喉良性增生性病变的嗓音学特点及治疗转归

目的 :探讨喉良性增生性病变对发声功能的影响及CO2 激光显微外科术后的转归特点。方法 :对2 92例喉良性增生性病变患者 (声带息肉、任克水肿、声带小结、囊肿、慢性肥厚性喉炎 )的流行病学、嗓音声学、形态及CO2 激光显微外科术后转归进行分析。结果 :声带小结患者均为青年女性 ,2 3.0 8%与职业有关 ;任克水肿为中老年患者。声带息肉及小结病变局限 ,手术仅涉及声带局部 ,术后改善明显 ,术后 1个月达正常状态 ;任克水肿患者术后 1个月改善明显 ,术后 3个月恢复最佳稳定 ;声带囊肿患者术后 1个月声音达最佳状态 ,但由于病变切除术后局部存在缺损 ,一定程度上影响预后 ;慢性肥厚性喉炎患者术后改善不满意。术后声门上代偿纠正均不明显。结论 :喉良性增生性病变主要累及声带被覆层 ,嗓音声障碍的程度及疗效与受累范围有关 ,激光显微外科手术可以保留良好结构及功能。除外科治疗外 ,还应及时矫正不良发声习惯等因素 ,以期获得最佳疗效。     

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     

嗓音显微手术治疗早期声门癌的远期疗效观察

目的观察应用嗓音显微手术治疗早期声门癌的远期疗效.方法1989-1997年采用嗓音显微外科技术对44例声带早期癌（T1a）进行了手术治疗.声带早期癌按病变的侵袭深度分为：原位癌（5例）、低侵袭癌（33例）和侵袭癌（6例）.原位癌和低侵袭癌采用微瓣切除技术;对侵袭癌则采取激光切除声带,切缘经过微波或激光处理的方法.每例患者均进行术前、术中和术后录像,术后常规病理送检,并进行长期随访.随访最长时间为11年,最短时间5年.结果应用微瓣切除方法的38例原位癌和低侵袭癌中有6例在手术后随访的2～3年内发现局部复发,局部复发率为15.8%.6例复发患者再次行微瓣切除,其中1例在10年内经历3次微瓣切除手术.1例失随访后1年再次因肿瘤复发就诊,后改喉全切除手术.微瓣切除术病例失访4例,其余随访5年以上均存活,5年生存率为89.5%（失访以死亡计）.应用声带切除术的6例早期侵袭癌中2例于术后2个月发现肿瘤复发而行喉切除术,1例失随访后3年复发改喉全切除术,1例梭型细胞癌术后采用局部放射治疗.声带切除术局部复发率为4/6;3例在3年内死亡,1例3年后失访,2例存活5年以上.结论对病变局限的早期癌,嗓音显微手术不仅能有效地治愈疾病,同时能保护和维持正常的发声功能.对于病变局限在黏膜表面的声带早期癌,嗓音显微手术的微瓣技术不仅是有效的微创治疗措施,同时微瓣切除的病变标本经连续切片的病理诊断也成为了早期声带癌诊断及鉴别诊断的“金标准”.     

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     

内侧微瓣技术治疗声带良性病变手术前后嗓音主客观分析

目的探讨经支撑喉镜显微镜下内侧微瓣技术治疗声带良性病变的手术疗效及嗓音主客观分析在评价其疗效中的作用。方法对34例声带息肉、6例声带囊肿共40例患者行显微嗓音手术内侧微瓣技术切除病变,手术前后分别行动态喉镜检查、嗓音声学检测及嗓音障碍指数量表评估。以20例(男、女各10例)嗓音正常成年人作对照组。结果全组病例术后第4周行动态喉镜检查示声带黏膜光滑,活动好,开闭佳,手术前后各嗓音声学参数及嗓音障碍指数量表评分变化均有统计学意义(P<0.05),声学参数与嗓音障碍指数评分之间无明显相关性。结论内侧微瓣技术治疗局限声带内侧的良性病变具有安全、切除病变精确彻底、创伤小等优点,疗效满意,符合微创和功能外科的发展趋势;嗓音声学检测、动态喉镜检查及患者自我评估三者相结合可对手术疗效起到综合评估作用。     

Exudative laryngeal diseases of Reinke's space: a clinicohistopathological framing

OBJECTIVE: To establish the relationship between the macroscopic and histologic diagnosis of nodules, polyps, and Reinke's edema of the true vocal folds and to propose a clearer clinical definition of them in the hope of settling the difference of opinion between otolaryngologists and pathologists. DESIGN: Retrospective study SETTING: Otolaryngology Department of "La Sapienza" University of Rome. METHODS: The pathologic reports of 203 patients subjected to direct laryngoscopy were studied. MAIN OUTCOME MEASURES: Examination of the histologic specimen of the epithelium and the chorion. RESULTS: Microscopic examination revealed a high percentage of normal epithelium both for nodules (33.79%) and polyps (40.65%). No dysplasia was observed, whereas dysplasia was present in 10 cases of Reinke's edema (7 laryngeal intraepithelial neoplasia 1 and 3 laryngeal intraepithelial neoplasia II). Five different stages of histologic progression resulted from the examination of the chorion in both nodules and polyps. CONCLUSIONS: Our suggestion is to consider polyps as "older" lesions and nodules as "younger" lesions. A polyp may be defined as an abnormal unilateral growth of vocal folds, a nodule as a bilateral growth situated between the anterior and medium third of the vocal fold, and Reinke's edema as a bilateral wound that extends to the whole of the true vocal fold.     

CO2激光喉显微外科技术治疗喉良恶性病变

目的回顾分析应用CO2激光喉显微外科技术治疗喉部良恶性病变的效果。方法自1999年1月1日至2003年6月30日，应用CO2激光喉显微外科技术治疗喉部良恶性病变313例，其中采用切割或汽化方法切除声带息肉236例，声带小结30例；采用声带黏膜剥脱术切除声带白斑、声带角化症、声带不典型增生27例；应用声带黏膜剥脱术或声带切除术切除声门型喉癌(T1aN0M0％)20例。结果所有患者均一次切除病变，术中出血少或不出血，术野清楚。术后无一例出现呼吸困难、出血等严重并发症。声带息肉和声带小结患者的有效率达100％；声带白斑、角化症、不典型增生患者的有效率为92．6％；声门型喉癌患者半年复发率10％。结论应用CO2激光进行喉显微外科手术术中出血少、术野清楚，有效率高，拓展了手术的适应证和范围，值得推广应用。     

声带息肉和Reinke水肿细胞外基质蛋白mRNA表达

目的探讨声带息肉和Reinke水肿中，声带固有层细胞外基质主要成分mRNA表达的变化，为阐明疾病发病机制提供依据。方法应用逆转录-聚合酶链反应检测手术切除标本（声带息肉12例，Reinke水肿2例，5例行全喉切除而声带未受肿瘤侵犯的声带作为正常对照），细胞外基质中与胶原纤维、弹性纤维和透明质酸有关的9种蛋白的mRNA表达。结果声带息肉与对照声带比较，胶原酶mRNA表达下降，纤连蛋白mRNA表达升高，而纤调蛋白mRNA表达下降，差异均有统计学意义（P值均〈0．05）；赖氨酰氧化酶、透明质酸合成酶在病变和对照组织mRNA表达量差异无统计学意义（P值均〉0．05）；前弹性蛋白原、透明质酸酶、弹性蛋白酶在病变组织mRNA阳性表达率低于对照组织；前胶原Ⅰ在所有组织中均无表达。声带Reinke水肿组纤连蛋白表达量接近息肉组，纤调蛋白表达量接近对照组，因样本量小未做统计学分析。结论纤连蛋白和纤调蛋白是参与声带息肉病理过程的两种细胞外基质成分。反复用声造成损伤以及声带对损伤的修复过程可能在声带息肉发病机制起重要作用。     

声带癌前病变及癌变动态喉镜追踪观察

目的 探讨动态喉镜下声带癌前病变的表现及其在癌变追踪中的观察价值。方法 用动态喉镜检测声带癌前病变５２例,观察静态图像及振幅的改变,并追踪观察癌变１～５．５年。结果 声带癌前病变５２例中粘膜波消失或减弱占８６．３％（４５／５２）,振三弱占９．６％（４／５２）,发现癌变（声门癌）Ｔ１１４例,粘膜波消失１００％,振消失或减弱１００％。结论 动态喉镜可用于声带癌前病变与早期声门癌的临别诊断,并作为癌变追     

Vocal outcomes following subepithelial infiltration technique in microflap surgery: a review of 30 cases

Understanding of the anatomy and physiology of the vocal folds, availability of better diagnostic tools and precise instruments has spurred the development of newer techniques for the management of benign lesions arising in the vocal folds. As the propensity of the superficial lamina propria to regenerate is minimal, it is of paramount importance to maximally preserve it. Microflap surgery of the vocal folds is based on this principle. There exists a dichotomy in opinion regarding the role of subepithelial infiltration in microflap surgery; the disadvantages cited being possible confusion of the surgical plane following infiltration and hydrodissection of the normal basement membrane from the superficial layer of the lamina propria. A prospective study was therefore carried out in 30 cases of benign glottic lesions and microflap surgery was performed with and without infiltration in similar pathologic lesions. The vocal outcomes i.e. fundamental frequency, jitter, shimmer and maximum phonation time were audited. The advantages of this technique with a review of the literature are discussed.     

声带癌前病变及癌变动态喉镜追踪观察

目的　探讨动态喉镜下声带癌前病变的表现及其在癌变追踪中的观察价值。方法　用动态喉镜检测声带癌前病变 5 2例 ,观察静态图像及动态图像中粘膜波及振幅的改变 ,并追踪观察癌变 1～ 5 5年。结果　声带癌前病变 5 2例中粘膜波消失或减弱占 86 3% (45 / 5 2 ) ,振幅减弱占 9 6 %(4/ 5 2 )。发现癌变 (声门癌 )T114例 ,粘膜波消失 10 0 %、振幅消失或减弱 10 0 %。结论　动态喉镜可用于声带癌前病变与早期声门癌的鉴别诊断 ,并作为癌变追踪观察的一种简便监测手段。     

Medial Microflap for Excision of Benign Vocal Fold Lesions

The goal of microlaryngeal surgery is to treat the pathology while preserving or improving vocal function. The medial microflap technique was thus developed. An incision is made over or abutting the lesion, which is then dissected from the vocal ligament and overlying mucosa. Seventeen patients underwent medial microflap excision of their lesions. Postoperative videostroboscopic examinations revealed the presence of mucosal wave and improved glottic closure in 15 of the 17 patients. Acoustic and perceptual analyses revealed improved voice quality. The medial technique is a modification of the previously described lateral microflap technique. Patients whose stroboscopic examination implies lack of involvement of the vocal ligament are candidates for this technique. By identifying normal histologic planes without extensive dissection, lesions can be excised with minimal interruption of vibratory mechanics.     

Voice function following CO2 laser microsurgery for precancerous and early-stage glottic carcinoma

CONCLUSIONS: With the cover layer injured, vocal function of mucosal ablation could be protected and even return to normal after surgery and vocal function of mucosal stripping was slightly affected with extensive mucosal injury. Once the body layer was injured, the compensatory mechanism would play an important role in phonation. OBJECTIVES: To investigate voice function following CO2 laser microsurgery for precancerous and early-stage glottic carcinoma. PATIENTS AND METHODS: Vocal function was examined by acoustic analysis, aerodynamic analysis and videostroboscopic examination. RESULTS: For mucosal ablation, vocal quality recovered 1 month after surgery. For mucosal stripping, although vocal quality was steady 3 months after surgery, slight hoarseness persisted in this group. The contour of the treated fold recovered postoperatively. There were no complications in recovery. For cordectomies, vocal quality became steady 6 months after the surgery. The supraglottal hyperfunction with supraglottal structure squeezing played an important role in phonation. The affected vocal fold mucosal wave was absent instead of a regular ventricular fold wave or mucosal wave of the vocal process during phonation. In comparison with the type III-IV cordectomy, the results of extended cordectomies (type Va and Vc) were worse; however, the difference was not statistically significant. Granulomas and anterior commissure webs were present. All granulomas resolved spontaneously 3 months postoperatively.     

声带Reinke′s水肿的微创外科治疗

目的 :介绍微创外科治疗 Reinke′s水肿的经验。方法 :全麻显微支撑喉镜下 ,行双侧声带微创剥脱术 38例。结果 :经随诊 3个月～ 1年 ,2 7例获满意发音效果 ,只有 6例发音低沉。结论 :保留一侧声带前 1/ 2粘膜的双侧声带微创剥脱术 ,未发生声带粘连 ,值得提倡。     

Videostrobokymographic analysis of benign vocal fold lesions

OBJECTIVES: Videostrobokymography (VSK) has recently been introduced. The aim of this study was to analyze vibratory patterns and objective parameters in various benign vocal fold lesions using VSK and to examine the efficacy of VSK in clinical applications. MATERIAL AND METHODS: Using VSK, we analyzed the vibration patterns of normal vocal folds, various benign lesions such as nodules, polyps, cysts and Reinke's edema and cases of unilateral vocal fold paralysis. We also calculated the objective parameters open quotient and asymmetric index and compared them with their mean values in normal controls. RESULTS: In nodules, polyps and cysts, the open quotient at the site of the lesion was similar to the mean value in the normal controls; however, on the other parts of the vocal folds, it was much larger than the normal mean value. In Reinke's edema, irregular and asymmetric vibrations were observed. The posterior area of the vocal folds showed larger open quotients than the anterior area. In unilateral vocal fold paralysis, irregular vocal fold vibration and incomplete closure of the vocal folds were documented. Much larger asymmetric indices were calculated for unilateral vocal fold paralysis than in normal controls or for other lesions. The asymmetric index may be a good quantitative parameter of vibration in patients with vocal fold paralysis. CONCLUSION: This study demonstrated that VSK could generate clear quantitative documentation of fine vibrations of vocal folds in many different types of benign lesion. VSK has the potential to be an effective tool for the quantitative analysis of vibratory patterns of vocal folds in clinical settings.     

Multidimensional Assessment of Voice Characteristics After Radiotherapy for Early Glottic Cancer

Objectives/Hypothesis: To assess voice characteristics of patients following radiotherapy for early glottic cancer through a multidimensional analysis protocol including vocal function and voice quality measures. Methods: Voice analyses were performed for 60 patients treated with radiotherapy (66 Gy/33 fractions, 60 Gy/30 fractions, or 60 Gy/25 fractions) for early T1 glottic cancer and 20 matched control speakers. There was a longitudinal group of 10 patients for whom data were collected before as well as 6 months and 2 years after radiation. Furthermore, data were collected for five separate groups of 10 patients each, before, 6 months after, 2 years after, 3 to 7 years after, and 7 to 10 years after radiation. Vocal function was investigated by means of videolaryngostroboscopy, phonetography, maximum phonation time, and phonation quotient measures. Voice quality was assessed by means of objective acoustical analysis and subjective perceptual ratings by trained raters. Results: Voice characteristics of patients were decreased before radiotherapy, improved after treatment, and became comparable to the voice characteristics of control speakers in at least 55% of the patients. Following radiotherapy, deviant voice quality was mainly negatively affected by increased age and stripping the vocal cord for initial diagnosis. Stroboscopy revealed that next to increasing age and stripping the vocal cord, continued smoking after treatment decreased vocal function following radio-therapy. Conclusion: Voices of patients diagnosed with early glottic cancer improved but did not normalize fully after radiotherapy. Stripping the vocal cord for initial diagnosis and continued smoking after treatment decreased voice characteristics. A multidimensional analysis protocol including perceptual and acoustical analysis of voice quality and stroboscopic analysis of vocal function is recommended to investigate voice characteristics following treatment for early glottic cancer.     

Regression of laryngeal dysplasia after serial microflap excision

There is no consensus on the ideal management of premalignant lesions of the larynx. Published reports describe the use of mucosal stripping, microsurgical techniques, CO2 laser excision and ablation, and even conservation laryngeal surgery and radiotherapy. We performed a retrospective evaluation of 43 men and 11 women who underwent serial excision of dysplastic lesions with the microflap technique between 1990 and 2001. The average age of the patients was 57.2 years; 64% had a history of cigarette smoking, and 46% a history of alcohol consumption. The lesions were located on the middle part of the left vocal fold in 65% and on the mid-portion of the right vocal fold in 66%. The patients were followed for an average of 4.4 years. Of the 20 patients with severe dysplasia or carcinoma in situ treated with the microflap technique, only 1 progressed to invasive disease. Overall, there was a reduction in the severity of dysplasia after each procedure (p = .0008). The microflap technique reliably reduced the severity of dysplastic lesions of the vocal fold and was effective in local disease control.     

Photocoagulation of microvascular and hemorrhagic lesions of the vocal fold with the KTP laser

OBJECTIVES: Ectasias and varices of the vocal fold are microvascular lesions that are often due to chronic abuse of the voice, and are occasionally encountered in association with other disorders such as polyps, Reinke's edema, and hematoma. The KTP laser can be used for photocoagulation of small vascular lesions, because the laser beam is well absorbed by hemoglobin, and damage to the epithelium is minimal. The present pilot study examined how the KTP laser could be used for microvascular lesions and their associated lesions. METHODS: Twelve patients who had undergone phonomicrosurgery were enrolled in the present study. The microvascular lesions were treated by photocoagulation with the laser set at a low power of 1.5 W in the continuous mode, while preserving the epithelium, and associated lesions were then treated by microdissection with cold instruments. The postoperative phonatory function was assessed by maximum phonation time, a perceptual test rating (GRBAS scale), and stroboscopy. RESULTS: The procedures were completed successfully in all cases. An exceptional case of a small hemorrhagic polyp allowed treatment with the laser only. The postoperative stroboscopic findings, maximum phonation time, and perceptual test rating all showed significant improvement compared with the preoperative state. No adverse effects, such as scarring or reduction of the mucosal wave, were observed in the current series. CONCLUSIONS: KTP laser photocoagulation is a relatively simple and safe procedure for treating microvascular lesions of the vocal fold. It is not recommended for photocoagulation of hemorrhagic polyps or hematomas, because such lesions have little blood flow inside and thus photocoagulation is usually impossible or requires too much laser energy. However, photocoagulation of perimeter or feeding vessels of such disorders may facilitate the following procedure by avoiding unnecessary bleeding, as well as preventing recurrence of hemorrhagic lesions.     

成人声带良性病变发病危险因素的病例对照调查

目的 探讨与成人声带良性病变发病相关的危险因素.方法 采用病例对照研究设计,对168例声带良性病变(包括声带小结、声带息肉、Reinke水肿、慢性喉炎)患者及153例喉部正常者进行问卷调查.Logistic回归分析方法 进行统计学分析.结果 多因素分析显示职业、工作或居住环境噪声、饮酒、每日用声时间和嗓音滥用5个因素是声带良性病变的危险因素.用声强度大的职业发病的危险性大,以用声强度小的Ⅰ类职业为参照,用声强度中等的Ⅱ类职业的发病危险为其1.934倍(OR=1.934),教师等用声强度大的Ⅲ类职业的发病危险为其2.633倍(OR=2.633).每日用声时间每增加1 h,发病的危险增加1.302倍(OR=1.302).习惯喊叫等有嗓音滥用行为的OR值为4.744,工作或生活在噪声环境中OR值为2.115,饮酒的OR值为2.177,均会大大增加发病的危险.结论 为预防功能不良性声带病变,应戒酒,降低环境噪声,养成良好的用声习惯,避免嗓音滥用,减少用声时间等.在用声强度大的高危人群应加强防护.     

支撑喉镜下喉硅胶膜置入及声带缝合手术治疗喉蹼

目的探讨喉硅胶膜置入及声带黏膜缝合术在治疗喉蹼中的价值及预后转归。方法21例喉蹼患者，4例儿童，17例成人；其中既往有双侧声带手术史（声带任克水肿、声带小结、声带息肉、声带角化）8例，喉乳头状瘤手术史6例，喉部外伤史6例，先天性喉蹼1例。患者在全麻支撑喉镜下行喉蹼瘢痕松解后，15例成人行声带黏膜缝合及喉硅胶膜置入术；4例儿童及2例成人行单纯声带黏膜缝合术。结果15例喉硅胶膜置入患者3—4周后取出支撑的硅胶膜，除1例既往曾有喉裂开史，治疗后前联合处仍残留2—3mm粘连带外，其余14例患者声带前联合均获得良好三角形形态，发音明显改善，无呼吸困难。6例行单纯声带黏膜缝合患者呼吸及发音得到明显改善，2例成年患者前联合处残存2～3mm正常黏膜，术后声带即获得很好成形效果；4例患儿术后前联合残留2—3mm粘连。全部患者随诊6个月-3年，无瘢痕再生。结论喉硅胶膜置入及声带缝合手术治疗喉蹼，利于患者呼吸及发音功能的改善，避免颈外入路手术或气管切开及长期声门支撑，创伤小，并发症少。而声带黏膜单纯缝合手术还可以单独应用于粘连带相对较薄（小于5mm）、黏膜相对丰富的儿童及前联合残存正常黏膜的喉蹼患者。