No abstract

Stenosis of the larynx and/or trachea presents perplexing problems. No one technique has proved totally satisfactory in the management of all varieties of stenosis. Recent reports have described the successful use of the CO2 laser in the endoscopic management of stenosis of the larynx and trachea. Failures of this technique need emphasis to assure appropriate selection of therapeutic method. Retrospectively, 49 cases of laryngeal stenosis, 6 cases of tracheal stenosis and 5 cases of combined laryngeal and tracheal stenosis were studied (total 60 patients) following treatment at the Boston University Affiliated Hospitals. Follow-up ranged from 1 to 8 years. Multiple procedures were required in 35 laryngeal patients. Of the laryngeal patients 39 were successfully managed (average number of procedures in successful cases 2.18). Of 11 tracheal patients with combined laryngeal and tracheal procedures, 3 were successfully managed (average number of procedures in successful cases 6). Failures in laryngeal stenosis included four patients in whom an adequate airway was not established though voice was present while maintaining tracheostomies. Thirteen patients failing endoscopic management required open surgery with good result. Factors associated with poor result or failure include circumferential scarring with cicatricial contracture, scarring wider than 1 cm in vertical dimension, tracheomalacia and loss of cartilage, previous history of severe bacterial infection associated with tracheostomy, and posterior laryngeal inlet scarring with arytenoid fixation. In these circumstances, multiple procedures, more extensive alternative open surgical techniques, or maintenance of tracheostomy were necessary. In successful cases only three or fewer procedures on average were required. The factors associated with failure or success of endoscopic methods in the management of laryngotracheal stenosis, including use of the CO2 laser and soft Silastic stents, are analyzed.

The sequence of histological change induced by CO2 laser irradiation was discussed in terms of two factors: the physiomechanical factor and the physiochemical factor. At sufficiently high heat energy levels, the immediate findings are characterized by crater formation resulting from rapid vaporization of the water and ejection of the solid component. In the immediate vicinity of the crater edge, the maximum tissue temperature rise is 65 degrees C above the 32 degrees C ambient tissue temperature and it decreases to the primary tissue temperature within a distance of 2 mm. The healing process of CO2 laser induced lesions proceeds with minimal delay. The lymphatic and vascular channels are occluded in the marginal area of coagulation resulting in a marked hemostatic effect. This sealing effect increases the margin of safety in preventing possible dissemination of tumor cells. By selecting the appropriate power, time, and focus cone angle, precise destruction of preselected areas of tissue can be achieved with an extraordinary hemostatic effect without damaging the underlying tissue. These advantages are especially helpful in function-preserving surgery.

The CO2 surgical laser and microscope assembly have been used to excise carefully selected T1 carcinomas of the membranous portions of the cord. Healing has been prompt and return of function satisfactory. General anesthesia and suspension laryngoscopy have provided excellent definitions of the lesions; the laser has provided a precise method of dissection. Initial results have been excellent and long term results will depend on the accuracy with which the margins of the tumor are defined and the presence or absence of the tendency of the larynx to produce multicentric disease.

The early postoperative hypopharyngeal anatomy of 37 consecutive patients undergoing total laryngectomy at the Boston Veteran's Administration Hospital between July 1977 and April 1980 was studied by barium swallow radiographs and correlated with the technique of closure. The "pseudoepiglottis," a structure radiographically resembling a normal epiglottis, was seen arising from the anterior hypopharynx near the base of the tongue in 21 of 28 evaluable patients. It occurred in all patients with vertical closures vs. 67% of patients with a "T" shaped closure. The average length in the "T" closure group was 9.6 mm (range 0-35) vs. 18.4 mm (6-40) in the vertical group, a statistically significant difference (p less than 0.05). Radiologic strictures occurred in 39% of all patients, dysphagia in 29%, fistulae in 18%, and sinus tracts in 14%. All complications occurred more frequently in the vertical closure group. Patients who received preoperative cis-platinum bleomycin chemotherapy and postoperative irradiation had 50% dysphagia and 67% stricture rates. The average ratio of the width of the retropharyngeal space to that of C4 was 0.48 in stricture patients vs. 0.29 in non-stricture patients (statistically significant at the p less than 0.01 level). This ratio taken in the early postoperative period may help predict which patients will develop strictures.

Relapse patterns in patients with locally advanced head and neck cancer who achieved complete remission were evaluated. After combined modality therapy with induction chemotherapy followed by surgery and/or radiotherapy, 71 of 103 patients were clinically free of disease. The 5-year recurrence rate was estimated at 51%, with a 39% local and 26% distant failure rate by 5 years. The factors significantly affecting the relapse patterns were: the site of the primary tumor (those with oral cavity lesions were more likely to fail locally, whereas hypopharynx patients had a higher risk of distant metastases); the type of definitive local treatment (those patients who received surgery and radiotherapy were at lower risk of pure local failure); TN Stage (patients with T4N3 or T3N3 tumor were at higher risk of both local and distant failure); and time to response and presence of oropharyngeal lesions (patients who had a longer period from diagnosis to final complete response [CR] and patients with oropharyngeal primaries were at higher risk for simultaneous local and distant failure). Type of chemotherapy, patient age, tumor differentiation, and response to induction chemotherapy did not significantly influence the patterns of relapse. A combined modality approach with induction chemotherapy, surgery, and/or radiotherapy does not seem to reduce the incidence of distant metastases significantly.

Seven cases of localized amyloidosis limited to structures of the head and neck and upper aerodigestive and lower respiratory tracts evaluated and treated at Boston University Hospitals in a recent 7-year period were reviewed. Negative Congo red staining of abdominal adipose aspiration biopsy or rectal biopsy specimens established that the amyloidosis was not systemic. Localized amyloidosis occurred in discrete masses in a variety of sites in the aerodigestive tract including the orbit, nasopharynx, lips, floor of mouth, tongue, larynx, and tracheobronchial tree. Five patients required surgical excision because of significant airway obstruction or organic dysfunction. Amyloid deposits completely excised with the carbon dioxide laser have not recurred, though other amyloid masses may appear elsewhere within the same organ or region. Amyloidosis may occur primarily or secondarily to other disease states. Localized amyloidosis has not been chemically identified but is usually defined by the absence of systemic features. While rare, amyloidosis must be recognized and understood by the otolaryngologist/head and neck surgeon to allow appropriate diagnostic and therapeutic planning.

Transoral excisional biopsy has been used in the evaluation and management of 103 T1 glottic cancers. A 3-year follow-up on these patients indicates that excisional biopsy unequivocally established the diagnosis and stage of the disease and that it is adequate treatment for micro and mini squamous cell cancers of the glottis in which the margins of excision are clear. Excisional biopsy with positive margins and larger T1 tumors establishes the absolute need for radiotherapy. Excisional biopsy is ideal for the diagnosis and management of verrucous carcinoma and spindle cell carcinoma. Recurrent/residual squamous cell carcinoma after radiotherapy should be explored by excisional biopsy which may be curative or will establish the need for partial or total laryngectomy. The appropriate use of excisional biopsy in the selective management of early T1 glottic cancers requires attention to detail by the surgeon and the pathologist and sound clinical judgment.