted on MRI. A barium swallow confirmed a polypoid mass of the upper esophagus with operative findings of two smooth pedunculated lymphangiomas occupying the entire lumen of the esophagus.

Previous reports have documented successful surgical intervention through open or endoscopic techniques, whereas the favorable location of the tumors in this case allowed for the first successful excision utilizing a CO₂ laser. We demonstrate here that esophageal laser surgery can provide an accurate, complete, and minimally invasive excision technique for lymphangiomas of the upper digestive tract with minimal morbidity for the patient. A complete review of all published cases is presented, with a focus on the clinical presentation and surgical treatment of this disease.     

Skull base surgery for removal of temporal bone tumors

CONCLUSION: When selecting the appropriate surgical approach the pathological type of tumor, the physiological status as well as the functional aspects should be considered. Understanding the strengths and weaknesses of each surgical technique and knowledge of the particular tumor biology facilitates selection of the most appropriate surgical approach and a successful outcome. OBJECTIVES: The purpose of this study was to review cases that underwent skull base surgery for a variety of tumors that involved the temporal bone. We reviewed a single center's 25-year experience for epidemiologic characteristics, symptoms, treatment type and outcomes. PATIENTS AND METHODS: The medical records and radiological images of 91 patients, who underwent skull base surgery, were retrospectively reviewed. RESULTS: Among the 91 patients, 61 cases had benign disease and 30 had malignancies. A facial nerve schwannoma was the most common benign intratemporal tumor and a squamous cell carcinoma was the most common malignant tumor. With the facial nerve schwannoma, facial nerve paralysis and hearing loss were the most common presenting complaints; otalgia was the most common presenting symptom for temporal bone cancer. For patients with a glomus tumor, there was a characteristic pulsating tinnitus. A majority of the facial nerve schwannomas were resectable through the transmastoid approach. The infratemporal fossa approach type A was usually required for lower cranial nerve schwannomas and glomus jugulare tumors. However, the fallopian bridge technique with hypotympanectomy was another surgical option. Partial temporal bone resection and subtotal temporal bone resections were performed in cases with temporal bone cancer. The disease free 5-year survival of the temporal bone cancers was 42% and for the squamous cell carcinomas, it was 44%.     

Combined subcranial approaches for excision of complex anterior skull base tumors

OBJECTIVE: To present our method for excision of complex anterior skull base tumors via combinations of the subcranial approach. PATIENTS: Of 120 anterior skull base tumor resections, 41 that included 27 (66%) malignant and 14 (34%) benign lesions were performed via combinations of the subcranial approach. Unilateral or bilateral medial maxillectomy was performed using the subcranial approach alone for 13 tumors infiltrating the anterior skull base, ethmoid bones, and medial maxillary wall. A combined subcranial-transfacial approach in 2 lesions or a combined subcranial-midfacial degloving approach in 14 lesions was performed for tumors involving the skull base and the lower or lateral segments of the maxilla. A combined subcranial-transorbital or transfacial-transorbital approach was used for 5 tumors invading the orbit. An extended subcranial-orbitozygomatic approach was used for 6 tumors invading the middle cranial fossa or involving the cavernous sinus. A combined subcranial-Le Fort I down-fracture approach was used for 1 dedifferentiated chordoma invading the anterior skull base and lower clivus. The surgical results, patient quality of life, survival, and complications were measured. RESULTS: Thirty-seven of 41 tumors (90%) were completely resected. Fifteen patients (35.5%) had perioperative complications. There were no postoperative deaths. Two-year overall and disease-free survival in patients with malignant tumors who underwent combined approaches was 66% and 60%, respectively. There was no significant difference in the quality of life between patients operated on via combined or classic subcranial approaches. CONCLUSION: Combinations and modifications of the subcranial approach for excision of complex anterior skull base tumors yield surgical results, survival, quality of life, and complications similar to those found with the classic subcranial technique.     

Functional results succeeding primary combined external radiotherapy and brachytherapy for head and neck tumors

BACKGROUND: Histologically proven radical resections often lead to severe functional problems especially in upper aero-digestive-tract tumors. Oncologically the combination of external radiotherapy and brachytherapy offers an alternative treatment option. The functional results and the complication rate in stage III and IV tumors of the oral tongue, floor of mouth and oropharynx are described in a patients series. METHOD: The follow-up includes 17 consecutive patients who were primarily treated by a combination of external radiotherapy and brachytherapy between 1997 and 2000. The oncological benefit (complete remission, disease-free survival), the functional results (mastication, swallowing, speech and pain) and the complications were reviewed. RESULTS: After the follow-up period 16/17 patients were alive. There were 3 major complications, one of them lethal. The functional results resembled those after surgical resections. CONCLUSIONS: A combined radiotherapy is a feasible method of treating patients who refrain from surgery. Moreover the application ranges from inoperability to postoperative radiotherapy in cases with close or positive margins. In connection with neck-dissections and therapy of recurrent cancer major complications may occur. In contrast to the general opinion radiation therapy was not superior to surgical resection concerning functional sequelae.     

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.     

Laryngotracheal reconstruction using prefabricated and preconditioned composite radial forearm free flaps. A report of two cases

OBJECTIVE: Total or subtotal laryngectomy performed as surgical treatment of locally advanced laryngeal tumors requires a permanent laryngostomy or tracheostomy, and are both associated with severe and lifelong disability. The hitherto published reconstructive methods for the rehabilitation of patients after subtotal anterior laryngotracheal resection of extended laryngotracheal malignancies have not been thoroughly convincing. METHODS: We present a successful method of extended laryngotracheal reconstruction that combines modern surgical and biomedical techniques. RESULTS: A stable three-dimensional anterior neolarynx was prefabricated, including the use of vacuum-assisted prelamination and preconditioning of a composite radial forearm free flap, which was then transferred to the neck and vascularized by microvascular anastomosis to the cervical vessels. This reconstructive procedure permitted the restoration of a stable laryngotracheal conduit in two cases, with the subsequent successful closure of the tracheo-laryngostomy. CONCLUSION: In the reported cases the pre- or post-operative irradiation did not compromise the success of reconstruction. Not only did our technique facilitate the rehabilitation of patients suffering from drawbacks of the laryngo-tracheofissure, but it also assisted in avoiding total laryngectomy in cases of advanced anterior laryngeal cancer by extending the indications for subtotal anterior laryngeal resections followed by reconstructive surgery.     

Endoscopic resections of glottic and supraglottic carcinomas with the C02 laser

Clinical experiences with transoral CO₂ laser resections of glottic and supraglottic carcinomas are presented. 47 patients with variously sized supraglottic tumors and 114 patients with early glottic cancers were treated at the University of Kiel from 1979 to 1993. Although 10 patients with glottic tumors developed recurrences, curative treatment was possible with either repeat laser surgery (3 cases), irradiation (3 cases) or salvage laryngectomy (3 cases). One patient refused further treatment. Among the 30 patients with supraglottic lesions treated for cure 18 are currently alive and free of disease. 6 patients died with no evidence of disease, 2 patients died from secondary malignancies and 3 patients succumbed to their tumors. Present findings justify routine use of laser resections of laryngeal neoplasms, although patients must still be carefully selected for treatment.Presented at the combined meeting of the Society of Head and Neck Surgeons and the European Organization for Research and Treatment of Cancer, Paris, France, 25–28 May 1994     

Transoral CO2 laser for surgical management of glottic carcinoma in situ

OBJECTIVES/HYPOTHESIS: In carcinoma in situ (CIS) tumors malignant cells have not penetrated the basement membrane and therefore have no metastatic potential. Treatment strategies of CIS are topics of ongoing discussion. The aim of this study was to evaluate long-term results of CO2 laser therapy in laryngeal CIS. METHODS: From 1986 to 1995, 29 patients with glottic CIS with a minimum follow-up of 2 years were treated initially with transoral CO2 laser surgery and were included is this series. RESULTS: A complete removal of the tumor was possible with superficial laser cordectomy in 21 patients and with subligamental laser cordectomy in 8 cases. There was no tumor-related death in this series. Repeated laser resections were performed in four patients for local recurrences. No patient required total laryngectomy or radiotherapy during a follow-up ranging from 25 to 143 months. CONCLUSIONS: Local control rates presented in this study are superior to those previously reported with conventional surgery and similar to those after radiotherapy. The ultimate rate of larynx preservation was seven times higher than reported after radiotherapy. Our results add further support to the observation that laser surgery is the best treatment option for CIS of the larynx. Based on the material of this study, recommended treatment for CIS is CO2 laser resection in combination with a meticulous follow-up for early recognition of local recurrence.     

Indikationen zur prim?ren operativen Therapie von Gef??anomalien im S?uglingsalter

LASER THERAPY: Since the introduction of laser therapy for treatment of hemangiomas and vascular malformations, primary surgical therapy has gradually lost importance. Particularly hemangiomas, but also venous malformations and lymphangiomas, are nowadays primarily treated by different types of lasers. Especially the Nd:YAG laser with a percutaneous or transcutaneous application technique often leads to satisfying results. SURGICAL THERAPY: Surgical therapy is mostly used secondarily in late childhood or in adults after several laser applications for excision of residual scars or other corrective procedures. Despite these improvements in laser therapy, there is still an indication for primary surgical treatment in subcutaneous vascular malformations and in rapidly growing hemangiomas after unsuccessful laser therapy. Even in large vascular anomalies, safe excision with only a little blood loss is possible if the tumors are encapsulated. CASE REPORTS: In this paper we want to point out the necessity of primary surgery in three children in whom complications such as loss of sight, facial nerve palsy, and a lethal outcome due to massive hemorrhage in a cystic lymphangioma could be avoided.     

Carotid body tumors

The surgical management of carotid body tumors requires identification and preservation of neural and vascular structures without compromising resection of the neoplasm. Fifteen patients were examined and treated for carotid body tumors at the Cleveland (Ohio) Clinic Foundation from 1979 through 1987. The benchmark of diagnosis is bilateral carotid angiography. When neural structures are free of tumor, meticulous dissection facilitates their preservation. Large tumor size increases risk for arterial resection necessitating reconstruction. The use of a vascular shunt minimizes the risk of cerebral ischemia. Postoperative intravenous digital subtraction angiography allows for evaluation of arterial repair. A retrospective review of 15 carotid body tumor resections performed in 14 patients revealed no evidence of tumor recurrence, no mortality associated with surgical intervention, no postoperative cerebrovascular accident, and limited morbidity associated with unavoidable sacrifice of neural elements.     

Treatment of recurrent carcinoma at the base of the skull with carbon dioxide laser

The extension of carcinoma to the cribriform plate is a poor prognostic finding. Two extremes of treatment approach have been advocated. On the one hand, patients may be abandoned to palliative chemotherapy. On the other hand, heroic and aggressive resections may be advocated including combined neurosurgical transdural and otolaryngologic facial-orbital resection. Armed with the surgical microscope and the CO2 laser there may be a place for a middle ground of therapy. We present our experience with recurrent tumor after full course radiation therapy and maxilloethmoidectomy. The biopsy proven recurrences were found at the cribriform plate but could not be shown to have crossed into the anterior cranial fossa by polytomography or high resolution CT scanning. The CO2 surgical laser delivered through the surgical microscope was used with repeated applications. Recurrent epidermoid carcinoma found to be confined to the nasal side of the cribriform plate can be controlled by careful microscopic stripping of soft tissue from the cribriform plate with a surgical laser.     

Prognostic implications of perineural spread in squamous carcinomas of the head and neck

The occurrence and prognostic implications of perineural spread were examined in 239 patients with mucosal squamous carcinomas of the head and neck. Perineural spread was demonstrated in resections from 64 patients (27%), the majority having primary tumors at one of three sites: buccal cavity, larynx, and pharynx. Perineural spread near nodal metastases was uncommon. There was no evidence that perineural involvement was more commonly associated with large tumors or less differentiated ones. No association was established between perineural spread and coexistent lymph node deposits in the surgical resections. Perineural spread was, however, shown to be a statistically significant prognostic factor for an increased incidence of subsequent locoregional recurrence and for decreased survival.     

Endoscopic endonasal transsphenoidal resection of pituitary adenomas: preliminary evaluation of consecutive cases,

IntroductionEndoscopic endonasal transsphenoidal surgery has gained increasing acceptance by otolaryngologists and neurosurgeons. In many centers throughout the world, this technique is now routinely used for the same indications as conventional microsurgical technique for pituitary tumors.ObjectiveTo present a surgical experience of consecutive endoscopic endonasal trans-sphenoidal resections of pituitary adenomas.MethodsIn this study, consecutive patients with pituitary adenomas submitted to endoscopic endonasal pituitary surgery were evaluated regarding the rate of residual tumor, functional remission, symptoms relief, complications, and tumor size.ResultsForty-seven consecutive patients were evaluated; 17 had functioning adenomas, seven had GH producing tumors, five had Cushing’s disease, and five had prolactinomas. Of the functioning adenomas, 12 were macroadenomas and five were microadenomas; 30 cases were non-functioning macroadenomas. Of the patients with functioning adenomas, 87% improved. 85% of the patients with visual deficits related to optic nerve compression progressed over time. Most of the patients with complaints of headaches improved (76%). Surgical complications occurred in 10% of patients, which included with two carotid lesions, two cerebrospinal fluid leaks, and one death of a patient with a previous history of complications.ConclusionEndoscopic endonasal pituitary surgery is a feasible technique, yielding good surgical and functional outcomes, and low morbidity© 2014 Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial. Published by Elsevier Editora Ltda. All rights reserved.     

Functional organ preservation in laryngeal and hypopharyngeal cancer

The principles of open vs. laser microsurgical approaches for partial resections of the larynx are described, oncological as well as functional results discussed and corresponding outcomes following primary radiotherapy are opposed. Over the last decade, the endoscopic partial resection of the larynx has developed to an accepted approach in the treatment of early glottic and supraglottic carcinomas thus leading to a remarkable decline in the use of open surgery. Comparing the various surgical approaches of laryngeal partial resections, the oncological outcome of the patients, as far as survival and organ preservation are concerned, are comparable, whereas functional results of the endoscopic procedures are superior with less morbidity. The surgical procedures put together, are all superior to radiotherapy concerning organ preservation. Transoral laser microsurgery has been used successfully for vocal cord carcinomas with impaired mobility or fixation of the vocal cord, supraglottic carcinomas with infiltration of the pre- and/or paraglottic space as well as for selected hypopharyngeal carcinomas. It has been well documented that laser microsurgery achieves good oncological as well as functional results with reasonable morbidity. However, patients with those tumours have been successfully treated by open partial resections of the larynx at medical centres with appropriate expertise. The initially enthusiastic assessment of study results concerning the efficacy of various protocols of chemoradiation with the intent of organ preservation for laryngeal and hypopharyngeal carcinomas are judged more cautious, today, due to recent reports of rather high rates of late toxicity complications.     

Laserstapedotomie

In addition to hearing aids, stapesplasty represents the standard treatment of otosclerosis-induced hearing loss. In this procedure, the stapes superstructure is replaced by a prosthesis that is attached to the long process of the incus and communicates through a perforation in the footplate with the perilymphatic space of the inner ear. The removal of the stapes superstructure and perforation of the footplate are the critical steps of this surgical procedure. With the introduction of laser-assisted perforation techniques, the surgical safety of this method has been improved compared to conventional techniques. KTP, argon, as well as diode, Er:YAG and CO(2) lasers are used for stapedotomy. By using the CO(2) laser in conjunction with a scanner system, the number of laser applications required for the perforation of the footplate has been markedly reduced. In contrast to other systems, a more reproducible perforation diameter of the stapes footplate is achieved with a CO(2) laser equipped with a scanner. Complications such as uncontrolled leakage of perilymph, irradiation of inner ear structures or the occurrence of pressure waves with subsequent damage to the inner ear can be reduced by using a CO(2) laser. In this review, the surgical technique of CO(2) laser stapedotomy, including clinically established variants and paying particular attention to the one-shot technique, are described and discussed in comparison to other laser systems.     

Nonflammable endotracheal device for co2 laser ablation of benign laryngeal and proximal tracheal tumors

A Holinger aspirating tube may be utilized as a nonflammable endotracheal device during CO₂ laser ablation of benign laryngeal and proximal tracheal tumors. Adequate jet ventilation may be performed through this small diameter (3.0 mm), metallic device while providing an unobstructed view of the surgical lesion. This technique was well-accepted by surgeons during the clinical trials. Because the 3.0 mm outside diameter was significantly smaller than the smallest flexible, uncuffed metal endotracheal tube currently available (6.9 mm), the rigid structure facilitated atraumatic insertion past the surgical lesion. Both the use of this device and the required anesthetic technique are described in three CO₂ laser ablative procedures. The authors consider that this device increases safety during this potentially hazardous procedure by eliminating the flammable polyvinyl chloride endotracheal tube and cottonoid packings most frequently used during this procedure.     

Endoscopic laser arytenoidectomy for the treatment of bilateral vocal cord paralysis

Most patients with bilateral vocal cord paralysis have a fairly satisfactory voice, but their airway is usually compromised. The management of such patients presents a challenge to the otolaryngologist-head and neck surgeon. Numerous surgical procedures have been developed in an attempt to improve the patients's airway insufficiency without leaving him with a breathy, weak voice. Arytenoidectomy is currently the most reliable method of treating patients with bilateral vocal cord paralysis. Although both endoscopic and external approaches have been described for performing an arytenoidectomy, the endoscopic technique is more desirable since it requires no incision and theoretically allows for the immediate assessment of airway size. The addition of the CO2 laser to the surgical armamentarium offers certain refinements to the technique of endoscopic arytenoidectomy. Eleven patients with bilateral vocal cord paralysis of the larynx have been treated by endoscopic laser arytenoidectomy by the authors utilizing a technique developed by the two senior authors and subsequently taught to over 200 participants of the CO2 laser workshops sponsored by the Department of Otolaryngology-Head and Neck Surgery at Northwestern University Medical School; 10 of the 11 patients have been successfully decannulated. The technique and problems of this operation will be discussed.