Voice analysis of patients with endoscopically treated early laryngeal carcinoma

Evolution of voice after transoral laser cordectomy for precancerous lesions and early glottic cancer

Purpose

To evaluate voice quality evolution after a transoral laser cordectomy (TLC) for precancerous lesions and early glottic cancer.

Methods

This prospective study enrolled 18 patients scheduled for TLC for high-grade dysplasia, Tis, T1, and T2 glottic squamous cell cancers, from May 2017 to March 2020. Patients were grouped according to the extent of TLC: Group I (n = 11, 61.1%): unilateral subepithelial or subligamental cordectomy; Group II (n = 7, 38.9%): unilateral transmuscular, total, or extended cordectomy. Voice quality parameters, including dysphonia grade (G), roughness (R), breathiness (B), maximal phonation time (MPT), jitter, and shimmer, were evaluated before, and at 6 weeks and 6 months after the TLC.

Results

In Group I, the degree of G and R items remained without substantial improvement 6 weeks after surgery; however, improved above the pre-surgery level up to 6 months after surgery. The MPT, jitter, and shimmer did not change significantly at 6 weeks or 6 months post-TLC. In Group II, G, R, and B remained significantly impaired even 6 months post-surgery. Jitter, and shimmer worsened at 6 weeks, but reached preoperative levels at 6 months post-surgery. MPT was significantly worse at 6 weeks and remained deteriorated at 6 months post-surgery. All measured parameters were significantly worse in Group II than in Group I at 6 weeks and 6 months post-surgery. No patient required a phonosurgical procedure.

Conclusion

After a TLC, voice quality evolution depended on the extent of surgery. It did not improve at 6 weeks post-surgery. Improvements in less extent cordectomies occurred between 6 weeks and 6 months post-surgery. Understanding voice development over time is important for counseling patients when considering phonosurgical procedures.

Analysis of Phonetic Balance in Standard English Passages

Purpose A common way of eliciting speech from individuals is by using passages of written language that are intended to be read aloud. Read passages afford the opportunity for increased control over the phonetic properties of elicited speech, of which phonetic balance is an often-noted example. No comprehensive analysis of the phonetic balance of read passages has been reported in the literature. The present article provides a quantitative comparison of the phonetic balance of widely used passages in English. Method Assessment of phonetic balance is carried out by comparing the distribution of phonemes in several passages to distributions consistent with typical spoken English. Data regarding the distribution of phonemes in spoken American English are aggregated from the published literature and large speech corpora. Phoneme distributions are compared using Spearman rank order correlation coefficient to quantify similarities of phoneme counts in those sources. Results Correlations between phoneme distributions in read passages and aggregated material representative of spoken American English ranged from .70 to .89. Correlations between phoneme counts from all passages, literature sources, and corpus sources ranged from .55 to .99. All correlations were statistically significant at the Bonferroni-adjusted level. Conclusions Passages considered in the present work provide high, but not ideal, phonetic balance. Space exists for the creation of new passages that more closely match the phoneme distributions observed in spoken American English. The Caterpillar provided the best phonetic balance, but phoneme distributions in all considered materials were highly similar to each other.

Endoscopic Treatment of cT2 Glottic Carcinoma: Prognostic Impact of Different pT Subcategories

Objectives:

The cT2 glottic squamous cell carcinomas are a heterogeneous group of lesions in terms of superficial and deep extension. As a consequence, they differ greatly in treatment indications and prognosis. The aim of the present study was to divide cT2 glottic tumors into subcategories according to radiologic and postoperative histopathologic information, in order to identify risk factors connected with determinate survival, local-regional control, and laryngeal preservation rates.

Methods:

We retrospectively analyzed 55 cT2 glottic lesions treated at a single institution by carbon dioxide laser with at least 2 years of follow-up. Clinical, radiologic, surgical, and histopathologic data were reviewed, and the tumors were accordingly divided into 5 subcategories: I, or pT2 with lateral supraglottic extension (19 patients); II, or pT2 with lateral subglottic extension (6 patients); III, or pT2 with supracommissural and/or subcommissural extension (10 patients); IV, or pT2 with deep vocal muscle infiltration (14 patients); and V, or pT3, for superior and/or inferior paraglottic space invasion lateral to the thyroarytenoid muscle not detected before operation by computed tomographic scan (6 patients).

Results:

The disease-free survival, ultimate local control with laser alone, and laryngeal preservation rates were compared for each subcategory. Statistically significant differences were found only for the pT3 subgroup (2-year rates of 16.7%, 16.7%, and 16.7% for pT3 versus 5-year rates of 80.5%, 84.7%, and 93.3% for the entire pT2 group).

Conclusions:

Endoscopic treatment of cT2 glottic tumors can be considered effective when the pT2 stage has been confirmed. In cT2/pT3 patients, after the first endoscopic resection that allows the correct pT staging, additional treatment should always be considered.

Laryngeal Compensation for Voice Production After CO2 Laser Cordectomy

Objectives

Carbon dioxide (CO₂) laser cordectomy is considered one of the modalities of choice for treatment of early glottic carcinoma. In addition to its comparable oncological results with radiotherapy and open surgical procedures, it preserves of laryngeal functions including voice production. The aim of this study was to detect how the larynx compensates for voice production after different types of CO₂ laser cordectomy for early glottic carcinoma together with assessment of the vocal outcome in each compensation mechanism.

Methods

One hundred twelve patients treated with CO₂ laser cordectomy were classified according to their main postoperative phonatory site. Perceptual analysis of voice samples using GRBAS (grade, roughness, breathiness, asthenia, and strain) scale was done for 88 patients after exclusion of the voice samples of all female patients to make the study population homogenous and the samples of 18 male patients due to bad quality (4 patients) or unavailability (14 patients) of their voice samples and the results were compared with those obtained from control group that included 25 age-matched euphonic male subjects.

Results

Five types of laryngeal compensation were defined including: vocal fold to vocal fold, vocal fold to vocal neofold, vocal fold to vestibular fold, vestibular fold, to vestibular fold, and arytenoids hyper adduction. Characters changes of voice produced by each compensation type were found to be statistically significant except for breathiness, asthenia and strain changes in vocal fold to vocal fold compensation type.

Conclusion

The larynx can compensate for voice production after CO₂ laser cordectomy by five different compensation mechanisms with none of them producing voice quality comparable with that of controls.

Longitudinal analysis of voice quality in patients with early glottic cancer after transoral laser microsurgery

BACKGROUND

We conducted longitudinal voice evaluations in patients with early glottic cancer who underwent transoral laser microsurgery (TLM) to determine the time to stability.

METHODS

Twenty-five patients underwent TLM, including 13 limited cordectomies (type I and type II) and 12 extended cordectomies (type III to type IV). Multidimensional voice evaluations were performed before treatment and at 1, 3, 6, and 12 months after treatment.

RESULTS

Voice parameters of asthenicity, strain, mean airflow rate (MFR), voice handicap index (VHI)-functional, VHI-physical, and VHI-total scores improved in all patients. Most patients had improved 6 months after TLM. Patients with extended cordectomy showed higher breathiness, MFR, VHI-functional, and VHI-total scores. Healing was complete in all cases by 6 months and in a majority of cases (76%) by 3 months.

CONCLUSIONS

Voice quality achieved stability 6 months after TLM. Comparing treatment outcomes and surgical intervention are not recommended within 6 months of surgery.

Modified type III cordectomy to improve voice outcomes after transoral laser microsurgery for early glottic canser

BACKGROUND

We proposed a modified type III cordectomy for the treatment of early glottic cancer that removed the upper part of the vocalis muscle to improve glottic closure and voice outcomes.

METHODS

Twenty-two patients with early glottic cancer underwent type III cordectomy, including 9 classical (proposed by European Laryngological Society) and 13 modified resections. Multidimensional voice evaluations were performed.

RESULTS

Voice parameters including GRBAS (overall grade [G], roughness of the voice [R], breathiness [B], asthenicity [A], and strain [S]), jitter, shimmer, noise-to-harmonic ratio, maximum phonation time, voice handicap index-functional, physical, and total scores were better in modified resection. Eleven patients (85%) had complete glottic closure in modified resection and 3 (33%) in classical resection (p = .026). Only 2 patients had tumor recurrence, 1 (8%) in the modified resection and 1 (11%) in the classical resection group (p = 1.000).

CONCLUSIONS

Modified type III cordectomy proved to be an oncologically safe method. The voice outcomes were better than those in patients who underwent classical type III cordectomy.

Functional outcomes after radiotherapy or laser surgery in early glottic carcinoma: a systematic review

BACKGROUND

Early glottic carcinoma is treated with laser surgery or radiotherapy, but which treatment has better functional outcomes is unclear. This systematic review compared functional outcomes (voice, swallowing, quality of life [QOL]) in more extended T1a and limited T2 tumors (1) between treatments and (2) between greater and lesser laser resections.

METHODS

A systematic literature search covered relevant databases from 1990 to 2009, combining all patient/problem, intervention, comparison, outcome (PICO) keyword variations.

RESULTS

A total of 19 papers met the inclusion criteria, all of which were level IV evidence. Papers reported only voice and QOL. Heterogeneity of outcome measures prevented data pooling. Uncertainty about tumor comparability (depth, extent) between the 2 treatments, small subject numbers, and poor-quality reporting hindered interpretation.

CONCLUSIONS

To allow comparison of laser surgery versus radiotherapy, a standardized method is needed that accurately measures tumor extent and depth. Agreement on functional outcome measures is necessary to allow comparison of treatments and resection types. Multicenter studies should be encouraged to guarantee adequate subject numbers.

Voice evaluation following endoscopic laser CO(2) cordectomy and conventional cordectomy

INTRODUCTION

An analysis of long term voice quality outcomes of two different types of surgical intervention for Tis and T1 glottic carcinoma: laryngofissure conventional cordectomy and endoscopic laser CO(2) cordectomy, with or without additional radiation therapy.

MATERIAL AND METHODS

Total of 46 patients with Tis and T1 glottic carcinoma served as subjects. All have been treated surgically with laryngofissure conventional cordectomy (32.61%) or endoscopic laser CO(2) cordectomy (67.39%). The surgeries were performed in the Department of Otolaryngology at the Medical University of Warsaw (1990-2004). The presented voice assessments were made at least 3 years following the surgery, in between January 2006 and February 2007.

RESULTS

In patients after the endoscopic laser CO(2) cordectomy the following findings are more often observed: the unrestrained voice production, wider range of Fo in a spoken sentence, longer maximum phonation time, better intensity of phonation for normal and loud speaking, lower degree of hoarseness based on the Yanagihara's classification, and the lower VHI. No significant influence of the performed additional radiotherapy on voice parameters was found.

CONCLUSIONS

Patients after endoscopic laser CO(2) cordectomy, compared to laryngofissure conventional cordectomy, present better voice quality. The amount of the excised vocal fold tissue, which in our study was slightly larger in case of the conventional cordectomy, could account for the results mentioned above. This may also be explained by the necessity of the anterior thyrotomy, which is required for conventional cordectomy via external approach, and often results in anterior synechia and level difference between the neocord and the contralateral vocal fold.

Functional vocal results after CO2 laser endoscopic surgery for glottic tumours

INTRODUCTION

Vocal results after endoscopic cordectomy have not yet been well defined. The aim of this study was to assess the vocal function of patients who had undergone CO2 laser cordectomy.

DESIGN

Retrospective, observational and control group study, conducted in a tertiary care medical department.

METHODS

One hundred and thirty-five male patients (age range 36-83 years) underwent different types of endoscopic cordectomy. Forty age-matched, euphonic male subjects were selected as controls. Patients were classified according to the main site of the phonatory neo-glottis. Outcome measures were maximum phonation time, vocal intensity and harmonic/noise ratio. Mann-Whitney and rank Spearman tests were used for statistical analysis.

RESULTS

Findings indicated statistically significant differences for all parameters, comparing patients and controls (p<0.001), and a direct positive relation between type of functional compensation and outcome measures in the study patients (p<0.001).

CONCLUSIONS

The results indicate that functional compensation and outcome measures were related, and that no functional compensation enabled the study patients to achieve a voice quality comparable with that of controls.

Vocal assessment in patients submited to CO2 laser cordectomy

Aim

To evaluate voice outcomes in patients with early glottic carcinoma treated by CO₂ laser cordectomy.

Method

15 patients with glottic Tis and T1 squamous cell carcinoma treated with CO₂ laser were analyzed. The assessment consisted of perceptual voice analysis, objective voice evaluation and video-laryngo-stroboscopic exam. In addition, patients rated their voices and completed the Voice related Quality of Life (VR-QOL) questionnaire. The results were compared with those obtained in a matched control group.

Results

Most of the patients presented some degree of hoarseness on perceptual voice analysis, mainly rough and breathy voices. Their acoustic evaluation compared with the control group showed a small increase in fundamental frequency, but with no statistically significant difference, and the values of jitter, shimmer and noise to harmonic ratio were worse and statistically significant. As regards to video-laryngo-stroboscopic findings, better results were achieved in the less extensive resection group. Patients have had minimal repercussion in their life quality in respect to voice. Conclusions: In spite of voice alterations in patients submitted to cordectomy by CO₂ laser, functional results are acceptable, with minimal repercussion in their quality of life. Avaliação da voz em pacientes submetidos à cordectomia com laser de CO₂.

Voice quality after CO2 laser cordectomy—What can we really expect?

BACKGROUND

Endoscopic management of laryngeal carcinoma has gained popularity among laryngologists based on the good oncologic and functional results. We evaluated the voice quality after laser cordectomy for early glottic cancer in a variety of vocal situations and its relation with the extension of resection and the age.

METHODS

We conducted a cross-sectional study of voice quality in 42 consecutive male patients treated for T1 glottic carcinoma with laser cordectomy. Patients were compared with 21 controls. Voice quality was self-assessed by the patients. Perceptual analysis was done by a speech pathologist on a running speech sample [GRBAS (grade, roughness, breathiness, asthenicity, strain)]. Acoustic analysis included fundamental frequency (F0), jitter, shimmer, noise to harmonic ratio (N/H), and maximum phonation time (MPT) on the sustained vowels /a/ and /i/, and on various running speech voice samples.

RESULTS

Distribution of the patients included in the study by T classification was as follows: Tis, n = 2 (4.8%); T1a, n = 35 (83.3%); and T1b, n = 5 (11.9%). Cordectomy types were: (I), 14%; (II), 26%; (III), 21%; and (V), 38%. Voice improved in almost 60% of patients, returning to normal in 45%. GRBAS showed significant differences between patients and controls and correlated with type of cordectomy. Acoustic analysis showed significant differences in F0, and jitter, with smaller differences in shimmer, N/H, and MPT.

CONCLUSION

Voice quality after laser cordectomy differs from controls, but improves in a majority of patients after the surgery, with almost 50% of patients with subjective normal or near normal voice. Voice quality depends on type of cordectomy.

Endoscopic CO2 laser surgery for early glottic cancer in patients who are candidates for radiotherapy: results of a prospective nonrandomized study

BACKGROUND

Treatment of early glottic malignancies is controversial, particularly if postoperative endoscopy shows minimal/no residual disease.

METHODS

In a prospective nonrandomized study, we performed endoscopic laser surgery with curative intent in 59 patients with early glottic carcinoma presenting for radiotherapy after diagnosis elsewhere by random biopsy or cordal stripping. We analyzed outcomes and residual cancer in the specimen.

RESULTS

Clinical staging elsewhere did not correspond to (usually underestimated) the pathologic stage in 60.7%. In 22%, no tumor was identified on pathologic examination. After 35.3 months (mean), 93.2% were alive with no evidence of disease. Local control was achieved in 98.3% of the patients, and 13.5% of the patients required radiotherapy. The larynx was conserved in 98.3%.

CONCLUSIONS

Biopsy/stripping are best abandoned for persistent glottic lesions. A single laser endoscopic procedure provides reliable staging and definitive treatment in most cases using fewer resources. Biopsied patients presenting for treatment should be offered laser surgery as an alternative to radiotherapy.

Autologous Fat Augmentation for Voice and Swallow Improvement after Cordectomy

Surgery for the treatment of early-stage glottic carcinoma still remains a valid option. In most patients, newly formed neocord tissue preserves glottic functions, but in some patients an important glottic gap leading to glottic insufficiency may occur. In our study, 11 patients who had serious glottic insufficiency after endoscopic laser and laryngofissure cordectomy were treated with autologous fat injection (AFI) into the neocord tissue for voice and swallowing rehabilitation. One patient did not attend the first control visit and was excluded from the study. The remaining 10 patients were evaluated in the preoperative and postoperative periods for phonatory functions and efficacy of AFI by videolaryngostroboscopy and computerized acoustic analysis. Phonatory functions showed statistically significant improvement in the shimmer, noise-to-harmonic ratio, maximum phonation time and fundamental frequency. Perceptual ratings (GRBAS scale) also showed statistically significant improvement in all 5 parameters. Despite improvement in glottic closure, the mucosal wave deteriorated. Due to recurrence of symptoms of glottic insufficiency, AFI was repeated in 2 patients at the third and fifth months, respectively. One year later, the AFI resulted in successful rehabilitation of swallowing in all patients. The probability of resorption of autologous fat and the deterioration of the mucosal wave after AFI remain a problem, but re-injection can be done easily. As AFI is an easy, safe and cheap method, we concluded that it is a promising alternative procedure for managing voice problems after laser or laryngofissure cordectomy defects.

The efficacy of voice therapy in patients after treatment for early glottic carcinoma

BACKGROUND

After treatment for early glottic carcinoma, a considerable number of patients end up with voice problems that interfere with daily life activities. The objective of this randomized and controlled study was to assess the efficacy of voice therapy in these patients.

METHODS

Of 177 patients, 6-120 months after treatment for early glottic carcinoma, 70 patients (40%) suffered from voice impairment based on a 5-item screening questionnaire. Approximately 60% of those 70 patients were not interested in participating in the current study. Twenty-three patients who were willing to participate were assigned randomly either to a voice therapy group (n = 12 patients) or to a control group (n = 11 patients). Multidimensional voice analyses (the self-reported Voice Handicap Index [VHI], acoustic and perceptual voice quality analysis, videolaryngostroboscopy, and the Voice Range Profile) were conducted twice: before and after voice therapy or with 3 months in between for the control group.

RESULTS

Statistical analyses of the difference in scores (postmeasurement minus premeasurement) showed significant voice improvement after voice therapy on the total VHI score, percent jitter, and noise-to-harmonics ratio in the voice signal and on the perceptual rating of vocal fry.

CONCLUSIONS

Voice therapy proved to be effective in patients who had voice problems after treatment for early glottic carcinoma. Improvement not only was noticed by the patients (VHI) but also was confirmed by objective voice parameters.

Voice quality after carbon dioxide laser and conventional surgery for T1A glottic carcinoma

The different types of small vocal fold tumor therapy allow the preservation of respiration and deglutition; the quality of phonation is the most important criterion for the patient. The aim of the study is to compare vocal function after treatment of T1a tumors by conventional and laser cordectomy. Fifty-seven male patients were included in the study: 27 underwent conventional cordectomy using an external approach, and 30 underwent an endoscopic microscopic laser cordectomy. Videolaryngoscopy was performed for each subject, and the maximal phonation time was measured. Spectrograms were recorded, and a perturbation analysis was performed if a clear harmonic structure was visible. Voices were perceptually rated by two experienced phoniatricians using the GRBAS scale. Even though a slightly better voice was found after conventional surgery throughout the data, no statistically significant difference was measured in the two groups. The data on voice outcome per se do not indicate the selection of one surgical approach over another.

A screening questionnaire for voice problems after treatment of early glottic cancer

PURPOSE

After treatment for early glottic cancer, a considerable number of patients end up with voice problems interfering with daily life activities. A 5-item screening questionnaire was designed for detection of voice impairment. The purpose of this study is to assess psychometric properties of this questionnaire in clinical practice.

METHODS AND MATERIALS

The questionnaire was completed by 110 controls without voice complaints and 177 patients after radiotherapy or laser surgery for early glottic cancer.

RESULTS

Based on normative data of the controls, a score of 5 or less on at least 1 of the 5 questions was considered to state overall voice impairment. Reliability of the questionnaire proved to be good. Voice impairment was reported in 44% of the patients treated with radiotherapy vs. 29% of the patients treated with endoscopic laser surgery.

CONCLUSIONS

The questionnaire proved to be a reliable, valid, and feasible method to detect voice impairment in daily life. The questionnaire is easy to fill in, and interpretation is straightforward. It is useful for both radiation oncologists and otorhinolaryngologists in their follow-up of patients treated for early glottic cancer.

Bipedicled Strap Muscle Transposition for Vocal Fold Deficit after Laser Cordectomy in Early Glottic Cancer Patients

OBJECTIVE

In treating early glottic carcinomas, the outcomes of endoscopic laser cordectomy have been proven to be valuable in local control, survival, and vocal function preservation. In some extended cases, however, laser cordectomy may leave patients with poor vocal function because of vocal fold deficit. This work assesses the vocal outcome of medialization laryngoplasty with bipedicled strap muscle transposition for vocal fold deficit resulting from laser cordectomy in early glottic cancer patients.

STUDY DESIGN

A prospective clinical series.

METHODS

Thirteen early glottic cancer patients who had vocal fold deficit caused by previous laser cordectomy underwent medialization laryngoplasty with bipedicled strap muscle transposition. The thyroid lamina on the cordectomy side was paramedially separated. The inner perichondrium was circumspectly raised from the overlying thyroid cartilage. After separating the thyrohyoid and cricothyroid membranes, the lamina was retracted laterally. A bipedicled strap muscle flap was then transposed into the area between the lamina and the paraglottic soft tissue. The thyroid cartilages were carefully sutured back in position. All patients received pre- and postoperative voice assessments comprising laryngostroboscopy and vocal function studies.

RESULTS

Vocal enhancement was present in 92% (12/13) of patients after medialization laryngoplasty with strap muscle transposition. The glottal closure and maximal phonation time were noticeably improved by surgery. No dyspnea or other significant complications were observed in any patients.

CONCLUSION

The outcomes show that bipedicled strap muscle transposition is a prosthesis-free, safe, and valuable laryngoplastic technique for correcting glottal incompetence caused by endoscopic laser cordectomy in early glottic cancer patients.

The treatment of early laryngeal cancers (T1-T2 N0): surgery or irradiation?

BACKGROUND

Carcinoma of the larynx is the most common cancer affecting the head and neck region. In Northern Europe, early laryngeal cancer is almost universally treated by irradiation, but elsewhere it is treated by surgery. The main aim of this study was to determine whether there was any difference in survival between the two main therapeutic options. The secondary aim was to assess speech and voice quality in a small, randomized sample of patients from each treatment group.

METHODS

The subjects investigated were 488 patients with T1-2, N0 squamous cell carcinoma of the larynx. The patients form an unselected sequential group of our institution's experience with treating this disease over three decades. Four hundred nineteen patients were treated by irradiation, and 69 were treated with surgery. Most surgical patients were treated earlier in the series, whereas radiotherapy later became the treatment of choice. The primary outcome measures were recurrence at the primary site, recurrence in the neck, and tumor-specific survival. The secondary outcome measure was speech and voice quality. Statistical analysis was by univariate and multivariate analysis of association and survival. Surgery included horizontal or vertical partial laryngectomy and various minor procedures on the glottis, including cordectomy. Over a 30-year period, radiotherapy was administered to a dose of 60-66 Gy given over 30-33 daily fractions.

RESULTS

Surgery tended to be performed early on in the series and radiotherapy thereafter. Surgery was more likely to be carried out for supraglottic disease. These differences apart, the radiotherapy and surgery groups of patients were well matched. The 5-year tumor-specific survival for those treated by irradiation was 87% and for surgery it was 77% (p=.1022). Glottic cancer and T1 disease were associated with high 5-year survivals: 90% and 91%, respectively. Supraglottic site and T2 disease both had a poorer prognoses: 79% and 69%, respectively. The differences for both sets of data were significant. There was no significant difference in primary site recurrence rates for the two treatment modalities, but regional recurrence was higher in the surgery group. Further analysis demonstrated that this was not a function of surgery per se but rather of the unit's policy toward the N0 neck at the time surgery was carried out. Regarding speech and voice quality, radiotherapy was far superior to surgery. All patients in the radiotherapy group but only 3 of 10 in the surgery group were judged to have a good or normal voice (p=.0017).

CONCLUSIONS

Both surgery and irradiation are equally effective at treating early laryngeal carcinoma. Speech and voice were highly significantly better in patients treated by irradiation than in those treated by surgery.

Preoperative and postoperative voice in Tis-T1 glottic cancer treated by endoscopic cordectomy: an additional issue for patient counseling

Radiotherapy contends with endoscopic surgery for the role of treatment of choice for Tis-T1 glottic cancer. The amount of vocal cord to be surgically removed logically depends on the surface and deep extension of the neoplasm. Thus, a prerequisite for proper management includes an analysis of the voice changes after each of the progressive types of cordectomy described in the European Laryngological Society Classification. Between January 1998 and December 2000, 89 patients with glottic cancer (8 Tis, 63 T1a, 18 T1b) underwent different types of endoscopic cordectomy. Perceptual analysis (GRBAS scale); objective analyses of jitter, shimmer, and noise-to-harmonics ratio; and subjective (Voice Handicap Index) evaluation of voice were performed in 51 patients. Statistical evaluation of preoperative and postoperative objective results by analysis of covariance, as well as perceptual and subjective data, showed significant voice improvement after type I and II cordectomies, with the voice attaining nearly normal parameters. By contrast, after type III, IV, and V cordectomies, the vocal outcome was not significantly different from the preoperative pattern. It can therefore be concluded that type I and II resections, whenever indicated, are adequate procedures even for professional voice users. By contrast, accurate counseling is mandatory before type III, IV, and V cordectomies.

Voice, speech, and swallowing outcomes in laser-treated laryngeal cancer

OBJECTIVE

To describe preliminary voice, speech, and swallowing outcomes in patients treated by endoscopic laser excision of laryngeal cancer with or without adjuvant radiation therapy.

STUDY DESIGN

Retrospective review.

METHODS

Seventeen surgically treated patients (five T2 glottic and 12 clinically staged T2 supraglottic squamous cell carcinomas) participated in the study. Self-ratings of voice (Voice Handicap Index) and swallowing (M. D. Anderson Dysphagia Inventory) were completed, as well as independent auditory-perceptual ratings of voice and speech recordings.

RESULTS

Although no significant difference between Voice Handicap Index, M. D. Anderson Dysphagia Inventory, and listener ratings was identified based on tumor site and irradiation status, there was a trend toward poorer outcomes in patients who received adjuvant radiation therapy. Whereas the patients having supraglottic cancer tended to report better voice but poorer swallowing outcomes, the glottic cancer group displayed the opposite pattern. Severity on Voice Handicap Index correlated significantly with listener severity ratings of speech, suggesting that the patients' perception of their voice handicap was similar to the listeners' judgments of their speech severity.

CONCLUSIONS

The results suggest the following trends: 1) Adjuvant radiation therapy was associated with poorer outcomes for voice, speech, and swallowing and may be associated with more impairment than surgery alone and 2) poorer outcomes on voice and swallowing were observed for the glottic and supraglottic cancer groups, respectively. To bolster these preliminary findings, additional outcomes studies in patients treated with conservation therapy are needed.

Vocal outcome after endoscopic cordectomies for Tis and T1 glottic carcinomas

A cohort of 101 patients with previously untreated glottic cancer (15 Tis, 66 T1a, and 20 T1b) who underwent endoscopic CO2 laser excision between January 1995 and December 1997 was prospectively analyzed. The depth and extension of the excision were graded according to the European Laryngological Society Classification including 5 types of cordectomy. All patients were subsequently examined every 2 months for a period ranging from 30 to 66 months (mean, 48 months). The rates of 5-year overall survival, disease-free survival, ultimate local control with laser alone, and laryngeal preservation were 85%, 87%, 93%, and 95%, respectively. Sixty-nine patients underwent, at least 1 year after surgery, videolaryngostroboscopy combined with perceptual and objective evaluation of the voice, and spirometry. Acoustic parameters were compared with those obtained in a matched control group by Kruskal-Wallis test. No statistically significant difference was found (p > .05) between patients submitted to subepithelial (type I) and subligamental (type II) cordectomies and controls.

Voice and treatment outcome from phonosurgical management of early glottic cancer

Phonosurgical management of early glottic cancer has evolved considerably, but objective vocal outcome data are sparse. A prospective clinical trial was done on 32 patients with unilateral cancer (T1a in 28 and T2a in 4) who underwent ultranarrow-margin resection; 15 had resection superficial to the vocal ligament, and 17 deep to it. The subepithelial infusion technique facilitated selection of these patients for the appropriate procedure. All are cancer-free without radiotherapy or open surgery. Involvement of the anterior commissure (22/32) or the vocal process (15/32) of the arytenoid cartilage did not influence local control. Nine of 17 patients had resection of paraglottic musculature, and all underwent medialization reconstruction by lipoinjection and/or Gore-Tex laryngoplasty. Eight of the 17 had resections deep to the vocal ligament, but without vocalis muscle, and 1 of the 8 underwent medialization. Posttreatment vocal function measures were obtained for all patients. A clear majority of the patients displayed normal values for average fundamental frequency (72%) during connected speech, and normal noise-to-harmonics ratio (75%) and average glottal airflow (91%) measures during sustained vowels. Smaller majorities of patients displayed normal values for average sound pressure level (SPL; 59%) during connected speech and for maximum ranges for fundamental frequency (56%) and SPL (59%). Fewer than half of the patients displayed normal values for sustained vowel measures of jitter (45%), shimmer (22%), and maximum phonation time (34%). Almost all patients had elevated subglottal pressures and reduced values for the ratio of SPL to subglottal pressure (vocal efficiency). There were significant improvements in a majority of patients for most vocal function measures after medialization reconstruction. Normal or near-normal conversation-level voices were achieved in most cases, regardless of the disease depth, by utilization of a spectrum of resection and reconstruction options. These favorable results are based on establishing aerodynamic glottal competency and preserving the layered microstructure of noncancerous glottal tissue.

Surgical voice rehabilitation after laser surgery for glottic carcinoma

Transoral laser surgery today is the mainstay of treatment for T1 and T2 glottic carcinoma. The vocal ability remains sufficient in the majority of patients. However, in some cases, a significant glottic gap may persist, leading to poor voice quality. We report a special technique of medialization thyroplasty using autologous cartilage specifically adapted for vocal rehabilitation after laser resection. Six patients with a significant glottic gap following laser surgery were treated. For vocal rehabilitation, a special medialization technique was performed. The superior rim of the thyroid cartilage of the resected side was exposed. A 1 x 2-cm piece of cartilage was harvested and reimplanted into a subperichondrial pouch created on the inner side of the thyroid cartilage. When phonation was optimal, this cartilaginous strut was sutured and/or glued in place. In all 6 cases, the vocal function improved significantly. The dysphonia index (0 = normal, 3 = aphonia), which includes objective parameters as well as expert voice ratings and the patient's perception, increased by 1.1 on average (range, 0.4 to 1.6). The results have been lasting. The established medialization techniques are of limited value in a larynx scarred by laser surgery. Injection augmentation is often futile because the tight scar tissue does not lend itself to augmentation. Implantation of nonorganic material may cause problems if revision surgery for tumor recurrence should become necessary or if the implant protrudes into the scarred endolarynx. The technique reported avoids these pitfalls and leads to voice quality improvement comparable to that of established medialization procedures.

Management of vocal fold scar with autologous fat implantation: perceptual results

Vocal fold scar disrupts the mucosal wave and interferes with glottic closure. Treatment involves a multidisciplinary approach that includes voice therapy, medical management, and sometimes surgery. We reviewed the records of the first eight patients who underwent autologous fat implantation for vocal fold scar. Information on the etiology of scar, physical findings, and prior interventions were collected. Videotapes of videostroboscopic findings and perceptual voice ratings [Grade, Roughness, Breathiness, Asthenia, Strain (GRBAS)] were randomized and analyzed independently by four blinded observers. Etiology of scar included mass excision (7), vocal fold stripping (3), congenital sulcus (2), and hemorrhage (1). Prior surgical procedures performed included thyroplasty (1), autologous fat injection (9), excision of scar (2), and lysis of adhesions (2). Strobovideolaryngoscopy: Statistically significant improvement was found in glottic closure, mucosal wave, and stiffness (P = 0.05). Perceptual ratings (GRBAS): Statistically significant improvement was found in all five parameters, including overall Grade, Roughness, Breathiness, Asthenia, and Strain (P = 0.05). Patients appear to have improved vocal fold function and quality of voice after autologous fat implantation in the vocal fold. Autologous fat implantation is an important adjunctive procedure in the management of vocal fold scar, and a useful addition to the armamentarium of the experienced phonomicrosurgeon.

Acoustic Analysis of Voice Quality with or without False Vocal Fold Displacement After Cordectomy

Conventional cordectomy by means of a laryngofissure is one of the therapeutic options for treatment of early glottic cancer. To improve the poor voice quality related to this kind of operation, many authors have developed different techniques to repair the mucosal defect. We analyzed voice quality acoustically and compared it after cordectomy alone and after cordectomy with the reconstruction of the vocal cord in a group of 14 patients affected by T1 glottic carcinoma. All the patients underwent postoperative speech therapy. Three patients who underwent cordectomy with reconstruction showed the presence of diplophonia, while two patients without reconstruction showed the presence of bitonality. The differences of the acoustic parameters (jitter, shimmer, harmonic-to-noise ratio) between the two groups of patients were not statistically significant. Reconstruction of the vocal cord does not seem to improve voice quality after cordectomy even in combination with postoperative speech therapy.

Radiotherapy outcome and prognostic factors in early glottic carcinoma

OBJECTIVE

To evaluate radiotherapy outcome and prognostic factors in early glottic carcinoma.

METHODS

The medical records of 76 patients with glottic T1N0 or T2N0 squamous cell carcinoma diagnosed at Tampere University Hospital from 1970 to 1991 and treated with primary radiotherapy were retrospectively reviewed. Except for three patients treated during the last years of the study period, radiotherapy was delivered by split-course technique with a pause of 1-3 weeks in the middle of the treatment. Primary locoregional control and disease-specific survival were analysed by the Kaplan-Meier method, and the log rank test was applied to compare the survival functions. Prognostic factors were evaluated by uni- and multivariate Cox regression analysis.

RESULTS

The 10-year locoregional control rate after radiotherapy was 83 and 48% for patients with T1 and T2 tumours, respectively (P = 0.0005). The 10-year disease-specific survival was 91% for T1 and 69% for T2 disease (P = 0.0018). The larynx could be preserved in 87% of T1 and 44% of T2 cases. Tumour extent expressed by the number of vocal cord thirds involved was the only factor with significant prognostic value in the multivariate analysis of primary locoregional control (hazard ratio (HR) 3.2, 95%CI 1.8-5.8, P = 0.0001). Involvement of the posterior vocal cord third (HR 8.4, 95%CI 1.0-69.5, P = 0.04899) and T-category (HR 3.0, 95% CI 0.9-10.2, P = 0.0790) were connected with poorer prognosis in the multivariate analysis of disease-specific survival. In the multivariate analysis of T1 cases only, higher number of vocal cord thirds involved (HR 5.9, 95%CI 2.2 16.2, P = 0.0005) and longer treatment duration (HR 1.1, 95%CI 1.0-1.3, P = 0.0188) indicated worse locoregional control. Treatment duration (HR 1.2, 95%CI 1.0-1.3, P = 0.0384) together with posterior cord involvement (HR 9.9, 95% CI 1.1-92.7, P= 0.0437) signified poorer survival.

CONCLUSION

Our findings indicate that the extent of the tumour is the most important predictor of radiotherapy outcome in early glottic carcinoma. This suggests that a classification based on the actual size of the tumour could be a better prognostic indicator than the conventional T-grouping. Although treatment duration was significant only in separate analysis of T1 cases, the split-course regimen resulting in long treatment times may be considered a major contributor to our relatively low local control rate also in T2 disease.

Voice quality after narrow-margin laser cordectomy compared with laryngeal irradiation

Voice quality remains the issue often used to support preference for radiotherapy in treatment of early glottic cancer. We therefore conducted a perceptual voice study in 2 groups, one treated with radiotherapy for malignant disease and the other with narrow-margin laser cordectomy for either malignant or extensive benign lesions. Sequential patients, 12 treated with radiotherapy and 30 with CO(2) laser excision, were included. Voice samples were recorded before and at intervals after surgery. Ratings of validated judges were used for statistical analysis of various voice characteristics at each time point. Voice deteriorated temporarily after surgery as compared with the radiated group; however, at 6 and 24 months no significant differences were found between the groups. Preferential use of narrow-margin laser cordectomy for appropriate early glottic tumors can be supported not only for oncologic reasons but also on the basis of voice results, cost, and efficiency considerations.

Cost-minimization analysis of treatment options for T1N0 glottic squamous cell carcinoma: comparison between external radiotherapy, laser microsurgery and partial laryngectomy

BACKGROUND AND PURPOSE

A cost minimization analysis of radiotherapy (RT), laser microsurgery (L) or partial laryngectomy (PL), which are equally effective options for T1N0 glottic SCC was carried out from the perspective of the National Health Care System.

METHODS

For each modality, the various events associated with the diagnostic procedure, the primary treatment, the complications, and the salvage treatment were individualized. The charges of each of these events weighted for the frequency of occurrence were then determined using the 'fee for service' policy established by the National Health Insurance of Belgium.

RESULTS

A total cost of 5172, 5847 and 11563 EURO were calculated for RT, L and PL, respectively. For L, cost included post-operative RT applied in case of positive margins (30%). For PL, the cost of the primary treatment accounted for 68% of the total cost whereas it only accounted for 50 and 43% for L and RT, respectively. For RT, L or PL, complications accounted for less than 10% of the total cost. The cost of salvage treatment reached 19, 14 and 8% of the total cost for RT, L and PL, respectively. A sensitivity analysis indicated that reduction of the duration of hospitalization decreases the costs without affecting the ranking between the three options. Also, the cost of L could be reduced even slightly below the cost of RT by decreasing the need for post-operative RT.

CONCLUSIONS

RT and L have almost the same expected average cost for the treatment of T1N0 glottic SCC, whereas PL is twice as expensive.

Quality of life measurements of speech in the head and neck cancer patient population

BACKGROUND

To employ patient-reported speech outcome data collected on head and neck cancer (HNC) surveys, there is a need to determine (1) the relationship of patient ratings to speech language pathologist (SLP) ratings and (2) whether patients' attitudes toward their speech are an important element of speech measurements.

METHODS

Associations were analyzed between (1) patients' ratings of speech function on surveys and equivalent SLP ratings and (2) patients' ratings of speech function and their satisfaction with speech function.

RESULTS

Patient-reported survey ratings were significantly associated with comparable SLP ratings. The associations were stronger for intelligibility than for voice quality. Patients' functional and attitudinal ratings were also significantly associated. The associations were relatively strong for composite speech items and intelligibility and moderate for voice quality.

CONCLUSIONS

Patient-reported speech outcomes can be interpreted as being fairly equivalent to SLP evaluations. Attitudinal ratings appear to contribute an important aspect of the patients' perspective, with substantially different variances between function and attitude.

Acoustic assessment of voice signal deformation after partial surgery of the larynx

OBJECTIVE

The main objective of the present study was to assess the degree of voice signal impairment among patients who had undergone partial surgery of the larynx due to cancer of this organ. Such on evaluation may be helpful in the selection of the optimal surgical technique for the treatment of tumors displaying a varying degree of local advancement.

METHODS

A prospective examination was carried out among 128 patients. Additionally a comparative study of the control group consisting of 36 healthy males was carried out. Acoustic tests were carried out in an echo-free chamber. The temporal changes in the value of acoustic pressure of the uttered text were registered. The 'distance' between the normal speech signal and the pathological voice has been established.

RESULTS

The values of the fundamental frequency increase together with an increase of the range of resection of anatomical structures. The biggest differences in the value of results describing the distance from the standard were observed after hemilaryngectomy. The shortest distance from the acoustic standard was observed after chordectomy. No significant differences in the degree of voice signal impairment among patients who had undergone extended chordectomy and hemilaryngectomy were observed.

CONCLUSION

The above findings can be of help in arriving at an optimum solution in cases of partial surgery of the larynx. The problem is particularly important in situations where there is the choice between different types of surgery.

Phonatory results after laser surgery for glottic carcinoma

OBJECTIVE

To identify the influence of type and extent of surgery on postoperative voice parameters after endoscopic laser resection for glottic carcinoma.

SETTING AND DESIGN

A multidisciplinary university-based head and neck cancer center. Objective and subjective measures of voice were correlated with type and extent of surgery following a standardized classification in a prospective study including 80 patients.

SUBJECTS AND METHOD

The postoperative mechanism of phonation was assessed by videostroboscopy 6 months after surgery at the earliest. A phonetogram was produced, and its area was calculated (relative phonetogram (RP)) in relation to a gender-different normal phonetogram. Two speech therapists (ST) and a trained otolaryngologist (TO) rated each voice independently for communication ability in a grade from 1 (poor) to 5 (near normal).

RESULTS

After simple cordectomy the means were as follows: RP = 24.8%, TO = 3.26, and ST = 3.33. When the anterior commissure was completely preserved, mean results were better (RP = 34%, TO = 3.92, ST = 3.83). Results were worse after extended cordectomy (RP = 14.7%, TO = 2.82, ST = 3.00) and transglottic resection (RP = 13.7%, TO = 2.30, ST = 2.86) but were similar within these two groups. The parameters RP TO, and ST do not differ significantly between the group who had speech therapy after surgery (n = 33) and the group who did not (n = 47). Voice production at glottic level yields better results for every parameter than supraglottic substitute phonation. The amount of tissue removed was less significant.

CONCLUSION

Postoperative phonatory results correlate with the postoperative mechanism of phonation. There is no linear correlation with the amount of tissue removed. Comparison of similar types of resection preservation of the anterior commissure plays a key role. From the data in this study, there is no evidence for a significant benefit from speech therapy. The parameter RP is an effective and relatively simple parameter to complete auditory voice assessment.

Comparison of external radiotherapy, laser microsurgery and partial laryngectomy for the treatment of T1N0M0 glottic carcinomas: a retrospective evaluation

PURPOSE

The aim of this study was to retrospectively compare the efficacy and functional results of three treatment options for T1N0M0 glottic carcinomas applied in a single institution.

MATERIALS AND METHODS

One hundred six charts of patients with biopsy-proven T1N0M0 glottic carcinomas treated between 1979 and 1995 were reviewed. There were 81 T1a and 25 T1b tumors. Forty-one patients were treated by radiotherapy (RT) (median dose of 64 Gy), 34 patients were treated by partial laryngectomy (PL) and 31 patients were treated by laser microsurgery (L) of which 10 received postoperative RT for positive margins. In 18 patients, a perceptual voice rating on a visual scale was performed by the patients themselves, three non-speech specialists and two speech therapists.

RESULTS

With a median follow-up time of 63.5 months, the 5- and 10-year loco-regional control probabilities reached 91 and 87%, respectively, without any difference between the treatment groups. After salvage laryngectomy, the 5- and 10-year loco-regional control probabilities reached 97% without any difference between the treatment groups. For the whole population, overall survival reached 78 and 62.4% at 5 and 10 years, respectively. The actuarial incidence of second primary reached 19% at 10 years. Regarding the quality of voice, overall there was a trend towards a worse satisfaction index, more hoarseness and more breathiness after PL than after L or RT.

CONCLUSIONS

Our data suggested that assuming proper selection of patients, RT and L yielded similar outcomes and functional results. Local recurrence can be adequately salvaged by surgery. On the other hand, PL appeared to yield similar loco-regional control probability but with a worse quality of voice.

Has radiotherapy become too expensive to be considered a treatment option for early glottic cancer?

BACKGROUND

External beam radiotherapy and surgery produce equivalent long-term survival and tumor control in early glottic cancer. The expense and cost of radiotherapy have been challenged.

METHODS

A retrospective review was performed for 57 patients undergoing radiotherapy for glottic cancer. End points included local tumor control, relapse-free survival, cause-specific survival, medical charges, and costs. The results were compared with those of 265 patients who underwent transoral endoscopic removal or an open laryngeal procedure at the same institution.

RESULTS

The local control, larynx preservation, re-treatment, voice quality, relapse-free survival, and cancer death results and medical charges and costs are reported by treatment.

CONCLUSIONS

Radiotherapy provides at least equivalent, if not superior, local tumor control, larynx preservation, voice quality, and survival, compared with the surgical options. Overall medical charges and costs for radiotherapy are similar to transoral endoscopic resection and less than partial vertical laryngectomy.

Pressure-flow relationships during phonation as a function of adduction

Pressure-flow relationships were obtained for five excised canine larynges. Simultaneous recordings were made of average subglottal pressure, average air flow, and the electroglottograph at various levels of adduction and vocal fold lengths. The level of adduction was controlled by positioning the arytenoid cartilages via laterally imbedded three-prong attachments and by the use of intra-arytenoid shims. Adduction was quantified by measuring the vocal process gap. Results indicated a linear pressure-flow relationship within the experimental range of phonation for each level of adduction. Differential glottal resistance increased as the vocal process gap was reduced. A model is presented for the differential resistance as a hyperbolic function of vocal process gap. The pressure-flow relationship and the model can be used in computer simulations of speech production and for clinical insight into the aerodynamic function of the human larynx.

Sources of error in estimation of laryngeal airway resistance in persons with spasmodic dysphonia

Estimation of laryngeal airway resistance is a noninvasive method that has proven useful in the study of people with normal and some types of disordered voices. We were interested in examining more closely the application of this method to persons with spasmodic dysphonia (SD), a voice disorder sometimes associated with fluctuating airflow. We speculated unstable airflow could affect the estimation of subglottal pressure and laryngeal airway resistance. Oral pressure and airflow were collected from 10 subjects with SD and 10 control subjects during repetition of /pi/. The coefficient of variation (COV) of airflow during vowel production was calculated to quantify stability of airflow. The results indicated that although some SD subjects produced steady flows during the syllable repetition task, others exhibited substantially varying flows. Inability on the part of the subject to attain steady flows could compromise the usefulness of a midpoint measure of airflow and/or estimation of subglottal pressure, resulting in sources of error in estimation of laryngeal airway resistance. As a result, of the 10 subjects with SD in this study, laryngeal airway resistance could not be estimated in 6 subjects with unsteady flows. Laryngeal airway resistance was estimated in 4 SD subjects who produced steady airflow. Two of these subjects exhibited high laryngeal airway resistance; the others exhibited normal laryngeal airway resistance.

Voice evaluation before and after laser excision vs. radiotherapy of T1A glottic carcinoma

Quality of voice after treatment for T1A glottic squamous cell carcinoma was studied in two matched groups of males treated either with CO2 laser cordectomi (n = 18, mean age 65.2 years) or with full dose radiotherapy (n = 18, mean age 65.1 years). All patients had histologically verified invasive squamous cell carcinoma. Fifteen male patients (mean age 63.9 years) without laryngeal disorders were used as controls. Voice recordings prior to treatment, and both at 3 months and at 2 years after completed treatment were analyzed. Acoustic measures of shimmer, jitter, breathiness, harmonic-to-noise ratio and fundamental frequency (F0) average were calculated with the Soundscope program. Two plain measures were also used: time required to read a running speech voice sample, and number of breaths. Perceptual voice analysis was performed blindly by two groups of listeners, Group A (4 experienced listeners) and Group B (4 naive listeners). Group A estimated quality of voice according to a modified GRBAS score, whereas Group B estimated Grade only. We found voice quality both at 3 months and at 2 years after radiotherapy to be significantly better than after laser treatment, as assessed by the acoustic variables breathiness, jitter, F0 average, running speech voice sample reading time and number of breaths. The perceptual variables Grade (Group A and B), Breathiness, Asthenia and Strain were also significantly better after radiotherapy.

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)