Laryngeal Compartments Research Articles

Impact of magnetic resonance on the decision of conservative surgery in advanced larynx cancer

ObjectiveTo evaluate the utility of magnetic resonance images (MRI) in the selection of treatment procedures for intermediate–advanced laryngeal cancers. Material and methodThis study included patients with histologically proven laryngeal squamous cell carcinoma defined as cT3 and T4a at our tertiary academic care hospital. All scans were evaluated by two radiologists experienced in head and neck cross-sectional studies. Signal patterns in MRI sections of laryngeal compartment subsites were delineated as T1w, T2w hyperintensity, and T2w intermediate signals, and were compared with the postoperative pathological results. Sensitivity, specificity, positive predictive values (PPV), and negative predictive values (NPV) were calculated. ResultsThe study included 51 patients with a mean age of 62.55 ± 9.14 (range, 45–80) years. Tumor was glottic in 12 (23.5%) patients, supraglottic in 19 (31.4%) patients, glottic-supraglottic in 11 (21.6%) patients, transglottic in 9 (27%) patients. The posterior paraglottic space had the strongest specificity of MRI according to tumor infiltration in the histologic analysis (specificity 96.9% and sensitivity 78.6%). The specificity of MRI was poor for tumor infiltration in thyroid cartilage (specificity 70.0%). Spearman's test demonstrated that there was a statistically significant correlation between the MRI-based prediction scores of all subunites and the findings of histopathologic analyses (mean±SD: 4.96±4.46–5.53±4.38, respectively, R2: 0.711, p<0.001). ConclusionThe high specificity values of the predictions, which were MRI-based in all subsites, indicated that MRI could provide an important contribution for defining tumor infiltration and the presurgical assessment of patients with tumors of the larynx.

Laryngeal Compartmentalization Does Not Affect the Prognosis of T3-T4 Laryngeal Cancer Treated by Upfront Total Laryngectomy.

A picture is emerging in which advanced laryngeal cancers (LCs) are potentially not homogeneous and may be characterized by subpopulations which, if identified, could allow selection of patients amenable to organ preservation treatments in contrast to those to be treated with total laryngectomy (TL). This work aims to analyze a multicentric cohort of T3-T4a LCs treated by upfront TL, investigating the clinical and pathological features that can best predict oncologic outcomes. A total of 149 previously untreated patients who underwent TL for T3-T4a LC at four institutions were analyzed. Survival and disease-control were considered as the main outcomes. A secondary end-point was the identification of covariates associated with nodal status, investigating also the tumor thickness. T and N categories were significantly associated with both overall and disease-specific survival. The number of positive nodes and tracheal involvement were associated with loco-regional failure; post-cricoid area invasion and extra-nodal extension with distant failure. Posterior laryngeal compartment involvement was not a significant prognostic feature, by either univariable and multivariable analyses. These results support the conclusion that laryngeal compartmentalization has no impact on survival in patients treated by upfront TL and the current TNM staging system remains a robust prognosticator in advanced LC.

Prediction of Posterior Paraglottic Space and Cricoarytenoid Unit Involvement in Endoscopically T3 Glottic Cancer with Arytenoid Fixation by Magnetic Resonance with Surface Coils.

Discrimination of the etiology of arytenoid fixation in cT3 laryngeal squamous cell carcinoma (SCC) is crucial for treatment planning. The aim of this retrospective study was to differentiate among possible causes of arytenoid fixation (edema, inflammation, mass effect, or tumor invasion) by analyzing related signal patterns of magnetic resonance (MR) in the posterior laryngeal compartment (PLC) and crico-arytenoid unit (CAU). Seventeen patients affected by cT3 glottic SCC with arytenoid fixation were preoperatively studied by state-of-the-art MR with surface coils. Different signal patterns were assessed in PLC subsites. Three MR signal patterns were identified: A, normal; B, T2 hyperintensity and absence of restriction on diffusion-weighted imaging (DWI); and C, intermediate T2 signal and restriction on DWI. Signal patterns were correlated with the presence or absence of CAU and PLC neoplastic invasion. Patients were submitted to open partial horizontal or total laryngectomy and surgical specimens were analyzed. Pattern A and B did not correlate with neoplastic invasion, while Pattern C strongly did (Spearman’s coefficient = 0.779, p < 0.0001; sensitivity: 100%; specificity: 78%). In conclusion, MR with surface coils is able to assess PLC/CAU involvement with satisfactory accuracy. In absence of Pattern C, arytenoid fixation is likely related to mass effect and/or inflammatory reaction and is not associated with neoplastic invasion.

High Frequency Jet Ventilation during Transoral Laser Microsurgery for Tis-T2 Laryngeal Cancer.

Transoral laser microsurgery (TLM) for early to intermediate laryngeal squamous cell cancer (SCC) can be technically challenging when adequate exposure of the posterior laryngeal compartment is required due to the presence of the orotracheal tube. The goal of our study was to analyze the efficacy of high frequency jet ventilation (HFJV) in achieving appropriate laryngeal exposure and safe oncologic resection of lesions located in such a position. We reviewed the clinical records of 62 patients affected by Tis-T2 SCC of the posterior laryngeal compartment treated by TLM between 02/2012 and 12/2016. The cohort was divided into two groups according to the anesthesiologic technique used: Group A included patients treated using intraoperative infraglottic HFJV, while Group B encompassed patients treated by standard orotracheal intubation. The main outcome was postoperative surgical margin status. Group comparison analysis was performed. Significant difference in deep margin status was observed between the two groups: in Group A, the rate of negative deep margins was 86% compared to 56% in Group B (p = 0.04). A trend of better overall and superficial margin control was observed for patients treated using HFJV (Group A), although no statistical significance was achieved. Use of HFJV during TLM allows easier and safer management of patients affected by Tis-T2 SCC of the posterior laryngeal compartment, reducing the rates of positive superficial and deep surgical margins.

Valor prognóstico da invasão de cartilagem no câncer de laringe

OBJETIVO: Avaliar o valor prognóstico da invasão de cartilagens (tireóide, cricóide) no câncer de laringe, com relação à sobrevida livre de doença. MÉTODO: Foi realizada uma análise retrospectiva de 102 pacientes com câncer de laringe atendidos no período de 1992 a 1994 no Hospital do Câncer - INCA/MS-RJ, que foram divididos em quatro grupos: pacientes com tumores T3N0M0, estádio III (excluídos os pacientes com tumores T3N1M0); T4N0M0 (com invasão tumoral de cartilagem do laringe sem extravasamento); T4N0M0 (com extravasamento neoplásico pelo compartimento laríngeo); e pacientes com linfadenopatia cervical metastática (T3N2-3/T4N1-2-3). Foram realizadas curvas de sobrevida para cada grupo e comparada a diferença de sobrevida entre estes grupos, utilizando o método de Kaplan-Meier. O valor da significância estatística da diferença de sobrevida dos quatro grupos foi avaliado pelo método de Wilcoxon-Gehan. RESULTADOS: Os pacientes que apresentaram apenas invasão tumoral de cartilagem de laringe, sem extravasá-la (T4N0M0), se comportam como os pacientes com tumores T3N0M0, sem diferença estatística com relação à sobrevida (p=0,36). Os que apresentam apenas invasão neoplásica de cartilagens de laringe (T4N0M0) tiveram melhor prognóstico com relação à sobrevida, do que aqueles com extravasamento neoplásico pelo compartimento laríngeo (T4N0M0) (p=0,02). A presença de linfonodos metastáticos foi o fator que apresentou maior impacto adverso no prognóstico com relação à sobrevida (p=0,002). CONCLUSÃO: Os achados deste estudo questionam a validade da atual classificação TNM em estadiar tumores T4N0M0 de laringe. Novos estudos, com uma casuística maior, são necessários para que os resultados obtidos sejam corroborados.

Region-specific immunological response of the different laryngeal compartments: significance of larynx-associated lymphoid tissue.

The occurrence of primary extranodal marginal-zone B-cell lymphoma [of the mucosa-associated lymphoid tissue (MALT) type] has only been described in the supraglottic region, implying that preexistent organized lymphoid tissue is present at that site only. To date, studies have not established clearly whether organized MALT shows a site-related distribution in the larynx. The supraglottic region of the false vocal folds and the subglottis from 87 unselected cadavers with no known history of nasal, oral, pharyngeal, laryngeal, tracheal, or esophageal disease were examined for the presence of organized MALT. Organized lymphoid tissue was found with the cytomorphological and immunophenotypic features of MALT in 100% of false vocal folds of children and in more than 90% of adolescents, decreasing to 7.1% in persons in their sixth decade, whereas MALT was completely absent in the subglottis in all age groups. The results explain why primary extranodal marginal-zone B-cell lymphoma has only been described in the supraglottic region but is absent in the subglottis. Moreover, the results suggest a region-specific immunological response of the different laryngeal areas as reflected in clinical observations and animal studies. However, the impact on presence or absence of laryngeal MALT awaits clarification.

Acute laryngotracheitis in the rat induced by Sendai virus: the influx of six different types of immunocompetent cells into the laryngeal mucosa differs strongly between the subglottic and the glottic compartment.

Acute laryngotracheitis is a disease in which mainly the subglottic area is infected, whereas adjacent parts of the larynx, especially the narrow glottic fold, remain unaffected. The reason for the difference between these two directly adjacent regions is unknown. Therefore, in the present study the influx of dendritic cells, neutrophils, T and B lymphocytes, natural killer cells, and macrophages into the mucosa of different laryngeal compartments was investigated after Sendai virus infection in the rat. The aims were to study both the influx of immunocompetent cells and the adhesion of the pathogen and to correlate them to the different reactions of the laryngeal areas during pseudocroup. Acute laryngotracheitis was induced by intranasal application of Sendai virus in brown Norway rats. This virus is exclusively pneumotropic in rodents and belongs to the parainfluenza virus type 1, the main pathogen of acute laryngotracheitis in children. The numbers of dendritic cells, neutrophils, T and B lymphocytes, natural killer cells, and macrophages were determined in the supraglottic, glottic, subglottic, and tracheal mucosa on days 2, 5, 7, and 14 after virus application. Furthermore, the nucleoprotein of the virus and major histocompatibility complex (MHC) Class II expression were detected immunohistologically on the laryngeal epithelium. All cell subsets entered the laryngeal mucosa during inflammation. The highest influx was detected among dendritic cells subglottically. This was accompanied by a strong virus adhesion and MHC Class II expression on the subglottic epithelium. In contrast, only a few immunocompetent cells entered the adjacent glottic mucosa, and on the glottic epithelium staining for virus nucleoprotein and MHC Class II expression was weak. The inflammatory response of the laryngeal mucosa shows great regional differences in this animal model during experimental viral infection. The response was characterized by a strong subglottic and a weak glottic reaction. A possible reason for this difference might be region-specific viral adhesion on the epithelium of the laryngeal areas, as well as differences in MHC Class II expression. Thus, these data agree with the clinical observation during acute laryngotracheitis and may explain why the subglottic part of the larynx is affected preferentially during pseudocroup. The molecular mechanisms mediating the different reactions await clarification.

Genioglossus muscle responses to upper airway pressure changes: afferent pathways.

The afferent pathway of an upper airway reflex in which genioglossus muscle electromyographic (GG EMG) activity is influenced by pharyngeal pressure changes was investigated in 20 anesthetized rabbits. We took advantage of the fact that the upper airway was separated into two compartments by pharyngeal closure occurring when the animals breathe through a tracheostomy. This allowed pressure to be delivered selectively either to the nose and nasopharynx or to the larynx and hypopharynx. Midcervical vagotomy did not eliminate the GG EMG response to pressure stimuli. On the other hand high cervical vagotomy or superior laryngeal nerve section eliminated the response in the laryngeal compartment, but not in the nasopharyngeal compartment. Topical anesthesia of the mucosa of the nose, pharynx, and larynx abolished the response in both compartments. Therefore we conclude that more than one afferent pathway exists for this upper airway pressure reflex; the primary afferent pathway from the laryngeal compartment is the superior laryngeal branch of the vagus nerve, whereas the primary afferent pathway for the nasopharynx is nonvagal. Trigeminal nerve, glossopharyngeal nerve, and/or nervus intermedius carry nonvagal afferents from the nasopharynx and nose. The topical anesthetic and nerve section studies suggest that superficial receptors mediate this response. The occurrence of swallowing in response to upper airway pressure changes and its elimination by topical anesthesia or superior mechanoreceptors may mediate both genioglossus respiratory responses and swallowing responses.

Epidemiology of laryngeal cancer.

The patients with cancer of the larynx at the Ear, Nose and Throat Department in Zagreb during the period from 1945 to 1972, and the cases of laryngeal cancer at the Institute of Public Health of Croatia, were examined epidemiologically. The patients were from all parts of Croatia (West and south part of Yugoslavia) with the characteristics of Mediterranean and Continental climate. The following factors were discussed: age and sex distribution, localization of the tumor in three compartments of larynx, relationship between the villages and cities, occupation (peasants, workers and intellectual people), histologic types and the etiological factors (smoking and alcohol.

Analysis of laryngeal compartments.

Analysis of laryngeal compartments.

Observations on the experimental use of radioactive isotopes within the larynx of the dog; notes on the submucosal compartments of the human larynx.

Studies on the local spread of fluids injected into the larynx, carried out as a preliminary investigation to the use of radioisotopes, have revealed interesting anatomical data pertaining to the presence of isolated submucosal laryngeal compartments. These are herein reported. Whether the use of radioisotopes will be effective in the treatment of laryngeal cancer is not known, but before it is attempted, certain basic facts should be established. These include the direction and degree of spread of fluids injected into a particular site, and the effects of locally injected radioactive isotopes on the normal structures of the larynx. A technique needs to be developed for the injection of the isotopes to assure effective distribution throughout the involved area and to avoid contamination. Determination of the length of time that the radioisotope will remain within the larynx is of particular importance, since up to now it has not been known