Vocal fold epithelial hyperplasia. Vibratory behavior vs extent of lesion

Value of high-speed videoendoscopy as an auxiliary tool in differentiation of benign and malignant unilateral vocal lesions

PURPOSE

The study aimed to assess the relevance of objective vibratory parameters derived from high-speed videolaryngoscopy (HSV) as a supporting tool, to assist clinicians in establishing the initial diagnosis of benign and malignant glottal organic lesions.

METHODS

The HSV examinations were conducted in 175 subjects: 50 normophonic, 85 subjects with benign vocal fold lesions, and 40 with early glottic cancer; organic lesions were confirmed by histopathologic examination. The parameters, derived from HSV kymography: amplitude, symmetry, and glottal dynamic characteristics, were compared statistically between the groups with the following ROC analysis.

RESULTS

Among 14 calculated parameters, 10 differed significantly between the groups. Four of them, the average resultant amplitude of the involved vocal fold (AmpInvolvedAvg), average amplitude asymmetry for the whole glottis and its middle third part (AmplAsymAvg; AmplAsymAvg_2/3), and absolute average phase difference (AbsPhaseDiffAvg), showed significant differences between benign and malignant lesions. Amplitude values were decreasing, while asymmetry and phase difference values were increasing with the risk of malignancy. In ROC analysis, the highest AUC was observed for AmpAsymAvg (0.719; p < 0.0001), and next in order was AmpInvolvedAvg (0.70; p = 0.0002).

CONCLUSION

The golden standard in the diagnosis of organic lesions of glottis remains clinical examination with videolaryngoscopy, confirmed by histopathological examination. Our results showed that measurements of amplitude, asymmetry, and phase of vibrations in malignant vocal fold masses deteriorate significantly in comparison to benign vocal lesions. High-speed videolaryngoscopy could aid their preliminary differentiation noninvasively before histopathological examination; however, further research on larger groups is needed.

Surgical Treatment of Early Glottic Cancer

The incidence of all head and neck malignancies is rising worldwide, with carcinoma of the larynx constituting approximately 1% of all cancers. Early glottic cancer responds quite favorably to surgical intervention due to its early presentation, coupled with the low rate of regional and distant metastases. This article focuses on various approaches to the surgical treatment of early glottic cancer. Details include the clinical and radiological evaluation of laryngeal cancer, the goals of treatment, current surgical options for early disease, approach to surgical resection margins and management of nodal disease, and complications associated with each treatment modality.

Changing trends in the clinical features of laryngeal tuberculosis: a report of 19 cases

OBJECTIVE

This study was undertaken to evaluate the changing trends in the clinical features of laryngeal tuberculosis, with the goal of reducing misdiagnosis and incorrect treatment.

METHODS

A retrospective clinical analysis compared the clinical patterns in five cases with pathologically confirmed laryngeal tuberculosis seen before 1990 with those of 14 cases of laryngeal tuberculosis seen after 1998.

RESULTS

The five patients seen before 1990 ranged in age from 19 to 41 years of age, with a mean of 32 years. The most frequent chief complaint was odynophagia accompanying system symptoms and pulmonary tuberculosis. The posterior part of the larynx was commonly involved and the lesions tended to be ulcerative and multiple. The 14 patients seen after 1998 were aged from 17 to 71 years with a mean age of 49.9 years. The most frequent chief complaint was hoarseness (71.4%). The most common lesion site was in the true vocal cords (57.2%). Most of patients with normal lung status had single, nonspecific, polypoid lesions. Stroboscopy revealed four different appearances.

CONCLUSIONS

Laryngeal tuberculosis may occur even without pulmonary tuberculosis, and the characteristics of the lesions appear to be more nonspecific. It is important to consider tuberculosis in the differential diagnosis of laryngeal disease.

Mucosal Wave: A Normophonic Study Across Visualization Techniques

Visualization of vocal fold vibration is essential for accurate diagnoses and optimal treatment of persons with voice disorders. Recently, scientific and anecdotal reports have evidenced an increased amount of variation in the diagnostically relevant features of extent and symmetry of mucosal wave magnitude in normophonic speakers. The objectives of this study were to preliminarily ascertain the variation in mucosal wave magnitude and symmetry for normophonic speakers as assessed via standard and novel techniques, and compare findings across modal and pressed phonations. A correlational design with a multiple baseline across visualization methods approach was used. Mucosal wave presence, magnitude, and symmetry from 52 normophonic speakers were judged via stroboscopy, high-speed videoendoscopy (HSV) playback, mucosal wave playback, and mucosal wave kymography playback. Results demonstrate a prevalence of atypical magnitude and symmetry of mucosal wave during modal and pressed phonations by normophonic persons, differences across techniques, and a relationship between judgments and habitual fundamental frequency. Given the prevalence of mucosal wave magnitude and symmetry variations in the normophonic population, overdiagnosis may be possible without caution. The various visualization techniques provided unique information suggesting that it may be beneficial to use both full view and kymographic visualization techniques in combination. A major restriction of the current commercial HSV systems is the frame rate, typically limited to 2000 frames per second, which appears insufficient for most female habitual phonations.

Valoración estroboscópica de laringitis crónicas

INTRODUCTION

The laryngostroboscopy allows analysis of the vocal fold vibrations during phonation. Disruption of normal viscoelastic properties of the superficial lamina propria results in aberrant vocal fold vibration and mucosal wave propagation. Therefore, an investigation was performed to relate the stroboscopic results with the anatomopathologic results of chronic laryngitis and glottic cancer.

MATERIAL AND METHODS

We performed a retrospective study, which included 30 direct laryngoscopies with biopsy of 25 patients and their corresponding laryngostroboscopies.

RESULTS

60% of the cases of "absence of mucosal wave" displayed severe dysplasia or carcinoma. 20% of the cases of "limited or present mucosal wave" were carcinoma.

CONCLUSIONS

The probability of finding severe dysplasia or carcinoma is significantly greater when we find absence of mucosal wave. The presence of mucosal wave does not exclude the possibility of malignant lesion of the vocal fold.

Analysis of recurrences in 322 Tis, T1, or T2 glottic carcinomas treated by carbon dioxide laser

An endoscopic approach to early glottic carcinoma is considered a sound treatment for both previously untreated lesions and selected recurrent lesions. Between January 1988 and December 2000, we treated 322 patients by CO2 laser at a single institution; 37 had Tis, 191 T1a, 55 T1b, and 39 T2 lesions (mean follow-up, 77 months; range, 6 to 180 months). Kaplan-Meier curves showed a 5-year overall survival rate of 88%, a determinate survival rate of 99%, a disease-free survival rate of 81%, a rate of ultimate local control with laser alone of 91%, and a laryngeal preservation rate of 97%. Univariate and multivariate analysis showed that the only factor that statistically affected endoscopic control was lateral extension of the tumor with involvement of the bottom of the ventricle (hazard risk ratio, 4.0; 95% confidence interval, 1.71 to 9.35). The 58 recurrences were classified according to their location compared with the site of the primary tumor as follows: 14 in the same area (group A), 27 in adjacent subsites with superficial spreading or multifocal distribution (group B), and 17 in adjacent sites by submucosal diffusion to the visceral spaces, cartilaginous framework, or extralaryngeal tissues (group C). For each group, we analyzed the rate of patients who underwent salvage by endoscopic or open neck procedures and the rate of laryngeal preservation. Recurrences in groups A and B were endoscopically treated in 86% and 74% of cases, respectively. By contrast, in group C no patient was endoscopically cured, and there was a low laryngeal preservation rate (47%). The pathways of spread in recurrent carcinoma are therefore the single most important factor in predicting its endoscopic curability.

Tratamiento con láser co2 de las lesiones glóticas leucoplásicas premalignas

Pre-malignant lesions of the larynx can degenerative into invasive carcinoma. There is not an universally accepted classification and treatment. We present our experience in the treatment with endoscopic CO2 laser for the pre-malignant glottic epithelial lesions. At the same time we carry out a review of the literature published. During a period of ten years we have treated 69 patients with one of these techniques: resection of the epithelial lesion or vaporization. The election of the technique depends on the size of the lesion, the macroscopic aspect, anterior commissures involvement and the surgeons experience. The histological findings were: 53.6% keratosis and 23.2% mid dysplasia both of them treated with vaporization and resection; 14.5% moderate dysplasia and 8.7% severe treated with resection of the lesion. There were no important complications during the operation. Recurrence occurred in 7 patients (10%) but after treatment all of them were free of disease during the follow-up period, they didn't progress to carcinomatosis. 9 patients (13%) had a malignant evolution: 3 keratosis, 1 mild dysplasia, 3 moderate dysplasia and 2 severe dysplasia. Only one case (1.5%) underwent total laryngectomy. The early diagnosis and an appropriate treatment reduced the possibilities of malignant transformation. The therapy with CO2 laser is the treatment of choice in this kind of lesions.

Stroboscopic assessment of vocal fold keratosis and glottic cancer

Disruption of the normal viscoelastic properties of the superficial lamina propria (SLP) results in aberrant vocal fold vibration and mucosal wave propagation. Therefore, an investigation was performed to determine whether stroboscopy is a reliable method for 1) differentiating invasive glottic carcinoma from intraepithelial atypia or 2) determining the depth of cancer invasion. An analysis was done on the preoperative vocal fold vibration characteristics of 62 keratotic (intraepithelial, 45; cancer, 17) lesions that were subsequently resected by means of microlaryngoscopy. Histopathology and intraoperative mapping were used to specify the depth of invasion. A panel of 4 blinded judges was used to assess the amplitude of vocal fold vibration and the magnitude of mucosal wave activity in the region of the lesion from videostroboscopic recordings. The final comparative data set comprised only those ratings that achieved at least 75% interjudge agreement. Of the 28 intraepithelial lesions that could be reliably evaluated for amplitude of vocal fold vibration, only 2 were normal, with the amplitude reduced in 24 and absent in 2. Of the 30 intraepithelial lesions in which mucosal wave activity could be reliably assessed, only 2 were normal, with the wave reduced in 24 and absent in 4. Furthermore, amplitude of vocal fold vibration and magnitude of mucosal wave propagation were absent in 2 of 4 carcinomas in which the depth of microinvasion did not reach the vocal ligament. According to the findings herein, reduced amplitude of vocal fold vibration and/or mucosal wave propagation associated with keratosis did not reliably predict the presence of cancer or the depth of cancer invasion into the laminae propriae. However, the presence of a flexible mucosal wave probably indicates that there is not extensive vocal ligament invasion. Reductions in the amplitude of vocal fold vibration and in mucosal wave magnitude were usually noted in intraepithelial atypia, despite the fact that there was no invasion into the SLP. The reduced epithelial pliability could be due to bulky keratosis and/or alteration of the SLP occurring as a result of inflammation or fibrovascular scarring.

Premalignant epithelium and microinvasive cancer of the vocal fold: the evolution of phonomicrosurgical management

Phonomicrosurgical treatment of premalignant vocal fold epithelium and microinvasive cancer combines principles of surgical oncology with advanced laryngoscopic microsurgical-techniques. This treatment is guided by mucosal-wave theory of voice production and strives not only to cure the disease but also to achieve optimal vocal function. Surgical techniques developed during the past two centuries have improved methods for vocal fold visualization, tissue retrieval, and tissue evaluation. Examination of the evolution of these surgical techniques reveals the incomplete convergence of laryngoscopic surgical theory with both the concept of premalignancy and the anatomical-physiological principles of voice production. This historical review, which helps to explain the lack of consensus about current treatment options, led to a series of four investigations. They were conducted with the aim of developing a laryngoscopic (phonomicrosurgical) management approach for improving the treatment of premalignant and microinvasive vocal fold epithelium. In the first of four investigations, 42 patients (each of whom had a significant smoking history) underwent microlaryngoscopic biopsy of 52 vocal fold lesions. These lesions, which were suspicious for atypia or malignancy and were confined to the musculomembranous vocal fold, were mapped according to surface involvement and depth of penetration. Review of the maps revealed that 27 of the 52 lesions involved only the superior/ventricular surface. For these patients, the entire layered vocal fold structure could potentially be preserved on the medial/vocalizing surface. Twenty-five of the 52 lesions involved both the superior/ventricular surface and the medial/vocalizing surface. No lesion involved only the medial surface. These data suggest that (in smokers) geographic localization of keratotic and erythroplastic lesions on the superior/ventricular surface of the musculomembranous vocal fold are likely to contain atypia. This characteristic facilitates the appropriate selection of patients for biopsy and may spare individuals, who have lesions resulting from hyperfunctional dysphonia and/or gastroesophageal reflux, from unnecessary biopsy. These two disorders typically result in pathology on the medial and/or posterior glottal surfaces. In order to determine whether a directed biopsy or an excisional biopsy approach is preferable for obtaining an accurate diagnosis, all specimens underwent whole-mount sectioning for three-dimensional histopathological analysis. Keratosis was noted: without atypia in 14; with atypia in 27; and with carcinoma in 11. The severity of the atypia usually varied throughout each specimen. The surface appearance of the lesion was not a reliable prognosticator of the severity of dysplasia either between patients or in different areas of the same lesion; therefore, excisional biopsy and whole-mount, multiple-section histopathological analysis were necessary for obtaining an accurate diagnosis.(ABSTRACT TRUNCATED AT 400 WORDS)

Laser surgery for epithelial hyperplasia of the vocal fold

A total of 88 patients with epithelial hyperplasia of the vocal fold were treated with endolaryngeal microscopic carbon dioxide laser surgery during the period from 1978 to 1990. The majority of the patients were male smokers. During the follow-up period ranging from 12 to 156 months, 15 patients developed recurrence(s). The recurrent lesion was benign epithelial hyperplasia in 8 patients and invasive carcinoma in 7 patients. The recurrences occurred only in preoperative smokers. Discontinuation of smoking following laser surgery did not affect the incidence of recurrence. The incidence of development of carcinoma did not differ between two histologic types: simple hyperplasia without cellular atypia and dysplasia associated with cellular atypia. The incidence of cancer development for dysplasia cases in the present series (6%) was lower than that in previous reports in which the carbon dioxide laser was not employed for the treatment. Postoperative improvement of vocal function was manifested in an increase of the maximum phonation time, a decrease of the mean airflow rate, and an increase in vibratory amplitude and mucosal wave.