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Inducible laryngeal obstruction (ILO) describes an inappropriate, transient, reversible narrowing of the larynx in response to external triggers. ILO is an important cause of a variety of respiratory symptoms and can mimic asthma. Current understanding of ILO has been hampered by imprecise nomenclature and variable approaches to assessment and management. A task force of the European Respiratory Society (ERS) and European Laryngological Society (ELS) was thus set up to address this, and to identify research priorities. A literature search identified relevant articles published until June 2016, using all identifiable terms for ILO, although including only articles using laryngoscopy. In total, 172 out of 252 articles met the inclusion criteria, summarised in sections on diagnostic approach, aetiology, comorbidities, epidemiology and treatment. The consensus taxonomy published by ERS, ELS and the American College of Chest Physicians (ACCP) in 2015 is used throughout this statement. We highlight the high prevalence of ILO and the clinical impact for those affected. Despite recent advances, most aspects of this condition unfortunately remain incompletely understood, precluding firm guidance. Specifically, validated diagnostic and treatment algorithms are yet to be established, and no randomised control studies were identified in this search; hence we also make recommendations for future research.

Transoral CO2 laser cordectomy for squamous cell carcinoma (SCC) of the glottis has resulted in excellent voice and oncologic outcomes as compared with non-surgical therapy. However, published experience with primary CO2 laser cordectomy specifically for glottic SCC involving the anterior commissure (AC) is limited. A review of single academic institution experience with CO2 laser cordectomy for glottic SCC involving the AC. Patients undergoing European Laryngological Society (ELS) classification cordectomy type Va or type VI between 2005 and 2013 were included. Post-surgical voice analysis was performed by speech language pathologists (SLP) from the reporting institution. Thirty patients were identified for inclusion. Mean post-surgical follow-up time was 47.6 months (range 11–59). Initial local recurrence was identified in 5/30 (16.7 %) patients. 2/5 recurrences were successfully salvaged by repeat CO2 laser resections, 2/5 ultimately required salvage total laryngectomy, and 1/5 patient developed a second primary preventing further curative treatment. Overall laryngeal preservation rate was 28/30 (93.3 %). Overall survival of the study cohort was 96.7 %. Mean postoperative voice handicap index-120 score was 36.9 (SD = 21.4). Perceptual analysis performed on the GRBAS scale resulted in mean scores: G = 2.1 (SD = 0.9), R = 1.3 (SD = 1.1), B = 1.6 (SD = 1.2). Though cancers involving the AC represent an aggressive subgroup of glottic SCC, CO2 laser cordectomy results in encouraging oncologic and voice outcomes without the need for further therapy in the majority of cases. Clinical trials are encouraged to further define optimal treatment recommendations for glottic SCC involving the AC.

Spasmodic dysphonia (SD) remains one of the most difficult of laryngeal pathologies to treat. With limited role for speech therapy, various surgical modalities have been tried with various success rates. The objective of the study is to report the results of vocal outcome after thyroarytenoid myoneurectomy in patients of adductor spasmodic dysphonia (ASD). 15 patients of ASD were selected. GRBAS, and voice handicap index (VHI) were used for perceptual evaluation of voice. Thyroarytenoid myoneurectomy was performed by vaporizing the muscular layer of the vocal fold with CO2 laser, at an intensity of 6 W with 1.2 mm diameter in scanner mode. Voice analysis was repeated at 12, 24 and 48 months follow-up. Preoperative GRBAS scores and VHI score of all the patients were poor. At 12 months 12/15 (80 %) patients having strain score of 0. There was marked improvement in VHI scores at 6 months. 10/15 (67 %) patients have been followed up for 24 months. 5/10 (50 %) patients have strain (S) value of 0. VHI scoring of 5/10 (50 %) patients was

To evaluate type IIIB thyroplasty using the excised larynx bench apparatus and determine how altering vocal fold contour by performing bilateral medialization of the inferior vocal fold affects phonation. This procedure could be performed in patients for whom pitch lowering is desirable, such as female-to-male transsexuals or male patients with mutational falsetto in whom intensive voice therapy was insufficient. Aerodynamic, acoustic, and high-speed videokymographic data were collected for nine larynges at three subglottal pressure inputs for each of three conditions: normal; type IIIB thyroplasty; and combined type IIIB with modified bilateral type I thyroplasty intended to create a more rectangular glottal configuration. Each larynx served as its own control. Phonation threshold flow (p = 0.005), phonation threshold power (p = 0.031), and airflow varied across conditions with highest values for type IIIB thyroplasty and lowest for the combined procedure. Fundamental frequency was significantly different (p

Objective: Although high-speed imaging (HSI) has been identified as a valuable tool in phonatory biomechanics research, to date, there have only been a selected number of reports investigating the clinical utility of HSI. We aim to elucidate the role of HSI in the diagnosis of the dysphonic patient. Methods: The video files from 28 consecutive dysphonic patients with concurrently acquired videostroboscopy and HSI were retrospectively collected. Stroboscopy video files were edited to include vibratory motion only. Videos were then anonymously and randomly presented to four academic laryngologists. Experts were asked to assign a single best diagnosis for each video file. Assigned diagnoses were then compared with treatment diagnoses conferred based on medical history, phonatory evaluation, laryngeal examination, and response to treatment. Results: Interrater analysis for the four laryngologists demonstrated significant and meaningful correlations for the diagnoses of polyps, cysts, nodules, and normal examination using stroboscopy (kappa > 0.40, P < 0.001). The experts demonstrated significant and meaningful correlations for the diagnoses of polyps, presbyphonia, and normal examination using HSI (kappa > 0.40, P < 0.001). Combined intrarater analysis performed by comparing single rater's diagnosis for single patient across both modalities resulted in poor correlation without statistical significance (kappa = 0.30, P = 0.07). Both stroboscopy- and HSI-assigned diagnoses matched the treatment diagnoses at equal predicted frequencies (32.3%), as demonstrated through multivariate logistic regression analysis (P < 0.001). Conclusion: Overall, HSI did not improve the diagnostic accuracy above stroboscopy alone. Although specific laryngeal states such as presbyphonia may be better diagnosed with HSI, further studies are required to define HSI's precise role in the clinical setting. © 2013 The Voice Foundation.

Acronyms and abbreviations are frequently used in otorhinolaryngology and other medical specialties. CO2 laser-assisted transoral surgery of the pharynx, the larynx and the upper airway is a family of commonly performed surgical procedures termed transoral laser microsurgery (TLM). The abbreviation TLM can be confusing because of alternative modes of delivery. Classification and definition of the different types of procedures, performed transorally or transnasally, are proposed by the Working Committee for Nomenclature of the European Laryngological Society, emphasizing the type of laser used and the way this laser is transmitted. What is usually called TLM, would more clearly be defined as CO2 laser transoral microsurgery or CO2 TOLMS or CO2 laser transoral surgery only (with a handpiece) would be defined as CO2 TOLS. KTP transnasal flexible laser surgery would be KTP TNFLS. Transoral use of the flexible CO2 wave-guide with a handpiece would be a CO2 TOFLS. One can argue that these clarifications are not necessary and that the abbreviation TLM for transoral laser microsurgery is more than sufficient. But this is not the case. Laser surgery, office-based laser surgery and microsurgery are frequently and erroneously interchanged for one another. These classifications allow for a clear understanding of what was performed and what the results meant.

Background: Voice disorders resulting from glottic insufficiency are a significant clinical problem in everyday phoniatric practice. One method of treatment is injection laryngoplasty. Our study aimed to assess the voice quality of patients treated with hyaluronic acid injection into the vocal fold. Material/Method: We studied 25 patients suffering from dysphonia, conducting laryngological and phoniatric examination, including videostroboscopy and acoustic voice analysis, before the operation and 1, 3, and 6 months later. Results: In all cases there was complete or almost complete glottic closure after the operation. One month after the procedure, videostroboscopic examination revealed reappearance of vocal fold vibration in 8 cases; after 3 months this had risen to 15 cases. Perceptual voice quality (as assessed by the GRBAS scale) in patients with glottic insufficiency was improved. The most significant improvement was obtained 1 month after surgery (p=0.0002), and within the next months further statistically significant improvements (p=0.000002) were noted. Multidimensional voice analysis showed statistically significant and rapid improvement in frequency parameters, especially vFo. Other parameters were also improved 3 and 6 months after surgery. Conclusions: Injection of hyaluronic acid into the vocal fold improves phonatory functions of the larynx and the quality of voice in patients with glottic insufficiency. It may be a safe and conservative method for treatment of voice disorders. Hyaluronic acid injection to the vocal fold is an easy, effective, and fast method for restoration of good voice quality. © Med Sci Monit.

The objective of the study was to determine the etiology and subsequent management of patients with unilateral vocal fold immobility (UVFI) and compare our results with other such studies. This was a retrospective case series of all patients that were treated for UVFI at one single tertiary referral centre between 2010 and 2014. The medical records of 161 patients over a 5-year period diagnosed with UVFI were analyzed. We looked at the patient demographics, side of immobility, etiology, management and voice assessment. A total of 21 patients were excluded due to varying reasons including second presentation and incomplete data. Our results demonstrated 37.1% of cases to be due to non-thyroid surgery (mainly vascular or anterior cervical spine surgery) compared to thyroid or parathyroid (18.6%). Carotid endarterectomy was the commonest cause followed by cervical spine discectomy or fusion. Other iatrogenic causes included thoracic surgery either involving the lung or not. Our results are very much in keeping with those seen by our colleagues in North America. A better appreciation of the causes of UVFI especially in cases not performed by otolaryngologists and head and neck surgeons should be highlighted and the necessary steps should be taken to prevent this iatrogenic complication.

To evaluate the application of the Flex Robotic System in transoral robotic surgery (TORS).Multicenter, prospective, open-label, single-armed clinical study.A prospective clinical follow-up multicenter study was performed from July 2014 to October 2015 assessing the safety and efficacy of the Medrobotics Flex Robotic System for access and visualization of the oropharynx, hypopharynx, and larynx as well as for resection of benign and malignant lesions. A total of 80 patients were enrolled. Access and visualization of five anatomic subsites (base of tongue, palatine tonsil area, epiglottis, posterior pharyngeal wall, and false vocal cords) were individually graded by the surgeon. Setup times, access and visualization times, surgical results, and adverse events were documented.The relevant anatomic structures could be exposed and visualized properly in 75 patients, who went on to have a surgical procedure performed with the Flex Robotic System. Access and visualization of the palatine tonsil area, posterior pharyngeal wall, epiglottis, and posterior pharyngeal wall were excellent. However, false vocal cords and vocal cords were more difficult to expose. Seventy-two patients were treated successfully with the Flex Robotic System. There were no serious or unanticipated device-related adverse events caused by the Flex Robotic System.Lesions in the oropharynx, hypopharynx, and larynx could be successfully resected with the Flex Robotic System, specifically developed for TORS. Our study provides evidence that the Flex Robotic System is a safe and effective tool in TORS. Laryngoscope, 2016 127:391-395, 2017.

The article ‘Laser-assisted surgery of the upper aero-digestive tract: a clarification of nomenclature. A consensus statement of the European Laryngological Society,’ written by Marc Remacle, Christoph Arens, Mostafa Badr Eldin, Guillermo Campos, Carlos Chiesa Estomba, Pavel Dulguerov, Ivana Fiz, Anastasios Hantzakos, Jerome Keghian, Francesco Mora, Nayla Matar, Giorgio Peretti, Cesare Piazza, Gregory N. Postma, Vyas Prasad, Elisabeth Sjogren, Frederik G. Dikkers, was originally published Online First without open access. After publication in volume 274 issue 10, page 3723–3727 the authors decided to opt for Open Choice and to make the article an open access publication. Therefore, the copyright of the article has been changed to © The Author(s) 2018 and the article is forthwith distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits use, duplication, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

Endoscopic cricopharyngeal myotomy (ECPM) with CO(2) laser is indicated in cases with swallowing disorders when a dysfunction of the cricopharyngeal muscle is diagnosed. We present the results of a retrospective study including 32 of the 65 consecutive patients who underwent ECPM in our center between 2002 and 2009. The aim of this study is to evaluate the postoperative complications and complaints, the improvement of swallowing after surgery, the global satisfaction of the surgery and the swallowing improvement according to the deglutition handicap index (DHI). No major postoperative complication was reported. Postoperative pain was present in 46.9 % of the patients and estimated on an analog scale at 4.4/10. For the others, this surgery was painless. Improvement in swallowing liquids was present in 75 % of the patients and 81 % of the patients could swallow solids. The overall patients' satisfaction on a scale of 10 was 7.2; if needed, 83.9 % of the patients would do the surgery again. Concerning the DHI, we report a significant improvement of all items except the last one. ECPM is a safe procedure which provides improvement of symptoms and satisfaction for the majority of patients.

OBJECTIVES/HYPOTHESIS: To describe a single center outcomes following transoral robotic surgery for supraglottic laryngectomy (TORS-SL). STUDY DESIGN: Prospective data collection. METHODS: Patient records receiving TORS-SL for squamous cell carcinoma (SCCA) with at least 12 months follow-up fit inclusion for this study. Two patients with previous SCCA were excluded. RESULTS: 18 patients (14 male, 4 female) were included in the study, having a mean follow-up time of 28.1 months (SD = 12.1). All patients had negative margins confirmed on final pathology. Nine (50%) patients received postoperative chemoradiation therapy for advanced neck disease. No (0%) patients received tracheostomy or gastrostomy tubes. There were no (0%) local recurrences, and three (16.7%) regional recurrences. Five (27.8%) patients experienced temporary postoperative complications. Overall 2-year outcomes reached 83%, 100%, and 89% for locoregional control, disease-specific survival, and overall survival respectively. CONCLUSIONS: Initial outcomes for TORS-SL are encouraging and are comparable to previously described treatment modalities. Larger studies are encouraged.

has been reported with feasibility trials andpromising initial data. The combination of the two proce-dures, supraglottic and hypopharyngeal TORS resection,can be adapted to perform a TORS total laryngectomy(TORS-TL). In the past, TORS-TL has been met with skep-tical criticism as to its ultimate clinical benefit. Conversely,the authors suggest that the minimally invasive TORSapproach offers significant benefits toward improvingpatient recuperation and the avoidance of substantial post-operative morbidity. However, such benefits can only bedemonstrated following repeated clinical experience. It isthe purpose of this report to describe the surgical protocolutilized by the authors to encourage further application andstudy of this promising surgical advancement.

It is hypothesized that real time objective measurement of the subglottic pressure could contribute to the choice of the implant's size (IS) in medialization thyroplasty (MT). A prospective study was conducted with patients with glottal insufficiency. Patients had a MT using a Montgomery implant(®) (Boston medical, Boston, USA). Peak direct subglottic pressure (PDSGP) was measured intraoperatively using a catheter inserted in the cricothyroid membrane. The implant's choice was based on the results of PDSGP measured prior and after placement of the implant and was compared to the surgeon's and patient's perception and fiber optic estimation of the glottis aperture. Six patients were included in the first part of the study. The PDSGP could be measured in all the patients without increasing the surgical time or patients' discomfort. The mean PDSGP before and after the placement of the implant was 15.2 (SD = 5) and 10.6 (SD = 4) cmH(2)O, respectively. In the second part of the study, five patients were included. The PDSGP varied with the size of the implant and the implant with the lowest pressure was chosen in 4/5 patients. Peroperative measurement of PDSGP is easy, feasible and might allow a more objective choice of the IS in MT. Level of evidence 2c.

We present a series of patients treated by transoral robotic surgery (TORS) using a new CO(2) laser wave guide (CO(2) LWG) (Lumenis, Santa Clara, CA). Patients older than 18 years, with malignant pharyngo-laryngeal tumors were enrolled in this prospective study after signing an informed consent. Four patients were enrolled in the study. The mean age was 56 years. One patient had a T1 base of tongue tumor, two patients had supraglottic tumors (T1, T2), and one had a T1 palatine tonsil tumor. All the procedures could be performed using a Maryland forceps, a 0° endoscope and a CO(2) LWG introduced via the robotic arm introducer. The laser parameters were: superpulse or continuous mode, 7-15 W, continuous delivery. The average set-up time was 30 min. The average surgical time was 94 min. No complications were noted due to the intraoperative use of the robot or the CO(2) LWG. One laser fiber was used for each of the surgeries. The mean coagulation depth was 200 μm (range 100-300). The mean hospital stay was 6 days. The CO(2) LWG is a reliable tool for TORS. It allowed more than 1 h of work without any trouble.

Introduction: Method of vocal folds implantation with allogenic materials has been applied in medical centre all over the world for over 30 years. This voice improving method is usually applied in several indications such as: presbyphonia, vocal folds paralysis, glottis insufficiency, vocal fold scars or sulcus vocalis. All of these illnesses prevent the patients to obtain full glottis closure and produce good quality voice. Aim: To assess quality of voice after implantation of hyaluronic acid to the vocal folds. Material: Consisted of 15 patients, who underwent surgical implantation of hyaluronic acid to the vocal folds. 10 patients had the procedure performed on both sides of the larynx, this group included 6 patients with vocal insufficiency of the glottis, 2 with scars and atrophy of the vocal folds and 2 with presbyphonia. In 5 cases the hyaluronic acid was applied on one side of the larynx. The group included 4 patients with vocal folds paralysis and one person with single sided scars and atrophy of the vocal fold. Method: Each patient was examined with videostroboscopy and underwent objective and subjective assessment of voice. Hyaluronic acid was injected surgically under Jet Ventilation general anesthesia. In two cases during the procedure scars were removed from the vocal folds. All patients after hyaluronic acid augmentation took part in the rehabilitation program that included series of voice emission exercises before operation and up to 3 months after the procedure. Examination was performed 1, 3 and 6 months after injection. Results: In all cases improvement of quality of voice was obtained which was stated by a physician and the patients subjectively. Improvement of harmonic voice structure was confirmed by spectrographic record. Acoustic examinations revealed that the improvement was obtained within parameters describing frequency, amplitude disturbance and noise existence. Conclusions: Injection of the hyaluronic acid to the vocal folds improves functional phonation and quality of voice in cases of patients with glottis insufficiency. Injection of the hyaluronic acid to the vocal folds is an efficient method improving quality of voice and can be safe alternative for no surgery method in rehabilitation of voice. This method is a simply, effective and quickly to improve of voice disorders. © 2011 Polish Otolaryngology Society.

Transoral CO 2 laser microsurgery is gaining ground at the expense of external approaches in the management of laryngeal tumors. Endoscopic surgical indications depend on the location, extension, and accessibility of the tumor as well as the surgeon's expertise. The status of surgical margins is a very important prognostic factor. One of the major criticisms against endoscopic resection is the difficulty of interpretation of histologic specimens because of the thermal effect of laser on tissues and specimen shrinking when formalin fixation is used. This article describes the authors' experience with transoral CO 2 laser microsurgery for laryngeal tumors resection based on the European Laryngological Society established classifications for cordectomies and supraglottic laryngectomies as well as systematic frozen section analysis.

Sulcus vocalis is one of the most difficult benign laryngeal lesions to manage. This article describes the authors' technique for treatment of sulcus vocalis using the CO 2 laser digital scanning system and injectable collagen. The aim of this surgery is to increase the pliability of the vocal folds and decrease the glottal gap. The surgical technique is based on the concept of Cornut and Bouchayer, where the dissection of the epithelium adherent to the deep subepithelial plane improves the vocal fold vibration. When the vocal fold is atrophic, surgery is completed by collagen injection. This technique, combined with speech therapy, improves significantly voice efficiency.

Subjective evaluation of the voice by the patient is routinely assessed in the adult dysphonic population; this is, however, not the case in the pediatric population. There were three objectives of this study: the first goal was to study the ability of children aged 5-13 years to express themselves about physical, emotional, and sociofunctional aspects of their voice. The second goal was to explore if specific voice-related complaints were expressed by dysphonic children as compared with normophonic children. The third goal was to compare the dysphonic children's voice-related complaints with those of their mothers. The overall objective was to set the grounds for the elaboration of a standardized questionnaire in French concerning subjective evaluation of voice in children. Twenty-five dysphonic children with vocal complaint (15 nodules, one polyp, one microweb, eight unspecified) and 55 normophonic children aged 5-13 years were interviewed. The interviews were semistructured based on a canvas of voice-related questions. The dysphonic children's mothers were interviewed with the mean of a written questionnaire and were invited to discuss their answers orally with the examiner. The results were analyzed qualitatively and statistically. A Chi-square test and the Fisher's test were used to analyze the differences between the complaints expressed by the dysphonic and the normophonic children, and a binomial test was used to compare the children's answers with their mothers' answers. The qualitative analysis of the interviews suggests that children are capable of reflecting over their own voice and of giving autonomous information about different aspects of their voice. It also appeared that voice is a complex phenomenon and that it needs to be clearly and cautiously defined to the children. We identified 27 different complaints related to the voice, out of which 17 were significantly more expressed by dysphonic than by normophonic children (P

Transoral robotic surgery (TORS) is an emerging technique for the treatment of head and neck tumors. The objective of this study is to describe our first steps and present our experience on the technical feasibility, safety, and efficacy of TORS for the treatment of selected malignant lesions. From April 2008 to September 2009, 24 patients were enrolled in this prospective trial. Inclusion criteria were: adults with T1, T2 and selected T3 tumors involving the oral cavity, pharynx, and supraglottic larynx and a signed informed consent was obtained from the patient. Exclusion criteria were: tumors not accessible to TORS after unsuccessful attempts to expose properly the lesion to operate. The ethical committee's approval was obtained to perform this study. Twenty-four patients were included in this study: 10 supraglottic tumors, 10 pharyngeal tumors and 4 oral cavity tumors. Nine patients had T1 tumors, 12 had T2 tumors, and 1 patient had a T3 tumor. In all cases, tumor resection could be performed by robotic surgery exclusively and negative resection margins were achieved with control by frozen section. None of them received intraoperative reconstruction. None of the patients required tracheotomy. There was no intraoperative complication related to the use of the robot. The average setup time was 24 ± 14 min (range 10-60 min). The average surgical time was 67 ± 46 min (range 12-180 min). Surgical and setup time decreased after the first cases. The mean hospital stay was 9 days. Oral feeding was resumed at 3 days. TORS seems to be a safe, feasible, minimally invasive treatment modality for malignant head and neck tumors with a short learning curve for surgeons already experienced in endoscopic surgery.

The prognosis of cancer patients is highly dependent on the time of diagnosis. Early, stage 1 disease is often curable whereas late stage diseases are usually beyond curable treatments. Therefore, new diagnostic tools for malignancies of the upper aerodigestive tract are developed all the time and narrow band imaging (NBI) is one of these new options for early diagnostics. In this paper, we describe the implementation of NBI technique in our institution. During the first 6 weeks we used NBI to examine 73 patients with different types of pharyngeal or laryngeal problems. Most of the patients (77%) were on follow-up visits after earlier malignant disease. In our series we had 11 NBI-positive patients and the histological diagnosis was carcinoma or dysplasia among 10 of these. Among the NBI negative patients we found four carcinomas. It is notable that NBI affected the decision of a biopsy procedure in three patients, with final diagnosis of dysplasia or carcinoma. In conclusion, we find NBI useful in the diagnostics of malignancies of the upper aerodigestive tract. This is a useful tool in improving the accuracy of the diagnostics. However, it still takes an experienced clinician and a learning curve can be expected.

OBJECTIVES: The aim of this study was to evaluate the objective voice results of Wendler's glottoplasty in male-to-female transsexuals. METHOD: We retrospectively reviewed our patients treated with Wendler's technique with minor modifications. Glottoplasty consisted in CO(2)-laser epithelial ablation of the anterior commissure and the two vocal folds in anterior third, suturing of the two vocal folds with two stitches of 3.0 resorbable thread, and application of fibrin sealant to strengthen the suture. Voice assessment was based mainly on fundamental frequency (F(0)), frequency range, jitter, maximum phonation time, phonation quotient, estimated subglottic pressure (ESGP) grade of dysphonia (G), and voice handicap index (VHI). These measures were taken before surgery and on the last follow-up visit. RESULTS: Our series included 15 patients with a mean age of 36 years. The mean follow-up period was 7.2 months. We did not observe any early complications related to the technique. The comparison between the preoperative and the postoperative measurements, using Wilcoxon signed rank test, showed a significant improvement of median F(0) from 139 to 191Hz (P=0.006) with an increase in the grade of dysphonia (G(pre)=0.2, G(post)=1, P=0.013) and ESGP (ESGP(pre)=8.1+/-3.2, ESGP(post)=12.0+/-3.8, P=0.002). Other measurements, including VHI, did not show any significant differences pre- and postoperatively. CONCLUSION: Wendler's glottoplasty can contribute to feminize the voice.

OBJECTIVE:: To study the reliability of the sentinel node technique (SNT) in the management of the N0 neck in patients with supraglottic laryngeal cancer. METHODS:: Patients presenting to our department, between 2001 and 2004, with T1-T3 supraglottic cancer and N0 neck, clinically and radiologically, were included in the study. All patients underwent sentinel lymph node detection, using the hand-held gamma probe followed by bilateral modified radical neck dissection (MRND) and resection of the primary tumor. We compared the results of the SNT with those of the gold standard MRND for the staging of the neck. The histologic examination was performed after fixation for both the products of SNT and MRND. RESULTS:: Twenty-nine patients were included in the study. Twenty-one had T2, 2 had T1, and 6 had T3 tumors. Patients had transoral CO(2) laser-assisted resection of the primary tumor. All the patients underwent bilateral neck dissection immediately after the sentinel node biopsy. Of the 95 sentinel lymph nodes harvested, 22 were positive for lymph node metastasis. The mean number of sentinel node per patient was 3. Of the 58 modified neck dissections (2 neck sides/patient), there was 1 additional positive lymph node, in the prelaryngeal area, and the patient had already positive sentinel lymph nodes. The SNT allowed the identification of node metastasis in 100% of the cases with a sensitivity of 100 (48-100), specificity of 78 (64-88), negative predictive value of 100 (91-100). CONCLUSIONS:: SNT is reliable in the staging of the clinically N0 neck in patients with supraglottic cancer. Laryngoscope, 2010.

Microsurgery for intracordal cysts is a challenging procedure, because cysts are close to the vocal ligament and the risk of inducing a scar is high. In this retrospective study, our experience with the CO(2)-laser scanning system (Acublade(®)) is reported on 49 patients. There were 41% epidermoid cysts and 59% mucous retention cysts. A quarter of the patients presented with bilateral cystic lesions and 59% had a contralateral lesion other than a cyst. The cyst was removed after a minimicroflap. It was dissected away from the lamina propria and the epithelium. Collagen was injected intraoperatively if the glottal gap was considered important. The epithelium was redraped using Tissucol (Baxter, Vienna, Austria). The mean follow-up time was 160 days. We noted a statistically significant improvement in the grade of the dysphonia according to Hirano's perceptual scale (G pre = 2, G post = 1, p = 0.002); the Vocal Handicap Index (VHI pre = 51, VHI post = 28, p = 0.001) and the maximal phonation time in milliseconds (MPT pre = 11, 1 MPT post = 12.7, p = 0.033) in all the patients. In the professional voice subgroup (20/49 patients), there was a significant improvement in the frequency range (FR pre = 310 Hz, FR post = 434 Hz, p = 0.001). The CO(2)-laser scanning system is reliable in the treatment of intracordal cysts.

Endoscopic resection of laryngeal tumors is replacing external approaches. One drawback of endoscopic resection is the difficulty of interpretation of histological specimens because of thermal effect of laser on tissues. Our goal is to assess the reliability of frozen section in this setting by comparing its results with those of routine histology. We, retrospectively, reviewed the charts of all consecutive patients, who underwent cordectomies in our institution between January 2000 and 2008, using the CO(2) laser Acublade system (Lumenis, Santa Clara, CA). Age, sex, staging of the tumor, previous treatments, type of cordectomy, frozen section and routine histology results were analyzed. Ninety-seven patients fulfilled the inclusion criteria; 22.7% had severe dysplasia, 54.6% had T1 epidermoid carcinoma, 17.5% had T2 carcinoma and finally 5.2% had T3 carcinoma. We performed type I cordectomy in 36.1% of patients, type II cordectomy in 18.6%, type III cordectomy in 10.3%, type IV cordectomy in 5.2%, type V cordectomy in 28.9% and type VI cordectomy in 1% of patients. Most of the patients did not have any previous treatment. The mean number of margins per surgery was 2. Routine histological examination confirmed frozen section in 94.8% of the interventions. Frozen section is reliable in laser-assisted cordectomies, when performed by an experienced team; it has a high negative-predictive value. It can limit the need, cost and emotional stress of second look surgeries.

OBJECTIVE: The aim of this study was to evaluate long-term results of endoscopic surgery for supraglottic carcinoma. STUDY DESIGN: Case series with chart review. SETTING: Tertiary care university hospital. SUBJECTS AND METHODS: From 1992 to 2004, 45 patients diagnosed with supraglottic squamous cell carcinoma (two Tis, nine T1N0, 27 T2N0, two T2N1, one T2N2, four T3N0) underwent different types of endoscopic supraglottic laryngectomies according to the European Laryngological Society (ELS) classification: three limited excision (type I); 27 medial without resection of the preepiglottic space (type IIb); one medial with resection of the preepiglottic space (type IIIa); three medial with resection of the preepiglottic space (type IIIb); nine lateral (type IVa); two lateral (type IVb). RESULTS: Overall survival was 93 +/- 4 percent (SE) after three years and 89 +/- 6 percent (SE) after five years. The median follow-up is 3.7 years. Patients with clinically N0 necks were found to have positive nodes in eight (19%) cases. Two cases of postoperative hemorrhage were controlled by electrocautery. All of the patients without previous treatment for larynx cancer regained swallowing function within five days to three weeks after surgery. Mean duration of hospitalization was 12.5 days. CONCLUSION: Endoscopic partial laryngectomies, as defined by the ELS classification, for selected supraglottic squamous cell carcinoma proved to be an excellent alternative to radiotherapy and open neck surgery.

Resume Objectif Internet est devenu le premier media par lequel les patients s’informent. Le type et la qualite de l’information medicale disponible en langue francaise demeurent mal connus notamment dans le domaine de l’oncologie ORL. L’objectif de cette etude etait de reproduire la strategie de recherche d’information des patients sur Internet et d’evaluer la qualite des sites visites. Methode Six mots cles « cancer du larynx », « cancer de l’amygdale », « cancer de la thyroide », « carcinome papillaire de la thyroide », « cancer de la langue » et « cancer de la parotide » ont ete soumis a deux moteurs de recherche. Les 50 premiers sites Internet correspondant a chaque mot cle ont ete evalues pour un total de 600 sites. Resultats Quatre-vingt quinze sites (16 %) presentaient une information exploitable par le patient et ont fait chacun l’objet d’une evaluation portant sur la qualite (outil DISCERN et lecture par deux chirurgiens ORL) et le caractere comprehensible du contenu. Selon ces criteres, 8 % des sites sont juges « Excellent », 24 % « Bon », 14 % « Assez bon », 15 % « Moyen », 27 % « Pauvre » et 12 % « Tres pauvre ». Quarante-neuf a 62 % des sites sont consideres comme comprehensibles par le grand public. L’etude statistique montre que l’ordre de classement d’un site dans les moteurs de recherche, son affiliation, sa cible ou son type de financement ne sont pas des gages de qualite. Seul un auteur identifie medecin, l’existence de reference bibliographique et une date recente de mise a jour sont en faveur d’un site de qualite. Conclusion Ce travail confirme que la quete d’information medicale sur Internet est fastidieuse et decevante. Rares sont les sites delivrant une information a la fois exhaustive et comprehensible. Les inexactitudes graves sont cependant peu frequentes. La creation, dans l’espace francophone, de sites Internet de qualite sur les cancers ORL repondrait a un besoin croissant des patients. De meme, l’existence d’un site portail en oncologie ORL orientant vers des sites comprehensibles et selectionnes offrirait, en plus du gain de temps et de securite, des gages de qualites aux patients.

Objectives: To evaluate the long-term effectiveness of calcium hydroxylapatite (CaHA) vocal fold injection for patients with glottal insufficiency. Study Design: Multicenter, open-label, prospective clinical study of CaHA vocal fold injection. Methods: Each patient served as his/her own control. Voice-related outcome measures were collected for pre-injection, 1, 3, 6, and 12 months. Results: Sixty-three patients were available for evaluation. Fifty-three percent of the injection procedures were done in the office. Fifty-seven percent of patients were diagnosed with unilateral paralysis and 43% with glottal incompetence with mobile vocal folds. Patient satisfaction 12 months after injection showed 67% reporting a significant improvement in voice and 81% reporting at least a moderate improvement in voice. Utilizing the Voice Handicap Index-10, visual analog scale (vocal effort), Consensus Assessment Perceptual Evaluation V (judgments of voice severity), and objective voice measures of glottal closure (maximum phonation time and S:Z ratio), paired t tests showed significant improvements after treatment. A 22% further treatment rate was found at the 12-month time point. Conclusions: One-year results in this large cohort of patients with glottal incompetence treated with CaHA vocal fold injection demonstrate that excellent clinical results were achieved.

Le reflux pharyngo-larynge (RPL) est actuellement largement mis en cause dans les pathologies laryngees. Le diagnostic et le traitement, calques sur les methodes appliquees au reflux gastro-œsophagien, rencontrent de nombreux echecs. Depuis peu, plusieurs auteurs tentent de mettre en evidence les mecanismes d’action propres du RPL au niveau moleculaire. Des pompes H+/K+ ATPase ont ete mises en evidence au niveau des glandes sous-muqueuses du larynx humain. D’autre part, l’absence d’anhydrase carbonique au niveau de l’epithelium des cordes vocales chez les patients presentant un RPL pourrait rendre compte de la localisation preferentiellement glottique des atteintes laryngees. Enfin, la presence de pepsine active et d’acides biliaires dans l’epithelium larynge semble jouer un role preponderant dans la physiopathologie du RPL.

Le reflux pharyngo-larynge (RPL) en amont du sphincter proximal provoque de nombreux symptomes, temoins possibles d’une agression acide dans l’aire supraglottique. La relation entre ces symptomes et les lesions de la sphere ORL sont difficiles a etablir. La presente revue les considere sous deux aspects: 1) la laryngite posterieure couramment decrite est aspecifique. Les lesions presentees peuvent etre associees a d’autres facteurs inducteurs (rhinorrhee posterieure, asthme, consommation d’alcool); 2) Une echelle de severite des symptomes elaboree par Belafsky (RFS: Reflux Finding Score) associee a une pH-metrie œsophagienne sous-pharyngee pourrait a l’avenir, ameliorer le diagnostic etiologique differentiel des lesions.

A prospective study was designed to compare two single-dilator percutaneous tracheotomy techniques, the Ciaglia BlueRhino and the Percutwist technique. One hundred and ninety adult patients were included, 166 with the BlueRhino, a conical shaped, flexible rubber dilator, and 24 with the Percutwist, a screw like dilating device. The procedure was performed under fiberscopy in the intensive care unit (ICU). Age, body mass index (BMI), indication for tracheotomy, surgical landmarks, duration of the procedure and surgical complications were recorded. Median age and indications were similar for the two groups. Dilation was successful in all patients. The mean time for surgery was shorter with the Ciaglia technique: 8 +/- 3 versus 12 +/- 5 min with the Percutwist technique (P = 0.004). There was no significant difference related to weight, BMI, duration of tracheotomy and complications between both groups. One posterior tracheal wall puncture was observed with the Ciaglia technique and four with the Percutwist technique. No serious complications were noted with either technique. The Percutwist technique represents an alternative to the more established Ciaglia BlueRhino technique. The Ciaglia technique is a safe and more rapid procedure for bedside tracheotomy.

Objectives: The development of the scanning system AcuBlade has considerably enhanced carbon dioxide laser energy delivery, improving cutting and ablation modes. The scanning system can be applied with the 2 available high-powered pulsed waves, SuperPulse and UltraPulse. This study was conducted to determine whether there are any differences in phonosurgery between the SuperPulse and UltraPulse lasing applications with regard to thermal diffusion into the surrounding tissues, healing time, and clinical results. Methods: Thirteen patients with bilateral and similar vocal fold lesions underwent operation — One side in SuperPulse mode and the other side in UltraPulse mode. The parameters for phonosurgery were depth of 0.2 mm, 10 W, single pulse, and 0.10 second for SuperPulse, and 2 passes, 10 W, single pulse, and 0.10 second for UltraPulse. Results: Incisions were sharper with UltraPulse, making the surgery easier, but at the first postoperative follow-up visit, after 8 to 10 days, no differences were observed in the presentation, the healing, or the vibration of the 2 vocal folds. Coagulation along the incision line was 25 μm for SuperPulse and 15 μm for UltraPulse (median values). Conclusions: In comparison with SuperPulse, the UltraPulse carbon dioxide laser made the procedure easier, but did not improve the clinical outcome.

The term phonosurgery (PS) refers to any operation designed primarily for the improvement or restoration of voice. It is defined by the intended operative goal, which pertains to quality of life rather than its preservation, and informed consent needs to account for this emphasis. Since the aim is improvement or maintenance of vocal function, it is essential to document voice accurately pre-operatively. As important as the surgery itself is a team approach to perioperative care and rehabilitation. Although not a new concept, the PS portfolio of operations continues to grow rapidly, making this one of the most dynamic field in Laryngology. However, this has also led to confusion regarding terminology and classification, with the result that it is presently difficult to compare results between institutions. The aim of this paper is to establish a practical classification system for PS and to thereby establish a common language for reporting results. We propose four groups of operation: vocal fold surgery (VFS), laryngeal framework surgery (LFS), neuromuscular surgery (NHS) and reconstructive surgery (RCS) (for either partial or total laryngeal replacement).

PURPOSE OF REVIEW: This review outlines the indications, surgical techniques and follow-up, with results, for current collagen use. RECENT FINDINGS: Micronized AlloDerm (Cymetra) is a presently available injectable substance made from human collagen and elastin particles. A mean follow-up of 8-10.5 months showed lasting results after injection for vocal fold immobility. Collagen injection is one possible method for treating a vocal fold scar - or sulcus -vergeture by medialization of one or both of the scarred vocal folds. Collagen injection laryngoplasty is presently the treatment of choice for presbyphonia if speech therapy is insufficient. Collagen injection for Parkinson-related dysphonia is an effective temporary method of subjectively improving voice and speech in selected patients. Laryngeal collagen injection can also permit further medialization of one or both vocal folds after medialization thyroplasty. SUMMARY: Injection laryngoplasty with micronized AlloDerm, a presently available homologous collagen, remains a suitable option for the treatment of vocal fold immobility with a moderate gap. Collagen injection is also efficient for sulcus vergetures, scars and presbyphonia, and can help in cases of Parkinson's disease. Complications are uncommon but patients must be advised that the stability of results is unpredictable. Collagen injection can be repeated and does not prevent other surgical solutions.

OBJECTIVES: Evaluate the effectiveness of CaHA injection for patients with glottal incompetence. METHODS: Multi-center, open-label, prospective clinical study with each patient serving as his/her own control. Voice-related outcome measures were collected for pre-injection and 1, 3, and 6 months. RESULTS: Sixty-eight patients were available for evaluation. Fifty percent of the injection procedures were done in office. Fifty-seven percent were diagnosed with unilateral paralysis and 42% with glottal incompetence with mobile vocal folds. Patient satisfaction 6 months post showed 56% had significantly improved voice and 38% reported moderately improved voice. Paired t tests from baseline to 6 months showed significant improvements on the VHI and VAS (vocal effort), CAPE-V judgments of voice severity and videoendostroboscopy ratings of glottal closure, and objective voice measures of glottal closure (MPT and S:Z ratio). CONCLUSIONS: Preliminary results in this large cohort of patients demonstrate excellent clinical results. (C) 2007 American Academy of Otolarynaology-Head and Neck Surgery Foundation. All rights reserved.

Voice rehabilitation after transoral laser microsurgery to the larynx is challenging. We wait at least 6 months before surgical intervention. Only a few patients after total or extended cordectomy requested voice restoration. Subjective perception of voice using the Voice Handicap Index in medialization thyroplasty was significantly better. Medialization thyroplasty with elevation of the fibrous tissue from the inner surface of the thyroid cartilage is critical in achieving success. We preferred the Montgomery Thyroplasty Implant System. Transoral larynx anterior commissure stent placement after laser-assisted sectioning of anterior synechiae with application of mitomycin C is an effective procedure for anterior synechiae.

PURPOSE OF REVIEW: Cricopharyngeal muscle myotomy to treat swallowing disorders has a definite role in the management of cervical dysphagia. Several reports emphasize the benefits of the endoscopic approach compared with the transcervical technique. This review examines recent surgical management of cricopharyngeus dysmotility. RECENT FINDINGS: Several investigations have provided pertinent information on selecting patients for cricopharyngeal myotomy. Manofluorography appears to be more accurate in detecting intrabolus pressure anomalies during swallowing. Isolated cricopharyngeus dyscoordination, however, is not easily identified using this method. Electromyographic activity of the inferior pharyngeal constrictor and cricopharyngeus recorded by transcutaneous electrodes at rest and during deglutition has shown different dysfunction patterns. Ambulatory 24 h double probe pH monitoring and the triple sensor combination pH test demonstrate clinical correlation between pH results and symptoms in patients suffering from dysphagia related to laryngopharyngeal reflux. Transoral cricopharyngeal myotomy for the treatment of cricopharyngeus dysmotility is now established as a safe and effective method. The development of new devices has enhanced the procedure's efficacy and the overall success rate without major complications. SUMMARY: Diagnosis of cricopharyngeus dysfunction is based on anamnesis and videoradiograph findings. In doubtful cases manofluorography and electromyography should be performed. Endoscopic cricopharyngeal myotomy is a safe and effective treatment option for patients with cricopharyngeus dysphasia.

We report the history of an 8-year-old girl who was treated for suspected lung lesions of respiratory papillomatosis with Indole-3-Carbinol, local and intravenous injections of Cidofovir for 27 months. This is the first report where a complete cure of the lung lesions occurred in a child, and was sustained for at least 24 months. ispartof: Journal of Medical Virology vol:75 issue:2 pages:332-335 ispartof: location:United States status: published

Laryngotracheal stenosis has been and remains one of the most vexing problems in the field of head and neck surgery. Two treatment modalities prevail, endoscopic and external. The indication for each modality is not yet clearly defined. This undefined situation motivated our current work, and we decided to assess laser-assisted endoscopy (with or without stenting) vs. open surgery for treating chronic laryngotracheal stenosis. Our study included 28 cases of chronic laryngotracheal stenosis that were classified according to treatment in two main groups: group I included 13 patients who were endoscopically treated and group II included 15 patients with surgical reconstruction. The mean follow-up period was 12.58 months for group I and 27.43 months for group II. Respiratory function tests (RFT) were carried out preoperatively, 1-month postoperatively and on completion of follow-up. Except for age, which was significantly higher in group I ( P

In an attempt to identify molecular prognostic markers, a series of laryngeal and hypopharyngeal carcinomas was examined for PCNA, Ki67, p27(Kip1), p53, E-cadherin and CD44 by immunohistochemistry and for DNA content by flow cytometry. No correlation was found between E-cadherin, CD44, p53 or DNA ploidy and the clinicopathological data. The fraction of cancer cells immunolabelled for p27(Kip1) correlated with tumour differentiation, but not with lymph node metastasis. In contrast, the PCNA, Ki67 and S-phase fractions of cancer cells were significantly higher in tumours with lymph node metastasis than in those without lymph node metastasis and were correlated with pathological T-stages and with tumour dedifferentiation. In univariate analysis, advanced pathological T-stage, lymph node metastasis and high fractions of cancer cells immunolabelled for PCNA or Ki67 inversely correlated with overall and disease-free survival. In multivariate analysis, lymph node metastasis was the only factor significantly associated with poor survival. The data suggest that immunohistochemical investigation of PCNA and Ki67 and flow cytometric analysis of S-phase fractions may be useful predictive markers of biological aggressiveness in laryngeal carcinomas.

Purpose of review Transoral robotic surgery (TORS) has seen substantial surge since its introduction in around 2007. Although initially described for cancer of the oropharynx, advances in robotic instrumentation and endoscopy have allowed for application of TORS toward laryngeal cancer. This review discusses the recent published experience of TORS for laryngeal cancer. Recent findings TORS supraglottic laryngectomy continues to be the most frequent application of robotic surgery for laryngeal cancer. A number of case series have described the positive experience with TORS supraglottic laryngectomy with both oncologic and functional outcomes rivaling alternative therapy options. TORS total laryngectomy also continues to be applied in selective cases for laryngeal cancer. The objectives of TORS total laryngectomy is to reduce the size of the resultant pharyngotomy and to limit the lateral exposure of the cervical vessels. Although limited in numbers, TORS total laryngectomy appears to be a technique of increasing application. TORS approach for primary glottic cancer has also been described in limited case series. Although the majority of patients demonstrated positive outcomes following TORS glottic cordectomy, this technique may still require additional advancement of robotic technology before widespread application is seen. Summary A TORS approach for laryngeal cancer is increasing in application and utility. The major surgical procedures described to date include supraglottic laryngectomy, total laryngectomy, and glottic cordectomy with promising results.

We reviewed 242 cordectomy or supraglottic laryngectomy cases operated since 1989. The vocal fold epithelium removed during subepithelial cordectomy with diagnostic intent or biopsies of the operative site after tumor resection underwent frozen section examination. However, the surgical specimen never underwent frozen section analysis. Conventionally, the histopathologist examined the margin area free of laser coagulation. Using the Acuspot micromanipulator alone, coagulation depth was less than or equal to 100 µm; with the Acublade, it was less then 20 µm. Of 181 frozen sections, 154 (85.1%) had negative margins, 23 (12.7%) had positive margins and 1 (0.6%) had moderate dysplasia of the section margin. Reading was inconclusive in 2 cases (1.1%) and impossible in 1 (0.6%). The second examination of the margins during examination of the surgical specimen did not reveal false-positive or false-negative results. Of the 23 patients with positive resection margins at frozen section analysis, 8 (34.8%) underwent immediate and more extensive cordectomy. Frozen section analysis is reliable and cost-effective in oncology for endoscopic partial laryngectomy.

Objective Transoral laser microsurgery (TLM) for endoscopic excision of head and neck cancers of the upper aerodigestive tract has become an accepted treatment modality. As in any excision of head and neck tumors, the persistance of tumor at the surgical margins influences the outcome. One of the frequent criticisms of endoscopic resection is that the laser use makes interpretation of the surgical margins difficult due to the thermal effect. The goal of this study is to assess the reliability of frozen section after laser excision in locally advanced tumors. Methods The charts of patients with T2 and T3 tumors, who underwent TLM between January 2000 and 2008, using the CO2 laser AcuBlade system were reviewed. Frozen section margin results obtained during TLM were compared with margins after formalin fixation. Results Sixty-seven patients fulfilled the inclusion criteria. 20 had supraglottic tumors, 22 had oral cavity tumors, 13 had oropharyngeal tumors and 12 had hypopharyngeal tumors. Fifty-nine had no prior treatment, seven had prior radiation therapy and one had prior open surgery. The mean number of frozen margins per surgery was 4. Histological examination on the formalin-fixed tissue confirmed frozen section in 97% of the cases. In 3% of the frozen sections, the diagnosis of invasive carcinoma was missed. None of these patients had significant locoregional disease progression. Conclusion Frozen section analysis of margins is reliable during TLM when performed by an experienced team. It enables a one-stage approach reducing the need of a planned second procedure.