早期声门癌的手术治疗:以室带成形声带

目的:探讨早期声门癌手术切除后的成形方法及治疗效果.方法:1989至1996 年治疗声门癌23例,T1a15例、T1b8例,均为N0M0,T1b者术后配合放疗40～48Gy.方法是切除声带肿物,剥离室带,纵行剖开,下移成形声带并消灭创面.结果:随诊5年以上9例,3～5年8例,1～3年6例,其中2例分别于术后8个月和1年局部复发行全喉切除术,至今患者生存.结论:喉室是声门癌向室带浸润的屏障,喉室深6～8mm,纵行剖开室带,适于成形声带并消除创面,以室带成形声带不影响治疗效果,且发声功能好,3～5年的生存率高于放射治疗.     

Laser surgery for vocal cord carcinoma involving the anterior commissure

Endoscopic laser surgery is an established means of treatment for benign laryngeal lesions. Laser surgery for early (stages I and II) squamous cell carcinoma is still being tested. Treatment of glottic tumors extending to the anterior commissure is in itself controversial. Approximately 20% of all glottic tumors involve the anterior commissure, with only 1% of these lesions being purely anterior commissure tumors. The anatomy of the anterior commissure is such that an apparent T1 lesion may actually be a T4 lesion if it involves the thyroid cartilage. The distance between the anterior commissure ligament and the thyroid cartilage is only 2 to 3 mm. A preoperative computed tomographic scan can aid us in evaluating this space. Therefore, tumors of the anterior commissure present as a therapeutic challenge. Radiation therapy has proven to be inadequate, with a high rate of recurrence and increased risk for radiochondronecrosis. The literature with regard to radiotherapy varies widely as to survival rates. Conservation surgery has consistently demonstrated an 80% survival in T1 lesions. Recently, it has been suggested that laser surgery in the region of the anterior commissure might offer satisfactory results. We have found the opposite. We will report on five patients who underwent endoscopic laser surgery on T1 vocal cord lesions involving the anterior commissure. All of these patients had tumor recurrence and subsequently have undergone salvage surgery and/or radiation therapy. The difficulties associated with endoscopic laser surgery of the anterior commissure will be discussed with a supporting animal study.     

Treatment of early vocal cord carcinoma: a comparison of apples and apples

Radiation therapy, hemilaryngectomy, and even cordectomy will cure a very large percentage of patients with early vocal cord cancer and preserve the voice. However, hemilaryngectomy and cordectomy are conceded by most surgeons to usually produce a poorer voice, compared to radiation therapy, and the operations are restricted to certain anatomical distributions. Those surgeons advocating hemilaryngectomy or cordectomy have compared their results with radiation therapy series which include a proportion of patients with lesions not suitable for voice-sparing operations. One hundred and thirty-nine patients with T 1-2 carcinoma of the vocal cords with a 2-15 year follow-up, who were treated initially by radiation therapy, were analyzed in detail by initial extent of disease. Patients were identified whose lesions were anatomically suitable for hemilaryngectomy or cordectomy, and results for these patients compared to operative results. Since the curative results with voice sparing by irradiation were at least equal, and since the quality of the voice is thought to be much better, there is little justification for recommending a major operation except in specific situations. Lesions initially suitable for voice-sparing operations which subsequently recur after irradiation can usually be treated by a voice-sparing operation.     

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。     

The mechanical reduction of early acquired cholesteatomas in children: indications and limitations

The standard treatment for acquired cholesteatoma involves surgical removal of the lesion and reconstruction of the tympanic membrane. In some children, these lesions can be treated more conservatively. We conducted a retrospective study of 29 ears in 24 children who had been treated for early acquired cholesteatoma with mechanical reduction and a tympanostomy tube. Outcomes measures included hearing status, the postoperative appearance of the tympanic membrane, and the need for additional surgery. We found that anterior and inferior pars tensa lesions, with or without squamous debris, can be successfully reduced, but that posterosuperior retractions respond less well when the ossicular chain has been eroded. None of the children who responded to mechanical reduction required major reconstructive surgery later. We conclude that mechanical reduction of retraction pocket cholesteatomas with tympanostomy tube placement is sufficient to restore normal hearing and a normal tympanic membrane appearance in selected children with early lesions. We also identified several important prognostic features, including the patient's age, the specific location of the retraction pocket on the tympanic membrane, the extent of the pocket, ossicular chain involvement, and the patient's adenoid status.     

Transtympanic perfusion: indications and limitations

PURPOSE OF REVIEW: To review the most recent literature regarding the application of transtympanic inner ear perfusion in the treatment of inner ear disorders including Meniere disease, sudden sensorineural hearing loss, and autoimmune inner ear disease. RECENT FINDINGS: The use of gentamicin perfusion in the management of Meniere disease with intractable vertigo has been demonstrated to have a very high rate of success, and is much less invasive than alternative surgical procedures such as vestibular nerve section or labyrinthectomy. The technique for achieving the highest rate of success while still minimizing the risk of cochleotoxicity continues to be investigated. Sustained delivery techniques such as the Silverstein MicroWick appear to achieve the best pharmacokinetic profile within the inner ear fluids. The end point of treatment does not necessarily require complete vestibular ablation to cure the patient, and shorter courses of treatment may help to reduce the risk of hearing loss. Cochlear Meniere disease can be treated with dexamethasone 4 mg/cc perfusion of the inner ear, which may improve the hearing, tinnitus, and pressure in the ear. Sudden sensorineural hearing loss has been managed with transtympanic steroid delivery, and this appears to be beneficial for some patients who have failed to respond to oral steroids, or have medical contraindications to systemic steroids. SUMMARY: Inner ear perfusion via transtympanic delivery is an emerging technique in the management of inner ear disease. Improved results are expected over time as research in this area answers questions about dosage and delivery techniques, as well as identifying new applications and pharmaceuticals.     

Failures after irradiation in early vocal cord cancer

Radiation therapy for early laryngeal cancer offers an excellent probability of cure as well as preservation of vocal function. Reported failure rates range from 9 to 21% in patients with T₁ lesions, and from 28 to 44% in those with T₂ lesions, the majority of whom are subsequently salvaged by surgery. Results obtained at the Radiotherapy Center of the University of Wisconsin Hospitals in 44 patients during the period from 1960 to 1972 yielded failure rates of 21% in patients with T₁ tumors and 38% in patients with T₂ tumors at 5 years. Five of the eight recurrences were salvaged with surgery yielding an overall tumor control rate of 93%. The larynx was preserved in 82% of the cases. Determinate 5-year survival was 91% in T₁ cases and 86% in T₂ cases. Failure rates at 3 years were 18% for T₁ tumors and 30% for T₂ lesions. These results are in conflict with those reported by Brandenburg and Rutter as being 46% and 60% respectively. Ultimate success in the treatment of laryngeal cancer rests in the full cooperation between surgeons and radiotherapists.     

Laser surgery in the treatment of bilateral vocal cord paralysis

The introduction of surgical lasers into microsurgery of the larynx has made the resection of the posterior vocal cord with or without the arytenoid cartilage possible. This method of surgical treatment allows one to carry out a fast, non-open larynx procedure and practically bloodless operation with minimal postoperative trauma and edema of the surrounding tissues. Since November 1990 at the Clinic of Otolaryngology of the University School of Medical Sciences 48 arytenoidectomies (40 on the right side, 8 on the left side), 19 partial chordectomies and 25 Kashima operations. All surgical treatment were performed by means of CO2 laser in patients with bilateral paralysis of the vocal cords. In all patients postoperative recovery was correct and breathing difficulties were not observed after extubation. Laryngoscopic control examinations were performed a day after operation and a wide lumen of air through the operative field was observed. At the control examination, narrowing of the lumen of the larynx was not observed, the healing process of the operation area was without granulation. Laser arytenoidectomy allows good results of the breathing and phonation function. No changes of granulation proliferation were observed at the side of the CO2 laser treatment. Lack of reaction to laser beam there was possibility to use endoscopic procedures in patients who did not undergo a tracheotomy.     

Laser arytenoidectomy in the treatment of bilateral vocal cord paralysis

The introduction of the CO2 surgical laser into laryngeal microsurgery has made resection of the posterior vocal cord together with the arytenoid cartilage possible. Since November 1990, 30 arytenoidectomies, 17 partial cordectomies and 18 bilateral cordectomies as described by Kashima were performed by means of a CO₂ laser in patients with bilateral paralyses of the vocal cords. In this group there were 58 women and 7 men. The patients’ ages ranged from 28 to 71 years (mean, 46.7 years). In one case the operation was performed twice: the right arytenoid cartilage was excised initially and the left arytenoid cartilage was removed in the second procedure. Three patients required tracheotomy before being transformed to the ENT Clinic, Poznañ. The etiologies of the vocal cord paralyses were complications arising from thyroid gland surgery (n = 62), trauma (n = 2) and excision of a bilateral glomus caroticum tumor. In all patients except one postoperative recovery was correct and no breathing difficulties were observed after extubation. In the one failure after operation endolaryngeal scar tissue resulted in glottic stenosis.     

不同表面麻醉药在声带息肉摘除术中的应用

目的探讨1%丁卡因、1%达克罗宁、2%利多卡因在电子喉镜下声带息肉摘除术中的麻醉效果.方法将声带息肉120例患者分为3组,丁卡因组(A组)、达克罗宁组(B组)经环甲膜穿刺注入,最大用量分别为2ml、4ml,利多卡因组(C组)经喉镜活检孔滴入,最大用量为10ml,单一表面麻醉药最大用量不能完成手术时联合两者或三者使用.结果按表麻药起效时间快慢为丁卡因、利多卡因、达克罗宁,药物作用时间长短为丁卡因、达克罗宁、利多卡因.3种药物的最大用量均能完成＜5min的手术,2种药物联合运用均能完成5～10min的手术,3种药物联合运用能完成＞10min的手术.结论联合应用表面麻醉药能降低药物的毒副作用,延长药物的作用时间,3者联合应用能完成难度较大,时间较长的声带息肉手术.     

Scanning electron microscopy of vocal cord hyperplasia, keratosis, papillomatosis, dysplasia and carcinoma

The vocal cord fine surface structure was examined by scanning electron microscopy (SEM), and the observations related to the light-microscopical (LM) findings after embedding and cutting. The SEM micrographs were assessed using a rating system based on 7 parameters. The proportion of "normal" and "abnormal" SEM areas varied within the respective histologic groups. There was, however, a significant difference between the SEM ratings in the group with hyperplasia-keratosis, with or without mild dysplasia, compared to the groups with severe dysplasia-carcinoma in situ and invasive squamous cell carcinoma. In the small number of cases with moderate dysplasia and juvenile laryngeal papilloma, the SEM ratings displayed pronounced disparity.     

Surgery and obstructive sleep apnea syndrome: indications and precautions

Surgery has long been a therapeutic option for obstructive sleep apnea syndrome (OSAS). The first procedures targeted the soft palate but results of isolated uvulo-palatopharyngoplasty (UPPP) were inconstant. A better understanding of the mechanisms involved in pharyngeal collapse incited interest in the role of the tongue and the retropharyngeal space. Surgical procedures were then developed for this level of the upper airways. There are a large number of possibilities. Excepting tracheostomy which court-circuits the collapsed zone, all the other procedures are designed to widen more or less one or more of the upper airway levels. The target can be the nose, the soft palate or the tongue, alone or in combinations. In all cases, the surgical alternative should be balanced against a non-invasive option: continuous positive pressure ventilation. The objective is to minimize the operative risks and sequelae while assuring success equivalent to positive pressure ventilation. It is important to note that sufficiently effective and permanent results have not been proven for any surgical technique, excepting tracheostomy and to a lesser degree bimaxillary advancement osteotomy, due to the lack of objective long-term rigorous evaluation. A considerable effort must be made in this domain.     

Early vocal cord carcinoma in obese patients: A surgical lesion

Early epidermoid carcinoma of the vocal cord is treated successfully by radiation therapy with high 5-year survival rates, low morbidity, and preservation of excellent voice quality in most cases. Typically, surgery is reserved for salvage of radiation failure and provides overall 5-year survival rates of 98% and 90% for T1 and T2 lesions, respectively. The extremely obese patient, often with a short neck and excessive amounts of subcutaneous fat, is difficult for both radiotherapist and surgeon to diagnose and treat. The recent observation of an unusually high rate of radiotherapy failure in a cluster of obese patients with early vocal cord cancer called attention to this problem. Because the larynx is near the thoracic inlet in obese patients, they are not suitable for administration of radiotherapy by accurate opposed lateral portals. The patients reported herein were treated entirely with anterior oblique portals. Of the five obese patients who underwent primary radiation therapy for early vocal cord cancer, three developed recurrent disease (60%) and a fourth developed a severe perichondritis requiring tracheostomy. Two patients with recurrent disease were successfully salvaged with total laryngectomy, while the third patient refused surgery and died 2 years later. The sixth patient was treated by partial laryngectomy with imbrication reconstruction and is alive and without evidence of disease 2 years following surgery. Recurrence rates and complication rates following primary radiation therapy for early vocal cord cancer appear to be unacceptably high in obese patients treated with anterior oblique portals. Therefore, we recommend primary conservation laryngeal surgery for obese patients with early vocal cancer who cannot undergo “standard” radiotherapeutic techniques.