Laryngeal preservation by treatment with induction chemotherapy and radiotherapy protocol for stage III & IV carcinoma larynx--results of a pilot study.

Total laryngectomy for advanced carcinoma of the larynx is effective but functionally disabling. In an effort at laryngeal preservation, 33 patients of stage III/IV carcinoma larynx were treated between 1987 and 1991 with induction chemotherapy followed by definitive radiation. Two chemotherapy protocols were administered. Group I patients received one to three cycles of cisplatin 100 mg/m2 (day 1), bleomycin 15 U/m2 (day 1), and 5-fluorouracil 1000 mg/m2/day (day 2 to 5) at three weekly intervals. This was then followed by radiotherapy. Group II received one to six weekly injections of single agent methotrexate 50 mg/m2 with or without leucocovorin rescue followed by radiotherapy. Any recurrence was salvaged by surgery. Midway through the study, Group II protocol was discontinued as the initial results were not comparable with Group I or standard treatment. The Group I protocol, however, yielded an initial locoregional control rate of 83.3 per cent With the addition of surgical salvage the locoregional control rate was 94.4 per cent and the control rate with laryngeal preservation was 88.8 per cent. The Kaplan-Meier probability of two years and five years disease-free survival was 81.9 per cent and 61.4 per cent respectively. For disease-free survival with laryngeal preservation the corresponding figures for two years and five years were 58.3 per cent and 41.7 per cent. The control group of 51 patients treated with radical surgery followed by radiotherapy yielded survival figures at two years and five years of 64.3 per cent and 57.2 per cent. The difference in the survival of Group I and the control group was not statistically significant (p value = 0.280). These initial results indicate that for stage III and for surgically resectable stage IV laryngeal carcinomas, a protocol of induction combination chemotherapy consisting of cisplatin, bleomycin and 5-fluorouracil followed by radiotherapy and combined with surgical salvage whenever required, can lead to comparable cure rates. In addition, a large proportion of patients are spared the morbidity of a total laryngectomy.     

喉接触性肉芽肿临床分析及治疗方法探讨

目的：探讨喉接触性肉芽肿的临床特点及治疗方法。方法：回顾性分析我科2005-01-2012—12期间13例有完整资料的喉接触性肉芽肿的发病特点、相关病因、临床表现及治疗方法,比较保守治疗及手术治疗疗效并探讨其治疗方法选择。结果：喉接触性肉芽肿好发于男性（84．6％）,其相关病因以胃食管返流病、慢性咳嗽及习惯性清嗓病史、气管插管病史多见,无明显病因亦占重要比例（38．4％）。临床表现以喉异物感、说话易疲劳、声嘶多见,无任何喉部症状占30．7％。手术治疗6例,初次复发率为66．6％,1次及2次手术后有效率为50．0％。保守治疗7例,抗胃食管返流、避免过度用嗓、减少习惯性清嗓动作以及未予药物治疗,有效率为57．1％。2组总有效率为53．8％,2组间疗效比较差异无统计学意义。结论：目前喉接触性肉芽肿治疗疗效较差,治疗方案尚无统一标准,应采取个体化治疗。首选针对病因保守治疗,对于有明显声音嘶哑或肉芽肿过大影响呼吸者可考虑手术治疗。     

喉非特异性肉芽肿治疗方法的优先选择

目的 探讨喉非特异性肉芽肿的综合治疗方式的优先选择及治疗效果。方法 确诊为喉非特异性肉芽肿的患者20例,对8例有气管插管史者,未经任何保守治疗即行支撑喉镜下手术治疗,术后吸入类固醇2周;12例无气管插管史者,给予制酸药为主,支撑喉镜下手术、吸入类固醇、语音疗法为辅的治疗。结果 所有患者治疗疗程结束后随访6个月,有气管插管史患者出现复发1例,经再次手术、术后吸入类固醇治疗后治愈;无气管插管史患者,10例仅经制酸治疗后症状完全消失,2例经同时配合予支撑喉镜下手术、吸入类固醇及语音疗法后治愈。结论 喉非特异性肉芽肿病因复杂,治疗方法多样,对于有气管插管史者,优先选择手术及术后吸入类固醇治疗可缩短治疗时间,疗效显著;对于无气管插管史者,优先选择以制酸治疗为主的综合治疗,疗效显著。     

Wegener's granulomatosis and subglottic stenosis: management of the airway

Wegener's granulomatosis is a multisystemic disease characterized by foci of necrotizing vasculitis and granuloma formation. Subglottic stenosis may occur either as a presenting feature or a late-stage manifestation of the disease, but will occur in approximately 10-20 per cent of cases. We present a series of seven cases of Wegener's granulomatosis with subglottic stenosis and discuss our management of this condition. Where there is active disease, tracheostomy is the first-line surgical treatment of respiratory obstruction, as an adjunct to full medical therapy. More aggressive or elaborate surgical treatments should be reserved for non-active cases in which patients have not required medical treatment for one year.     

成人气管插管后喉肉芽肿的临床分析

目的探讨成人气管插管后喉肉芽肿的形成原因及诊疗方法。方法回顾性研究1996年1月-2006年12月诊治的8例气管插管后喉肉芽肿成人患者，分析其气管导管口径和留置时间与发生插管后喉肉芽肿的关系，总结诊疗经验体会。结果所有患者所用气管导管均为F28-F30；导管留置2-23h，平均7．4h。全部病例均有拔管后的迟发性声嘶发生；喉肉芽肿物多位于声带突处，6例为单侧，2例双侧。均先予以保守治疗，2例经保守疗法治疗而痊愈，另6例经手术切除而治愈。肉芽肿组织病理学表现为炎性肉芽肿。经随访观察1年以上，所有病例的喉肉芽肿均完全消失而无复发。结论结合气管插管史，综合分析咽喉部症状特别是迟发性声嘶和喉镜检查所见，即可确诊。保守治疗或手术切除均可获得良好疗效。     

Laryngeal preservation in cases of advanced laryngeal cancer treated with platinum based induction chemotherapy before local treatment.

In this study we analyse our preliminary results after treating 28 patients with locally advanced laryngeal cancer with platinum based induction chemotherapy followed by radiation therapy or surgery. The median age of our patients was 60 (46-75) years and median performance status was 80 (60-100). In 18 of the 28 patients locoregional treatment was radiation therapy with an overall response of 94.4 per cent. After a median follow-up of 26 (15-40) months 39.3 per cent of the whole group of patients are alive and disease-free and six (21.4 per cent) patients are alive and disease-free preserving their larynx. We conclude that although more extensive studies with large groups of patients and longer follow-up is needed to reach definite conclusions, it seems that platinum based induction chemotherapy can be used successfully in locally advanced laryngeal cancer followed by radiotherapy. In those cases who respond well, the patient's larynx is preserved without compromizing the overall survival.     

气管插管后持续性声嘶的原因及其治疗

目的：探讨气管插管后持续性声嘶的原因及评估杓状软骨复位的治疗效果。方法：对78例病人通过检查及疗效观察,确定声嘶原因,采用杓状软骨复位术及肉芽摘除术治疗。结果：78例中,71例为杓状软骨脱位（91．03％）,5例声带麻痹（6．41％）,2例喉内肉芽形成（2．56％）,杓状软骨脱位的病人全部治愈;声带麻痹治疗无效,喉肉芽形成的病人,1例治愈,另1例发音改善,结论：杓状软骨脱位,声带麻痹及喉内肉芽形成是气管插管后持续性声嘶的主要原因;杓状软骨复位术对杓状软骨脱位所致的声嘶疗效明显。     

喉接触性肉芽肿的发病机制及治疗

喉接触性肉芽肿(laryngeal contact granuloma, LCG),也称为声带突肉芽肿或喉接触性溃疡,是由于各种原因导致的声带突周围黏膜损伤及溃疡反复发作,进一步组织增生形成的肉芽肿样病变。该疾病发病机制尚不明确,常见于持续性声带压迫、咽喉反流以及有长期清嗓史的人群。具有难治愈、易复发的特点。临床上部分患者常出现药物治疗无效、无法耐受药物治疗或反复手术后复发及后续的治疗方案难以抉择等问题。因此针对不同患者选择个体化治疗方案非常重要。本文将重点对LCG的发病机制及不同治疗手段进行综述与总结,为个体化治疗的选择提供依据。     

Fiberoptic laryngeal surgery for vocal process granuloma

We developed a technique of fiberoptic laryngeal surgery for the treatment of vocal process granulomas. In this system, the granuloma can be removed relatively easily and repeatedly under topical anesthesia on an outpatient basis. We treated 27 patients for a total of 4 intubation granulomas and 23 contact granulomas. Ten of the 23 contact granulomas recurred after the initial surgery, but the intubation granulomas did not recur. Most of the recurrent lesions were resolved by fewer than 3 procedures, and all patients were finally cured. Although conservative therapies such as voice therapy and proton pump inhibitors have recently prevailed, surgical removal remains useful in treating vocal process granulomas. Fiberoptic laryngeal surgery facilitates repeated surgical procedures.     

Treatment outcomes of primary and recurrent inverted papilloma: an analysis of 96 cases

This series was undertaken to investigate the incidence of associated polyps and the recurrence rates of inverted papillomas with, or without, malignancies, as well as the treatment outcomes of the recurred cases. A retrospective study evaluating the pathology, associated polyps, types of operation, recurrence rate after original operation, and surgical outcomes of recurred cases was conducted upon 96 patients diagnosed with inverted papilloma. The overall malignancy rate was 11.5 per cent with synchronous tumours accounting for 9.4 per cent and metachronous for 2.1 per cent. Inflammatory polyps were found in association with inverted papilloma in 21.9 per cent. In cases without malignancies, the recurrence rate after the original conservative procedure was 33.9 per cent, compared to 14.3 per cent after a medial maxillectomy. In cases with malignancies, the recurrence rate after the original surgical procedure was 22.2 per cent. Our study indicates that more aggressive and bolder surgical resection of inverted papilloma should be undertaken as a primary treatment method, or as a treatment for recurrent cases to reduce the recurrence rate of inverted papilloma with, or without, malignancy.     

Zinc sulfate therapy of vocal process granuloma

Vocal process granuloma is a benign lesion that occurs on the arytenoid cartilage. It tends to recur locally, and there is a great diversity of methods to treat it. Here, we reviewed the effects of zinc sulfate therapy program in 16 patients with vocal process granulomas. Eleven patients had a history of trauma or laryngeal intubation and five patients had unknown origin. Eleven had recurrence after one to three failed surgeries, and the others had no prior treatment. Symptoms included hoarseness, sore throat, lump sensation in the throat and cough that apparently improved. The granulomas did not recur for at least 1?year. No complications occurred. For vocal process granuloma, zinc sulfate therapy is good either as an initial or compensatory treatment.     

Erythema multiforme after application of aural Gentisone HC drops

Erythema multiforme is an uncommon acute self-limiting condition characterized by mucocutaneous lesions of varying severity with a variable pattern of recurrence. This is a case of a four-year-old girl who developed erythema multiforme secondary to topical aural application of Gentisone HC drops (hydrocortisone acetate one per cent, gentamicin 0.3 per cent (as sulphate)) prescribed as a treatment for otorrhoea following grommet insertion. The clinical features are described and the literature reviewed. To my knowledge, this is the first reported case in the literature, of erythema multiforme secondary to a topical aminoglycoside/steroid preparation.     

Botulinum toxin: helpful adjunct to early resolution of laryngeal granulomas

Treating laryngopharyngeal reflux is the most accepted treatment for laryngeal granulomas. However, response to this treatment is prolonged and in some cases persistent. The authors hypothesize that this is due to the continuous trauma to the mucoperichondrium from adduction of the vocal folds thus preventing regeneration of healthy mucosa. A prospective study was performed on six patients with laryngeal granulomas failing prolonged laryngopharyngeal reflux treatment, speech therapy, and surgical excisions. Botulinum toxin A was injected into the affected thyroarytenoid to reduce adduction trauma. Video-stroboscopy was used to assess response. A 50 per cent reduction in the size of the granulomas was noted within two weeks with a complete and permanent response within two to eight weeks in five out of six patients. One patient had an obstructing pyogenic granuloma that required excision and recurred after excision but responded to a repeated injection. The addition of a single injection of botulinum toxin A to the standard treatment expeditiously eliminated persistent and recurrent laryngeal granulomas.     

Cupular deposits and aminoglycoside administration in human temporal bones

In this study, the deposits of basophilic material on the cupula of the semicircular canals in temporal bones from patients who had aminoglycoside administration within six months prior to death were compared with normal temporal bones. Subjects were divided into two groups. Group I included 24 normal control temporal bones age-matched to group II patients. Group II consisted of 23 temporal bones that had received aminoglycosides within six months prior to death. All temporal bones were examined under light microscopy. One (4.2 per cent) of 24 temporal bones in group I (normal) showed basophilic deposits. In group II, deposits were observed in 8 (34.8 per cent) of 23 temporal bones. The prevalence of basophilic deposits in group II was significantly higher than group I. This study demonstrates that within six months after aminoglycoside administration there is an increased prevalence of basophilic deposits on the surface of the cupula. Such changes may be related to the benign paroxysmal positional vertigo (BPPV) seen in some patients who have had aminoglycoside administration.     

Salvage surgery following irradiation with different fractionation regimes in the treatment of carcinoma of the laryngo pharynx: experience gained from a British Institute of Radiology study.

The 10-year follow-up of patients in a clinical trial involving the comparison of treatment by three fractions per week versus five fractions per week in radiotherapy of squamous carcinoma of the larynx and hypopharynx has now been completed. The trial involved an intake of 734 patients between 1966 and 1975. No statistically significant differences have been found between the two trial arms in terms of overall survival, age corrected survival, local recurrence, laryngectomy-free rates or effects on the normal tissues. Local recurrence was found in 320 of the 713 evaluable patients (45 per cent). Salvage laryngectomy was performed in 151 of the 320 patients with recurrence (47 per cent). Survival at 10 years for all node negative patients was 50 per cent in those patients without primary recurrence, compared with 40 per cent in those undergoing salvage laryngectomy.     

Role of lifestyle modifications for patients with laryngeal granuloma caused by gastro-esophageal reflux: comparison between conservative treatment and the surgical approach

Conclusions: It is considered that a regimen combining pharmacologic management and lifestyle modifications is the most effective treatment for laryngeal granulomas caused by GER.

Objectives: This study compared the results of the combination therapy and surgery to determine the best treatment of laryngeal granuloma caused by gastro-esophageal reflux in 51 patients.

Methods: Prospective study.

Results: In the conservative treatment group, the CR rate was 89.7% and recurrence rate was 2.6%, while the lesions remained in patients (7.7%). This study compared the CR and recurrence rates between conservative treatment and surgery for granuloma. The results showed that the laryngeal granuloma recurrence rate was significantly lower with the conservative treatment regimen compared with surgery (p?=?.0016).     

低温等离子治疗喉损伤性肉芽肿9例

目的 研究提高喉损伤性肉芽肿手术治疗效果的新方法。方法 9例喉损伤性肉芽肿患者中男2例,女7例;22～65岁,平均45岁; 9例患者就诊前1～3个月均有气管内插管史;经抗炎、禁声、雾化吸入治疗1～2月后无好转。2例尚有呼吸困难。在支撑喉镜下导入显微镜调整焦距,充分显露喉腔病变,开启流量泵和低温等离子射频消融系统,连接喉用7.0刀头,用脚踏板控制刀头,将等离子刀头置于肉芽肿表面,从上至下消融肉芽肿,直至肉芽肿基底,尽可能避免损伤周围黏膜。术后应用地塞米松及庆大霉素雾化吸入1周。结果 9例患者均一次手术成功,手术后肉芽肿复发1例,复发部位为对侧,经再次手术,未再复发。8例随访3个月～2年,未见复发,1例失访。病理检查证实,切取的肉芽组织表现为鳞状上皮黏膜慢性炎性反应,并有少量炎性细胞浸润。结论 低温等离子射频消融术治疗喉损伤性肉芽肿,为喉损伤性肉芽肿提供了一种安全、有效、微创的理想治疗术式,可避免术后复发。     

Use of middle ear ventilation tubes in recurrent acute otitis media

A method of treatment of recurrent acute otitis media with polythene middle ear ventilation tubes in young children is presented. 56 ears in which infection had persisted for one to six months despite antibiotic therapy and multiple myringotomies were included in the study. The tubes were inserted under topical anaesthesia and cure within one week was obtained in 73 per cent of ears. In another 9 per cent the otorrhoea stopped within 3 weeks, but in 18 per cent reinsertion of the tube became necessary and in this latter group 11 per cent resolved in two weeks following adenoidectomy as well. In 7 per cent the problem remained unresolved. Therefore with this regimen a total of 93 per cent of recurrent infections settled. It is emphasized that the ventilation tube should remain 'in situ' for over 3 months.     

Vocal process granuloma and glottal insufficiency: An overlooked etiology?

Objectives/Hypothesis:

Vocal process granuloma has been attributed to intubation, laryngopharyngeal reflux, and phonotraumatic/hyperfunctional vocal behaviors. Vocal process granuloma has recurrence rates following surgical excision approaching 92%. We hypothesize that a portion of persistent or idiopathic cases of vocal process granuloma result from underlying glottal insufficiency (GI) caused by paresis, scar, or atrophy. Our goal was to examine our vocal process granuloma population and determine the incidence of GI, treatment interventions, and outcomes.

Study Design:

Retrospective chart review.

Methods:

Thirty‐four patients with vocal process granuloma were divided into surgically or conservatively managed groups. Patients were identified if they carried a diagnosis of GI. The time to resolution and number of recurrences within the overall treatment period was recorded and compared between subgroups. Pre‐ and post‐treatment Voice Handicap Index‐10 (VHI‐10) and Reflux Symptom Index (RSI) scores were compared.

Results:

Eighteen of 34 patients (53%) carried an underlying diagnosis of GI, 13/34 (38%) were treated surgically, and 8/13 (62%) surgical patients had underlying GI. VHI‐10 and RSI scores significantly improved after disease resolution (P < .05).

Conclusions:

The incidence of GI among patients with vocal process granuloma was 53%. Conservative therapies including treatment of laryngopharyngeal reflux and voice therapy may lead to resolution despite underlying glottal incompetence. If conservative measures fail, recognizing and treating glottal incompetence with true vocal fold augmentation may lead to a shorter surgical treatment course. Laryngoscope, 2010     

Subtotal parathyroidectomy for secondary hyperparathyroidism in chronic renal failure

Twenty-seven patients on chronic haemodialysis and with secondary hyperparathyroidism underwent subtotal parathyroidectomy during the period 1985-1989. The operation was indicated by severe clinical symptoms and evidence of radiological abnormalities not responsive to conservative treatment (low phosphorus diet, phosphate binding substances, oral calcium and vitamin D). If despite intensive medical management, inadequate control of parathyroid hyperplasia continues surgical intervention becomes necessary. Ultra-sonography was performed pre-operatively in all 27 cases and detected 42 of 99 glands (42.5 per cent). Also scintigraphy was carried out in every patient but it gave a relatively low detection rate (24.5 per cent). Surgery was followed by improvement in 20 patients and progression of hyperparathyroidism in seven cases. Three of the seven patients failed to improve after subtotal parathyroidectomy, necessitating a re-intervention; the remaining four responded sufficiently to medical therapy. From our experience we conclude that subtotal parathyroidectomy for renal hyperparathyroidism is recommended.