Compact endoscopy of the larynx

Correlation of narrow-band imaging findings using the Ni and European Laryngeal Society classification systems during in-office flexible laryngoscopy with histopathology

OBJECTIVE

This study used the European Laryngeal Society (2016) and Ni (2011 and 2019) classifications for narrow-band imaging and correlated the findings with histopathology.

METHODS

Retrospective analysis was conducted by retrieving data of patients who underwent micro-laryngoscopy for suspicious glottic lesions. The narrow-band imaging findings were classified using both classification systems. Retrieved histopathology report findings were correlated with narrow-band imaging data.

RESULTS

Using the European Laryngeal Society and Ni classifications, 37 (69.8 per cent) and 35 (66 per cent) patients, respectively, were suspected to have malignant lesions. Upon histopathology, 37 (69.8 per cent) lesions were malignant. Sensitivity, specificity, positive predictive value, negative predictive value and accuracy using the European Laryngeal Society classification were 91.9 per cent, 81.3 per cent, 91.9 per cent, 81.3 per cent and 88.7 per cent, and using the Ni classification were 91.9 per cent, 93.8 per cent, 97.1 per cent, 83.3 per cent and 92.5 per cent, respectively.

CONCLUSION

The Ni classification had better specificity and accuracy. The European Laryngeal Society classification is simple to use and may serve as a useful screening tool. For optimum results, both European Laryngeal Society and Ni classifications may be used together, in that order.

Role of Narrow Band Imaging in Laryngeal Lesions: A Prospective Study from Southern India

To assess the utility of Narrow Band Imaging (NBI) as a diagnostic tool in evaluating laryngeal pathology in patients presenting with hoarseness. Study design: Prospective cross sectional diagnostic study. Methods: 200 patients with voice change were recruited and laryngeal findings documented with high definition flexible endoscopy with both white light and narrow band light and the representative still images recorded for analysis. The NBI intraepithelial papillary capillary loop (IPCL) patterns was compared with the histopathology report. Of the 200 patients evaluated, 84 lesions were biopsied which included both benign and malignant lesions. The sensitivity obtained was 73.3% [54.1-87.7% with 95% CI] and the specificity was 87% [75.1-94.6% with 95% CI] for detecting malignant lesions. NBI can be considered as a useful diagnostic tool in evaluating laryngeal pathology and can be used to detect early premalignant and malignant lesions.

Evaluation of laryngeal vascular changes with image1 s enhancement system in reference to the European laryngological society guideline

OBJECTIVES

To assess the feasibility of using Image1 S™ endoscopic enhancement system for discrimination of the vascular patterns in laryngeal lesions.

DESIGN

Forty patients presenting with benign, dysplastic and malignant laryngeal lesions were examined with Image1 S system. The vascular patterns were classified by a group of authors according to the European Laryngological Society (ELS) guideline, as perpendicular or longitudinal, in all lesions. The relationship between the vascular patterns and the pathological results was statistically analysed. Endoscopic images of the lesions were evaluated through an online survey by a group of otolaryngologists with different levels of clinical expertise and asked them to choose a diagnosis and a vascular pattern. The vascular pattern evaluations of the participants were compared to the authors' evaluations to determine the interobserver reliability. The final diagnostic judgements of the participants were compared with the definitive histopathological diagnoses.

SETTING

Tertiary university hospital.

PARTICIPANTS

Forty patients with laryngeal lesions and thirty otolaryngologists with different clinical experience levels.

MAIN OUTCOME MEASURES

The study evaluates the usefulness of the Image1 S system for the detecting the vascular patterns associated with benign, dysplastic, and malignant lesions and measures the level of accuracy and inter observer agreement in detecting the final histopathology.

RESULTS

Histopathological examination diagnosed 12 patients as benign, 12 dysplastic and 16 malignant. Using Image1 S, the vascular patterns were longitudinal in 11 lesions, perpendicular in 28 lesions and undetectable in 1 lesion. With white light, longitudinal pattern was observed in 14 lesions, perpendicular in 21 lesions and undetectable in 5 lesions. The correlation between the vascularisation pattern and the pathological diagnosis was found to be significant (p < .001). The qualitative evaluation of the vascular patterns by the two groups of observers showed significant reliability (κ = 0.63, p < .001). The agreement with the final diagnoses was also significant (κ = 0.56, p < .001).

CONCLUSIONS

Image1 S endoscopic enhancement system with spectral modes provides an improved visibility of the vascular patterns defined by the ELS in laryngeal lesions. ELS classification can reliably distinguish benign lesions from suspected ones and can be applied even by less-experienced clinicians but the final diagnosis needs experience and should be confirmed with histopathology.

Laryngeal Lesion Classification Based on Vascular Patterns in Contact Endoscopy and Narrow Band Imaging: Manual Versus Automatic Approach

Longitudinal and perpendicular changes in the vocal fold’s blood vessels are associated with the development of benign and malignant laryngeal lesions. The combination of Contact Endoscopy (CE) and Narrow Band Imaging (NBI) can provide intraoperative real-time visualization of the vascular changes in the laryngeal mucosa. However, the visual evaluation of vascular patterns in CE-NBI images is challenging and highly depends on the clinicians’ experience. The current study aims to evaluate and compare the performance of a manual and an automatic approach for laryngeal lesion’s classification based on vascular patterns in CE-NBI images. In the manual approach, six observers visually evaluated a series of CE+NBI images that belong to a patient and then classified the patient as benign or malignant. For the automatic classification, an algorithm based on characterizing the level of the vessel’s disorder in combination with four supervised classifiers was used to classify CE-NBI images. The results showed that the manual approach’s subjective evaluation could be reduced by using a computer-based approach. Moreover, the automatic approach showed the potential to work as an assistant system in case of disagreements among clinicians and to reduce the manual approach’s misclassification issue.

A Preliminary Study on Automatic Characterization and Classification of Vascular Patterns of Contact Endoscopy Images

The structure and organization of blood vessels in the vocal fold go through changes during the advancement from healthy to benign and further on to malignant stages. Contact Endoscopy (CE) is an optical technique providing real-time information related to the vascular structure of laryngeal mucosa. However, this technique comes with subjectivity in the interpretation of vascular patterns. In this study, a novel automated approach is proposed for vessel pattern charac-terization and classification of larynx CE + Narrow Band Imaging (NBI) images. This method is mainly based on the computation of indicators related to the level of disorder of vessels. 12 features were extracted from the indicators and were fed into two supervised classifiers. Linear Support Vector Machine (SVM) and K-Nearest Neighbor (KNN) showed an accuracy of 95.76% and 93.92% for vascular patterns and 86.04% and 82.23% for larynx histopathologies classification, respectively. These promising results show that the proposed method can potentially solve the subjectivity issues of CE.

Interrater variation of vascular classifications used in enhanced laryngeal contact endoscopy

PURPOSE

Combined use of contact endoscopy (CE) and Narrow Band Imaging (NBI, Olympus^®) is suggested for the visualization of specific vascular changes indicative of glottic neoplasia. We investigated the interrater reliability and agreement in 3 recognized classification systems of vascular changes applied to images from CE + NBI in patients suspected for glottic neoplasia.

METHODS

Six experienced head and neck surgeons familiar with NBI rated 120 images obtained by CE + NBI by 3 classification systems of vascular changes as suggested by Ni et al. (N-C), Puxeddu et al. (P-C), and the European Laryngological Society (ELS-C). Three raters were experienced in CE, and three raters had only limited experience with CE. Crude agreement and Fleiss' kappa with 95% confidence interval were estimated for all 6 raters, and for the 2 levels of expertise for each original classification system and for dichotomized versions of the N-C and the P-C based on suggested neoplastic potential.

RESULTS

The interrater crude agreement and the corresponding kappa values for the ELS-C were good and significantly higher than those for the N-C and P-C for all raters, irrespective of the level of experience with CE (p < 0.0001). There were no significant differences between the N-C and the P-C (p = 0.16). Kappa was considerably improved for both the N-C and the P-C to a level not different from the ELS-C (p = 0.21-0.71) when their 5 original categories were pooled into dichotomized classifications.

CONCLUSION

Difficulties in reliably classifying vascular changes in CE + NBI are evident. Two-tier classification systems are the most reliable.

Evaluation of Vascular Patterns Using Contact Endoscopy and Narrow-Band Imaging (CE-NBI) for the Diagnosis of Vocal Fold Malignancy

The endoscopic detection of perpendicular vascular changes (PVC) of the vocal folds has been associated with vocal fold cancer, dysplastic lesions, and papillomatosis, according to a classification proposed by the European Laryngological Society (ELS). The combination of contact endoscopy with narrow-band imaging (NBI-CE) allows intraoperatively a highly contrasted, real-time visualization of vascular changes of the vocal folds. Aim of the present study was to determine the association of PVC to specific histological diagnoses, the level of interobserver agreement in the detection of PVC, and their diagnostic effectiveness in diagnosing laryngeal malignancy. The evaluation of our data confirmed the association of PVC to vocal fold cancer, dysplastic lesions, and papillomatosis. The level of agreement between the observers in the identification of PVC was moderate for the less-experienced observers and almost perfect for the experienced observers. The identification of PVC during NBI-CE proved to be a valuable indicator for diagnosing malignant and premalignant lesions.

[Combined application of modern endoscopic techniques in the detection of precancerous and malignant lesions of larynx]

INTRODUCTION

Early detection of malignant laryngeal tumors is crucial but still challenging. And 5-year survival rate depends on a stage of revealing. The aim of the study - assessment of the effectiveness of combined application of narrow band imaging and contact endoscopy in visualization of neoangiogenesis.

MATERIAL AND METHODS

102 patients were included in this study. All the patients were evaluated by means of narrow band imaging and contact endoscopy.

RESULTS

Combined application of narrow band imaging and contact endoscopy gained a high level of effectiveness: accuracy - 93.9%, sensitivity - 96%, specificity - 93.4%, positive predictive value - 94.3%, negative predictive value - 93.4%.

CONCLUSION

Combined application of narrow band imaging and contact endoscopy may contribute to early detection of malignant laryngeal tumors.

Pediatric dysphonia: It's not about the nodules

OBJECTIVE

Despite the fact that vocal nodules are the most common cause of chronic dysphonia in children, uncertainty and lack of consensus complicates practically every diagnostic and management decision. Selecting an optimal staging system is fundamental to understanding a disease process, mandatory for uniform reporting, and crucial to predicting natural history and treatment outcomes. The ideal prognostic model for vocal nodules is under intense debate. The purpose of this study was to analyze the predictive power of vocal nodule grade to severity of voice metrics in children.

METHODS

Seventy-nine patients diagnosed with vocal cord nodules between 2006 and 2012 were drawn from UPMC Children's Hospital of Pittsburgh Voice, Resonance and Swallowing Center Research Registry. Subject age at time of diagnosis, nodule grade, relevant co-morbidities, scores on The Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V), parent-reported Pediatric Voice Handicap Index (pVHI), the phonotraumatic behaviors profile, habitual speaking pitch fundamental frequencies, pitch range, volume intensity, and s/z ratio were recorded and compiled into a de-identified database for analysis.

RESULTS

Based on the Kruskal-Wallis H Test, there was no statistically significant correlation between nodule grade and total pitch range (p = .21), s/z ratio (p = .50), volume intensity (p = .33), overall CAPE-V Scores (p = .15), or pVHI Scores (p = .29). Chi-squared tests also revealed no significant associations between nodule grade and abnormality in habitual speaking pitch (p = .14 for fundamental frequency while sustaining a vowel sound, p = .37 for fundamental frequency while speaking structured tasks i.e. counting, or p = .76 while speaking in conversation).

CONCLUSION

The current "gold-standard" for grading vocal nodule size suggests that the nodules themselves are not driving the standard dysphonic metrics that are most commonly collected and monitored in such children. This outcome is consistent with other studies reporting similar findings and was expected based on the inconsistencies in the reported literature to date. By extension, the conventional wisdom of avoiding surgical treatment of vocal nodules in children seems prudent as there is little evidence to suggest that the nodules themselves are "driving" the severity of the dysphonia. Ultimately identifying the true "drivers" of dysphonia in children will suggest alternative therapies that are more specific and directed to the pathophysiology. Most pediatric voice care professionals will welcome such discoveries as those in the front line of patient care are often rendered helpless and frustrated.

Novel automated vessel pattern characterization of larynx contact endoscopic video images

Purpose

Contact endoscopy (CE) is a minimally invasive procedure providing real-time information about the cellular and vascular structure of the superficial layer of laryngeal mucosa. This method can be combined with optical enhancement methods such as narrow band imaging (NBI). However, these techniques have some problems like subjective interpretation of vascular patterns and difficulty in differentiation between benign and malignant lesions. We propose a novel automated approach for vessel pattern characterization of larynx CE + NBI images in order to solve these problems.

Methods

In this approach, five indicators were computed to characterize the level of vessel’s disorder based on evaluation of consistency of gradient and two-dimensional curvature analysis and then 24 features were extracted from these indicators. The method evaluated the ability of the extracted features to classify CE + NBI images based on the vascular pattern and based on the laryngeal lesions. Four datasets were generated from 32 patients involving 1485 images. The classification scenarios were implemented using four supervised classifiers.

Results

For classification of CE + NBI images based on the vascular pattern, polykernel support vector machine (SVM), SVM with radial basis function (RBF), k-nearest neighbor (kNN), and random forest (RF) show an accuracy of 97%, 96%, 96%, and 96%, respectively. For the classification based on the histopathology, Polykernel SVM showed an accuracy of 84%, 86% and 84%, RBF SVM showed an accuracy of 81%, 87% and 83%, kNN showed an accuracy of 89%, 87%, 91%, RF showed an accuracy of 90%, 88% and 91% for classification between benign histopathologies, between malignant histopathologies and between benign and malignant lesions, respectively.

Conclusion

These promising results show that the proposed method could solve the problem of subjectivity in interpretation of vascular patterns and also support the clinicians in the early detection of benign, pre-malignant and malignant lesions.

Silsesquioxane polymer as a potential scaffold for laryngeal reconstruction

Cancer, disease and trauma to the larynx and their treatment can lead to permanent loss of structures critical to voice, breathing and swallowing. Engineered partial or total laryngeal replacements would need to match the ambitious specifications of replicating functionality, outer biocompatibility, and permissiveness for an inner mucosal lining. Here we present porous polyhedral oligomeric silsesquioxane-poly(carbonate urea) urethane (POSS-PCUU) as a potential scaffold for engineering laryngeal tissue. Specifically, we employ a precipitation and porogen leaching technique for manufacturing the polymer. The polymer is chemically consistent across all sample types and produces a foam-like scaffold with two distinct topographies and an internal structure composed of nano- and micro-pores. While the highly porous internal structure of the scaffold contributes to the complex tensile behaviour of the polymer, the surface of the scaffold remains largely non-porous. The low number of pores minimise access for cells, although primary fibroblasts and epithelial cells do attach and proliferate on the polymer surface. Our data show that with a change in manufacturing protocol to produce porous polymer surfaces, POSS-PCUU may be a potential candidate for overcoming some of the limitations associated with laryngeal reconstruction and regeneration.

Proposal for a descriptive guideline of vascular changes in lesions of the vocal folds by the committee on endoscopic laryngeal imaging of the European Laryngological Society

In the last decades new endoscopic tools have been developed to improve the diagnostic work-up of vocal fold lesions in addition to normal laryngoscopy, i.e., contact endoscopy, autofluorescence, narrow band imaging and others. Better contrasted and high definition images offer more details of the epithelial and superficial vascular structure of the vocal folds. Following these developments, particular vascular patterns come into focus during laryngoscopy. The present work aims at a systematic pathogenic description of superficial vascular changes of the vocal folds. Additionally, new nomenclature on vascular lesions of the vocal folds will be presented to harmonize the different terms in the literature. Superficial vascular changes can be divided into longitudinal and perpendicular. Unlike longitudinal vascular lesions, e.g., ectasia, meander and change of direction, perpendicular vascular lesions are characterized by different types of vascular loops. They are primarily observed in recurrent respiratory papillomatosis, and in pre-cancerous and cancerous lesions of the vocal folds. These vascular characteristics play a significant role in the differential diagnosis. Among different parameters, e.g., epithelial changes, increase of volume, stiffness of the vocal fold, vascular lesions play an increasing role in the diagnosis of pre- and cancerous lesions.

Contact endoscopy as a novel technique in the detection and diagnosis of oral cavity and oropharyngeal mucosal lesions in the head and neck

Objective:

We aimed to investigate the diagnostic accuracy of contact endoscopy in evaluating oral and oropharyngeal mucosal lesions.

Methods:

Between January 2010 and December 2011, 34 patients with lesions of the oral and oropharyngeal mucosa were enrolled in the study. Comparison between initial contact endoscopy results and ‘gold standard’ tissue biopsy was undertaken.

Results:

Nine patients had histologically confirmed squamous cell carcinoma, 2 had carcinoma in situ, 3 had dysplastic lesions and 20 patients had various benign lesions. Contact endoscopy demonstrated sensitivity and specificity of 89 and 100 per cent respectively in the evaluation of malignant lesions. Benign lesions were correctly categorised in 50 per cent of cases (10/20). The video images from contact endoscopy could not be interpreted in six cases.

Conclusions:

Contact endoscopy demonstrates high sensitivity and specificity in the imaging of malignant lesions with reduced reliability in the evaluation of benign lesions. Significant shortcomings also exist in the design of current technology that we believe represent a significant barrier to the reliable collection of useful video data.

High specificity of combined narrow band imaging and autofluorescence mucosal assessment of patients with head and neck cancer

BACKGROUND

The purpose of this study was to evaluate combined autofluorescence (AF) and narrow band imaging (NBI) for detection of mucosal lesions additional to known primary head and neck cancers and to determine impact on management.

METHODS

Patients with head and neck cancer requiring preoperative screening or posttreatment surveillance had white light (WL), AF and NBI inspection of the head and neck and bronchus. Known primary cancers were not analyzed, only additional lesions. Moderate dysplasia or worse was considered significant.

RESULTS

In all, 73 patients were recruited. Respectively, there were 24 and 18 additional lesions in the head and neck and bronchus that had significant histopathology. In both regions, AF and NBI were more sensitive than WL for detecting significant dysplasia with NBI demonstrating better specificity than AF (p = .003); 11 of 73 patients (15.1%) had additional findings detected by AF and NBI, which had an impact on management.

CONCLUSION

Combined AF and NBI inspection is highly specific at panendoscopy and can influence management.

Potentially malignant lesions of the upper aerodigestive tract

Mucosal lesions of the upper aerodigestive tract usually concern the squamous epithelium of the surface. Many precancerous alterations now designated as potentially malignant are caused by DNA damage resulting from long term exposure to tobacco and alcohol consumption. The distinction from conditions with a similar phenotype but caused by different reasons such as viral infection may be difficult. Furthermore, a magnitude of similar appearing lesions with different clinical background and different biological behavior are discussed in this paper.

Contact endoscopy as a novel technique in the detection and diagnosis of mucosal lesions in the head and neck: a brief review

Background. There are a variety of described noninvasive optical detection techniques for evaluation of head and neck mucosal lesions. Contact endoscopy is a promising method of in vivo microscopic examination whereby a rigid telescope is placed on a previously dye-stained mucosa allowing evaluation of the superficial cell layers of the epithelium. This technique produces real-time, magnified images of cellular architecture of surface mucosa comparable to histology without the need for biopsy. In this review, we will briefly summarize the efficacy of CE in the detection of precancerous and cancerous mucosal lesions and its potential as a novel technique in early diagnosis, monitoring, and preoperative assessment of mucosal lesions of the head and neck. Methods. PUBMED, MEDLINE, and COCHRANE search revealed five prospective articles on contact endoscopy for the diagnosis of mucosal lesions in the head and neck. Results. The literature search yielded five prospective studies examining contact endoscopy for the diagnosis of benign versus malignant head and neck mucosal lesions. These reported a sensitivity and specificity of 77-100%, specificity of 66-100% and an accuracy of 72-92%. Conclusion. Contact endoscopy is a promising optical technology that may be a useful adjunct in the evaluation and diagnosis of benign and malignant head and neck mucosal lesions. Future prospective randomized double-blind studies of this detection method are required.

Optical coherence tomography allows for the reliable identification of laryngeal epithelial dysplasia and for precise biopsy: a clinicopathological study of 61 patients undergoing microlaryngoscopy

OBJECTIVES/HYPOTHESIS

A newly developed microscope-based spectral-domain optical coherence tomography (SD-OCT) device and an endoscope-based time-domain OCT (TD-OCT) were used to assess the inter-rater reliability, sensitivity, specificity, and accuracy of benign and dysplastic laryngeal epithelial lesions.

STUDY DESIGN

Prospective study.

METHODS

OCT during microlaryngoscopy was done on 35 patients with an endoscope-based TD-OCT, and on 26 patients by an SD-OCT system integrated into an operating microscope. Biopsies were taken from microscopically suspicious lesions allowing comparative study of OCT images and histology.

RESULTS

Thickness of the epithelium was seen to be the main criterion for degree of dysplasia. The inter-rater reliability for two observers was found to be kappa = 0.74 (P <.001) for OCT. OCT provided test outcomes for differentiation between benign laryngeal lesions and dysplasia/CIS with sensitivity of 88%, specificity of 89%, PPV of 85%, NPV of 91%, and predictive accuracy of 88%. However, because of the limited penetration depth of the laser light primarily in hyperkeratotic lesions (thickness above 1.5 mm), the basal cell layer was no longer visible, precluding reliable assessment of such lesions.

CONCLUSIONS

OCT allows for a fairly accurate assessment of benign and dysplastic laryngeal epithelial lesion and greatly facilitates the taking of precise biopsies. Laryngoscope, 2010.

The role of computer-assisted analysis in the evaluation of nuclear characteristics for the diagnosis of precancerous and cancerous lesions by contact laryngoscopy

PURPOSE

Contact endoscopy (CE) through the direct contact with the surface of the mucosa enables in vivo visualization of upper epithelial layers. There is a broad spectrum of laryngeal pathologies, as has been confirmed by earlier CE reports. The aim of the study was to resolve some of the limitations of CE through the application of computer-assisted image analysis. Quantitative and qualitative evaluation of nuclei was applied in the diagnosis of precancerous and cancerous lesions.

MATERIALS AND METHODS

Fifty four patients with various laryngeal pathologies were included in the study. Paraffin section histopathology showed 15 benign lesions, 12 precancerous lesions (5 mild and 7 severe dysplasias) and 27 invasive squamous cell cancers (SCC). After staining the mucous with 1% methylen blue, examination with contact endoscope (Karl Storz, Germany) connected to the C-7070 Wide Zoom Olympus high-resolution camera was performed.

RESULTS

The most discriminative parameters were revealed to be as follows: nucleus area (p<0.001), nuclei density index (p<0.001), elongation coefficient (p<0.05), nucleus area to equivalent area ratio (p<0.05). Computer-assisted image analysis composed with data mining techniques is presented for nuclei categorization.

CONCLUSIONS

We established that computer-aided image analysis can indicate, with a high level of reliability, cases of severe dysplasia and carcinoma. By implementing the technique described in this paper, we can substantially increase the sensitivity of CE.

Comparison of contact endoscopy and frozen section histopathology in the intra-operative diagnosis of laryngeal pathology

Andrea et al. were the first to use contact endoscopy in the diagnosis of laryngeal disease, in 1995. This method enables in vivo microscopy of laryngeal mucosa.

In the present study, comparison of contact endoscopy with frozen section histopathology was performed in 142 patients with various diseases of the larynx. Paraffin section histopathology diagnosed 70 benign lesions, 23 precancerous lesions and 49 malignant lesions. Frozen section histopathology showed a sensitivity of 89.8 per cent, a specificity of 98.9 per cent and an accuracy of 95.7 per cent (χ2 = 1.5; p = 0.18). Frozen histopathology diagnosed 45 malignant lesions, including one false positive and five false negative results. Contact endoscopy yielded a sensitivity of 79.59 per cent, a specificity of 100 per cent and an accuracy of 92.95 per cent (χ2 = 8.1; p = 0.002). All malignant lesions diagnosed by contact endoscopy were confirmed by histopathology; contact endoscopy failed to recognise malignant lesions in 10 patients.

Contact endoscopy is preferable to frozen section histopathology as it is noninvasive, provides information on microscopic diagnosis and laryngeal lesion margins, and enables visualisation of the laryngeal mucosa microvasculature. The use of contact endoscopy along with frozen section histopathology improves diagnostic accuracy and allows for operative (or other) therapy to continue according to the results obtained.

Technique of optical coherence tomography of the larynx during microlaryngoscopy

Optical coherence tomography (OCT) is a new, noninvasive imaging technology for the evaluation of superficial lesions. Because of a penetrating depth of a few millimeters and an ultrahigh tissue resolution, it qualifies for use in the larynx and might in the near future play an important role in the pre-, intra-, and postoperative investigation of early laryngeal cancer and its precursor lesions. Especially directed to otolaryngologists, this paper describes the technique of in vivo OCT imaging of the larynx in detail during microlaryngoscopy and supplies a number of personal hints.

Postępowanie w stanach przedrakowych krtani – dylematy i znaki zapytania

BACKGROUND

Development of the laryngeal squamous cell carcinoma is taking place on the base of well-documented precancerous lesions. In histological examination precancerous lesions show dysplasia which may be reversible. The quick and proper diagnosis allows for applying the adequate and successful treatment.

AIM

Aim of the study was to evaluate the incidence of precancerous lesions of the larynx, their potential to evolve in relation to grade of dysplasia and discuss the pathologic findings.

MATERIAL AND METHOD

Retrospective analysis of histopathological documentation and ambulatory cards gathered in ENT Department between 1994-2003 was performed. The 173 patients with dysplasia and carcinoma in situ of vocal cord were analyzed.

RESULTS

The 2719 directoscopies were performed in 10 year period. Two out of 117 patients with moderate and 5 out of 27 with severe dysplasia were treated for laryngeal cancer during the follow up period. Out of these 117 patients the group of 46 patients was chosen, in whom more then 2 microlaryngoscopies were performed (more then 3 in 71,7%) with mean follow up period 4,2 years (from 4 month to 10 years). This group of 45 males and 1 female with dysplasia was carefully analyzed. The mean age was 59,6. Hoarseness from 2 weeks to 20 years (mean 17,5 month) was observed, but most often the patients were seen by the doctor in 2 month duration of complaints. The time between first presentation in Outpatient Department and direct laryngoscopy was from 1 day to 1,5 year, but as routine 2 week period was established. In 10 cases the up-grading of dysplasia was observed. The pathologic findigs were presented.

CONCLUSIONS

Quick, adequate (sensitive, specific) diagnostics of premalignancy in the glottis allows for effective and not humiliating treatment (phonosurgery, laser, partial laryngectomy). The rigid schedule of precancerous patient's treatment and follow-up should be drowning. The further diagnostic directions should attempt to find more sensitive methods than the routine histological examination for the assessment of the dysplastic lesions, allowing better evaluation of the risk for cancer development.

Management of laryngeal dysplasia: a review

Laryngeal dysplasia is a common clinical concern. Despite major advancements in otolaryngology, a significant number of patients with the condition progress to invasive carcinoma. In the recent years, new diagnostic techniques such as autofluorescence and contact endoscopy have been applied to increase the accuracy of the laryngeal biopsies. Moreover, significant efforts have been made to correlate the histopathological appearance of the dysplastic samples to their clinical course. So far, a wide range of therapeutic strategies for different grades of dysplasia has been suggested by authors; however, there is a lack of outcome reviews. In the current review, the outcome of different therapeutic strategies for severe dysplasia and carcinoma in situ has been compared with statistical analysis. The paper also summarises the current knowledge of the alternative management methods as well as current areas of research in the chemoprevention of the condition. (1) Significant efforts have been made to develop new techniques to improve the accuracy of microlaryngoscopic assessment of laryngeal premalignancy. Comparative studies are required using microlaryngoscopy against the new techniques to evaluate their clinical utility. (2) The meta-analysis suggests a better local control rate with radiotherapy compared to other standard methods of management of dysplasia; however, functional impairment and complications associated with each of the standard treatments should be further evaluated.

Laser Scanning Microscopy of the Human Larynx Mucosa: A Preliminary, Ex Vivo Study

OBJECTIVE

Laser scanning microscopy (LSM) supplies in vivo information from epithelia up to depths between 0.1 to 0.5 mm. The aim of this ex vivo prospective pilot study was to investigate the potential use of LSM for the diagnosis of laryngeal cancer and its precursors.

METHODS

Forty-three larynx specimens of 26 patients (age 35-61 years, mean age 51.9+/-9.5 years; 7 women and 19 men) with laryngeal lesions were investigated with LSM. The LSM findings were compared with histopathologic sections. The following criteria were used for characterization of cancerous lesions: enlarged nuclei, enlarged cells with variable shapes, cluster of cells, increased nucleus/cytoplasm ratio, irregular cell architecture, and loss of cellular junctions characterized by lack of visualization of the cell membrane.

RESULTS

LSM enables the visualization of epithelium up to the basement membrane, Reincke space, the subepithelial vessels, and the fibers of the subepithelial space. In contrast to the squamous epithelium, the respiratory epithelium bears kinocilia. The beat of the cilia and the directed mucous transport can be observed ex vivo. With the use of the presented malignancy criteria, a sensitivity of 72.7% and a specificity of 82.9% for differentiation of dysplasia and benign laryngeal lesions from cancer were reached.

CONCLUSIONS

LSM in an ex vivo manner supplies microscopic images up to the subepithelial space. LSM could represent a new technology in laryngology to visualize larynx epithelia. In the next step, in vivo LSM will be applied to evaluate laryngeal lesion in vivo.

Contact endoscopic findings in hereditary hemorrhagic telangiectasia

BACKGROUND

Hereditary hemorrhagic telangiectasia is characterized by angiodysplastic lesions. So far, knowledge is limited on the vascular architecture and rate of occult manifestation of telangiectases. Contact endoscopy has not been used for this task before.

METHODS

Eleven patients with hereditary hemorrhagic telangiectasia were examined with contact endoscopy to identify occult telangiectases. Sixty enoral telangiectases were studied in detail to characterize their architecture.

RESULTS

No occult telangiectases could be detected. In most cases, telangiectases consisting of a simple dilated loop were small. In contrast, most of the complex telangiectases were larger.

CONCLUSIONS

Visually normal areas in patients with hereditary hemorrhagic telangiectasia did not seem to have abnormal vascularization. Simple dilated capillary loops might be precursors of telangiectases with a more complex structure. Contact endoscopy seems to be a promising tool for the in vivo monitoring of therapies and the natural course of vascular disorders in humans and in animal models.

Management of advanced premalignant laryngeal lesions

PURPOSE OF REVIEW

Laryngeal carcinogenesis is a multistep process with premalignant lesions progressing to invasive carcinoma over a period of years. The approach to these advanced premalignant lesions has always been early diagnosis and treatment to prevent further progression. Unfortunately, with the current means of diagnosis and a lack of consensus regarding treatment of these lesions, the incidence of advanced laryngeal malignancies continues to rise. The purpose of this article is to review the most recent contributions to the literature regarding diagnosis and management of advanced laryngeal premalignant lesions.

RECENT FINDINGS

The current literature focuses on several new diagnostic procedures to improve early detection of high-risk laryngeal lesions. These procedures include autofluorescence endoscopy, compact endoscopy, and topical 5-aminolevulinic acid. One large long-term study suggests an aggressive surgical approach in the treatment of advanced laryngeal premalignancies to decrease the incidence of malignant transformation. The preliminary results of chemoprevention trials as well as potential new biomarkers are discussed.

SUMMARY

There are several new promising procedures that may have an impact on the early diagnosis of laryngeal precursor lesions. In addition, we are gaining knowledge about the molecular events occurring along the continuum of laryngeal carcinogenesis. This will hopefully allow the identification of additional biomarkers and future targets for chemoprevention.

Panendoscopy and synchronous second primary tumors in head and neck cancer patients

Endoscopy techniques are used to diagnose and to determine the extent and exact location of malignancies in the head and neck region, bronchial tree and esophagus. Panendoscopy is used to find the primary tumor in the case of metastatic disease from unknown primaries or to detect a simultaneous second primary tumor at the time of diagnosis of a malignancy in the upper aerodigestive tract (UADT). The value of panendoscopy has been debated lately because of the relatively small proportion of malignant findings and because of the lack of convincing data concerning its effect on survival rates. However, despite the relatively low proportion of positive findings, their significance is often crucial for the individual patient. The significant number of late metachronous, second primaries, especially in the lungs, also emphasizes the importance of follow-up endoscopies. This study consists of 203 consecutive patients with squamous cell cancer (SCC) of the upper aerodigestive tract who underwent panendoscopy in Turku University Central Hospital as part of the initial diagnostic workup from 1992-1999. Eight patients with synchronous second primaries were found to represent a prevalence of 3.9%, and in addition, 19 patients with metachronous tumors were diagnosed. In the case reports we illustrate the importance of some of these findings.