This retrospective study reviews 39 patients with primary subglottic cancer seen between 1955 and 1988 by the Department of Otolaryngology at Washington University. This number constitutes 1.8% of laryngeal cancer cases diagnosed during this period. Twenty-eight patients (71.8%) had epidermoid cancer, of which 19 (67.9%) had "early" disease (stages I and II), and nine (32.1%) had "advanced" (stages III and IV). Overall 5-year survival was 57.7%. Disease-free survival was 46.2%. Patients treated with radiotherapy alone, surgery alone, or both had disease-free 5-year survivals of 22.2%, 41.7%, and 100%, respectively. Combination therapy showed a significantly higher (P < .01) disease-free survival than radiotherapy alone.

Bleeding remains the most significant complication following tonsillectomy (TE), sometimes requiring revision surgery under general anesthesia. This study was undertaken to verify whether or not bleeding rates changed after bipolar coagulation was replaced by suture ligation to achieve hemostasis at a single institution. The charts of all patients who had undergone tonsillectomy between April 1, 2007, and April 30, 2013, at our institution were reviewed. The tonsils were bluntly dissected with scissors and a rasp. While hemostasis was achieved with bipolar coagulation during the first 36 months (group A), this method was replaced after a transition period of 1 month by intraoperative suture ligation (group B) during the last 36 months. Group A encompassed 2,137 patients including 963 children scheduled for adenotonsillectomy (ATE), and group B consisted of 1,521 patients and included 435 ATE cases. Bleeding from the tonsillar wounds occurred in 111/2,137 group A (5.2 %) and 68/1,521 group B patients (4.5 %). The difference was not found to be significant (p = 0.317). The incidence of primary bleeding (PB) and secondary bleeding (SB) was significantly (p = 0,000) associated with the method to achieve hemostasis: PB prevailed in group B and SB prevailed in group A. The overall incidence of post-tonsillectomy hemorrhage (PTH) varied at different ages, but the difference was not significant in group A (p = 0.401) and group B (p = 0.661). Repeated episodes of PTH occurred in 11/111 group A (9.9 %) and 8/68 group B (11.7 %) patients. The statistical difference was not found to be significant (p = 0.725). However, there were significantly more male patients with bleeding complications in both groups. Despite the strongest efforts to avoid it, the potential risk of PTH remains a fact to be accepted by surgeons and patients. An increased surgical precision achieved by introduction of a surgical microscope as well as replacing bipolar cautery by suture ligation to achieve hemostasis could only reduce the overall rate of PTH. Another fact remains unchanged: PB occurs predominantly when electrosurgical means are avoided and SB prevails, whenever surgeons use them. We will continue our research on refined methods of cold steel microsurgical TE including suture techniques.

In contrast to total or extracapsular tonsillectomy (TE), subtotal/intracapsular/partial tonsillectomy (SIPT) or tonsillotomy (TT) is associated with significant less postoperative morbidity. It has been stated that patients older than 8 years of age or with a history of tonsillitis should be excluded from SIPT/TT. Some health insurance companies mandate utilization of particular surgical instruments. Finally, it has been stated that the remaining tonsillar tissue may become a subject of recurrent tonsillitis or tonsillar regrowth, in both cases requiring revision surgery in terms of TE. This literature review was undertaken to clarify what has been validated in the literature concerning indications, surgical techniques, complications and outcome of SIPT/TT as reported since 1960. A Medline review was undertaken and all papers included that were published in English or German language until September 30, 2013. Exclusion criteria were: publication date 1960 and earlier, other languages, no relation to tonsil surgery, papers not available to the authors, uncommon surgical techniques, national surveys or studies without patients. The quality of the papers was classified according to "The Oxford 2011 Levels of Evidence". The surgical techniques were classified according to Windfuhr and Werner and extended to interstitial tonsil therapy. Other issues were: study period, hemorrhage, dehydration, intake of analgesics, return to normal diet, surgical instruments, operation time, number of surgeons involved, number of patients, age, indications, follow-up, rate of tonsillar regrowth, tonsillitis and secondary TE. A total of 379 different publications were retrieved, but only 86 studies found eligible for further analysis. There were 10,499 patients in the study groups and 10,448 patients in the control groups. Utilization of the microdebrider largely prevailed, followed by Coblation, CO2-LASER, surgical scissor, Radiofrequency, Interstitial ThermoTherapy with various instruments, Diode-LASER, and other instruments. Instruments were not specified for 1,815 patients. Data for operation time, intraoperative bleeding, return to normal diet, analgesic intake were in favor for SIPT/TT and ablation procedures. Regrowth and tonsillitis occurred in rates of <6 % on average. Secondary surgery became necessary in only every third patient of this subgroup. Studies of variable quality impede comparison of all aspects in the papers. At least every second study did not address issues like operation time, intraoperative bleeding, return to normal diet, analgesic intake, rates of tonsillar regrowth, postsurgical tonsillitis and secondary TE. There are insufficient data to show that a single surgical instrument is superior. A history of tonsillitis and an age >8 years are definitely not commonly accepted as contraindication for SIPT, TT or ablation procedures. There is a strong evidence that pain is less after SIPT, TT and tonsil ablation resulting in an earlier return to normal diet and activity. Large, well-designed randomized controlled...

To perform laryngeal research involving long-term survival surgery, a permanent tracheostomy is often necessary. For experiments using a long-term induced canine phonation model, we required a tracheostomy that was placed as low as possible, to maximize the subglottic space superior to the stoma. The ideal experimental tracheostomy would also be safe and easy to perform, require no tracheostomy tube, and be low maintenance, requiring minimal cleaning or suctioning. Tracheostomies were performed in 37 dogs based on previously published methods. If the stoma was placed below the twelfth tracheal ring, the perioperative mortality rate was 57% because of kinking of the trachea and subsequent airway obstruction. When the tracheostomy was performed above this level, the mortality rate was reduced to 3%. A number of significant modifications in technique were made to achieve this improvement and resulted in the last 12 dogs having no complications. Several of the tracheostomies were maintained for more than 18 months. The method derived meets the above criteria for the ideal experimental tracheostomy and also meets our needs for a long-term induced phonation model.

The hypoglossal nerve is a logical donor nerve for hemilaryngeal reinnervation because 1) its activity coincides with normal laryngeal adduction during speech and deglutition; 2) it is a large nerve with many axons; and 3) donor site morbidity is low. This method of laryngeal reinnervation has not been previously reported. Previous studies using the ansa cervicalis for reinnervation have failed to show spontaneous activity. Hypoglossal-to-recurrent laryngeal nerve anastomosis was performed on a series of 5 dogs. The vocal folds were viewed monthly, with the animals awake, by infraglottic examination through a permanent tracheostomy. One dog failed due to technical error. The remaining 4 dogs began to exhibit spontaneous vocal fold adduction within 2 to 4 months. Vocal fold motion was synchronous with spontaneous tongue motion. Complete glottic closure was seen during swallowing at 3 to 5 months. Intraglottic pressure measurements following reinnervation were normal. Hypoglossal nerve transfer appears to be capable of providing functional adduction to the paralyzed hemilarynx. The potential advantages and disadvantages of this new technique are discussed.

Experimental induced phonation in the dog has been used in short-term studies by several investigators and has proved quite useful in laryngeal research. In this study a long-term canine phonation model is described that uses permanently implanted electrodes on the superior and recurrent laryngeal nerves. A serial induced phonation model has not been previously reported and is needed for laryngeal research in which voice results are a primary end point. Inexpensive, reliable, nontoxic electrodes were designed and fabricated. The laryngeal nerves were found to be quite susceptible to injury, necessitating a series of changes in electrode design. Electrode durability and laryngeal nerve viability improved with each design modification; the final design gave a recurrent laryngeal nerve viability rate of 100% at 6 weeks, 83% at 9 weeks, and 73% at 12 weeks. Induced phonation was successfully produced on a repeated basis by stimulating the recurrent laryngeal nerves while passing air through the larynx, in 22 (95.6%) of 23 animals. Stimulation of the superior laryngeal nerves increased vocal fold length and tension but was not required for phonation. Technical aspects of chronic implantation and stimulation of the laryngeal nerves are discussed. The development and successful long-term implantation of electrodes on the laryngeal nerves and their use in repeated induced phonation have not been reported previously.

Medialization laryngoplasty has become a routine procedure for cases of unilateral vocal fold paralysis. In certain clinical situations, it may become desirable to reverse the procedure and remove the implant. This process was studied experimentally in eight dogs in a chronic model of induced canine phonation. A silicone polymer implant was inserted to medialize one normal vocal fold for a period of 1 month, after which it was removed. Motion of the cricoarytenoid (CA) joint and induced phonation were studied weekly while the implant was in place, and for another month following implant removal. Significant abnormalities were found even with this relatively short period of implantation. With the implant in place, impairment of CA joint mobility was found in seven of the eight dogs, precluding phonation. A dense fibrous capsule rapidly developed around the implant, making its removal technically difficult. Following implant removal, a gradual return to normal function was found in only three of the eight dogs. One of the animals had evidence of neural injury, while four had intact neural function but impaired mobility or fixation of the CA joint. Medialization laryngoplasty should not be considered a reversible procedure. The clinical implications of these findings are discussed.

To perform laryngeal research involving long-term survival surgery, a permanent tracheostomy is often necessary. For experiments using a long-term induced canine phonation model, we required a tracheostomy that was placed as low as possible, to maximize the subglottic space superior to the stoma. The ideal experimental tracheostomy would also be safe and easy to perform, require no tracheostomy tube, and be low maintenance, requiring minimal cleaning or suctioning. Tracheostomies were performed in 37 dogs based on previously published methods. If the stoma was placed below the twelfth tracheal ring, the perioperative mortality rate was 57% because of kinking of the trachea and subsequent airway obstruction. When the tracheostomy was performed above this level, the mortality rate was reduced to 3%. A number of significant modifications in technique were made to achieve this improvement and resulted in the last 12 dogs having no complications. Several of the tracheostomies were maintained for more than 18 months. The method derived meets the above criteria for the ideal experimental tracheostomy and also meets our needs for a long-term induced phonation model.