Abstracts of The 6th Congress of The European Laryngological Society

Eur Arch Otorhinolaryngol (2007) 264:295328
DOI 10.1007/s00405-006-0228-2
ABSTRACTS
Abstracts of the 6th Congress of the European Laryngological Society

31 August2 September 2006, Nottingham, England
Transnasal esophagoscopy (TNE)

Postma, Greg, USA
Chevalier Jackson and other otolaryngologists pioneered the use of
rigid esophagoscopy for examination, dilation, biopsy, and foreign
body removal. Over recent decades, other specialties developed
transoral flexible endoscopes to evaluate the upper gastrointestinal
tract in sedated patients. Now, thin, flexible TNE endoscopes are
available with distal-chip cameras for high-quality optics. These endoscopes, as well as fiberoptic endoscopes with specialized sheaths,
can be passed safely transnasally, while providing air insufflation,
irrigation, and biopsy capability. This is vastly safer than either rigid
esophagoscopy or sedated flexible endoscopy. TNE is particularly
useful in the management of individuals with dysphagia, reflux, and
head and neck cancer. It has been proven to be safe and well tolerated in the vast majority of patients and it may come to facilitate or
even replace routine panendoscopy for many of our cancer patients.
Indications: While there are many uses in an otolaryngologic practice, clear indications for TNE are poorly defined due to the novelty
of the technology. For example, it is unclear if all patients with
uncomplicated laryngopharyngeal reflux (LPR) should undergo
esophageal screening when the prevalence of Barretts metaplasia in
LPR patients may be as low as 7%. However, Reavis et al. demonstrated that symptoms of LPR and chronic cough were significantly
more prevalent than typical gastroesophageal reflux symptoms in
persons with dysplasia or adenocarcinoma of the esophagus. Thus,
symptoms of LPR may be the only indication of esophageal malignancy. In general, the indications for the transnasal evaluation of the
esophagus include patients with esophageal and those with extraesophageal requirements for the procedure. Dysphagia, esophageal
symptoms which persist despite an appropriate trial of therapy,
odynophagia, screening and possibly surveillance for Barretts
esophagus, caustic ingestion evaluation, and longstanding gastroesophageal reflux disease (GERD) represent the majority of this
group. Extraesophageal indications for TNE include patients with
globus pharyngeus, chronic cough, cervical dysphagia, head and neck
cancer, poorly controlled asthma, and moderate to severe laryngopharyngeal reflux. In addition the TNE endoscope can be used as a
therapeutic and diagnostic tool for procedures such as secondary
tracheoesophageal puncture, biopsy of lesions in the upper aerodigestive tract, balloon dilation of the esophagus, foreign body management, delivery of various flexible lasers, and placement of wireless
pH capsules.
Technique
Postma, Greg 2
Although I prefer that patients have nothing to eat for 3 h, a recent
meal is not a contraindication to TNE, but reflux of stomach contents
may interfere with visualization of the distal esophagus, gastroesophageal junction (GEJ), and gastric cardia.
The steps for successful TNE are:
Topical nasal anesthesia and decongestion with oxymetazoline

(0.05%) and lidocaine (4%), or cocaine (2%) soaked pledget(s)
for approximately 10 min
One spray of 20% benzocaine (Hurricaine) to the oropharynx
(optional)
TNE endoscope is lubricated
Endoscope is advanced with visualization of nasopharyngeal
closure, tongue base, hypopharynx, vocal fold motion, and possible pooling of oral secretions
The patient, sitting upright, flexes his head forward and swallows
as the endoscope is passed gently through the cricopharyngeus
muscle
With air insufflation and suctioning, the esophageal mucosa is
visualized and the scope advanced with the esophageal lumen
always in view
Esophageal motility is evaluated as the patient swallows (assessment may be enhanced by feeding the patient food coloredapplesauce with the endoscope in place), with normal esophageal
transit time less than 13 s
Lower esophageal sphincter (LES) function should be evaluated
with the esophagoscope a few centimeters proximal to it, determining if the LES is closed (normal) or open at rest and whether
or not it opens and then promptly closes following swallowing
The junction of the gastric and esophageal mucosa (squamocolumnar junction or Z-line) is carefully visualized to evaluate for
abnormalities such as reflux esophagitis, Barretts esophagus, or
hiatal hernia
The endoscope is advanced into the stomach and retroflexion is
performed to assist in the identification of small or medium sized
hiatal hernias
If mucosal lesions or irregularities are noted, multiple biopsies are
obtained
The endoscope is slowly withdrawn to re-examine the mucosa of
the entire esophagus
Postma, Greg 3
Transnasal esophagoscopy by its very definition refers to a complete
examination of the esophagus. This includes a retroflexed view of the
gastroesophageal junction while in the stomach to obtain a full view of
the entire esophagus. The majority of endoscopists performing TNE
do not make an attempt to visualize the entire stomach. This begs the
question of whether or not an esophagoscopy alone is needed for
otolaryngology patients and whether an esophagogastroduodenoscopy (EGD) would be more appropriate. This question was addressed
in a study by Wildi and colleagues in which 175 patients underwent
EGD and the findings were evaluated according to their symptoms.
The study demonstrates, and it is the experience of many experienced
gastroenterologists, that patients without daily abdominal pain, nausea, or a history of gastric or duodenal ulcers were highly unlikely to
have any significant findings in the stomach or duodenum. Therefore
esophagoscopy is sufficient in routine otolaryngology patients.
Complications: The complication rate for TNE is very low. A recent
review of over 700 TNE procedures revealed only six cases of self-
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limited epistaxis and two vasovagal episodes. While the TNE procedure was well-tolerated by most patients, failure to complete the
procedure was most commonly due to the inability to pass the TNE
scope through the nose (3%). No cases of esophageal perforation
have been reported with TNE performed by otolaryngologists.
Conclusion: TNE is a safe and effective procedure that maintains all
the advantages of previously reported flexible endoscopic techniques
with increased safety, while offering the distinct advantage of performance in the clinic without sedation. In addition, it gives the head
and neck surgeon the ability to perform a remarkable variety of
procedures in the outpatient setting without sedation. This should
result in overall better patient care and significant cost savings.
Confocal endomicroscopy
Martin Birchall
University of Bristol
The logical progression from advances in in-vivo imaging and
endoscopic technology is the move towards sophisticated in situ
diagnosis. The recent integration of a miniaturized confocal microscope into the distal tip of a conventional endoscope now permits
subsurface analysis of the mucosa and in vivo histology during
ongoing endoscopy in full resolution by point scanning laser fluorescence analysis. Cellular, vascular and connective structures can be
seen in detail to a depth of 250 lm, or several cells depth.
Graduation of cellular changes with endo-microscopy allows an
immediate in vivo diagnosis of different gastrointestinal diseases. The
diagnostic spectrum of confocal endo-microscopy is currently
expanding from screening and surveillance for colorectal cancer towards Barretts esophagus, Helicobacter pylori associated gastritis
and early gastric cancer. Implications for diagnosis and treatment of
laryngeal mucosal lesions are discussed, as is the future of in vivo
staining and imaging.
The future of an artificial larynx
G.J. Verkerke1,4, I.F. Herrmann2, H.F. Mahieu3
1
University Medical Center Groningen, University of Groningen,
Department of Biomedical Engineering, Groningen, Netherlands,
2
European Hospital, Department of OLR, Rome, Italy, 3 Vrije
Universiteit Medical Center, Department of ORL, Amsterdam,
Netherlands, 4University of Twente, Department of Biomechanical
Engineering, Enschede, Netherlands
Introduction: Laryngectomy as a treatment of laryngeal cancer is
very mutilating, leaving the patient with a low-pitched and sometimes
bad-quality voice, a tracheostoma and an inaccessible nasal function.
An artificial larynx could solve all of these problems. However, the
function of the larynx is complex. Whether such a device can be
realised, has been studied.
Methods: An inventory has been made on the functions that have to
be restored and on the solutions that are available for those functions.
Results: For voice reconstruction a voice-producing prosthesis, currently under development, could be applied. Fixation of the artificial
larynx to soft tissue structures can be realised by a tissue connector.
Selection between breathing and speaking can be done by using a
tracheostoma valve. Currently available HME-filters are suitable to
replace nasal functions. For preventing aspiration no solution is
available at the moment.
Conclusion: Failsafeness of an artificial larynx is the most difficult
requirement so an artificial larynx can only be located externally.
Most functions of an artificial larynx are feasible. Preventing aspiration is the most difficult function to fulfil. Since detailed knowledge
on deglutition is lacking and since failsafeness is very difficult to
realise, an artificial larynx is not feasible (yet). However, the different
components of such an artificial larynx can already be used to improve the quality of life of laryngectomised patients.
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Acknowledgments: The input of all project members of the Eureka
projects Artificial larynx and Newvoice was indispensable and is
highly appreciated.
Laryngeal transplantation
Martin Birchall
University of Bristol
There is no good surgical, medical or prosthetic solution to the
problems faced by those with a larynx whose function is irreversibly
damaged by tumour or trauma. I here propose that the only truly
functional replacement for a destroyed larynx will be a completely
new one and that this will only be achieved by transplantation.
Over the past 10 years, the pace of research designed to establish
laryngeal transplantation as a therapeutic option for these persons
has increased steadily. The biggest milestone in this field was the
worlds first true laryngeal transplant performed in Cleveland, OH,
USA in 1998. The recipients graft continues to function well, in
many respects, more than 7 years later. However, it has also highlighted the remaining barriers to full-scale clinical trials.
Stimulated by these observations, several groups have accumulated
data, which point to answers to some of the outstanding questions
surrounding functional reinnervation and immunomodulation. This
talk seeks to outline the progress achieved in this field by 2006 and to
point the way forward for laryngeal transplantation research in the
twenty-first century.
Laryngeal reconstruction
Olias Joas
The solution to cancer of the larynx involves in many cases, severe
surgery, a total laryngectomy that has as a consequence, the alteration in a definite form, of the important functions normally performed by the larynx. It limits the individual activity and his/her
participation in society, through its interference with some of the
more basic aspects regarding quality of life, such as the vegetative
functions of eating and breathing and the intellectual function of
verbal communication.
Despite being a malignant tumour, results show a reasonable amount
of patients recovering from this condition, which in turn, implies that
an elevated number of laryngectomised patients survive many years
and will permanently need support and differentiated cares, aiding of
an adequate family, social and professional reintegration.
In the last decades there have been some remarkable efforts and also
progresses in the rehabilitation of patients, mostly regarding the
recovery of the voice. However, the substitution/full reconstruction
of the larynx has still not been possible due to its complexity.
To try a better recovery of the laryngectomised patients, the authors
suggest some steps in the reconstruction of the larynx through the
prefabrication of structures constituted of totally autologous tissues.
The objectives were:
1. Surgical construction of a tubular structure with prefabricated
totally autologous tissues, with similar characteristics to the trachea;
2. Application of the tubular neo-structure, in substitution of tracheal circumferential defects; 3. Application of the tubular neostructure, in substitution of the respiratory segment of the larynx.
The author describes a technique of circumferential tracheal reconstruction developed for long defects, through the pre-fabrication in
the forearm and transference in delay as a totally autologous free
cutaneo-chondro-mucosal tubular flap. Applied so far in three cases
in which there was no known viable alternative, this neo-trachea has
made it possible in all of them the decannulation and normalization
of the respiratory function. Also described is the technique of some
surgical steps that attempt the total reconstruction of larynx.
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Vocal fold tissue repair in vivo using a synthetic extra cellular matrix
1
S Duflo , S Thibeault , G Prestwich , A Giovanni

1
Laboratoire dAudioPhonologie Clinique, Marseille,
2
Department of ENT, Salt Lake City, UT, USA
France,
Chemically-modified hyaluronic acid (HA)-gelatin hydrogels have

been documented to support attchment, growth and proliferation of
fibroblast in vitro and to facilitate repair and engineering of tissues in
vivo.
Aim: The objective of this study was to determine the optimal
composition of a synthetic extracellular matrix (sECM) that would
promote wound repair and induce tissue regeneration in a rabbit
vocal fold wound healing model.
Material and Methods: The sECM was formed using a thiol-modified semisynthetic
glycosaminoglycan (GAG) derived of HA
TM
(Carbylan -SX) mixed with a thiolated gelatin derivative,
co-crosslinked
with poly (ethylene glycol) diacrylate to form
TM
Carbylan -GSX.
Forty rabbits underwent
vocal fold biopsy bilaterally. Rabbits were
TM
treated
with Carbylan -SX, which lacks of gelatin, or with CarbyTM
lan -GSX with different gelatin concentration (2,5, 5, 10 and 20%)
via unilateral injection of vocal fold at the time of biopsy. Saline was
injected in the controlateral vocal fold as control.
Three weeks after biopsy and injection, animals were sacrificed and
mRNA levels of procollagen type 1, fibronectin, TGF B1, fibromodulin, HA synthase 2, Hyaluronidase 2, and tissues biomechanics
were evaluated.
Results: Hyaluronidase 2TMmRNA levels were found to be significatly
-GSX 20% w/w TM
gelatin compared to conelevated in for Carbylan
TM
significantly imtrols. Both Carbylan -SX and Carbylan -GSX
TM
proved tissue elasticity and viscosity. Carbylan -GSX containing 5%
w/w gelatin showed the most promise as a scaffold material for vocal
fold tissue regeneration.
Voice quality parameters in three vocal prostheses: comparison study

Lawson G1 , Watelet JB2, Bonte K2, Evrard AS1, Huot V1, Rijckaert
M1, Degreelle I1, Beatse V1, Remacle M1
1
Louvain University Hospital at Mont-Godinne, Yvoir, Belgium,
2
Gent University Hospital, Gent, Belgium
Background: After total laryngectomy, recovery of voice and
speech is one of the priorities for patient. However, only little
comparative information is available about the objective vocal
improvement with use of different prostheses. Vocal and acoustic
characteristics of prostheses were never compared in human by
using different prostheses on the same patient. The purpose of this
study was to compare the voice profile of three vocal prostheses
and analyze their respective maximal phonation time, phonation
quotient, intelligibility, intensity, sonogram and psychosocial
pattern.
Material and Methods: Twenty patients operated for total laryngectomy in the Department of Otorhinolaryngology of University
Hospital Mont-Godinne UCL were prospectively recruited with the
following inclusion criteria: good result at speech rehabilitation,
free of disease, minimum of one year follow-up after treatment.
The median age was 67 years, with a sex ratio of 5.6. All patients
used the three different prostheses consecutively: Provox, BlomSinger and Voice Master. Patients were asked about their subjective appreciation of the different prostheses and were submitted
to a battery of vocal, acoustic and psychosocial tests.
Results: Five patients considered the Blom-Singer prosthesis as the
more convenient, while four other considered Provox and fourVoice-Master as first choice. Three patients did not find subjective
differences between the prostheses. Blom-Singer prothesis presented higher fundamental frequency when compared to Provox
(P = 0.0056) and Voice-Master (P = 0.0225). Jitter in Blom-Singer
was also significantly increased when compared to the two other
prostheses (vs Provox P = 0.01, vs Voice-Master P = 0.0054). The
Provox prosthesis had a significantly higher airflow when compared
to the other prostheses. Voice-Master presented significantly reduced MPT values when compared to the other.
Conclusions: Even if no major subjective difference is reported by
the patient, the three different prostheses present significantly different vocal and acoustic characteristics.
Swallowing disorders and pharyngolaryngeal paralysis: management
with botulinum toxin in the upper esophageal sphincter (UES)
Woisard V, Simonetta Moreau M
ORL/HNS Department, Rangueil Larrey, 2Neurology Department,
Purpan University Hospital Toulouse, France
1
Aim: To describe the results of the treatment by botulinum toxin

injection in the UES performed in cases of severe dysphagia related to a disease of the cranial nerves with a pharyngolaryngeal
paralysis.
Material and Methods: A retrospective study composed of 12
patients. A swallowing assessment before and after the injection
analysed the physiopathologic mechanisms, measured the aspirations
and the stasis. Botulinum toxin injection was performed during an
electromyography of the pharynx and the UES with a local anaesthesia by external way. A mean dose of 43 U Botox are used.
Results: A faulty laryngeal closure was present in four cases, a faulty
lingual propulsion in five cases. The EMG found ipsilateral neurogenic tracks in the UES in only eight cases, an hyperactivity on the
safe side in eight cases, an hyperactivity on the paralyzed side in five
cases.
The injection modified the feeding status of the patients in 10 cases
and in 2 cases, there was no improvement after the injection despite
side effects: reflux and dysphagia worsening returning as before the
injection after 1 week.
After a follow up at least 1 year (and a maximum of 5 years), all
patients needed a new injection after the initial phase of treatment.
Discussion: The several UES behaviors lead to the hypothesis of a
particularity in the innervation and the neurological control of the
pharyngolaryngeal paralysis. The lack of new injections is in favour
of a reactional hypertonia more than in a dystonia of the UES.
Conclusions: The treatment of UES dysfunction by botulinum toxin
in severe dysphagia related to a pharyngolaryngeal paralysis is efficient when a paradoxal hyperactivity is detected in the UES.
Multidimentional characteristics of voice changes in reflux laryngitis

patients
Virgilijus Uloza, R
uta Pribuisiene_
Department of Otolaryngology, Kaunas University of Medicine,
Kaunas, Lithuania
The aim of the study was to analyse and quantify voice characteristics of reflux laryngitis (RL) patients, to determine voice tests
and voice-quality parameters of the most importance in the functional diagnostics of RL. Voices of 108 RL patients and 90 healthy
persons of control group were evaluated. Vocal function was
assessed using a multidimensional set of video laryngostroboscopic,
perceptual, acoustic, aerodynamic and subjective measurements
according to the protocol elaborated by the Committee of Phoniatrics of the ELS.
The mean values of hoarseness (VAS assessment) and VHI were
significantly higher (P < 0.05) in the group of RL patients as compare of the controls. Objective voice assessment revealed a significant
increase in mean values of jitter, shimmer and normalized noise
energy (NNE) along with a significant decrease in pitch range,
maximum frequency, phonetogram area (S) and maximum phonation
time (MPT) in RL patients, both in male and female subgroups.
According to the results of discriminant analysis, NNE, MPT, S and
intensity range were determined as an optimum set for functional
diagnostics of RL.
This study demonstrated that perceptual and subjective evaluation as
well as objective measures of voice parameters document deteriorated voice quality caused by RL. Deteriorated phonation pattern
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and voice-related problems lead to negative impact on patients
everyday life and professional activities, as reflected in significantly
increased values of VHI. Multidimentional voice assessment including both subjective and instrumental voice measurements is advocated.
Treatment of RL patients along with special medication and life style
modifications should involve care of the patients voice. Consequently, assessment of the results of the treatment of RL patients
should include monitoring of voice quality and VHI.
The VHI in different categories of voice patients: weighting

required?
M. Moerman1,2, A. Lieftink1
1
Institute for Phoniatrics Utrecht, The Netherlands, 2AZ Jan Palfijn,
Ghent, Belgium
Introduction: Literature has shown that the VHI in total laryngectomy (TL) is comparable with or even lower to the VHI in other
dysphonia groups. This can probably be explained by the patients
subjective interpretation and psychology. The large discrepancy between the VHI scores in TL and f.i. spasmodic dysphonia (SD) is
against clinical feeling and experience. By adding a subjective
measure of importance we tried to gain insight in the responders
personal view.
Methods: The original VHI was adapted by adding the question
how important do you think this issue is, regardless the frequency of
living it to each of the 30 VHI items. This question is to be scored
from 0 (not important at all) to 4 (extremely important). Thus the
total score of the additional question varies between 0 and 120 similarly to the VHI item scale. This adapted VHI version was filled out
by 32 TL and 20 SD patients.
Results: The total VHI score was 68 for the TL group and 75 for
the SD group. The TL group scored higher in the functional
domain (F) (24 vs 20) and lower in the psychological (P) and
emotional (E) domain (respectively, 21 vs 26 and 23 vs 29). In the
TL group the scores for the additional question were highest for the
F domain, and slightly lower for the P and E domain in contrast to
the SD group. Comparing the TL and the SD group, respectively,
we notice 22 vs 22 for F, 20 vs 26 for P and 19 vs 26 for E. After
applying a weighting factor the total VHI scores were similar in
both groups.
Conclusions: QOL measurements are largely influenced by psychological and subjective factors. Adding a question to each VHI
item gives insight in the different disease perception in two specific
pathology groups. Recalculation of the VHI scores with a weighting factor gives results which are more conform our clinical
expectations.
Aerodynamical model of the newborn larynx: an approach
of the first cry
Richard Nicollas1, Marc Medale2, Jerome Giordano2, Maurice
Ouaknine1, Antoine Giovanni1
1
Laboratoire dAudioPhonologie Clinique, Marseille, France,
2
IUSTI, Marseille, France
A sliding space between the vocal cord ligament and the mucosa is
necessary to obtain vocal cord vibration. This space does not exist
in newborn. To appreciate the role of vocal cords in newborn
phonation, authors performed simultaneous sound recording and
high-speed imaging on a human fetus larynx. No relationship exists
between sound frequency and vocal cords openclose frequency,
and no sound is obtained after resection of laryngeal structures
located upon the vocal cords. Moreover, this experiment showed
that the vibration frequency of the false vocal cords is the same as
the fundamental frequency of the sound recorded. On a second
step, numerical modeling of a rigid newborn larynx allowed
generation of a sound which FFT spectrum is very close to that
obtained with an excised larynx. These data demonstrate that the
role of vocal cords in newborn is not like the role in adults where
their vibration is the source of the voice.
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SLT endoscopy clinics for voice and swallowing evaluationtraining
and practice
Suzanne Slade, Nottingham
The use of laryngeal endoscopy by Speech and Language Therapists
is being increasingly reported in the UK. It has been reported that
use of flexible endoscopy can enhance the efficiency and effectiveness
of voice therapy.1
The Royal College of Speech and Language Therapists position
paper, SLT Endoscopy for Voice Disordered Patients gives guidelines on skills and competencies to be acquired.
This is the teams report on the growing use of endoscopy by speech
and language therapists, the training issues that are associated with it
and the experiences of the Nottingham Voice Disorders Team.
1. Rattenbury, HJ, Carding, PN, Finn, P. Evaluating the effectiveness and efficiency of voice therapy using trans-nasal flexible
laryngoscopy: a randomised controlled trial. J. Voice 2004 Dec;
18(4).
Vocal cord dysfunction: a proposed model for future
multi-disciplinary service provision
Miss Jemma Rogerson BSc (Hons) MRCSLT MHPC
Senior Specialist Speech & Language Therapist, Chorley & South
Ribble PCT
Vocal cord dysfunction (VCD) is characterised by the abnormal
adduction of the vocal cords upon inspiration, expiration, or both.
This leads to a diverse array of acute obstructive airway signs and
symptoms, likely associated dysphonia and developed laryngeal
sensitivity. Many patients are wrongly diagnosed with asthma and
suffer morbidity from unnecessary treatment.
VCD is becoming more frequently recognised and diagnosed but
prospective study into differential diagnosis and optimal treatment is
limited in the current literature. Historically laryngoscopy is the
recommended diagnostic tool, but intermittent symptoms make
endoscopic confirmation sometimes logistically difficult. Other diagnostic tools have been evidenced, namely pulmonary function testing.
Vlahakis et al. identified pulmonary function testing was instrumental in establishing the diagnosis of variable extra-thoracic large
airway obstruction.
Long-term treatment for VCD has been proved effective; speech
therapy has been used extensively with VCD patients with success.
However, effective treatment can only be utilized if individual specific aetiologies are identified. Psychological conditions were initially
recognized as the exclusive cause of VCD, however non-psychological causes are now linked. To facilitate a greater understanding of
the causes the relationships between physiological, patho-physiological and psychological factors, and their effects on glottic closure,
needs to be obtained.
The evolution of the Airways Clinic, Royal Preston Hospital, will be
outlined. Although in its infancy, it is currently the second of its kind
nationally and aims to improve quality of care delivered to patients
with VCD. The clinics overall goal is to draw on multi-disciplinary
team experts to develop diagnostic protocols and expedited efficient
therapeutic interventions, thus improving patients overall life quality.
Prospective study proposals will be discussed, which will aim to
provide invaluable evidence base, not only for the diagnosis and
treatment of VCD patients, but to also add weight for the need for
multi-disciplinary treatment forums for such a complex client group.
The reliability and validity of patient rating of voice quality
Lee Mei, Harris Sara
Queen Elizabeth Hospital Woolwich and Queen Marys Hospital
Sidcup
Research in progress: The research objective is to discover whether
patients are able to reliably and validly rate voices other than their
own. Clinicians voice rating ability has been extensively researched
but patients ability to rate voices has been minimally addressed. This
research is important, because the patients ability/inability to rate

voice quality impacts on therapeutic impact, prognosis and functional
outcomes. A previous paper by Lee et al. (Clin Otolaryngol, 2005)
highlights that patients appear to have good consistency in evaluating
their own voices using a simple perceptual scale, but that their
agreement with clinician ratings was poor. It was hypothesised that
voice patients were relying on other measures such as sensory and
emotional feedback rather than solely auditory feedback, in rating
their own voices.
This study seeks to find out whether patients will be less reliable in
rating other voices, not their own, as they will not have sensory
feedback. Additionally this paper seeks to find out if patients are less
reliable than clinicians in rating other voices. Evidence conflicts on
this - some papers say naive listeners are more reliable than experts
because they do not have internal voice templates based on unusual
voices. Naive listeners have internal templates based on normal
voices and might therefore be more consistent.
The study design is a prospective reliability/validity assessment of
voice ratings using a simple voice perceptual rating scale (GRBAS)
and two voice symptom questionnaires (VHI: Voice Handicap Index
and VPQ: Vocal Performance Questionnaire). Both have established
reliability and validity and are based on patient self-ratings of the
impact of their voice disorder on quality of life.
GRBAS stands for Grade, Rough, Breathy, Asthenic and Strain. The
GRBAS scale was chosen as it is extensively used amongst clinicians,
and has established inter and intra-rater reliability with expert raters.
Language Universals? in voice analysisissues to consider

Evelyn Abberton1,2, Adrian Fourcin1
1
Laryngograph, London, UK, 1,2University College London
Voice may be used differently from one language to another, and
although many languages are similar in their use of important voice
features it is not immediately obvious that it may be feasible for
methods of voice analysis to be capable of quantitative cross-comparison across languages.
Consonant and vowel contrasts are very different across languages
and could, in principle, differentially influence the smooth control of
voice timing so as to make cross language data comparisons invalid.
Although their phonemic inventories differ, the proportional use of
sonorants and obstruents is similar across many languages. There is
also a trend for the overall timing of voice duration intervals to be
similar. Indeed, in information theoretic terms, first order timing
structures may be almost ideal, across different languages in representative samples of connected speech. The fine detail in the use of
voice timing, however, does differ quite substantially from one language to another, varying from distributions that are far from ideal to
an approximation to first order perfection. These differences could
provide different foundations for the development of voice productive, and perceptual, skills that might have profound effects on language-dependent voice skill developmentfrom before birth
onwards. The implications of these findings are discussed with special
reference to cross linguistic voice clinic collaborations.
299
language therapists. They viewed 25 nasendolaryngoscopic images
(23 post radiotherapy patients and 2 healthy volunteers). Images
were rated using the 5 scale rating for degrees of oedema. This
process was repeated 1 week later.
Results: Images were taken from oral, oropharyngeal, nasopharyngeal and laryngeal cancer patients. All had received radiotherapy or
chemoradiotherapy. All raters were experienced in viewing larynxs
via nasendolaryngoscopy. The inter-rater reliability for scoring the
oedema rating scale was moderate (kappa 0.54). Lower levels of
agreement were found for tongue base, valleculae, pharyngeal walls
and anterior commissure. Intra-rater reliability was very good (kappa
0.84).
Conclusions: The oedema rating scale can be scored with very good
testretest reproducibility and moderate levels of agreement between
clinicians. Modifications to the methodology are suggested to
increase inter-rater reliability.
New and established techniques in the management of laryngotracheal stenosis (Intr. course)
Gyorgy Lichtenberger MD
Szent Rokus Hospital and Insitute, Department of ORL-HNS, 1085
Budapest, Gyulai P. u. 2, Hungary
Objective: The management of laryngotracheal stenosis is mostly a
great challenge also in the twenty-first century.
Study design and setting: The author gives an overview about the
diagnosis and techniques for the management of supraglottic, glottic,
cricotracheal and tracheal stenoses, based on more than 300 cases.
For the management of scarred anterior and posterior laryngeal
stenoses mostly endoscopic-microlaryngoscopic methods are used
based on the endo-extralaryngeal suture technique and device by
Lichtenberger. For the management of bilateral vocal cord paralysis
the operations are carried out in most of the cases without tracheotomy. In acute cases reversible operations, in chronic cases irreversible operations are carried out combining the laser technique
with suture lateralization of the medially preserved mucosa by
Lichtenberger. According to the traditions of the department for the
management of scarred cricotracheal stenoses laminotomy by Rethi
(posterior cricoid split) with costal cartilage autographt transplantation is performed or resection and thyrotracheal anastomosis
according to Pearson and Monnier. For the appropriate resection of
the stenotic segment by the management of tracheal stensosis a new
technique has been worked out by the authors to mark the site of the
stenosis.
Results: The success rate by the management of glottic laryngeal
stenosis is around 95%, and is around 90% by the management of
cricotracheal and treacheal stenoses; however, in some cases only
after repreated operations.
Conclusion: In the management of glottic laryngeal stenoses author
prefers the methods performed without tracheostomy in jet-anaesthesia. In the management of scarred cricotracheal and tracheal
stenoses in the majority of the cases the choice of the treatment is an
operation with outer exposure of the structures.
Rating post-radiotherapy laryngeal oedema

Jo Patterson
Newcastle upon Tyne, UK
Endoscopic imaging of pre-cancerous lesions of the vocal folds
Aim: Oedema is a common side effect of radiotherapy for head and

neck cancer. Systems have been developed to record and monitor
changes post radiotherapy. These lack the sensitivity to record
oedema in specific laryngopharyngeal structures. The aim of this
study is to develop a rating scale to measure oedema in the larynx
and pharynx.
Material and Methods: An exploratory study was conducted to
develop a new measure, using an expert panel, assessing inter and
intra-rater reliability. A consensus group developed the rating scale.
Eleven structures and two spaces were identified as areas sensitive to
the development of oedema. The terms no, mild, moderate or severe
were used to describe the degrees of oedema. The scale was piloted
and then tested for inter- and intra-rater reliability on five speech and
Background: The early detection of pre-cancerous lesions of the

vocal folds is associated with improved survival and the potential for
complete endoscopic resection. Standard white-light microlaryngoscopy and the ability of the laryngologist to reliably detect dysplastic
or early cancerous changes remains limited. Early detection may be
enhanced by several promising diagnostic imaging techniques such as
fluorescence endoscopy and contact endoscopy as these modalities
offer the potential to identify and quantify pre-cancerous as well as
cancerous lesions in real-time.
Methods: Patients in different stage of laryngeal dysplasia, carcinoma
in situ and laryngeal cancer were examined by means of the previous
mentioned imaging techniques during microlaryngoscopy. In fluorescence endoscopy cancerous mucosa was illuminated using blue
Christoph Arens, Mario Andrea
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300
filtered light in autofluorescence as well as 5-ALA induced protoporphyrin IX imaging for enhanced optical demarcation of the lesion.
Contact endoscopy was performed after the staining of the laryngeal
mucosa with methylene blue (1%). Two different endoscopes with
60 and 150 magnification were used. In both techniques a video
image was achieved by using a xenon light source and a special video
camera to register the fluorescence signal.
Results: During the autofluorescence examination of the endolaryngeal mucosa precancerous lesions showed a red to violet fluorescence outlined against the light green autofluorescence of the
normal mucosa. During 5-ALA induced fluorescence protoporphyrin
IX accumulated in these lesions presenting a bright red orange fluorescence. After staining the vocal cords with methylene blue, it was
possible to observe the cells, nuclei and cytoplasm of the laryngeal
mucosa and their different grades of abnormality using the specially
developed contact endoscopes.
Conclusion: Fluorescence endoscopy and contact endoscopy are
imaging techniques supplementing microlaryngoscopy. They are
suitable to differentiate dysplasia, carcinoma in situ, microinvasive
lesions as well as the evaluation of tumorous margins. Novel diagnostic techniques provide the laryngologist with more detailed
information that can considerably enhance the detection of early
stage lesions and helps the surgeon to perform a more functionally
oriented surgery.
Stroboscopy and high definition video: what the phonosurgeon
should know
Guillermo Campos, MD
Instituto de Laringologia, Clinica de Reflujo, Bogota DC, Colombia
Decisions in phonosurgery depend on objective assessment of the
vibratory pattern of the vocal folds. The aim of any phonosurgical
intervention is to make sure vibration can be as normal as possible.
Current diagnostic tools such as stroboscopy and the recently introduced high speed/high definition video cameras are indispensable for
every case in which surgery of the voice is considered.
Preoperative, intraoperative and postoperative images are presented,
dicussing details of vibration that should be taken into consideration
in every specific case to ensure the best possible outcome of surgical
treatment.

provides accurate removal of papillomas. However, this is a primarily
palliative method of treatment. Prevention of recurrences of papillomas is often unattainable and outcome of the disease remain
unpredictable.
Adjuvant therapy in recurrent respiratory papillomatosis (RRP)
E. Reckenzaun, G. Friedrich
ENT-University Hospital, Graz, Clinical Department of Phoniatry
Introduction: Surgical procedure is first line treatment of RRP,
although the disease cannot be cured and high recurrence rate is
common. Therefore adjuvant therapy including Cidofovir and
Diindolylmethan (DIM) or Indole-3-Carbinol (I3C) are widely used.
Method and results: In 2000 we started with combined surgical and
adjuvant therapy of RRP. Since that time we treated 24 patients. In
our adjuvant therapy concept we include patients with multiple
recurrences and other patients, where bad prognosis can be estimated. We perform a resection of exophytic obstructing papillomas
in order to establish an airway, but we do not resect lesions at the
anterior or posterior commissure. In extended or obstructing lesions
we prefer jet anaesthesia, in order to avoid passing the endotracheal
tube through the papillomas. Every 4 weeks Cidofovir is injected
intralesionally at a concentration of 15 mg/ml up to a volume of
injection 17 ml. Five to ten procedures were done. We continue
application 34 times after complete remission. In any case of
application we limit the number of application with ten times.
Rinsing of operating field and removal of carbonisation was also
done with Cidofovir soaked cotton. As an additional treatment we
suggest to the patient Diindolylmethan (DIM) or Indole-3-Carbinol
(I3C). As tumorgenicity and mutagenicity of intralesions Cidofovir
are unknown in human, a total maximum dose of 300 mg Cidofovir
was not exceeded. We could avoid tracheotomy and any permanent
laryngeal damage (stenosis or extended scar formation) with our
concept. No side effects were observed.
Conclusion: Because of the not known side effects of Cidofovir it
should be used very carefully, especially in children. On the other
hand RRP can be life threatening so we find it justified to use it in
cases where a bad prognosis can be estimated.
Laryngeal papillomatosis: treatment modalities and current opinion

Pure microsurgical treatment of laryngeal papillomatosis
Virgilijus Uloza
Department Otolaryngology, Kaunas University of Medicine,
Kaunas, Lithuania
Aim: The aim of the study was to detect the prevalence of human
papilloma virus (HPV) infection in the upper respiratory tract of
patients with laryngeal papillomatosis and evaluate outcomes of
endolaryngeal microsurgery (EM).
Material and Methods: The group of 36 patients with laryngeal
papillomatosis and the control group of 108 healthy persons was
examined for the presence of DNA of HPV. Viral typing using the
polymerase chain reaction (PCR) was performed. DNA of HPV was
detected in 35 out of 36 cases of laryngeal papillomatosis (97.22%)
and only in 25 persons (23.15%) from the control group. HPV types 6
and 11 were predominant. A total group of 89 patients including 32
with juvenile papillomatosis (JP) and 57 with adult papillomas (AP)
underwent EM. The aims of surgery in the JP group were as follows:
(1) meticulous removal of papillomas to maintain a stable airway,
and (2) preservation voice. The aims of surgery in the AP group were
slightly different: (1) radical removal of papillomas and restoration of
the voice, and (2) prevention of possible malignancy of papillomas.
Results: The recurrence rate in the follow-up period lasting at least
2 years was 72% (23 patients) in the JP group and 23% (13 patients) in
the AP group. The number of EM for the patients ranged from 1 to 18
(mean 3.2) in the JP group and from 1 to 5 (mean 1.35) in the AP group.
Summary: Recurrent laryngeal papillomatosis continues to be a
challenging disorder both for the patients and clinicians. Presently,
EM is considered as minimally invasive and safe technique that
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G. Peretti, A. Bolzoni, C. Piazza, A. Cattaneo

Department of Otorhinolaryngology, University of Brescia, Brescia,
Italy
Introduction: Laryngeal papillomatosis (LP) represents the most
common clinical manifestation of the respiratory tract due to human
papillomavirus (HPV-6, HPV-11). In the more aggressive cases
(especially with a juvenile onset), such a disease may present with
multifocal distribution and propensity for spread to the trachea,
bronchi and lungs, with worse prognosis and shorter disease free
intervals. Due to the frequent glottic involvement, dysphonia is the
most common sign in the adult onset form. By contrast, dyspnea is
not uncommon in the juvenile onset form because of the reduced
diameter of the airways. The most adequate treatment option must
be chosen among different surgical and non-surgical approaches, and
all treatment modalities should be discussed with the patient.
Treatment is often performed in a multi-step and symptom-related
fashion, so it is crucial to maximally reduce its long-term sequelae. As
a consequence, the treatment needs to be tailored to the specific case,
taking into account the extension and localization of the disease
among different laryngeal subsites, with special focus on anterior and
posterior commissure, Morgagnis ventricle and subglottic region.
Surgery, evolving in the last decade from cold steal resection to the
laser (CO2, diode, KTP) and microdebrider-assisted removal, is traditionally considered the gold standard approach. Moreover, the
recent introduction of new antiviral drugs such as Cidofovir can
integrate the surgical excision in a multimodal approach. This is a
valid option not only for symptomatic purposes, but also to address
the resection field and the macroscopically uninvolved laryngeal
mucosa (HPV-posive at PCR in 25% of cases).

Materials and Methods: From October 1990 to June 2006, 56 patients
with LP were treated at our department. Male to female ratio was
9:5; mean age 47 years (range: 1781). Ninety surgical procedures
were performed (mean, 2 per patient; range: 117) with a mean
interval of 13 months (range: 1131). From October 2004 to June
2006, eight patients underwent multimodal treatment by three
planned procedures at 30 days intervals. The macroscopic disease
was removed by microdebrider (bulky and exophytic lesions) then
refining the excision by CO2 laser, and all the mucosal surface were
subsequently injected by Cidofovir (5 mg/ml).
Results: Such an approach has the major advantage of allowing to
modulate excision in challenging laryngeal subsites thus minimizing
iatrogenic sequelae and to perform a therapeutic treatment by antiviral drugs with the intent to eradicate the HPV from the adjacent
laryngeal mucosa. Disease free intervals are significantly prolonged
in this subgroup of patients compared to those treated without
Cidofovir.
Conclusions: LP is a chronic infectious disease requiring multiple
treatments. The results are often frustrating for both patients and
physicians. Avoiding iatrogenic sequelae must be considered a major
concern (commissure and ventricular synechiae, supra- and/or subglottic stenosis). Multi-step surgical treatment, combined with low
antiviral drug injection, can be considered the treatment of choice in
order to prolong disease free intervals.
Suction coagulation in recurrent respiratory papillomas

C. Arens
Department of Otorhinolaryngology, Head & Neck Surgery,
University Hospitals Giessen and Marburg, Giessen, Germany
As long as a causal therapy of recurrent respiratory papillomatosis is
not attainable (vaccination), the aim of the treatment must be a
precise surgical removal, clearing the airways and restoring the voice
with minimal introduction of scars. Even with the application of
different treatment modalities recurrences still appear frequently
resulting in the danger of scar formation secondary to repeated
surgery. Instead of laser vaporisation we prefer suction coagulation
for local microsurgery. The heat is applied to the lesions by using
microcoagulators. White gelatinous remnants are sucked up without
bleeding. Depending on the extension of the lesion suction coagulation is combined with intralesional injection of Cidofovir. Especially in extended disease the combination of both treatment
modalities seem to be the treatment of choice in recurrent respiratory
papillomatosis. Our current treatment concept and the results are
presented.
301
We, therefore, propose the term exudative lesions of Reinkes
space to include Reinkes edema, polyps and nodules. These lesions share common histologic features which are located in the
Reinkes space and whose macroscopic appearance is largely
dependent upon the presence and duration of certain causative
factors. These actors may also provoke a possible evolution of one
lesion to another.
Fiberoptic videolaryngoscopy during bicycle ergometry - a promising
diagnostic tool for exercise-induced laryngeal dyspnea
Leena-Maija Aaltonen1, MD, PhD; Hanna Tervonen1, MD; Minna
Niskanen1, MD, PhD; Anssi Sovijarvi2, MD, PhD, and Erkki
Vilkman1, MD, PhD
1
Helsinki University Central Hospital, Department of OtorhinolaryngologyHead and Neck Surgery, 2Department of Clinical Physiology, Helsinki, Finland
Design: A prospective study with a sex- and age matched control
group.
Method: Determing the level (peripherial vs. central airways) of
exercise-induced dyspnoea is often difficult, and sometimes
wrong diagnosis of asthma causes inadequate medication. We have
established a relatively easy and well-tolerated test to diagnose
exercise-induced laryngeal dyspnea by combining fiberoptic videolaryngoscopy with bicycle ergometry. Patients ECG, heart rate, RR,
Sa02-saturation as well as FEV1 and breathing frequency are monitored. The subjective level of both dyspnea and strength of exercise
are assessed by using the Borg scales (former 010, latter 620). For
females, the load starts from 40 W and is added by 40 W every fourth
minute until the submaximal subjective exercise has been reached.
Laryngeal evaluation is performed during the test by transnasal
fiberoptic connected with a computer-based videolaryngoscopy
instrumentation (RP Szene, Rehder et Partner).
Results: Six patients with a suspicion of exercise-induced laryngeal
dyspnea have been studied since 2004 when we started to develop our
method. One showed inspiratory stridor and paradoxal adduction of
vocal folds, typical signs of vocal cord dysfunction. More patients and
healthy volunteers will be examined.
Conclusion: Ergometry-associated fiberoptic videolaryngoscopy is a
promising and feasible method to diagnose exercise-induced laryngeal dyspnea in laryngeal outpatient departments. In addition to
the standard instrumentation available in these units a bicycle ergometry, exercise program for ECG equipment, pulse oxymetry and
FEV1 meter are needed. Two physicians are required; an ENT
specialist for laryngeal visualization and anesthesiologist for monitoring other parameters during exercise.
Exudative lesions of Reinkes space: a terminology proposal
Evaluation of laryngeal obstruction in patients with exercise induced

laryngeal dysfunction
A. Hantzakos, J-C. Degols, F. Dikkers, G. Friedrich, A. Giovanni,

N. Rasmussen, M. Remacle
John-Helge Heimdal MD1, Ola D Roksund, MSc.2 Thomas

Halvorsen MD2, Robert C Maat MD1, Britt T Skadberg, MD2 and
Jan Olofsson MD1
Departments of Oto-rhino-laryngology/Head and Neck Surgery1 and
Pediatrics2, Haukeland University Hospital, Bergen, Norway
ELS Phonosurgery Committee

There has been an ongoing confusion among pathologists in their
attempt to accurately identify lesions of Reinkes space. Nodules,
polyps and Reinkes edema fall in the same basket and differentiation between them relies largely on the clinical description of the
pathologic specimen by the operating surgeon than on their distinct
pathologic features.
By revising the pertinent literature, however, the need for an
establishment of the aforementioned term still remains and is further
stressed out, as confusion among the various pathologic descriptions
of these lesions still exists. This is further verified by a study conducted in the Department of OtorhinolaryngologyHead and Neck
Surgery of the University Hospital of Louvain at Mont-Godinne,
Belgium, involving 321 operative specimens obtained from 200 patients with macroscopic descriptions of Reinkes edema, nodule,
polyp or serous pseudocyst. After being analyzed by a single
pathologist without the knowledge of their macroscopic picture, an
extensive overlap of the histologic findings of the aforementioned
lesions was observed.
Introduction: Breathing difficulties during exercise are often misdiagnosed as exercise induced asthma (EIA). Airway obstruction at the
laryngeal level may clinically mimic EIA. Misdiagnosed EIA should
be avoided to prevent unnecessary medication. A diagnostic set up
has been developed for continuous laryngeal inspection as well as
recording of gas exchange parameters, exercise flow volume loops
and breath sounds during exercise. This test is called: Continuous
Laryngoscopy Exercise Test (CLE-test).
Method: Endoscopic video recordings of larynx during exercise from
consecutive patients included in CLE-test were evaluated for signs of
inspiratory synchronous adduction of supraglottic structures and or
vocal cords. Based on these observations a classification system for
description of abnormal laryngeal response to exercise was developed, intended to validate a classification scale for dynamic laryngeal
pathology.
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302
Results: Fourty children and adolescents with a history of breathing
difficulties during exercise are until now evaluated and classified
according to this scale. Ten control subjects had normal laryngeal
responses to exercise, while two had mild supraglottic adduction. Ten
symptomatic subjects showed normal laryngeal function, 18 had
moderate to severe adduction of supraglottic structures or vocal
cords. Further details of the classification system will be presented
and discussed in the presentation.
Conclusion: It is feasible to perform continuous flexible laryngoscopy
concomitant with symptoms in most patients with breathing difficulties during exercise. An objective classification scale of laryngeal
dysfunction is important to achieve in order to determine correct
diagnosis and to select patients for intervention.
Solution of dyspnoe due to paradoxical vocal cord movement

Judit Falvai MD, Krisztina Meszaros MD, Gyorgy Lichtenberger MD
Szent Rokus Hospital & Institute, Department of ORL-HNS, 1085
Budapest, Gyulai Pal u. 2., Hungary
Introduction: Paradoxical vocal cord movement is a very rare
condition. It is characterized by the abnormal, conflicting adduction
of the vocal cord during inspiration and abduction during exspiration. Aetiology includes movement dysfunction, gastroesophageal
reflux, neurological, factitious or malingering and psychological
disorder. The treatment is complex. Managements of paradoxical
vocal cord motion are speech therapy, pharmacological therapy,
psychotherapy, and/or surgical intervention, that depend on the
causative factors. Paradoxical vocal cord motion can imitate upper
airway obstruction from dyspnoe to acut respiratory insufficiency,
for example symptoms of attack of asthma bronchiale. It is a
serious condition that requires prompt diagnosis and treatment.
Symptoms of functional disorder of the vocal cords can be
solved with intubation or urgent tracheostomy after unsuccessful
therapy.
Case history: We report a young female patient presenting with
inspiratory dyspnoe, stridor and dysphonia after upper airway
infection. Videofiberoscopy, direct microlaryngoscopy, lung function
tests, electromyography and phoniatric examination demonstrated
paradoxical vocal cord motion without laryngological organic disorder. The patient underwent an endoscopic reversible endo-extralaryngeal lateralisation by Lichtenberger in general anaesthesia with
high frequency JET ventilation.
Results: Postoperative control examination, lung function tests and
phoniatric checking proved, that patients breathing and voice became normal again. Probably the surgical thread-loop pressed the
vocal cords to perform near physiological motion.
Conclusion: This procedure may open new ways in solution of
dyspnoe and acute respiratory distress due to paradoxical vocal cord
movement.
Exercise induced laryngeal dysfunction, case reports and experiences

with surgical treatment
Robert C Maat MD1, John-Helge Heimdal MD1, Ola D Roksund
MSc.2, Thomas Halvorsen MD2, Britt T Skadberg MD2 and Jan
Olofsson MD1
1
Departments of Oto-Rhino-Laryngology/Head and Neck Surgery
and 2Paediatrics,
Haukeland University Hospital, Bergen, Norway
Introduction: Exercise related breathing difficulties concurrent with
noisy breathing and wheeze are often treated as exercise induced
asthma. Breathing difficulties during exercise can however, be caused
by airway obstruction at the laryngeal level.
Methods: A method for combined ergospirometry and continuous
laryngeal inspection during exercise, Continuous Laryngoscopy
Exercise test (CLE-test), has been used to verify this problem. From
the group of youngsters (120) complaining of exercise related
breathing difficulties, two patients were exceptional and therefore
selected for a more precise presentation.
123

Case reports: The first patient, a five years old boy with breathing
difficulties from newborn age. The second patient, a girl who developed breathing difficulties abruptly at the age of nine years. Both
children managed to complete the CLE-test. An adduction of the
supraglottic structures, synchronous to the inspiratory phase of respiration, was observed at a moderate effort during the test. Due to
the severity of problems and the motivation to obtain better respiratory function, the two children underwent laser surgery (Edoscopic
Supraglottoplasty, ES). We previously had experienced good results
with this treatment in youngsters showing exercise-induced stridor
due to obstruction at the supraglottic level.
Results: Both patients were treated uneventfully and returned to
normal physical activity. After surgery they showed less collapse of
the supraglottic structures at the CLE-test and improved subjectively
their breathing capacity during exercise.
Conclusion: The two patients had a subjective- and objective benefit
of ES as seen in the 12 other treated subjects. The described CLEtest is of great value for a correct diagnosis, to select patients for
surgery and to objectively evaluate the postoperative results.
Structural alterations of the vocal folds
A new classification system
Guillermo Campos, M.D. Director, Instituto de Laringologia, Consultant, Department of Surgery, Fundacion Santa Fe University
Hospital. Bogota DC, Colombia
Traditionally, structural changes of the vocal folds have been named
according to their appearance, and terms like nodules, polyps,
pseudocysts etc, have been used for years, but due to the wide range
of possible structural changes, it is difficult to define precisely every
single lesion we see in the vocal folds.
The diagnostic tools we now have routinely available (stroboscopy
and high definition video), allow us to have a better perspective of
the functional alterations on the vibratory pattern. This information,
combined with careful revision during phonosurgical procedures,
gives us a better idea of the problem. The ultimate goal of any surgical intervention for voice problems is to improve the vibratory
pattern, so the surgeons understanding of function is mandatory, and
it is easier to classify alterations from a functional perspective.
A new and simple classification system is proposed, based on functional evaluation and surgical findings; it includes three groups:
Type I: Lesions of the cover. Those that affect only the surface of the
cover, with a healthy subepithelial space.
Type II: Lesions under the cover. Those that do not involve the cover
but impede the free movement of it due to their location.
Type III: Trans epithelial lesions. Those that affect the cover, the
subepithelial space and sometimes deeper layers.
This classification is based on the mechanical impact caused by the
structural changes, and covers all kinds of lesions. It is very useful in
cases of sulcus and undesirable scarring.
A single lesion, regardless the size can alter the entire function of the
vibratory system, so this classification intends to simplify the approach and to ensure that the surgeon has guiding elements that
facilitate the choice of the best possible technique to recover the
vibratory capacity of the vocal folds.
Objective vocal assessment in a series of 449 patients in a clinical

laboratory. Comparison with perceptual analysis
Antoine Giovanni, Joana Revis
Laboratoire dAudio Phonologie Clinique, Marseille, France
Objectives/hypothesis: A comparative study of objective voice evaluation using a multiparametric protocol including aerodynamic
parameters and linear/nonlinear acoustic parameters recorded
EVA workstation, perceptual voice analysis by a jury.
Study design: 449 samples were retrospectively selected including
391 patients with pathological voices (308 women and 141 men) and
58 controls with normal voices (38 women and 20 men). A prospective complementary study concerning 43 female patients and 3
controls is presented.
303
Methods: Objective measures included fundamental frequency (Fo),

intensity, jitter, signal-to-noise ratio (SNR), Lyapunov coefficient
(Lya), oral airflow (OAF), estimated subglottic pressure (ESGP),
maximum phonatory time (MPT) and vocal range. A jury of four
experienced listeners was instructed to classify voice samples (continuous speech) according to the G (overall dysphonia) component of
the GRBAS score on a Visual Analogic Scale (VAS) scale secondary
transformed in a scale ranging from 0 for normal to 3 for severe
dysphonia.
Results: showed that a non-linear combination of only 7 parameters
in women (vocal range, Lya, ESGP, MPT, OAF, SNR, and Fo and 6
parameters in men (vocal range, Lya, OAF, ESGP, Fo, SNR) allowed classification of 81% voice samples in the same grade as the
jury in women and 84% in men. In the prospective study, 80.5% were
correctly classified with the same set of objective measurements.
Discussion: deals with the relative importance of the different
objective parameters in this type of discriminant analysis. Special
emphasis is placed on Lyapunov coefficient.
Ventilatory and phonatory function after burn/inhalation injury

1
Maciej Misiolek , Andrzej Krzywiecki , Lukasz Sikora , Grzegorz

Namyslowski1, Boguslawa Orecka1, Rafal Fira1, Hanna Misiolek3,
Jerzy Kozielski2, Dariusz Ziora2
1
Department of ORL-HNS, Silesian Medical University Zabrze,
Poland 2Department of Pulmonology, Silesian Medical University
Zabrze, Poland and 3Department of Anaesthesiology, Silesian
Medical University Zabrze, Poland
Burn/inhalation injury may result in impairment of both upper and
lower airways. The diminished quality of voice and some ventilation
problems are often recognized.
Aim: To assess the quality of voice and ventilation ability in miners
after burn/inhalation injury.
Material and Methods: Study group consisted of 17 men at the age
2854, mean 44.7, SD 9.2. They met with an accident (methane
burn/inhalation injury) in coal-mine 3 years ago. They underwent the
ventilation tests with flow volume-loop. Actual and predicted values
of folowing parameters: FEV1, FVC, FIV1, FEV1%/FVC, PEF,
MEF50, MIF50, PIF were analysed. The phonatory function was
estimated on the base of videostoboscopy and acoustic analysis:
Jitt%, RAP%, PPQ%, Fo, Shim%, APQ%, N/S and MPT. The
special control group was created. It also consisted of miners, at
comparable age, weight and height.
Results: Among ventilation parameters the significantly decrease of
actual and predicted values of FEV1, FVC and PEF was observed in
comparison with the control. Also the actual MEF50 was diminished
significantly. Videostroboscopy did not show important changes between study group and control, however APQ% and N/S were significant higher in comparison to the control. The TPT in examined
group was significantly smaller than in the control.
Conclusions: The sequele of the inhalation/burn injury may affect
voice which may be a result of some ventilation parameters impairment such as PEF and FVC in relation to MPT.
Comparison of outputs in two acoustic analysis programs:
PRAAT and MDVP
Haldun OGUZ1, Mehmet A. KILIC2, Mustafa A. SAFAK1,
Munir DEMIRCI1, Necmi ARSLAN1, M.D.
1
SB Ankara Training and Research Hospital, 2nd Clinic of Otolaryngology, Ankara, Turkey, 2Kahramanmaras S Imam University,
Department of Otolaryngology, Kahramanmaras, Turkey
Objective: Different voice analysis programs use similar descriptions
to define voice perturbation measures. The aim of this study was to
compare acoustic analysis outputs obtained by two computer programs, Praat and Multi Dimensional Voice Program (MDVP).
Study design: Subset analysis of a voice database, in two tertiary
referral hospital settings.
Method: 40 voice samples that belong to normal volunteers were
randomly selected from our database and exact the same voice
samples were used to obtain mean fundamental frequency, jitter,

shimmer and noise-to-harmonics ratio outputs from two acoustic
analysis programs.
Results: The outputs obtained by two computer programs for mean
fundamental frequency were exactly the same. The results for jitter,
shimmer and noise-to-harmonics ratio were significantly different
between Praat and MDVP. There was a perfect positive correlation
for mean fundamental frequency values. The correlation for jitter
values was strong; however, the correlations for shimmer and noiseto-harmonics ratio values were weak.
Conclusion: The numerical values obtained for mean fundamental
frequency can be compared between two computer programs.
However, the values obtained for perturbation measures are significantly different and cannot be compared. These differences were
observed under the same settings for two programs.
Phonatory modalities in permanent unilateral recurrent nerve palsy

(PURNP)
Vecerina Volic Santa, Prstacic Ratko
ENT Department, Zagreb School of Medicine, Zagreb, Croatia
Aim: We observed that the voice in some patients with PURNP is
not always satisfactory in spite of almost complete compensatory
vocal fold adduction.
Material and Methods: In 20 of such patients the mechanism of voice
production was investigated by endo-video-fiber-stroboscopy and
acoustical analysis.
Results: We detected the following possible mechanisms of inefficient voice in those selected patients: scars of both or one vocal fold,
glottic sulcus of one or both vocal fold, unilateral or bilateral Reinkes oedema, ventricular folds activation and approximation,
hypertrophy of the arytenoids mucosa at the paralytic side creating
mucosal voice. Also the changes in vibratory and acoustical pattern
was investigated when both vocal fold were approximated by external manual approach.
Conclusion: We concluded that other pathologies which alter the
vibratory pattern of vocal fold mucosa (glottic sulcus, scars, oedema)
could influence the voice production in PURNP. Also some wrong
compensatory mechanisms like ventricular folds activation and
vibration of supraglottic mucosa could be the source of pathological
phonatory mechanisms.
Summary: Thus, close collaboration between laryngologist and voice
therapist is essential for detecting optimal phonatory mechanism in
such patients. In some of them precisely designed phonosurgery
should be necessary.
Analysis of body posture during vocal effort
Leslie Akl1, Laetitia Papon2, Christine Assaiante3, Francois Le
Huche4, Antoine Giovanni (MD, PhD)5
1
Speech Therapist, Beyrouth, Lebanon, 2Speech Therapist, Laboratoire dAudio-Phonologie Experimentale et Clinique, Marseille,
France, 3CNRS, Marseille, France, 4Phoniatrician, Paris, France,
5
Laboratoire dAudio-Phonologie Experimentale et Clinique,
Marseille, France
Objective: To assess body posture modifications during a vocal effort
induced by a surrounding noise.
Design: Experimental study.
Methods: Segmental modifications were assessed using a 3D
numerical device based upon video detection and reconstruction
(Smart).
Experiment was conducted on 15 non-professional female speakers
asked to dictate a series of non meaning words to a nave listener
placed at a 12 m distance and unable to see the speaker. Measurements were made in silence then with a strong surrounding noise
delivered as well in the speakers earphones (Lombard effect) as in
the listeners one.
Results: We present standard deviation of the angles measured
(angle dispersion) and mainly concerning the pitch (anteriorposterior movements). We demonstrate that phonation in noise was
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304
correlated with an increase of parasite movements of the head, trunk
and even thigh compatible with the classic phoniatric prototypes of
vocal effort.
Discussion: Concepts of muscular tension dysphonia and relationship
between posture, voice and feelings of the subjects about the estimated need and emergency of vocal effort are discussed in order to
replace vocal effort not only as the result of an excessive vocal
loading but as well as an emotionally-marked behaviour
First clinical experiences of second generation videokymography

Tjouwke A. van Kalkerena, Harm K. Schutteb, Q. Qiub, Jan G Svecb,
Hans F. Mahieua
a
Department of Otorhinolaryngology and Head and Neck Surgery,
Meander Medical Centre, Amersfoort, The Netherlands, bGroningen
Voice Research Lab (H.K.S.), Biomedical Technology, Faculty of
Medical Sciences, University Medical Centre Groningen, Groningen,
The Netherlands
Design and method of study and analysis: Vibrational characteristics
of the vocal folds determine the quality of voice, therefore their
objective evaluation and quantification is essential. Stroboscopic
examination is currently the golden standard for investigating the
vocal fold behavior, but has some serious limitations. First of all the
principle of stroboscopy is based on periodic vibration. Every aperiodic occurrence disturbs the resulting image, rendering quantification difficult. Furthermore; irregular vibrations of the vocal folds
cannot be studied at all.1 High-speed visualization by means of videokymography developed by Svec and Schutte in 1994 does enable
investigation of irregular vibrations and qualitative evaluations.
However, widespread use was hampered by a number of shortcomings; firstly the scan position along glottal length was not shown
during videokymogram acquisition. Secondly the scanning line was
fixed at the top of the endoscopic view. Thirdly the videokymogram
was not continuous, which was caused by vertical blanking in TV
standard.
Summary of results: Recently a second generation user-friendly
videokymograph was developed in collaboration with the Groningen
Voice Research Lab with a scanning line in the middle of the usual
image. The system provides an even better resolution than initial
kymographic image, which was already superior to digital high-speed
camera images. Image acquisition can also be performed with flexible
endoscopy. First clinical experiences are presented.
1. Svec JG, Schutte HK. Videokymography: high-speed line scanning
of vocal fold vibration. J Voice. 1996. 10;201205
The role of phonatory tests in glottic wave evaluation

Santa Vecerina Volic, Vesna Kirinic Papes and Ratko Prstacic
ENT Department, Zagreb School of Medicine, Croatia
Material: In 20 examinees with normal vocal folds and voice and in
60 patients with defined vocal fold pathology (scars, glottic sulcus,
Reinkes oedema, early vocal fold cancer) we applied the following
phonatory tests: (1) usual prolonged vocalization (PV); (2) provoked
Bernoulli phenomenon (forced inspiratory phonation); (3) resonant
phonation ( RF) and (4) voiced friction (VF).
Results: In all examinees (normal and patients)mucosal wave was
much better expressed during RF and VF in relation to PV. This
phenomenon was of extreme importance in cases of scars and early
cancer infiltration, because this enabled the precise detection of
residual mucosal wave which can be of great help in defining the
extent of the process and in the treatment options. Also by a very
simple test of provoked Bernoulli phenomenon we could very precisely differentiate infiltrated from elastic free vocal fold margin.
Phonatory tests were performed by digital endovideofiberstroboscopy. Also acoustical analysis (Kay, Pratt) and KIPS analysis were
performed from the recorded data. Especially KIPS analysis confirmed the greater expression of glottic mucosal wave in resonant
phonation and voiced friction.
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Conclusion: The examined modified phonatory tests could be a significant contribution to evaluation of the vibratory modalities of
vocal fold mucosa. Better expressed glottic wave in resonant phonation and voiced friction could be attributed to greater aerodynamic
energy in vocal tract during voice production with closed lips.
A new spectrographic classification of dysphonia

Andrea Ricci-Maccarini
ENT Department, Bufalini Hospital, Cesena, Italy
The Yanagihara Classification of the noise components in the narrow-band spectrogram of the five vowels /i/, /e/, /a/, /o/, /u/, proposed
in 1967, is the most common method for the spectrographic examination of dysphomia. This method provides for the identification of
the noise components between the harmonics in the formant regions
of the five vowels and it is in four grades of severity. In 2002 we
proposed a modification of the Yanagihara classification in order to
apply it to the vowel /a/. This classification, in four grades of severity,
is simpler than the Yanagihara classification because it provides for
the identification of the noise components between the harmonics in
frequency regions instead of formant regions. On the bases of our
experience with this method, we recently reduced this classification
to three grades of severity (slight, moderate, severe), in order to
compare it to the Perceptual Evaluation of Dysphonia with the
GIRBAS scale (recommended by the ELS guidelines). Like the
GIRBAS scale, our spectrographic classification provides for
the identification of diplophonia (presence of sub-harmonics) and of
tremor (presence of oscillations). We applied this method, using the
Kay CSL digital spectrograph, to 50 patients with an evaluation before and an evaluation after a logopaedic and /or phonosurgical
treatment (total 100 perceptual and spectrographic evaluation): the
statistic analysis demonstrated a positive direct correlation between
the Perceptual Evaluation of Dysphonia with the GIRBAS scale and
our Spectrographic Classification of Dysphonia.
Vocal fold paralysesMRI findings

R. M. Muller1, P. Aikele2 , S. Klengel3
Klinik und Poliklinik fur HNO-Heilkunde, 2Institut und Poliklinik
fur Radiologische Diagnostik, University Hospital Carl Gustav
Carus, Technical University Dresden, 3Medizinisches Versorgungszentrum fur Diagnostik und Therapie RadCom GmbH, Riesa
1
Objectives: Idiopathic vocal fold paralysis can only be diagnosed

after extensive exclusion diagnosis. In case of genesis of further
undetermined origin of vocal fold paralysis and phobia of a tumor by
the patient examination by magnetic resonance imaging (MRI) of the
larynx should be taken into consideration.
Methods: In 20 patients suffering from unilateral vocal fold paralysis
in paramedian position MRI of the larynx was carried out. The following tentative diagnosis for the paralysis was made: idiopathic (6),
succession of an acute URTI (3), postoperative after strumectomy
(6), tumour of the larynx (5).
Summary of results: The MRI of 14 patients with the diagnosis of
idiopathic (6), postinfectious (3) and tumour paralyses revealed the
changes of the vocal fold typical of a tumour: hyper-intensive signal
alterations in the fat suppressing sequences and in the T2 weighted
sequences, iso-intense signal alterations in the native T1 weighted
sequences and distinct enhancement after the application of a contrast medium. The histological examination of the first 9 patients
showed no indication of malignancy. Six patients after strumectomy
and postoperative vocal fold paralyses certainly had no tumour in the
area of the vocal fold. But in the MRI they also showed changes of
the vocal fold typical for a tumour.
Conclusions: To detect infiltration, MRI was highly sensitive for
identification. However, the morphologically identifiable changes
were non-specific. These changes described before, often typical of
an infiltration of a tumour, in the case of neural vocal fold paralysis
have to be evaluated as a characteristic sign of the denervated vocalis
muscle without indication of malignancy.

Prevalence and relative risk of dysphonia in rheumatoid arthritis
R. Speyer1, I. Speyer2, M.A.M. Heijnen3
1
O.R.L. and Head and Neck Surgery, University Hospital Maastricht, 2Rheumatology, Bronovo Hospital, The Hague, 3Speech and
Language Pathology, Radboud University Nijmegen, The Netherlands
Objective: Laryngeal involvement in rheumatoid arthritis is not
uncommon and may include cricoarytenoid arthritis or vocal fold
lesions such as vocal fold rheumatoid nodules or bamboo nodes.
Dysphonia or voicing problems can be the result of such laryngeal
involvement. This cohort study investigates the prevalence and the
relative risk of dysphonia when suffering from rheumatoid arthritis
compared to that of healthy subjects.
Methods: 166 subjects with rheumatic arthritis and 148 healthy control subjects completed two quality-of-life questionnaires: the Voice
Handicap Index and a three-item outcome scale. Both instruments
measure the quality of the voice itself and the extent of impairment
resulting from dysphonia as experienced by the patient in social and
occupational settings.
Results: Patients proved to have statistically significant higher prevalence and relative risk of dysphonia. Depending on the questionnaire being used, prevalence data of dysphonia in patients varied
between 12 and 27% whereas the healthy subjects showed prevalence
data varying between 3% and 8%. A patients relative risk varied
between about 3 and 4 when compared to healthy subjects.
Conclusion: Patients suffering from rheumatoid arthritis have a
clearly higher risk of dysphonia compared to healthy subjects.
Bilateral vocal cord paralysis associated with myxoedema

kos Remenyi MD, Gyorgy Lichtenberger
Viktoria Kovacs MD, A
MD
Szent Rokus Hospital & Institute, Department of ORL-HNS, 1085
Objective: Bilateral vocal cord paralysis is a severe side effect of
thyroidectomy. Laryngeal myxoedema causing further laryngotracheal obstruction can potentially develop as a consequence of hypothyroidism which often sets in after near-total thyroidectomy.
Management of severe dyspnoea caused by the association of these
two side effects means a great therapeutic challenge.
Study design and setting: For managing dyspnoea caused by bilateral vocal cord paralysis as a severe side effect of thyroidectomy in
the acute post-operative period reversible endoscopic vocal cord
lateralisation is used at our department utilizing the endo-extralaryngeal suture technique by Lichtenberger. However, in the later
post-operative period of thyroidectomy when there is no chance for
the recovery of the recurrent laryngeal nerves we perform anirreversible procedure. This operation consists of partial arytenoidectomy and submucosal cordectomy done with laser preserving and
lateralising the medial mucosal part of the vocal cord according to
Lichtenberger. Applying these operative techniques we can achieve
satisfactory breathing in about 95% of cases avoiding the tracheostomy. In 5% of cases there are other side effects in the background of unsuccessful operative results which also can cause
dyspnoea potentially. From these side effects we emphasize the
role of laryngotracheal obstruction and myxoedema developed by
hypothyroidism. We have discussed the pathomechanism and presented our experience achieved by managing 3 male patients over
the last decade.
Summary: In all cases the main reason of dyspnoea developed after
thyroidectomy was the bilateral vocal cord paralysis associated with
myxoedema causing further laryngeal obstruction. Performing supplement endoscopic laryngeal operations and applying levothyroxine
replacement we could achieve laryngeal lumen of enough wideness in
all 3 cases.
Conclusion: According to our experience dyspnoea caused by
bilateral vocal cord paralysis after thyroidectomy needs complex,
interdisciplinary therapeutic approach beside glottis dilating operations.
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Objective voice changes in nondysphonic Parkinsons disease
patients
Haldun Oguz1, Tugba Tunc2, Mustafa Asim Safak1, Levent Inan2,
Selda Kargin1, Munir Demirci1
1
Saglik Bakanligi Ankara Training and Research Hospital, Department of Otolaryngology, 2Department of Neurology, Saglik Bakanligi Ankara Training and Research Hospital
Objective: To obtain objective acoustic analysis results from Parkinsons disease patients who do not have voice symptoms and to
compare these results with those from age- and sex-matched control
subjects.
Design: Prospective.
Setting: Tertiary reference hospital.
Method: The objective acoustic analysis results from 14 female Parkinsons disease patients with no voice symptoms were compared
with those of 22 age- and sex-matched normal subjects.
Results: Statistical analysis revealed no differences in mean fundamental frequency and shimmer values. However, differences in jitter
values, loudness, and the harmonics to noise ratio were statistically
significant between the two groups (P < 0.05).
Conclusion: With this study, it was shown that Parkinsons disease
patients who do not have any voice symptoms have objectively different acoustic values than their age- and sex-matched controls.
Clinicians must be aware of these initial findings on the voice changes
of Parkinsons disease patients.
Surgical treatment of tracheal dyskinesia in a fourteen month
old childcase report
Jovic M. Rajko, Janjevic Dusica, Canji Karol, Dragicevic Danijela
ENT University Clinic, Medical faculty, Clinical center, Hajduk
Veljkova 1, 21000 Novi Sad, Serbia
The primary form of tracheal dyskinesia in early childhood is a rare
congenital malformation of unknown origin. The degree of involvement of the posterior membranous part of trachea determines
intensity of obstruction and severity of clinical picture.
Presented is a case of a child whose trouble with sucking in form
of suffocation, noisy and difficult breathing and cyanosis started
3 months after birth. It became worse with first tracheobronchial
tree infection. After that apnoic crisis appeared without any
provocative factor. During six months of hospitalization child was
intubated several times. Diagnosis is based on clinical picture and
endoscopic examination which was performed in general anesthesia. In the awaking period from general anesthesia complete obstruction of tracheobronchial lumen was noticed by protruding posterior
membranous part which connects with anterior cartilaginous wall of
the trachea. Applied surgical technique of strengthing the tracheal
posterior membranous wall, placing fascia lata graft over the whole
tracheal and main bronchus posterior membranous wall is presented in
detail. The graft is fixed in position with fibrin glue.
One year follow up after surgical intervention showed no attacks of
difficult breathing and cyanosis. Repeated endoscopical examinations
registered minimal movements of the posterior tracheal wall during
childs breathing.
Trends in laryngopharyngeal reflux: a British ENT survey
Benton J1, Karkos PD2, Leong SC3, Karkanevatos A1, Badran K4,
Srinivasan VR2, Temple RH4, Issing WJ5
1
Leighton Hospital, Crewe, 2Arrowe Park Hospital, 3Royal Liverpool University Hospital, 4Countess of Chester Hospital, 5The
Freeman Hospital, Newcastle-Upon-Tyne
Objectives: There is much controversy surrounding laryngopharyngeal reflux (LPR). The aims of this survey were to identify widely
attributed symptoms, and to highlight current treatment trends in
LPR.
Methods: Questionnaires were e-mailed to 260 full members of ENT
UK (Consultants in Otolaryngology working in the UK). Recipients
were asked about type, duration and dose of anti-reflux treatment
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306
and if follow-up appointments were given. Finally, they were asked

about various reflux symptoms and reflux questionnaires.
Results: The response rate was 60%. The majority believed in laryngopharyngeal reflux and most manage it with proton pump
inhibitors (PPIs). The preferred duration of treatment was two
months (37%). A few prescribe PPIs for six months or more. Most
prescribed PPIs once daily (70%) and only a few (20%) prescribed a
dose more frequently. The commonest symptoms for which proton
pump inhibitors were prescribed are globus (73%), followed by
choking episodes (66%) and chronic cough (62%). If LPR is suspected, most (61%) follow up patients, although 31% discharge them
back to their general practitioners. Only 8% refer direct to gastroenterologists. The three commonest laryngoscopic signs admitted
to as suggesting the presence of LPR was erythema of the arytenoids
(86%), or erythema of the vocal cords (57%) and the presence of
granulomas (42%). The majority of clinicians (94%) did not use
symptom questionnaires.
Conclusions: Despite the controversy surrounding laryngopharyngeal
reflux (LPR), these results suggest that the majority of UK consultant
otolaryngologists who responded to the survey believe in LPR and
attempt to treat it. There appears little consensus on symptoms
attributable to LPR. Symptoms and signs questionnaires are rarely
used.
Methods: Each had a mucosal biopsy taken from the posterior glottis
and snap frozen. These were prepared for quantitative multiple
colour immunofluorescence histology (nine combinations). Comparison of log transformed data was by analysis of variance, confirmed by multiple range testing. Significance was accepted at the 5%
level.
Results: There was no increase in lymphocytes, neutrophils or macrophages in LPR. However, there was a significant decrease in
eosinophil markers. MHC Class I and II were likewise unchanged,
but CD1d (non-classical antigen presenting molecule) was increased.
Further studies showed an increase in an NK cell marker (CD161).
Conclusions: Surprisingly, we could find little evidence of changes in
the commonest classes of immunologically active cells in the
laryngeal mucosa of patients with LPR. However, elements of the
innate immune system showed up-regulation, specifically the CD1dNK (T)-cell axis. This suggests a possible fundamental role for this
system in laryngeal physiology, and also may explain the observed
fall in eosinophil markers.
Three dimensional mini organ cultures (MOC) of laryngeal epithelia

in genotoxicology studies
Objectives:
Norbert Kleinsasser, Rudolf Hagen

ORL-H&N-Surgery, JMU Wuerzburg, Germany
MOC of upper aerodigestive tract including nasal epithelia have been
shown to be a relevant tool in genotoxicology studies. MOC allow
repetitive or chronic exposure of cells to xenobiotics and monitoring
of possible adverse effects with, e.g., the comet assay. The present
report focuses on initial experiences with MOC from supraglottic
laryngeal epithelia.
Culture of mini organs was performed by cutting pieces of 1 mm3
from fresh specimens of human laryngeal epithelium. MOC were
incubated on multi-well plates with Bronchial Epithelial Basal
Medium and on days 7, 9, and 11 aliquots were exposed to xenobiotics and analysed for genotoxic effects.
Preliminary observations showed a less integrated growth of the
epithelial cells as compared to MOC from nasal epithelia. However,
there were sufficient cells that could be harvested for genotoxicity
analysis. These first experiences will be shared together with results
from investigations presently performed including exposure to typical inhalative xenobiotics, e.g., nicotine, N-nitrosodiethylamine and
sodium dichromate. This type of organ culture of laryngeal epithelia
provides an in vitro model suitable for the assessment of genotoxic
effects of environmental pollutants mimicking the in vivo situation
with target cells of carcinogens in their functional organ specific
intercellular architecture. However, further studies are necessary to
demonstrate the metabolic competence of laryngeal MOC.
Laryngopharyngeal reflux is associated with an upregulation
of CD1d expression in laryngeal epithelium, and downregulation
of eosinophils
Martin Birchall1, Louisa Rees1, Anne Phillips1, Mick Bailey1, Laszlo
Pazmany2, Gregory Postma3, Jamie Koufman3
1
University of Bristol, 2University of Liverpool, UK and 3University
of Wake Forest, USA
Background: Laryngopharyngeal reflux (LPR) is believed to be the
commonest chronic inflammatory disease of the larynx. However,
little is known about its pathogenesis.
Patients: 11 patients with LPR and 10 controls were recruited from
patients presenting to the Voice Center, Wake Forest University. All
patients received clinical assessment, dual probe pH studies and
transnasal esophagoscopy. Patients with RSI > 20, RFS > 10, pH test
positive and endoscopy confirmed reflux were cases.
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Primary care trends in management of Laryngopharyngeal reflux

Apurv Sinha, Anand Sastry, Apostolos Karkanevatos
Department of Otolaryngology, Leighton Hospital, Crewe
1. To assess the awareness of General Practitioners (GPs) towards

management of Laryngopharyngeal Reflux (LPR).
2. To assess the current trends in prescribing proton pump inhibitors (PPIs) by GPs with regard to dosage, timing, duration of
treatment and life style modification advise.
3. To assess the awareness of GPs towards current terminology use.
Design: Questionnaire survey.
Setting: Primary Care.
Participants: A questionnaire was sent to 100 GPs who routinely
refer patients to Leighton hospital. 96 of these responded (96%). The
data collected was analysed using SPSS software.
Results:
76% of GPs are aware of Laryngopharyngeal Reflux.
Among the atypical manifestations of LPR the most common
symptom for prescribing PPIs were: chronic cough (20%), followed by dysphagia (15%).
Maximum number of GPs (49%) prescribe PPIs for a period of 1
2 months and maximum (78%) prescribe it once a day.
81% of GPs give advice on life style modification.
81% of GPs were not aware of reflux symptom index and 86% of
GPs were not aware of reflux finding score.
Conclusions:
Most of the GPs are aware of Laryngo-pharyngeal reflux but they
are not fully aware of all the atypical manifestations of LPR. This
might lead to inaccurate diagnosis of LPR.
Most common symptom for PPI prescription after heart-burn is
chronic cough.
Most GPs prescribe PPI for 12 months and once daily which has
not been found appropriate in recent studies.
Most GPs are unaware of reflux finding score and reflux symptom
index and will need further awareness.
Endoscopic arytenoid mobilization and laterofixation for treatment
of scary fixation of the vocal cords
L Rovo, B Sztano, G Smehak, J Czigner, J Jori
ENT Clinic of Szeged University, Szeged, Hungary
Introduction: Prolonged intubation may cause suffocation by scary
fixation of the cricoarytenoid joints (CAJ). In severe cases only
external surgical interventions have been proved to be successful,
while endoscopic methods are generally suggested for only the mild
307
types of these stenoses, moreover these procedures often require

tracheostomy for a longer period of time. The aim of this study was to
introduce an endoscopic solution what does not require tracheostomy.
Subjects and methods: Examinations were performed on 33 patients
with a minimum of 1 year follow-up period. In 16 cases the
structure and the mobility of the CAJ proved to be intact intraoperatively at least on one side (group A). In another 17 patients
(group B) both CAJs structures were involved by the scar. In
group A, the interarytenoid scars were transsected by CO2 laser
then the arytenoid cartilages were temporarily fixed in a physiological abducted position by an endoscopically inserted suture for
6 weeks. In group B, the scar was completely excised, and the
fixating scar tissue remaining inside the joint was transsected by a
special blade designed for this intervention by the authors. Following this procedure the arytenoid cartilages were fixed by the
above mentioned way. The peak inspiratory flow (PIF) was measured before (I), in the first days after the procedure (II), and at
the end of the first postoperative year (III)
Results: Group A: avg. PIF I: 1.27 L/s; avg. PIF II: 2.53 L/s; avg. PIF
III: 2.78 L/s. Group B: avg. PIF I: 1.17 L/s; avg. PIF II: 2.59 L/s; avg.
PIF III: 2, 28 L/s. Good vocal cord function recovery with significant
voice quality inprovement was detected after the vocal cord release
in group A, and the voice remained hoarse but socially acceptable in
group B.
Discussion: The suggested minimally invasive method immediately
provides significant increase of breathing function even in the most
difficult cases of scary fixation of the CAJ, so perioperative tracheostomy can be avoided. Regained mobility, improvement of voice
quality can be expected in cases when the structure of the CAJ remained intact from the scar.
Laryngotracheal reconstruction (LTR): an adaptive flexible

approach
Objective phoniatric evaluation of reversible glottis dilatating

procedure
Aim: Cricotracheal resection (CTR) is a modern technique of airway

reconstruction in case of subglottic stenosis (SS). We report a case
series of adult, non-tracheotomized patients.
Material: 11 patients with significant SS were identified, presenting
with dyspnea and stridor. Grade of stenosis was III in 10 cases and II
in 1 case, according to the Cotton-classification. Etiology was manifold, with intubation and tracheotomy being the predominant risk
factors. CTR was performed in all cases with pre-and postoperative
videotracheoscopy.
Results: Mean postoperative intubation time was 47.7 h (11103 h),
mean length of ICU-stay was 4.4 days (39 days). Videotracheoscopy
for reassessment was performed after 69 days in the average. In 9/11
patients the subglottic lumen had been normalized. In 1 case a slight
restenosis could be managed with repeated endoscopic interventions.
1 patient died at post-OP day 4 due to a fulminant pulmonary
embolism. Further complications comprised 1 axillary vein embolism,
ventilator-associated pneumonia in 2 cases and 1 transient unilateral
recurrent nerve palsy, which recovered completely.
Conclusion: CTR is a reliable and versatile technique for reconstructing the subglottic airway, almost regardless of the underlying
etiology. Most complications observed have not been associated
directly to the procedure, but reflect the complex morbidity of the
patient population. There seems to be an increased risk for thromboembolic incidents, which may be attributable to pre-operative
immobilisation of the dyspnoeic patients.
G. Smehak. L. Rovo, J. Czigner, J. Jori

ENT Clinic of Szeged University, Szeged, Hungary
Introduction: From the beginning of the 1990s in the treatment of
bilateral vocal cord palsy a new conception has been suggested to
ensure wide airways. The basis of this method (vocal cord lateralisation with a suture technique) is that in case of movement
recovery the thread is removable without causing significant damage to the laryngeal movement. Our goal was to measure the
phoniatric changes during this procedure to find out if it causes
significant damage to the laryngeal structure from a phoniatric
aspect.
Material and Methods: In 7 women and 1 man after laterofixation the
vocal cord movement recovered on both sides. Their voices were
examined with a phoniatric computer program before the operation
(A), within 1 week after the glottis widening operation (B), after the
detection of the recovery of the movement of the vocal cords, but
before the removal of the laterofixation suture (C), within a week after
the removal of the suture (D), in the 6th month after the suture removal. (E) The examined parameters were: maximal phonation time
(MPT), signal-noise ratio/harmonicity (HNR), jitter (Jitt), shimmer
dB (Sh dB) base frequency/pitch (Fo). The phoniatric results were
compared with the stroboscopic examinations of the relevant times.
Results: average values: MPT (s): 3,6 (A), 2,8 (B), 4,8 (C), 9,9 (D),
17,8 (E); HNR (dB): 18,8 (A), 13,1 (B), 19,2 (C), 22,0 (D), 27,0 (E);
Jitt (%): 18,8 (A), 2,19 (B), 0,55 (C), 0,45 (D), 0,24 (E); Sh dB (dB):
0,58 (A), 0,76 (B), 0,45 (C), 0,28 (D), 0,14 (E) ; Fo (Hz): 240 (A), 203
(B), 230 (C), 217 (D), 244 (E).
Discussion: The investigated parameters verified a continuous and
obvious improvement in sound quality. In case of movement recovery after removal of the laterofixation (E), normal physiological
parameters were measured which were in good accordance with the
results of the stroboscopic examinations. The results confirm the
clinical observation that minimal invasive glottis widening operation
based on the physiological abduction of the arytenoid cartilage which
is performed in the early phase of vocal chord palsy is reversible
from the point of view of phonation.
Mohamed Bitar, Omar Sabra, Charbel Rameh, Nabil Fuleihan

American University of Beirut & Medical Center, Beirut, Lebanon
Objective: To evaluate the experience of an airway service in a small
community.
Patients and Method: Case series patients undergoing management
of airway stenosis.
Results: Thirteen patients (4F, 9M) with a mean age of 12.7 years
managed between January 2003 and May 2006. 5 had congenital
stenosis, with 1 concomitant subglottic hemangioma and 2 having
posterior glottic/subglottic stenosis. The acquired type 5 isolated
subglottic stenosis and 3 had tracheal component. The chief complaint: 2 dyspnoea, 4 stridor, 4 failed decannulation, 3 inability to
intubate for an elective surgery. Fifteen reconstructive procedures
were performed: 5 single stage LTR, 7 double-stage LTR, 3 tracheal
resection-anastomosis, (2 requiring LTR later). Use of stents: endotracheal tube 6, silicone stent 4 and T-tube 4. Stenting lasted for 1
21 days (mean of 9.285). Decannulation was achieved in 90% (9/10).
Patients required a mean of 1.36 procedure. Postoperative bronchoscopy was performed 17 times (mean 2.941/ reconstruction).
Conclusion: Airway reconstruction is a rewarding procedure but
needs good planning and close postoperative follow up. The best
reconstructive procedure should be tailored to each patient
depending on the site, severity and the etiology of the stenosis.
Cricotracheal resection in non-tracheotomized adults: prospective
case series
Sittel C, Blum S, Plinkert PK
University of HNO-Klinik, INF 400, 69120, Heidelberg, Germany
Fiberoptic endoscopic evaluation of deglutition in critically

ill patients
G. Hafner, A. Neuhuber, S. Hirtenfelder, B. Schmedler, H. E. Eckel
Klagenfurt General Hospital, Austria
Aim: Aspiration in critically ill patients frequently causes severe
co-morbidity. We evaluated routine transnasal fiberoptic endoscopy
in critically ill patients at risk to develop aspiration following extubation. We instructed intensive care unit physicians on specific risk
factors for and clinical signs of aspiration following extubation in
critically ill patients and offered bedside endoscopy for such patients.
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Material: Over a 45 month period, we were called to perform 913
endoscopic examinations in 553 patients.
Results: Silent aspiration or aspiration with acute symptoms was
detected in 69.3% of all patients. Prolonged non-oral feeding via a
naso-gastric tube was initiated in 49.7% of all patients. In 13.2% of
patients, a percutaneous endoscopic gastrostomy was initiated as a
result of endoscopic findings, and in 6.3% an additional tracheotomy
to prevent aspiration had to be initiated. In 81 out of 258 patients
(31.4%), pre-existing tracheotomies were closed, and 30.7% of all
patients could be managed with the immediate onset of an oral diet
and compensatory treatment procedures. Additional radiological
examinations were not required. Conclusion: FEES in critically ill
patients allows for a rapid and cost-effective evaluation of deglutition
and for the immediate initiation of targeted treatment or for an early
resumption of oral feeding.
Swallowing disorders and pharyngolaryngeal paralysis: management
with botulinum toxin in the upper esophageal sphincter
V. Woisard, M. Simonetta Moreau
ENT Department and Head & Neck surgery, Rangueil Larrey
University Hospital, Toulouse, France, Neurologie Department,
Purpan University Hospital of Toulouse, France
Aim: The upper esophageal sphincter (UES) dysfunction associated
with pharyngolaryngeal paralysis has a dramatic impact on the
severity of swallowing disorders. The aim of this retrospective study
is to describe the results of the treatment by botulinum toxin injection in the UES performed in cases of severe dysphagia related to a
disease of the cranial nerves with a pharyngolaryngeal paralysis.
Material and Methods: 12 patients were included, 5 having an enteral
feeding. Swallowing disorders were present since at least for 1 year.
Pharyngolaryngeal paralysis occurred after cervical surgery in 5
cases, skull base surgery in 4 cases, brainstem infarct in 3 cases. A
swallowing assessment before and after the injection analysed the
physiopathological mechanisms, measured the aspirations and the
stasis. Botulinum toxin injection was performed during a electromyography of the pharynx and the UES with a local anaesthesia by
external way. A mean dose of 43 U Botox is used.
Results: Regarding the physiopathologic mechanisms, an UES dysfunction is found in all cases associated with a faulty unilateral
pharyngeal propulsion. A faulty laryngeal closure was present in 4
cases, a faulty lingual propulsion in 5 cases.
The UES dysfunction leads to an ispilateral hypopharyngeal stasis in
video fluoroscopic examination. A paradoxal way of the bolus by the
side of the paralysis during the deglutition is observed in 4 cases. The
EMG found ipsilateral neurogenic tracks in the UES in only 8 cases,
an hyperactivity on the safe side in 8 cases, an hyperactivity on the
paralyzed side in 5 cases. The injection modified the feeding status of
the patients in 10 cases with:
The recuperation of an oral feeding with suppression
of the enteral one in 4 cases,
An improvement in oral feeding without suppression
of the enteral one in 1 case,
An improvement allowed feeding without aspiration
and with a more solid food in 5 cases
In 2 cases, there was no improvement after the injection despite side
effects: reflux and dysphagia worsening returning as before the
injection after 1 week.
After a follow up at least 1 year (and a maximum of 5 years), any
patient needed a new injection after the initial phase of treatment.
Discussion: The several UES behaviors lead to the hypothesis of a
particularity in the innervation and the neurological control of the
pharyngolaryngeal paralysis. The lack of new-injection is in favour of
a reactional hypertonia more than in a dystonia of the UES.
Conclusions: The treatment of UES dysfunction by botulinum toxin
in severe dysphagia related to a pharyngolaryngeal paralysis is efficient when a paradoxal hyperactivity is detected in the UES.
123

Severe dysphagia and aspiration resulting from radiotherapy or
radiochemotherapy; targeted solutions
Hans Mahieu
Department Otolaryngology, Head and Neck Surgery, VUMC,
Amsterdam, The Netherlands,
Department of Otolaryngology, Meander MC, Amersfoort, The
Netherlands
Introduction: Radiotherapy or radiochemotherapy for laryngeal and
pharyngeal cancer can have many serious sequelae. Among the most
difficult to treat are severe dysphagia and aspiration. Our centre is
considered a last resort for patients with intractable aspiration and
dysphagia from all over the country.
Method: Review of the most serious cases presented over the past
years, with special emphasis on the treatment options, the treatment
strategy and outcome.
Results: All patients had histories of failed conservative swallowing
rehabilitation prior to their referral. Videofluoroscopic examination
invariably demonstrated severe disturbances of deglutition, usually
with severe aspiration, not amendable to conservative swallowing
rehabilitation. Patients in whom the problems occurred as late sequelae of radiotherapy, could often be successfully treated with a
combination of UES myotomy and a laryngeal suspension. Occasionally laser excision and endoscopic mucosal flap reconstruction was
performed in cases of pharyngeal stenosis. For patients with complete
obliteration of the cervical oesophagus, retrograde puncture and
dilatation or stenting was used. Occasionally following radiochemotherapy proximal tracheal occlusion was performed with secondary
puncture and voice prosthesis placement between tracheostoma and
the proximal trachea and larynx, for voice restoration.
Conclusion: Severe dysphagia and aspiration following radiotherapy
or radiochemotherapy are difficult to treat. More emphasis can be
placed on prevention (e.g. treatment of reflux! prevention of mucositis!). Individualised treatment options should be taken into consideration.
Laryngeal transplantation in a pig model: the first week
Martin Birchall1, Rachel Burt1, Louisa Mitchard1, SM Ayling1,
Alan Jones1,2, Pamela Murison1,2, Chris Stokes3, Mick Bailey3
1
Laryngeal Research Group, 2Clinical Veterinary Sciences and
3
Veterinary Pathology, Immunity and Infection, University of
Bristol, UK
Background: Despite work on tissue transfer, prosthetics and
bio-engineering, there remains to date no good solution for an irreversibly diseased larynx. The ideal replacement would be another
larynx. However, issues of immunosuppression and reinnervation
need resolution before clinical trials can be properly proposed. This
is best achieved by preclinical studies in a large animal model, for
which the pig is ideal.
Methods: We have performed 10 laryngeal transplants in juvenile
(2040 kg) NIH minipigs fully matched at the MHC loci. All recipients received high dependency care for 1 week. Feeding was via
percutaneous endoscopic gastrostomy (PEG) and drugs were given
by central line. A dedicated T-tube provided an airway. Animals
were monitored clinically, by laser Doppler fluxmetry, videofluoroscopy and immunofluorescence of mucosal biopsies.
Results: Seven (70%) and five (50%) recipients survived with healthy
grafts to 2 and 7 days, respectively. Laser Doppler studies showed an
initial increase in mucosal blood flow in grafts (day 2) followed by a
decrease to normal levels by 1 week. Video-fluoroscopy showed
competent swallowing without aspiration or leaks in those pigs surviving to 1 week. At one week, recipients were able to phonate via
the graft. Mucosal immunology studies are underway to study the
effects of ischaemia-reperfusion injury (IRI) in this model.
Conclusions: Laryngeal transplantation is feasible in pigs, with little
discomfort after the first 2 days and with competent swallowing and
some phonation by 1 week. Early problems with airway control and
feeding have been prevented by use of a dedicated T-tube and PEG
respectively. At 1 week, larynges are healthy with normal mucosal
perfusion. It is now possible to use this model to study the effects of

transplantation across immunological boundaries and the effects of
reinnervation.
Re-epithelialisation process and mucosal wave pattern of the vocal
fold after subepithelial cordectomy
Glanz H
Department of Otorhinolaryngology, Head and Neck Surgery, University Hospitals Giessen and Marburg GmbH, Campus Giessen,
Germany
Background: Microsurgery for dysplastic lesions and microinvasive
cancer of the vocal folds requires a combination of oncological and
phonosurgical functional aspects. Totally different results after subepithelial cordectomy may occur. In the current literature there is no
study dealing with a precise description of the reepithelisation process and mucosal wave pattern after subepithelial cordectomy in
patients.
Material and Methods: One special case of a voice professional (60year-old non-Caucasian male) who underwent a subepithelial cordectomy for a moderate dysplasia is presented. The patient used his
voice very shortly after surgery, was closely monitored by videostroboscopies during more than 12 months after surgery. This resulted in a special documentation of the re-pithelisation process and
scarring.
Results: The re-epithelisation process lasted eight weeks, but the
scarring process lasted for several months, the mucosal wave pattern
returned after 6 months. Results are presented schematically as well
as in a quick motion video.
Conclusion: Early vocalising 23 weeks after microlaryngoscopy in
combination with controlled reflux have a positive influence on the
restitution of the mucosal wave and may prevent excessive scarring.
309
Results: According to the animal experiment injected autologous
fascia forms, at first, a randomly oriented mesh. After 12 months
collagen fibers show elongation and parallel orientation with viable
fibroblasts and vascular supply.
Material: From year 1995 a total of 158 patients with unilateral
vocal fold paralysis (UVFP) have been operated at our hospital
using fascia augmentation. When asked 6 months later, donor site
morbidity is considered insignificant. Retrospective review reveals
no major complications. 18 (11%) patients received a second
injection due to insufficient gap closure ( < 6 months), 3 late
re-injections have been made due to slow deterioration of voice
(>6 months), 15 (9%) arytenoid adductions have been carried
out as a second procedure. Fourteen consecutive patients were
analysed according to the voice results (mean 13 months after the
surgery). Mean phonation time doubled, shimmer, jitter and noiseto-harmonics ratio decreased significantly. Perceptual evaluation of
grade, breathiness and roughness improved significantly. Videostroboscopical evaluation showed significant gap reduction. Before
the operation, full vocal fold closure was not present, but was
established in half of the cases. The mucosal wave phase was
symmetrical in every case with a complete glottic closure. The
procedure is fast. The mean operation time is 32 min (N = 84)
including harvesting of fascia, mincing, placing it in a syringe as
well as performing the laryngomicroscopy and injection. Patients
leave the hospital on the day of surgery. No antibiotics or steroids
are prescribed.
Conclusions: Fairly large gaps can be successfully closed with injection laryngoplasty. Whenever UVFP needs surgical intervention, I
perform injection laryngoplasty with 0.30.4 ml of fascia first. About
20% of the patients will need a second procedure in order to
establish a proper vocal fold closure or tonus.
Fibrin glue implants: a good alternative for difficult cases in
phonosurgery
Do polyps develop because of laryngoscopically invisible sulcus

vocalis?
Markus Hess, MD; Susanne Fleischer, MD; Anna-Katharina Licht
Department of Phoniatrics and Pediatric Audiology, University
Hospital Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg,
Germany
Some patients with unilateral vocal fold polyps have an additional
sulcus vocalis. The polyp with its superior boundary directly ends at
the inferior edge of the sulcus. Because this inferior-polyp-to-superior-sulcus formation was demonstrated in many cases in otherwise
not clearly plausible cases of unilateral polyp formation, i.e., in cases
where functional voicing problems were not apparent, we came up
with a new hypothesis. Given that the upwards directed mucosal
travelling wave is abruptly stopped at the sulcus, the epithelium right
at the inferior sulcus border has to stop the phonatory energy that is
contained in the fluid-filled tissue of the subepithelial tissue. Thus,
every single oscillationand the energy vector within the subepithelial tissue bangs at the epithelium inferior to the sulcus and
causes epithelial slackening and ballooning. This balloon is seen as
polyp in clinical videostroboscopy, whereas in most cases the sulcus cannot be visualized even with high-resolution telescopes. Visualization of the sulcus was possible in high microscopic magnification
within suspension microlaryngoscopy, when additional palpation was
possibly. Cases and images will be demonstrated.
http://www.uke.uni-hamburg.de/kliniken/hno/phoniatrie/
index.de.htmlhess@uke.uni-hamburg.de
Ten-year-experience in vocal fold augmentation with autologous

fascia
Heikki Rihkanen, MD
Helsinki University Hospital, Department of ORL and HNS, Finland
Design: Review of prospective studies, retrospective chart review,
and hospital administrative data.
Guillermo Campos, M.D.

Director, Instituto de Laringologia, Consultant, Department of Surgery, Fundacion Santa Fe University Hospital. Bogota DC, Colombia
Objectives: Sulcus vocalis and undesirable scarring of the vocal folds
are a challenge for the voice surgeon due to their impact on the
vibratory behaviour. The great variability of structural damage
makes it impossible to predict the outcome of surgical treatment. The
purpose of this study was to evaluate whether fibrin glue implants
could prevent fibrosis and improve vibration after liberation of the
lesions.
Methods: Twelve patients with sulcus and/or undesirable scarring
of the vocal folds underwent surgical treatment to solve the problem
of the cover and the subepithelial space of the vocal folds. At the end
of each procedure, fibrin glue components were mixed outside the
surgical field until solidified. An implant was tailored and placed in
the subepithelial space. The cordotomy incision was closed with 7-0
absorbable sutures. Four patients with bilateral compromise underwent two surgical interventions. In one case the second intervention
was a fat injection of the fold that did not receive the implant. All
patients were evaluated preoperatively and postoperatively with
stroboscopy. The last four cases were also evaluated pre- and postoperatively by means of high speed/high resolution videolaryngoscopy.
Results: In the cases with bilateral compromise, in which clearly
abnormal vibratory behaviour and glottic incompetence were present
before surgery, a marked improvement on the vibratory pattern and
glottic closure, along with important improvement in voice quality
could be obtained. In the patients with unilateral lesions caused by
subepithelial fibrosis, very satisfactory vibratory characteristics and
voice improvement after surgery could be achieved. Average postoperative control: 14.5 months.
Conclusion: Liberation of sulcus and removal of fibrous tissue from
the subepithelial space are commonly needed in surgical treatment of
voice problems. The final purpose is to improve the pliability of the
cover. Fibrin glue implants are easy to manufacture and may be a
good alternative to prevent new scar formation and to ensure a better
behaviour of the cover of the vocal folds.
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310
Modified Gore-Tex medialisation thyroplasty: voice quality
outcomes
S. Davis, H. Wilson, M. White-Thomson, S. Khalil, P.A. Tierney
Department of Otorhinolaryngology, Southmead Hospital, Bristol,
UK
Introduction: We describe a modified technique for Gore-Tex medialisation thyroplasty used in vocal cord paralysis. The inferior and
lateral displacement of the vocal cord is corrected in order to improve voice quality outcome, both short-term and longer term.
Material and Methods: Seven patients with unilateral vocal cord
paralysis underwent day-case Gore-Tex medialisation thyroplasty,
using a modified technique, performed by one surgeon under local
anaesthetic. Voice quality was assessed pre-operatively and at suitable postoperative intervals up to 9 months. Objective assessment
involved voice recordings with acoustic analysis (Visi-Pitch 3) and
maximum phonation time (MPT). Subjective assessment included
Voice Handicap Index (VHI) and the Grade Roughness Breathiness
Asthenia and Strain (GRBAS) scores. Median and interquartile
ranges (IQR) were used to comment on the results in this small
number.
Results: Review at 3 months revealed a reduction in median shimmer
from 5.90% (4.209.49% IQR) to 3.70% (2.546.99% IQR). Median
jitter decreased from 3.03% (1.253.58% IQR) to 0.67% (0.412.23%
IQR). The pre-operative median MPT/a/score of 4 s (IQR 48) rose
to 8 s (IQR 712) in the same period. The VHI score was reduced
from a pre-operative median of 59 (IQR 4569) to a 3 month median
of 24 (IQR 740). Longer term data, at 9 months, was only available
from 3 patients. This group had a median shimmer of 3.61%, a further improvement from 3 months.
Discussion: These results show short-term improvement in objective
and subjective measures of voice quality, following this modified
technique. Longer term data suggest continued objective improvement. Ongoing study will determine whether this modification will
produce superior voice outcomes and become more widely adopted.
Statement of conclusion: Our modified Gore-Tex medialisation thyroplasty improves voice quality short-term. Long-term outcome may
be improved, though further investigation is warranted.
Muscle fiber type distribution in the PCA: evolution after

non-selective laryngeal reinnervation, and influence
of the calcineurin inhibitors
Ph. Gorphe1,4, P. Kingham2, Y. Lacoume1, M. Birchall3, G. Terenghi2, J.P. Marie1,4
1
Experimental Surgery Laboratory, EA 3830 GRHV, IFRMP 23,
University Hospital of Rouen, France, 2Blond McIndoe Laboratories, University of Manchester, UK, 3Laryngeal Research Group,
University of Bristol, UK, 4European Laryngeal Research Group
Objectives: To describe the distribution of the type 1, 2a and 2b
muscle fibers in posterior crico-arytenoid muscle in rats after nonselective laryngeal reinnervation, within daily administration of
calcineurin inhibitors, in low doses and immunosuppressive doses.
Method: 6 groups were: healthy group (n = 6), surgery control group
(n = 6), low dose Cyclosporin A surgery group (n = 6), immunosuppressive Cyclosporin A surgery group (n = 6), low dose FK506
surgery group (n = 6), immunosuppressive FK506 surgery group
(n = 6). Surgery was a section-anastomosis of the left vagus nerve.
Drugs were given daily for 45 days, then the PCA muscle was taken
for muscle fibers immunohistochemistry, and blood sample for drug
concentration dosage. Percentage of each muscle fiber type was
calculated in the whole muscle section.
Results: Fiber type 1 distribution was lower in the surgery control
group, the low dose FK506 surgery group and the immunosuppressive Cyclosporin A group, than in the healthy group, without any
differences between the whole surgery groups. There was no significant difference in fiber type 2a distribution. There was more fiber
type 2b in control surgery group than in the immunosuppressive
FK506 group and in the Cyclosporin A surgery group, without any
difference between the drug surgery groups.
123

Conclusion: Immunosuppressive groups had a lower rate of muscle
fiber type 2b than the surgery control group. There was no significant
difference in fiber type 1, 2a and 2b muscle fibers between the FK506
immunosuppressive group and the healthy group, but there was a
difference in fiber type 1 distribution between the surgery control
group and the healthy group.
A new procedure for arytenoid adduction through the thyroid ala
combined with type I thyroplasty for unilateral vocal cord paralysis
Ryoji Tokashiki, Hiroyuki Hiramatsu, Mamoru Suzuki
Department Otolaryngology Tokyo Medical University Tokyo,
Japan
Design: We present the techniques and the outcome of new approach
of arytenoid adduction through the thyroid ala combined with thyroplasty type I.
Patients and Methods: Between October 2004 and February 2006, 12
patients with unilateral vocal cord paralysis whose maximum phonation time (MPT) were under 5 s underwent the operation. In all
cases, MPT and mean air flow rate (MFR) was measured before and
after operation. The voices were analyzed using shimmer and jitter.
Surgical procedure: Two surgical windows were made in the lower
part of the thyroid ala. The anterior one is for typical type I thyroplasty and the posterior is for arytenoid adduction (AA). The
locations of the two windows were determined based on three
dimensional computer tomography (3DCT) data. AA was performed
by pulling the lateral crycoarytenoid muscle (5 cases) or muscular
process (7 cases) through the posterior window without releasing the
cricothyroid joint. Operation was performed under local anesthesia
with sedation except for two cases operated under general anesthesia
using a laryngeal mask. The vocal cord medialization was confirmed
endoscopically during the operation.
Result: All patients achieved MPT of over 12 s. MFR, which ranged
from 340/ml/s to over 1,000/ml/s before the operation, improved to
under 200/ml/s in all cases. Shimmer and jitter were improved to
within or near the normal range.
Conclusion: Our new procedure simplified the combination of AA
and type I thyroplasty because the two treatments can be done in the
same operating field obtaining good voice improvement. Determination of the surgical approach using 3DCT and endoscopic vocal
cord observation may contribute to the results.
Extrusion forces of resorbable tacks and titanium screws in laryngeal

chondrosynthesis
Norbert Kleinsasser, Rudolf Hagen
ORL-H&N-Surgery, JMU Wuerzburg
Laryngotracheal trauma, partial laryngectomy and phonosurgery
may necessitate reconstruction of the cartilaginous skeleton to ensure
the quality of respiration and voice. The present report focuses on
initial experience gained with a new resorbable material for plates
and tacks that allows chondrosynthesis of the laryngeal skeleton. A
comparison of the extrusion forces necessary to pull out the resorbable tacks vs. conventional titanium screws and the degree of
deformation until failure represent the experimental parameters of
reconstruction quality under investigation.
The PolyMax system (Synthes, Oberdorf, Switzerland) was used in a
human cadaver dissection. 16 tacks with a diameter of 1.5 mm and 16
titanium screws with a diameter of 1 mm were placed into the two
wings of the thyroid cartilage. Extrusion forces and the degree of
deformation occurring until mechanical failure of the devicebody
interface were measured for the two types of fixation systems.
Results in N and millimeters were compared using a two-sided
Wilcoxon test.
Neither parameter differed significantly between the two groups.
However, within the two groups the necessary strength to pull the
tacks or the screws out of the cartilage varied markedly depending on
both the inhomogeneous quality of cartilage and the degree of calcification.

The PolyMax system with the tacks is recommended as an effective
tool for reconstructing the cartilaginous skeleton of the larynx and
the trachea with the inherent advantage of resorption as well as
avoidance of a second surgery for material withdrawal.
Fluency related acoustic criteria for objective evaluation
of treatment effects in patients with dysphonia spastica
P.H. Dejonckere
University Medical Center Utrecht
Design and methods: Two acoustic measures for vocal fluency were
tested on a short, phonetically selected sentence. The phonetical
selection consisted of the constantly voiced character of the sentence
in normal speakers. The measures for fluency consisted of the total
duration of the sentence (ms), and of the ratio: total duration of
voiced segments/total duration of sentence.
Material and Methods: 17 patients with spasmodic dysphonia (diagnosis clinically considered as certain) and treated by means of 5 U
Botox injected in each Musculus Vocalis were included. All of them
had pre-treatment measurements, a measurement at about 2
3 weeks later, and a measurement just before the next Botulinum
injection, between 4 and 9 months after the first one. Perceptual
ratings and self-evaluations were also performed.
Results: There is a quite strong correlation between both acoustic
parameters, and both correlate in a satisfactory way with perception
and self-rating. In average, a significant increase in fluency is measured at the first control, as well as a recurrence of the dysfluency a
few months later.
Conclusion: Both acoustic parameters for fluency seem to be valuable
objective criteria for effectiveness of treatment in case of spasmodic
dysphonia. They are very useful for monitoring the evolution and
timing of a new Botulinum injection.
311
phrenic nerve, and bilateral reinnervation of the adductor muscles by
intralaryngeal anastomosis with thyroarytenoid branches of right and
left hypoglossal nerves. Diaphragm consequences, ventilation and
voice were analysed after 6 and 12 months.
Results: Today, five patients were included. Decannulation was
always possible. Voice was altered at the beginning, consequence of
the recurrent nerve resection. It was markedly improved after four
months and became as normal within 6 months. Aspiration was
transitory observed. Ventilation was improved and allowed as normal
physical activity in some patient when visible abductory motion was
observed during inspiration. Diaphragm parameters demonstrated
remarkable recovery.
Conclusion: Bilateral reinnervation with one upper phrenic nerve
root and thyroid branches of the hypoglossal nerve may become a
suitable option for persistent BVCP.
Functional electrical stimulation in recurrent nerve paralysis:

endoscopic procedure for electrode placement
R. Hagen, W. Harnisch, N. Kleinsasser, W. Lindenthaler
University Department of ORL, Head and Neck Surgery, Wurzburg,
Germany
Primary goal of functional electrical stimulation (FES) in patients
with bilateral recurrent nerve paralysis is the improvement of the
opening function of the larynx. This can be obtained by direct
stimulation of the posterior cricoarytenoid muscle (PCM). In order to
keep the surgical trauma for electrode placement as low as possible
an endoscopic procedure would be desirable. In an experimental and
a clinical setting a special puncture technique was tested, which allowed sufficient placement of a multi-channel electrode with selective stimulation of PCM.
A new surgical treatment for spasmodic dysphonia

Yusuke Watanabe*, Hisanori Sasai**, Asako Miyagi*, Hiroshi
Muta***
*Department of ENT, MITA Hospital, International University of
Health and Welfare, Tokyo, Japan, **Osaka Pref. Hospital, Osaka,
Japan, ***Osaka Voice Centre, Osaka, Japan
Adductor spasmodic dysphonia is a vocal disorder of uncertain etiology.
Section of recurrent laryngeal nerve or injection of botulinum toxin
has been used as an effective treatment. But they are not satisfactory
long-term treatments.
Bilateral thyroarytenoid muscle myectomy is performed by microlaryngoscopic method to six patients of adductor spasmodic dysphonia. Good speech results are obtained immediately after the
operation, and no side effect is observed.
No patient has experienced a return of symptoms, after four-year
follow-up. Bilateral thyroarytenoid myectomy may be a hopeful new
long-term approach to spasmodic dysphonia treatment.
Bilateral motor reinnervation of bilateral vocal cord paralysis. First
successful results of a prospective human trial
J.P. Marie, W. Woisard, L. Traissac, J. Lacau St Guily, E. Verin
Department of Otolaryngology, Head & Neck Surgery, and Physiology Department, University Hospital of Rouen, Experimental
Surgery Laboratory, EA 3830 GRHV, IFRMP 23, School of Medicine, University of Rouen, France
Aim: Most of the bilateral vocal cord paralysis (BVCP) do not recover. But few patients need glottic enlargement with consecutive
voice alteration. Selective bilateral laryngeal reinnervation, which
allows good results in animals, is applied in humans within a prospective ethically approved trial.
Method: In case of BVCP in adductory position, reinnervation of
both posterior cricoarytenoid muscles by the upper root of the right
Laryngeal pacing in humans

Andreas Mueller1, Gerhard Foerster1, Bernd Faenger2, Beatrice
Reinhardt2, Hans-Christoph Scholle2
1
Department of ORL/Plastic Surgery, SRH Waldklinikum Gera
gGmbH, Gera, Germany
2
Workgroup on Exp. Motology and Pathophysiology, Department of
Traumatology, University of Jena, Germany
For almost 30 years world wide a small number of researchers tried
to find ways to introduce functional electric stimulation of the larynx
into treatment of vocal chord paralysis. In 2003 David Zealear
(Nashville) published a first clinical trial on seven patients using an
electrode originally developed for spinal chord stimulation in chronic
pain treatment (Itrel II).
Numerous unsolved problems concerning electrode design, side effects of surgery and electric stimulation, missing synchronisation with
breathing und vocalisation, safety reasons and last but not least
inconstant success have hampered a broader clinical use so far.
In 2003 our group began basic preclinical studies with the aim of a
programmable, trigger driven implant for stimulation supported by
grants of the BMBF (German Ministry of Education and Research).
A host of electrode designs and materials were tested on a small
mammal model (forearm of the rat) and biocompatibility in muscle
was examined. EMG-Triggered electric stimulation using recordings
from a non paralysed reference muscle were studied in a thenar
muscle model to develop algorithms for detecting appropriate
trigger points in the EMG.
In January 2006 after a positive vote of our ethics committee we
began with first clinical trials to test open surgical as well as endoscopic ways of electrode applications during laryngectomy as a first
step. The multi-electrodes we used had been tested in our animal
model. We show stimulated opening and closing movements of the
vocal folds and give a short prospective on probable clinical applications in future.
123
312
A porcine model for recurrent laryngeal nerve repair using a phrenic

nerve anastomosis
1
L. Pope , S. Butler , S. Ayling , R. Burt , P. Murison , A. Jones ,

G. Terenghi2, C. Stokes1, M. Birchall1
Laryngeal Research Group1, University of Bristol, Langford, Tissue
Engineering2, Plastic and Reconstructive Surgery, Stopford Building,
University of Manchester
Background: Dynamic solutions to recurrent laryngeal nerve (RLN)
paralysis have proved elusive. Our group has explored the use of
phrenic nerve transfer using a poly 3-hydroxy butyrate (PHB) conduit.
Design: Pre-clinical large animal pilot study.
Animals and methods: Ten Minnesota minipigs were divided into
two groups of five, killed at 2 and 4 months respectively. The right
RLN was cut and the adductor branches divided to allow specific
abductor (posterior crico-arytenoid) muscle reinnervation. The
upper two roots of the phrenic nerve were divided and reflected
to allow a direct repair using a PHB conduit fixed with fibrin glue.
Videolaryngoscopy (VLE) and evoked electromyography
(EMG) with concentric needle electrodes were performed premortem.
Results: There was no VLE or EMG evidence of regeneration in the
two-month group. In the 4-month group, 3 animals showed VLE
evidence of recovery. Two of these had EMG evidence of ipsilateral
reinnervation, whereas one suggested contralateral reinnervation by
the unoperated nerve.
Conclusion: We have developed an animal model for recurrent laryngeal nerve repair using a phrenicRLN anastomosis with a PHB
conduit, in which good functional recovery is possible even at
4 months. The finding of a mixture of ipsilateral and contralateral
reinnervation is worthy of further investigation.
Glottic vs supraglottic tumours: analysis of molecular content

K. Kourelis1,2, T. Papadas1, G. Sotiropoulou-Bonikou2, G. Vandoros2,3, P. Goumas1 1University Hospital of Patras, Department of
Head and Neck Surgery, 2Department of Anatomy, Medical School
of Patras, 3Department of Pathology,General Hospital of Aegion,
Greece
Design and method: Glottis and supraglottis, although anatomically
interconnected, are embryologically distinct. Moreover, squamous
cell carcinomas arising from these subsites, differ in terms of epidemiology, risk factors, clinical behaviour and prognosis. This study
aims to explore any possible differences between their molecular
profiles. We investigated in the two tumour types, the expression of
Epidermal Growth Factor Receptor (EGFR), Nuclear FactorjB(NF-jB) and Retinoid X Receptor-a(RXR-a), principal cellular
transducers associated with cancer, as well as Cyclooxygenase2(COX-2), an enzyme induced in malignant neoplasms. The clinical
material includes tumour specimens from 70 patients with laryngeal
cancer of glottic or supraglottic origin. Subsite groups were matched for patient gender and histological Grade. Paraffin-section
immunohistochemistry was performed, utilizing primary antibodies
against the above-mentioned molecules.
Results: Staining patterns were membranic and cytoplasmic for
EGFR, purely cytoplasmic for COX-2, nuclear for RXR-a and
cytoplasmic, as well as nuclear, for NF-jB. Intense EGFR and RXRa expression significantly correlated with glottic tumour descent
(P = 0.011 and P = 0.016, respectively). Nuclear, but not cytoplasmic, NF-jB presence was stronger in glottic carcinomas, without
statistical significance, though. Supraglottic tumours demonstrated
higher expression of COX-2, lacking again statistical confirmation.
Conclusions: Our results show that tumours emerging from the two
laryngeal regions, are different with regard to their molecular constitution. Upregulation of EGFR and RXR-a in carcinomas of the
glottis, might be important in the design of subsite-specific chemotherapeutic approaches.
123
Gene expression profile in laryngeal carcinoma

J. Markowski1, M. Oczko-Wojciechowska2, T. Gierek1, M. Kowalska2,
J. Paluch1,
Z. Wygoda2, P. Wardas1, M. Jarzab3, D. Lange4
1
ENT Department, Silesian Medical University, Katowice, 2Department of Nuclear Medicine/Oncologic Endocrinology, 3Department
of Neoplasm Biology, Oncology Centre, 4Department of Neoplasm
Pathology, Oncology Centre, Gliwice, Poland
Aim: of the study is the analysis of gene expression profile in laryngeal carcinoma.
Group of 14 patients with Sq CCA Stages IIIV, diagnosed and
treated surgically (20032005) ENT Department of Silesian Medical
University (Katowice, Poland).
Method: Total RNA was isolated from squamous larynx cancer
tissue and fragments of macroscopically unchanged, healthy larynx
tissue, from the same patient. RNA isolation used 40 mg of frozen
tissue using the RNeasy Midi and Mini Kit (Qiagen). cDNA synthesis 5 ug of RNA (GeneChip Expression 3 Amplification OneCycle cDNA Synthesis Kit, Affymetrix) has been used. Transcription in vitro followed (GeneChip Expression 3 IVT Labeling
Kit, Affymetrix), while the multiplied cRNA underwent fragmentation, applying high temperatures and magnesium ions. After 16-h
hybridisation on high density microarrays Human Genome U 133
Plus 2.0 (Affymetrix) read-out was performed, followed by data
analysis.
Analysis: used non-parametric U MannWhitney test, with the
assessment of percentage of false positive results (FDR) applying the
method of Benjamini-Hochberg, and the Holm method. Using
MannWhitney test, 1,241 transcripts were singled out, differentiating between both groups at FDR < 5%. Then the group was narrowed
down to 398 genes, meeting the criteria assumed, analysing by means
of parametric test. Two genes, agiopoietin like transcript (231773_at,
ANGPTL1, angiopoietin-like 1) and undefined protein CGI-115
(219037_at) revealed a very substantial difference in expression, and
complied with very rigorous criteria of error risk assessment for
group of genes (FWER) applying Holm method.
Conclusions: Analysis of gene expression profile in laryngeal carcinoma allows us to pick out new genes, which may become molecular
markers of that carcinoma.
Project financed by a Grant of Polish Ministry of Education and
Science No. 3 PO5B 112 25.
The role of surface brushings in the differential diagnosis of laryngeal

epithelial lesions
P. Chatrath, I.S. Scott, L.S. Morris, R.J. Davies, S. Vowler, R.A.
Laskey, N. Coleman
MRC Cancer Cell Unit, Addenbrookes Hospital, Cambridge, CB2
2XZ
Royal National Throat Nose & Ear Hospital, Grays Inn Road,
London, WC1X 8DA
Objectives: In previous work we demonstrated expression of the cell
cycle marker minichromosome maintenance protein-2 (Mcm-2) in
the superficial epithelial third of biopsies taken from severely dysplastic but not mildly dysplastic or benign laryngeal lesions. We have
now investigated whether surface laryngeal brushings combined with
an immuno-enhanced cytological technique can accurately differentiate pre-malignant from benign lesions of the larynx, with analogy to
similar methods successfully applied to the cervix.
Methods: Surface brushings were obtained under general anaesthesia
from clinically suspicious laryngeal lesions, from which a formal
biopsy was also taken as the gold standard. Samples including benign
(n = 10), moderately dysplastic (n = 3) and severely dysplastic lesions (n = 12) were subjected to immunocytochemistry using antiMcm-2 antibodies. Patterns of Mcm-2 immunopositivity and cellular
atypia were recorded and compared with Mcm-2 immunohistochemistry of the definitive biopsy specimens.

Results: Brushings from eleven of the cases of high grade dysplasia
showed severe cytological atypia and significant Mcm-2 expression,
as predicted from the immunohistochemical study. The twelfth case
yielded an inadequate sample. Brushings from the three moderately
dysplastic lesions showed moderate cytological atypia and variable
Mcm-2 immunopositivity. Brushings from five of the ten benign lesions revealed no Mcm-2 expression, with the remaining five cases
being falsely immunopositive.
Conclusions: Laryngeal brushings, combined with Mcm-2 immunocytochemistry, could be useful in identifying benign laryngeal lesions
in many patients where no specific epithelial changes are seen on
laryngoscopy. By confirming a negative result in an adequately
sampled larynx, brushings alone may help to reassure patients with
non-malignant disease without unnecessary recourse to biopsy under
general anaesthetic, thereby permitting a reduction in the number of
inappropriate laryngoscopies being performed. The technique may
also be employed as an adjunct to formal biopsy, enabling a wide
surface area of laryngeal epithelium to be sampled, thereby increasing
the sensitivity of detecting sub-clinical areas of field change.
Determination of epithelial thickness in precancerous lesions

and their influence on photodynamic diagnostic
C. Arens, S. Schoberlein, H. Glanz
Giessen, Germany
Background: Photodynamic diagnostic and therapy are predominantly influenced by epithelial thickness (ET). Infiltration depth of
radiated light is dependent of light intensity, wavelength and tissue
structure. Therefore ET leads to changes of the autofluorescence
picture. The aim of the present study was to measure the ET of
different dysplastic lesions and to analyze the corresponding autofluorescence picture.
Material and Methods: In a retrospective study we measured the ET
of H&E colored object slides of 106 patients with normal, precancerous and cancerous lesions of the vocal folds. Prior to surgical
intervention all patients had undergone an autofluorescence examination. Specimen were measured by an object micrometer and
compared to autofluorescence imaging.
Results: Normal epithelium demonstrated an ET of 145 lm. A
change of the autofluorescence picture was visible between 300 and
350 lm (moderate epithelial dysplasia). Carcinoma in situ measuring
490 lm and microinvasive cancer (915 lm) presented a reddish-violet color.
Conclusion: Results clearly show that in cancerous lesions the blue
light beam is not able to reach the intensive fluorescing lamina
propria of the vocal folds causing a change in fluorescence color from
green to red.
Autofluorescene (DAFE) and ALA induced protoporphyrin IX
fluorescence imaging in the endoscopic diagnostic of laryngeal and
pharyngeal cancer
Miklos Csanady, Jozsef G. Kiss, Laszlo Szakacs, Robert Paczona,
Jozsef Jori
Department of Otorhinolaryngology, Head and Neck Surgery,
Faculty of Medicine, University of Szeged, Hungary
Introduction: Autofluorescence and ALA induced fluorescence
imaging are additional video-endoscopic methods for the superficial
laryngeal and pharyngeal cancer differentiating neoplastic from
healthy tissue by different fluorescent spectrum of the tumours.
Photodynamic imaging of laryngeal and pharyngeal tumours, precancerous and benign lesions of the larynx was evaluated by white
light and blue light (fluorescence) endoscopy.
Material: 59 patients underwent autofluorescence imaging (DAFE)
and 31 patients were examined by ALA induced fluorescence
method.
Method: Rigid endoscope and fiberoscope were applied in the larynx
and pharynx in general or local anaesthesia. Intensity of fluorescence
was compared with pathological findings. Fluorescence imaging of
laryngeal and pharyngeal cancers resulted in a visible strong intensity
313
of red autofluorescence, but precancerous and benign lesions. Healthy
tissues showed green autofluorescence. Margins of superficial mesopharyngeal and vocal cord tumours were clearly seen under fluorescent
vision giving a helpful contribution to the diagnostic and therapy.
Differentiation of precancerous lesion from malignancy was difficult.
Results: Laryngomicroscopy combined with CO2 laser excision of T1,
T2 vocal cord tumours indicated fluorescence examination visualising
margins of the cancer and helping the endoscopic laser resection.
Both methods revealed a high sensitivity (over 95%), but lower
specificity (about 60%).
Conclusion: These methods are applicable for the appropriate,
endoscopic detection and outlining of early superficial vocal cord and
mesopharyngeal tumours.
Voice in early glottic cancer compared to benign voice pathology
C.D.L. Van Gogh MD1, H.F. Mahieu MD PhD1, D.J. Kuik MSc3,
R.N.P.M. Rinkel MD1, J.A. Langendijk MD PhD2 & I.M Verdonckde Leeuw SLP, PhD1
1
Otorhinolaryngology, Head & Neck Surgery AmsterdamVUmc,
2
Radiotherapy GroningenUMCG, 3Clinical Epidemiology and
Biostatistics AmsterdamVUmc
Purpose: The purpose of this study is to compare (Dutch) Voice
Handicap Index (VHIvumc) scores from a selected group of patients
with voice problems after treatment for early glottic cancer with
patients with benign voice disorders and subjects from the normal
population.
Material and methods: The study included a group of 35 patients with
voice problems after treatment for early glottic cancer and a group of
197 patients with benign voice disorders. Furthermore, VHI scores
were collected from 123 subjects randomly chosen from the normal
population.
Results: VHI reliability was high with high internal consistency and
testretest stability. VHI scores of glottic cancer patients were similar
to those of patients with voice problems due to benign lesions. Both
groups of patients were clearly deviant from the normal population.
Within the normal population, 16% appeared to have not-normal
voices. Based on ROC curves a cut-off score of 15 points was defined to
identify patients with voice problems in daily life. A clinical relevant
difference score of 10 points was defined to be used for individual
patients and of 15 points to be used in study designs with groups.
Conclusions: Patients with voice problems after treatment for early
glottic cancer encounter the same amount of problems in daily life as
other voice patients. The VHI proved to be an adequate tool for
baseline and effectiveness measurement of voice.
Is routine CT thorax a necessary staging investigation in early glottic

cancer?
Andrew Evans1, Anna Le Cras1, David Hurman2, Kim Ah-See1
1
Department of Otolaryngology, Head & Neck Surgery, Aberdeen
Royal Infirmary, Aberdeen, UK, 2Department of Radiation Oncology, Aberdeen Royal Infirmary, Aberdeen, UK
Background: In patients with head and neck malignancy the incidence of synchronous primary tumours in the thorax is approximately 4%. Higher rates of second primary tumours are seen in
advanced head and neck cancers (1533%). Controversy surrounds
the need to image the thorax for staging in early head and neck
cancer and which imaging modality is best. Soon to be published
Scottish Intercollegiate Guidelines Network (SIGN) guidelines state
that all patients with head and neck malignancies should undergo a
CT thorax. This is based on level four evidence.
Aim: To assess the incidence of synchronous lung tumours in patients
with early glottic cancer. To establish which imaging modality was
used for staging of the chest and whether CT chest is necessary.
Method: Retrospective case note review.
Results: Seventy-three patients were diagnosed with T1N0 glottic
carcinoma from 19952006. Sixty-two patients underwent plain chest
X-ray for staging of the chest. Four of these also had CT chest on the
basis of a suspicious initial X-ray. Eleven patients had no chest
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314
imaging (15%) none of whom developed pulmonary disease in subsequent follow up. One synchronous lung tumour was detected
(1.3%) by plain chest X-ray.
Conclusion: There is currently little data in the literature that indicates the rate of synchronous tumours by T-stage of the primary. In
our series the incidence of synchronous pulmonary tumour for T1
glottic carcinomas was 1.3%. We therefore question the need for all
patients with early (T1) glottic tumours to undergo CT scanning of
the thorax for staging. We suggest that further evidence is required
before blanket CT scanning is recommended in national guidelines.
Treatment of mild and moderate laryngeal (glottic) pre-cancer with
laser CO2
A. Minni, M. Barbaro, G. Rispoli, F. Diaferia, R. Filipo
Neurology and Otolaryngology Department, University of Rome la
Sapienza, Rome, Italy
Introduction: Several authors proved since 1974 the efficacy of CO2
laser in laryngeal precancer treatment. Nevertheless, they showed
high rate of relapse.
Material: In this study, 58 patients (44 males and 14 females, mean
age 54.3 years) with mild and moderate dysplasia (32 LIN I and 26
LIN II) diagnosed on biopsy exam, were treated by CO2 laser cordectomy (as suggested by the European Society of Laryngologic
Classification). All underwent a periodical follow-up evaluation using
a fibre-optic-laryngoscopic examination. 84.5% of the patients were
smokers, 13.8% present gastro-oesophageal reflux.
Results: Observed 12.5% of relapse in patients with LIN I (all of
them had been treated by subepithelial cordectomy) whereas only
3.5% relapsed in patients with LIN II (all had a subligamental cordectomy performed).
Conclusion: To minimize relapse we suggest subepithelial cordectomy
for LIN I, subligamental cordectomy for recurrent LIN I. Patients with
LIN II lesions we recommend a subligamental cordectomy in all case.
Treatment results of carcinoma in situ of the glottic larynx:
61 patients treated with radiotherapy
Nicolas Charbonneau, MD, Michel Gelinas MD, Pierre del Vecchio
MD, Louis Guertin MD, Daniel Larochelle MD, Jean-Claude Tabet,
MD, Phuc Felix Nguyen-Tan MD
Montreal, Canada
Background: To review the Notre-Dame Hospital experience in the
treatment of carcinoma in situ of the glottis treated by radiotherapy
and evaluate the different factors affecting local control and survival.
Methods: Between January 1990 and June 2002, 61 patients presenting with carcinoma in situ of the glottis were treated with curative intent radiotherapy. No patient received either surgery or
chemotherapy in the initial treatment of his or her cancer.
Results: Median follow-up for the entire population was 3.2 years.
Local control rate was 96 and 94% at 2 and 5 years, respectively.
Overall survival was 100 and 90% at 2 and 5 years, respectively. No
statistically significant prognostic factor could be identified either for
local control or survival. No patient experienced severe treatment
complications or death.
Conclusion: Radiotherapy offers excellent treatment results for carcinoma in situ of the glottic larynx with few treatment complications.
These results are comparable to those published in the literature and
justify our choice of primary radiotherapy for carcinoma in situ of the
glottis.
Oncologic and functional outcomes after carbon dioxide laser
treatment of early glottic carcinoma
Roberto Puxeddu1, Gian Peppino Ledda2
1
Department of Otorhinolaryngology, Queen Alexandra Hospital,
Portsmouth, United Kingdom, 2Department of Surgical Sciences and
Organ Transplantations, University of Cagliari, Cagliari, Italy
Objectives: To analyze oncologic and vocal outcomes after endoscopic CO2 laser treatment of early glottic carcinoma.
123

Methods: Retrospective analysis of 141 consecutive patients (136
males and 5 females; mean age: 64.2 years; median: 64 years)
undergoing surgery for previously untreated early glottic carcinoma
between October 1993 and July 2003. The tumors were classified as
carcinoma in situ (Tis): 20 patients (14.2%), T1a: 82 patients (58.2%),
T1b: 24 patients (17%) and T2 with reduction of cordal mobility: 15
patients (10.6%). Five types of laser cordectomies as classified by the
European Laryngological Society classification were performed.
Comparison of voice results between the different types of cordectomies as well as with a control group was performed by perceptive
and objective assessment.
Results: According to the KaplanMeier method, local control
5 years after primary laser surgery was 100% for Tis, 96.17% for T1
(S.E.: 1.88%) and 100% for T2. According to the KaplanMeier
method, the 5-year local control after exclusive endoscopic salvage
surgery was 98.7% (S.E.: 1.29%). The probability of remaining free
of local recurrence 5 years after any type of salvage surgery was
100% for all classes. Laryngeal preservation was achieved in 100% of
cases. N.S. in vocal parameters between subepithelial and subligamental cordectomies and controls (P > 0.05). Significant difference
between the groups of transmuscular, total and extended cordectomies and controls (P < 0.05). The mean hospitalization time was
2.4 days (median: 2.6 days).
Conclusion: Good oncologic results and vocal outcomes with no
difference between controls and subepithelial and subligamental
cordectomies support the use of CO2 laser endoscopic surgery as the
first line of treatment for early glottic cancer.
Local recurrence after endoscopic treatment of T1, T2 glottic

carcinoma
D. Chevalier, G. Mortuaire, E. Azul
ENT, Head and Neck Department, University Hospital, Lille, France
Method: A cohort of 110 patients endoscopically from 1990 to 2000,
were retrospectively reviewed. There were 96 males, 14 females, the
mean age was 64 years. All patients had a proven squamous cell
carcinoma of the true vocal cord classified Tis (21), T1a (76), T1b (7),
T2 (6). Excision technique was graded according to the European
Laryngological Society classification.
Results: According to the KaplanMeier method the 5 year overall
survival and the disease-free survival were 87 and 75%. The cause
specific survival, ultimate local control with endoscopic treatment,
and laryngeal preservation were 97, 84, and 90% respectively. Univariate analysis revealed that vocal muscle infiltration (p.001) and
subglottic involvement (p.002) had a significant impact on diseasefree survival.
Of the 22 patients with local recurrence, 9 were treated with total
laryngectomy, 5 with a partial laryngectomy, 4 with further endoscopic surgery and 2 with radiotherapy.
Conclusion: Endoscopic laser cordectomy for early glottic carcinoma
is effective to cure glottic carcinoma. It allows re-treatment options in
case of failure with a good laryngeal preservation rate.
Long-term efficacy of voice therapy in patients after treatment
of early glottic cancer
C.D.L. van Gogh1, I.M. Verdonck-de Leeuw1, J.A. Langendijk2,
D.J. Kuik3, H.F. Mahieu1
1
Otorhinolaryngology, Head & Neck Surgery, AmsterdamVUmc,
2
Radiotherapy GroningenUMCG, 3Clinical Epidemiology and
Biostatistics AmsterdamVUmc
Purpose: Evaluation of longterm efficacy of voice therapy in patients
with voice problems after treatment of early glottic cancer.
Material and methods: In this prospective study all 12 patients, selected in a previous study1 based on a screening questionnaire about
voice problems and randomly assigned for treatment with voice
therapy (versus no treatment), were evaluated again. This was done
more than half a year after finishing voice therapy, to evaluate the
longterm voice effects. Voice assessment consisted of the Voice
Handicap Index (VHI) and acoustic analyses.

Results: Directly after voice therapy the VHI as well as Jitter,
Shimmer and the Noise to Harmonics Ratio (NHR) improved significantly. With exception of the NHR the obtained voice improvement was still present after a mean of 13 months (618 months).
Conclusion: Also on the longterm voice therapy proved to be successful in patients with voice problems after treatment of early glottic
cancer.
The study was financed by the College voor Zorgverzekeringen and
the Vereniging voor Academische Ziekenhuizen.
1. Van Gogh CDL, Verdonck-de Leeuw IM, Boon-Kamma AB,
Rinkel RNPM, de Bruin MD, Langendijk JA, et al. Efficacy of voice
therapy in patients after treatment of early glottic cancer. Cancer
2006;106(1):95105
Multiinstitutional prospective study on the prevalence of sublevel IIB

metastases in laryngeal cancer
C. Piazza, A. Bolzoni, G. Peretti, L. Calabrese*, R. Pellini,
F. Chiesa*, G. Spriano, P. Nicolai
Departments of Otolaryngology, University of Brescia, Brescia, Italy
*European Oncologic Institute of Milan, Milan, Italy Oncologic
Institute Regina Elena of Rome, Rome, Italy
Aim: The aim of this study was to prospectively evaluate the prevalence of sublevel IIB
LN metastases in laryngeal cancer (LC).
Materials and methods: Between 2002 and 2004, 106 patients (M:F
ratio 25.5:1 ; mean age, 58.9 years; range 1889) affected by LC were
treated by surgery on the primary and/or the neck. Inclusion criteria
were no previous surgery on the lateral compartment of the neck and
no previous treatment for other head and neck primaries. The subsites distribution was: supraglottis (62 cases), glottis (27), hypoglottis
(2), and the whole larynx without a clear site of origin (15). Sublevel
IIB LNs were dissected, separated from the other levels during neck
dissection (ND), labeled, and processed apart. Sublevel IIB was
evaluated for the number of LNs and pN status.
Results: A total of 173 NDs were performed (39 unilateral, 67
bilateral). The mean number of LNs collected at sublevel IIB was 5.4
(range 024). cN0/pN0 patients were 37%, cN+/pN+ 39%, cN+/pN0
9%, and cN0/pN+ 15%. The overall prevalence of sublevel IIB
metastases was 1.1% (2 NDs: 1 in a supraglottic pT3cN+/pN+ cancer,
and 1 in a glottic pT3cN0/pN+, both never treated before by RT and/
or chemo-RT).
Conclusions: Sublevel IIB dissection is strongly recommended for all
cN+ patients with LC. In all other settings, careful exploration of the
sublevel IIB should be always accomplished before avoiding its dissection. However, comparing the low incidence of positive LNs at
level IIB in LC with those observed in parotid gland, skin, and unknown primary cancer, we suggest a conservative approach to this
particular neck sublevel, even though the functional gain of this
policy remains to be demonstrated by prospective studies on large
series.
Heterogeneity of advanced squamous cell carcinomas of the

larynxanalysis of tumour biologic factors as seen in serial sections
Claus Wittekindt1; Christian Sittel2; Hans Edmund Eckel3
1
University Hospital Cologne, 50924 Koeln, Germany, 2University
Hospital Heidelberg, 69120 Heidelberg, Germany, 3Landeskrankenhaus Klagenfurt, 9020 Klagenfurt, Austria
Purpose of the study: To demonstrate heterogeneity of biologic
factors in different regions of advanced squamous cell carcinomas
(SCC) of the larynx.
Method of study: Twelve excised human larynges were blockembedded in parafin. Serial sections were stained by Giemsa and
standard immunohistochemistry protocols with commercial antibodies against Cytokeratine5/6, Ki-67, Topoisomerase IIa, and p53.
Morphometric surface maps of protein expression were generated for
each parameter. Variation coefficients were computed to demonstrate intra-individual variation.
315
Summary of results: The tissues remained intact without major artefacts. Specific characteristics of the tumors were identified after
evaluation of the whole-mount sections. Staining of cytokeratine was
homogonous, whereas nuclear markers showed a distinct heterogeneity in the respective staining patterns. By analysing the colourcoded fusion images the spatial expression of the respective antibodies could be visualized. Variation coefficients for three-dimensional distribution of proliferation rates and p53 expression were
obtained.
Conclusions: To demonstrate the heterogeneity in SCC of the larynx,
biologic parameters were shown in a three-dimensional model. The
results confirmed previous observations that SCC of the larynx are
heterogenous tumors. Controversial results of studies from biopsy
samples on proliferation rates or p53 protein expression and clinical
outcome hereby can be explained. Regions with increased proliferation might predict locations of possible tumour recurrence.
Clinical value of chest computed tomography (CT) for staging

of patients with T3/4 laryngeal/hypopharyngeal squamous
cell carcinoma
U. Schroeder, Luers, C. Wittekindt, C., Bongartz, R., Klussmann, J.P.
Department of Otorhinolaryngology, H&N Surgery, Kerpener Str.
62, 50924 Cologne, Germany
Background: The detection of distant metastases in patients (pts)
with advanced laryngeal/hypopharyngeal squamous cell carcinoma
(LHSCC) is of highest value since often it will change aggressive
treatment to a palliative concept. According to the German guidelines routine screening implies chest X-ray. The role of chest CT is
discussed controversially due to its reported low sensitivity and
specificity for occult nodal metastases and the low incidence of distant metastases.
Objective: To evaluate the clinical value of pre-operative chest CT
for detection of mediastinal or lung metastases or secondary primaries in pts with cT3/4cN1-3 LHSCC.
Pts: In a prospective study 42 subsequent pts with first diagnosis of
cT3/4cN1-3 LHSCC underwent chest X-ray and chest CT prior to
therapy.
Results: Chest X-ray found suspicious lung lesions in two pts. Chest
CT detected mediastinal metastases in four and lung lesions suspicious for metastases or secondary malignancy in further nine out of
42 pts (31%). The planned therapy was changed in 10 out 42 pts
(24%): Two pts got a partial lung resection. In eight pts surgery was
cancelled. The follow-up of pts staged M1 revealed that most of them
died of tumor within 8 months. Three pts with unconfirmed suspicious lung lesions underwent surgery and adjuvant radiotherapy: One
pt died of metastatic disease; two pts are tumor free alive for 3,
respectively 4 years. The follow-up of pts staged M0 revealed two
late distant metastases, two secondary primaries, six deaths of locoregional recurrences and two intercurrent deaths. Four pts were lost
in follow-up and 13 pts are tumor free alive.
Discussion: Our results depict that chest X-ray was of limited clinical
value, while chest CT had substantial impact on treatment and
prognosis in 24% of pts. Although it is difficult and time-consuming
to rule out false positive CT-scans, we propose that chest CT should
be part of the routine pre-operative workup in pts with cT3/4cN1-3
LHSCC.
Conservative management of supraglottic cancer: carcinologic results
Olivier Merrot, B. Navailles, Mustapha Bouchene, Alain Cosmidis,
Jean-Christian Pignat, Marc Poupart
Department of ORL-HNS, CHU La Croix-Rousse, Lyon, France
Purpose: Evaluate carcinologic results in conservative management
(partial laryngectomy and brachytherapy) of supraglottic cancer.
Patients and methods: A retrospective analysis of 128 consecutive
cases of supraglottic larynx SqCCa, treated between 1990 and 2005.
Surgical procedures included hyosubglossoepiglottectomy (LHSG) in
56 patients, 48 hyothyroepiglottectomy (LHTE) and 24 hyothyroepiglottectomy extended to hypopharynx (LHTEE). UICC classifi-
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cation: 11T1, 64 T2, 49 T3, 4 T4 ; 80 N0, 16 N1, 21 N2 et 5 N3 were
treated. Elective bilateral neck dissection was always performed except in two cases. Radiotherapy was delivered in 90 cases to doses of
5560 Gy to the primary tumor and the neck nodes were electively
irradiated (5070 Gy) according to preorative histologic findings.
Results: The 5 and 10-year overall specific survival of the whole series
was, respectively, 69 and 60%. The 5 and 10-year overall global
survival was, respectively, 58 and 46%. A multivariate analysis
showed that 45 patients died during this time of follow up, 11 local
node recurrences and 12 distant metastases. Nodes invasion (clinical
and/or histological) and extended surgery significantly influence disease-free survival. Whereas tumoral extension and surgical margins
do not. Extension to involve the base of tongue, is a preorative factor
to local control.
Conclusion: Conservative management (surgery and brachytherapy)
of T2T3supraglottic cancer can allow good cure rates with larynx
preservation in most of the patients. The decision between different
conservative surgical treatments may be influenced by the patients
conditions, tumor characteristics and treatment modalities.
Functional results of supracricoid partial laryngectomy
M. de Vincentiis; A. Gallo; G. Pagliuca; P. Soldo
Department of Otorhinolaryngology, Audiology and Phoniatrics
G. Ferreri; University of Rome La Sapienza, Rome, Italy
Objective: The purpose of laryngeal partial surgery is to keep the
patient under control from an oncological point of view, but also to
restore phonatory, respiratory and swallowing functions. Supracricoid partial laryngectomys, and in particular Cricohyoidopexy (CHP)
and Cricohyoidoepiglottopexy (CHEP), are surgical procedures that
permit, through the conservation of a cricoarytenoid unit, the creation of a neolarynx adequate for swallowing as well as for speaking.
The aim of this study is to evaluate if there are functional differences
age-related in patients who underwent supracricoid partial laryngectomies at the G. Ferreri Department of Otorhinolaryngology,
Audiology and Phoniatrics of the University of Rome La Sapienza
between 1984 and 2004.
Material: In our retrospective study we considered a total of 290
patients (214 CHP, 76 CHEP). They divided in 4 groups according to
their age (I group: 3545 years, II group: 4555 years, III group:
5565 years, IV group: over 65 years).
Method: We performed a short time evaluation (removal time of
naso-gastric tube, removal time of tracheal tube, pneumonia related
to swallowing) and a long time evaluation (radiological time of oral
transit and pharyngeal transit in videofluoroscopy, total laryngectomy for dysphagia) of the functional results.
Results: The time for decannulation and removal of naso-gastric tube
was more likely to increase with age and was great in patients who
underwent CHP than CHEP. Pneumonia from aspiration occurred in
27 patients (9.3%): 22 CHP and 5 CHEP. Total laryngectomy for
dysphagia occurred in 5 patients who underwent CHP (1 in the II
group, 2 in the III group and 2 in the IV group). Duration of oral
transit time and duration of pharyngeal transit time were extracted
from each swallow recorded at the videofluoroscopic assessment.
Conclusion: The long time evaluation does not show any substantial
differences between age groups and between CHEP and CHP.

According to UICC classification: 11T1, 64 T2, 49 T3, 4 T4; 80 N0, 16
N1, 21 N2 et 5 N3 were treated. Elective bilateral neck dissection was
always performed except in two cases. Radiotherapy was delivered in
90 cases with 5560 Gy to the primary laryngeal tumor and the neck
nodes were electively irradiated (5070 Gy) according to preorative
histologic findings.
Results: The mean time for removal of the naso-gastric tube was
29 days (LHSG), 33 days (LHTE) and 36 days (LHTEE). Twelve
permanent gastrostomies were necessary and one total laryngectomy
for severe swallowing disorders was achieved. The mean time until
cannulae removal was 58 days (LHTEE), 33 days (LHSG) and
18 days (LHTE). The hospitalisation mean time was, respectively, 22
(LHSG), 27 (LHTE) and 31 days (LHTEE).
Conclusion: These functional results suggest that conservative management is a good treatment in T2T3 supraglottic cancer. Removal of
the base of the tongue contributes to deglutition problems as epiglottis and pharyngolaryngeal sensibility.
Organ preservation with transoral CO2 laser resection in advanced

tumors of the larynx and hypopharynx
Manuel Bernal-Sprekelsen, Isabel Vilaseca, Jose-Luis Blanch
ENT Department, Hospital Clinic, Barcelona, Spain
Background: Transoral laser surgery has been increasingly accepted
to approach early tumors, but there is controversy concerning T3 and
T4 tumors. Organ preservation protocols with concomitant radio and
chemotherapy achieve acceptable results, but scarcely report on the
function of the preserved organ.
Material and Methods: SPSS databank including data obtained prospectively from a group comprising more than 600 patients treated by
means of transoral laser surgery since 1998 was split to study a selected group of transorally treated T3 and T4 tumors with a minimum
follow-up of 24 months.
Results: One hundred and six consecutively and selected T3 and T4
previously untreated patients were included. Eighty-four supraglottic, 26 glottic and 16 piriform sinus tumors met the inclusion criteria.
Thirty-one (25.6%) had a fixed vocal cord. Most patients presented
stage III (n = 78; 61.9%) and stage IVA (n = 44; 34.9%). A total of
76 (60.3%) had no postoperative radiotherapy, 18 (14.3%) had RT
neck, and 29 (23%) RT to tumour and neck. Eight patients needed a
temporary gastrostomy and four a definitive one. Eight (6.3%)
aspiration pneumonias were registered. After initial treatment 100
patients (79.4%) never had a tracheostomy, 18 (14.3%) needed a
temporary, and 8 (6.3%) a definitive one. Function was found to be
good and or acceptable in 63/84 supraglottic (75%), 22/26 glottic
(84.6%) and 7/16 piriform sinus (43.8%) tumors. After definitive
surgical treatment (tumour or neck recurrences) 84/125 (67.2%)
patients preserve their functional larynx.
Summary: Among those who following classical indications might
have underwent a total laryngectomy (n = 41) (T3 with vocal cord
fixation, T4 glottic tumors, T3 supraglottic with fixation and all T3
and T4 piriform sinus tumors) 16/41 (30%) were only treated by
means of transoral resection and never had tracheostomy or gastrostomy, whereas a total of 23/41 (56%) (thus including cases with
temporary tracheostomy and or gastrostomy) do preserve organ and
function.
Conservative management of supraglottic cancer: functional results

Olivier Merrot, B. Navailles, Mustapha Bouchene, Alain Cosmidis,
Marc Poupart, Jean-Christian Pignat
Department of ORL-HNS, CHU La Croix-Rousse, Lyon, France
Purpose: Evaluate the functional results of conservative management
(partial surgery and brachytherapy) of supraglottic cancer.
Patients and methods: A retrospective analysis of 128 consecutive
cases of squamous cell carcinoma of the supraglottic larynx, treated
conservatively with partial laryngectomy between 1990 and 2005, was
performed. Surgical procedures included hyosubglossoepiglottectomy (LHSG) in 56 patients, 48 hyothyroepiglottectomy (LHTE) and
24 hyothyroepiglottectomy extended to hypopharynx (LHTEE).
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Alternative fixation systems for voice rehabilitation devices

E.J.O. ten Hallers1,2,4, G.J. Verkerke1, H.A.M. Marres2, E.B. van der
Houwen1, J.A. Jansen3, G. Rakhorst1, J.P. van Loon4
1
Department of BioMedical Engineering, University Medical Center
Groningen, University of Groningen, NL; 2Department of OtoRhino-Laryngology, Head and Neck Surgery, and 3Department of
Biomaterials, Radboud University Medical Centre, Nijmegen, NL, 4
Intra-Vasc.nl BV, Groningen, NL
Introduction: The results in rehabilitation after laryngectomy are still
subject to improvement. Leakage around shunt valves frequently
occurs. For most patients it is not possible to use a tracheostoma (TS)

valve (to allow hands-free speech) due to peristomal fixation difficulties. For both sites we developed a tissue connector as an interface
between soft tissue and shunt, respectively TS-valves. Aim of this
study was to study the tissue connector (TC) at both sites in vivo.
Methods: Animal experiments were performed with 19 adult Saane
goats. Each TC basically consists of a micro-grooved titanium ring,
combined with polypropylene mesh with a variation in ring and mesh
material. In each animal tissue connectors were implanted at both
sites. After 12-week follow-up the experiment was terminated and
histological analysis performed by scoring inflammation, vascularisation, tissue ingrowth, adhesion and epithelial downgrowth.
Results: Post-op care was very extensive and accompanied by complications (mostly not device-related), like stoma stenosis. Infections
developed at the TS-site. At the shunt TC no infections were seen.
Histology at the TS-site showed bending of the polypropylene mesh,
inflammation, neo-vascularisation, tissue ingrowth, profound epithelial downgrowth along the percutaneous parts and stress-shielding. At the shunt-site a firm implant fixation was achieved. In nearly
all animals, no signs of infection of the implant was seen.
Conclusion: The tracheostoma TC appeared not to be feasible in its
present form. The shunt TC, however, showed promising results and
could provide a good solution against leakage around shunt valves.
New method in the management of postoperative haemorrhage
by transoral operations
Gyorgy Lichtenberger MD
Szent Rokus Hospital & Institute, Department of ORL-HNS 1085
Budapest, Gyulai P. u. 2. Hungary
Objective: The bleeding by or after transoral operations may cause
serious problems in narrow anatomical areas such as the pharynx and
larynx. Placing sutures transoral in this area is cumbersome and
difficult. A Ligature-Suture Instrument has been developed to
alleviate this problem.
Study design and setting: The Ligature-Suture Instrument and
Technique was developed in cadaver and in vitro model experiments
in an effort to greatly simplify suturing of vessels in the base of the
tongue, larynx, hypopharynx and oropharynx. The instrument consists of a tip structure that will accept a suture and with one simple
thrust of the handle will encircle the blood vessel allowing easy
ligation. The further developed and designed instrument is commercially available by the Karl Storz Co.
Results: The instrument and technique was utilized to control operative hemorrhage in 31 cases: 4 patients with base of the tongue
lesions, 2 patient with laryngeal surgery, 7 patients with hypopharyngeal surgery and most helpful was in lesions of the pharynx in 18
cases. The best results were achieved to control difficult tonsillectomy hemorrhage but its use was limited for laryngeal bleeding. Full
details of the Ligature-Suture Instrument will be presented.
Conclusion: The advantages of this Ligature-Suture Technique are
simple, straightforward, and safe as compared to other suture
methods.
The treatment of laryngeal squamous carcinoma recurrent after
radical irradiation
A.S. Jones, T.M. Jones, D. Husband
The School of Surgery and Oncology, University of Liverpool, UK
Introduction: Recurrent laryngeal cancer following radical irradiation has traditionally been treated by total laryngectomy. The reasons for this approach are many but include the concept that such
recurrences are defuse or extensive and that healing following
radiotherapy is impaired and the corresponding fistula rate high.
Methods: We examined the records of 689 patients with squamous
cell carcinoma of the larynx treated by radical irradiation and with no
metastases at presentation. Of these 425 were T1, 229 T2 and 52 T3.
170 developed a recurrence at the primary site. Of the 170 patients,
158 underwent a total laryngectomy. Details of recurrence data on
the complete laryngectomy specimens were available in 146 patients.
Recurrences were classified into groups and allocated appropriate
treatment using present day methods and experience.
317
Results: The primary site stage at recurrence was higher than at
presentation (p < 0.0001) and was significantly correlated
(P < 0.0001) and primary stage at presentation was highly correlated
with the risk of recurrence at the primary site (P < 0.0001). Of the
146 recurrences studied 38 had a small recurrence amenable in the
present day to some type of partial laryngeal or laser surgery. 81
patients had a large recurrence and in 63 this was defuse the only
treatment option would be total laryngectomy. 25 patients had a very
large recurrence with spread outside the larynx and no curative
treatment exists even now and 2 patients had distant metastases.
Conclusion: Large primary tumours are more likely to recur than
small ones and this is the only statistical predicator of recurrence.
These results show that 27% of recurrent laryngeal cancers are
resectable avoiding total laryngectomy.
Intrinsic and extrinsic tumors of the crico-tracheal junction:

the role of laryngo-tracheal resection and anastomosis
G. Peretti, C. Piazza, P. Nicolai
Department of Otolaryngology, University of Brescia, Italy
Introduction: Laryngotracheal resection and anastemosis (LTRA) is
mostly applied to iatrogenic stenosis. Even though there are few
reports , concerning its use for the treatment of extrinsic and intrinsic
tumurs of the cricotracheal junction (CTJ), in the last decade we
successfully employed LTRA as an organ preservation surgical
strategy with good oncologic and functional outcomes in management of such a rare pathologic condition. Aim of this paper is to
retrospectively review our experience.
Material and Methods: Between September 1996 and June 2006, we
performed LTRA in 86 patients, 29 of whom (34%) with CTJ tumors
(age range, 1982 years; mean, 55; male:female ratio, 16:13). Eighteen patients had extrinsic tumors infiltrating the airway: 15 were
thyroid carcinoma (papillary in 7, dedifferentiated papillary in 3,
metastasis from rectal adenocarcinoma in 2, mixed follicular-papillary, Hurtle cell, and thyroid adenoid cystic carcinoma in 1 each), and
3 were recurrential lymph nodes metastasis from previously treated
head and neck squamous cell carcinomas. Eleven patients had primary cricoid and/or tracheal tumors (low-grade chondrosarcoma in 6,
low-grade mucoepidermoid carcinoma in 2, pleomorphic adenoma,
adenoid cystic, and squamous cell carcinoma in 1 each). The extent of
resection ranged between 2 and 7 tracheal rings, was limited to the
trachea in 7 patients and involved the cricoid cartilage in 22 cases
(excision of the anterior arch in 12 and of the arch plus part of the
cricoid plate in 10). Three patients had received preoperative
radiotherapy (RT) or chemo-RT, while 2 received complementary
RT and 2 postoperative chemotherapy.
Results: Extubation was accomplished at the end of surgery in 29
patients, after 848 h. One remained tracheotomy-dependent for
partial anastomotic dehiscence with restenosis and 1 needed total
laryngectomy for complete dehiscence and tracheo-esophageal fistula
(both had LTRA after RT failure). Three patients died for distant
metastases or local recurrence (range, 232 months; mean, 15), 6 are
alive with distant metastases (range, 783 months; mean, 33), and 20
did not reveal any local-regional recurrence (range, 2117 months;
mean, 39).
Conclusions: LTRA can be considered a successful conservative
surgical option for selected CTJ tumors when the endoscopic approach failed or was thought to be unfeasible. Even in lesions with
distant asymptomatic metastases, it allows a prolonged palliation.
Supracricoid partial laryngectomy with tracheo-crico-hyoidopexy

and tracheal remodelling: a novel technique and preliminary
experience on 5 cases
C. Piazza, G. Peretti, D. Cocco, P. Nicolai
Department of Otolaryngology, University of Brescia, Italy
Introduction: Subglottic neoplastic extension below the crico-thyroid
membrane has been so far considered a contraindication to supracricoid partial laryngectomy (SCPL), particularly when associated to a
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318
simultaneous involvement of the pre-epiglottic space. In such an
evenience, SCPL with tracheo-crico-hyoido-epiglottopexy (TCHEP)
cannot be performed for the need to remove the entire epiglottis
together with the entire anterior cricoid arch, with the consequent
impossibility to impact the residual gap during tracheo-crico-hyoidopexy (TCHP). We herein describe a novel technique of SCPL
with TCHP and tracheal remodelling (TCHP-TR) in which, after
removal of the epiglottis, thyroid cartilage, anterior arch of the cricoid between the crico-thyroid joints, and both vocal cords, the
anterior portion of the cricoid is reconstructed by means of a tracheal
flap similar to that used during crico-tracheal resection and anastomosis.
Materials and Methods: Between January 2002 and March 2006, 5
males (mean age, 67 years; range, 5776) affected by laryngeal
cancer (2 pT3 and 3 pT4 according to the latest TNM Classification) with simultaneous involvement of the pre-epiglottic space and
of the anterior cricoid arch or the first tracheal ring were evaluated
at our Institution. Four of them were recurrences of previous
endoscopic procedures. None of them had received radiotherapy
(RT) and all refused or cannot tolerate an organ preservation
option based on concomitant chemo-RT. A traditional SCPL with
TCHEP was deemed contraindicated and therefore a novel technique called SCPL with TCHP-TR, previously developed at our
Institution on human cadavers, was proposed.
Results: SCPL with TCHP-TR and preservation of both the arytenoids was successfully performed in all patients (in association to
bilateral neck dissection in 3 cases and with central compartment
neck dissection in 2) without significant perioperative complications. The mean decannulation time was 11 days (range 714) and
mean time for feeding tube removal was 20 days (range 1425). No
postoperative ab ingestis pneumoniae was recorded. One patient
received complementary RT. Four of them are free of local-regional disease (mean, 21 months; range 354). One experienced a
local recurrence 7 months after surgery and was therefore submitted to total laryngectomy. He is free of disease 9 months after
surgery.
Conclusions: Our preliminary experience with SCPL and TCHP-TR
is encouraging from both an oncological and functional point of view.
Such a novel surgical organ preservation technique for advanced
anterior transglottic tumors should be taken into account in selected
patients with contraindication and/or refusal of other organ preservation strategies.
Total reconstruction of the cricoid cartilage after chondrosarcoma

resection by using a pedicled osseomuscular flap composed from the
hyoid bone and strap muscles
A. Hantzakos, A-S Evrard, G. Lawson, M. Remacle
Department of Otorhinolaryngology, Head & Neck Surgery,
University Hospital of Louvain at Mont-Godinne, Yvoir, Belgium
Introduction: Laryngeal chondrosarcomas are rare tumours of the
head and neck. These are considered to be relatively low-grade
neoplasms, both histologically and clinically. Most chondrosarcomas
involve the posterior portion of the cricoid cartilage. Depending on
the extension and the histopathological grade of the tumour, surgical
treatment ranges from local excision to total laryngectomy.
Case report: A 74-year-old male patient with an extensive chondrosarcoma of the left cricoid cartilage. An open extended left hemicricoidectomy was subsequently performed. The defect was covered
with a pedicled osseomuscular flap composed by the greater cornu of
the hyoid bone and the right strap muscles. The flap was further
supported by the left strap muscles. A Montgomery T-tube was left in
place for 4 months and was subsequently replaced by a tracheostomy
tube which was removed 1 month later. The patient remains in
excellent condition up to date, the reconstructed site being patent
without any signs of restenosis.
Summary: Our salvage technique appears to be a reliable alternative
to total laryngectomy in cases of extended chondrosarcomas. Further
follow-up and additional cases are warranted.
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Surgical organ preservation strategies after radiotherapeutic failure
for laryngeal cancer: report on 37 cases
G. Peretti, C. Piazza, A. Cattaneo, F. Garrubba, L.O. Redaelli De
Zinis, P. Nicolai
Department of Otolaryngology, University of Brescia, Brescia, Italy
Aim: Aim of this study was to retrospectively evaluate our experience in management, salvage surgery after radiotherapy (RT) for
laryngeal cancer (LC) by voice preserving surgical strategies, ranging
from endoscopic resections to partial laryngectomies.
Materials and Methods: Between 95 and 04, 71 patients affected by
LC previously treated by RT or chemo-RT were treated for persistence (11 patients), recurrence (50), or second laryngeal tumor (10).
Our treatment policy encompassed endoscopic resection for glottic
rT1a, rT1b with limited anterior commissure involvement, and rT2
with normal cord mobility (Group A). Partial laryngectomies were
performed for rT1 and rT2 with suboptimal endoscopic exposure, rT2
with impaired cord mobility and/or transcommissural extension, and
rT3 for limited paraglottic space invasion or involvement of the inner
portion of the thyroid cartilage (Group B). Total laryngectomy was
planned in patients not suitable to partial laryngectomy for general
conditions, for rT3 with massive involvement of the paraglottic space,
and rT4. Last follow-up was obtained in March 2006 and survival
curves were calculated by the KaplanMeier method.
Results: Voice preserving salvage surgery consisted of endoscopic
resection in 22 patients (Group A) and included: 12 Type III, 1 Type
IV, and 9 Type V cordectomies. Open-neck partial laryngectomy,
performed in 15 (Group B), included: 1 horizontal supraglottic laryngectomy, 1 tracheo-crico-hyoido-epiglottopexy, 9 crico-hyoidoepiglottopexy, and 4 crico-hyoidopexy. Complication rates were 9%
(Group A) and 47% (Group B). Five-year determinate, disease-free
survival, and laryngeal preservation rates were 95, 63, and 77%
(Group A), and 100, 83, and 80% (Group B).
Conclusions: Our therapeutic guidelines for surgical salvage of RT
failure allowed us to initially spare the laryngeal box in 52% of patients.
This attempt was associated to a low complication rate in Group A,
while in Group B no negligible amount of postoperative problems was
encountered, even though they seldom represented a cause of failure
for the organ preservation. The laryngeal preservation rates decreased
in the follow-up period to 77% (Group A) and 80% (Group B), due to
both oncological and functional reasons. Survivals for the whole series
are not different from those reported in the literature by using more
aggressive approaches without any organ preservation attempt.
Elevated galecetin-1 expression is a negative prognostic predictor
of recurrence in laryngeal squamous cell carcinomas
S. Saussez1,2, C. Decaestecker3, F. Lorfevre1, R. Cucu1, D. Chevalier
D4, A. Wacreniez5, H. Kaltner 6, S. Andre 6, G. Toubeau7,
H.J. Gabius 6, I. Camby 3, R. Kiss3
1
Laboratory ofAnatomy, Faculty of Medicine and Pharmacy,
University of Mons-Hainaut, Mons, Belgium, 2Department of
Oto-Rhino-Laryngology, University of Brussels (ULB), Brussels,
Belgium, 3Laboratory of Toxicology, Institute of Pharmacy, Free
University of Brussels (ULB), Brussels, Belgium, 4Department of
Oto-Rhino-Laryngology and 5Department of Pathology, Faculty of
Medicine, Hopital Claude HuriezCHRU, Lille, France, 6Institute
of Physiological Chemistry, Faculty of Veterinary Medicine, LudwigMaximilians University, Munich, Germany, 7Laboratory of Histology,
Faculty of Medicine and Pharmacy, University of Mons-Hainaut,
Mons, Belgium
Background: Advances that have been made in the discovery of
many genes and gene products, including galectins, involved in the
development of laryngeal squamous cell carcinomas (LSCCs) cancers
will increasingly be used to guide patient therapy.
Methods: We investigated the prognostic value contributed by the
quantitative determination (computer-assisted microscopy) of the
immunohistochemical levels of expression of galectins-1, -3 and -7 in
a series of 62 LSCCs, including 42 low and 20 high stages LSCCs. As

galectin-1 may have a key role in helping tumors to escape immune
surveillance, we also investigated whether the level of galectin-1
expression correlated or not with lymphocyte infiltration in LSCCs.
Results: The determination of the immunohistochemical levels of
expression of galectin-1 is of prognostic value in human squamous
laryngeal cancers, while those relating to galectin-3 and -7 are not.
LSCCs that display elevated levels of galectin-1 contribute worst
prognoses than those laryngeal cancers with weak levels of galectin-1
expression. The elevated levels of galectin-1 in laryngeal cancers
associated with dismal prognoses could relate to the fact that galectin-1 contribute to the process of tumor immune escape by killing the
activated T cells that attack the laryngeal cancers.
Conclusions: The quantitative determination of galectin-1 in LSCCs
is an independent prognostic marker when challenged against TNM
staging and could predict those patients who should escape any
benefits from immunotherapy based on the use of activated T cells.
Recurrent laryngeal carcinoma: rTNM versus composite laryngeal

recurrence staging system
Miquel Quer, Xavier Leon, Cesar Orus, Montserrat Lopez, Ignasi
Gich
Department of ORL-HNS, Hospital de la Santa Creu i Sant Pau,
Universitat Auto`noma de Barcelona, Barcelona, Spain
Introduction: The classification of the recurrent laryngeal carcinoma
is not easy. TNM system (rTNM) has some limitations. Lacy and
Piccirillo developed in 1998 a new staging system, Composite Laryngeal Recurrence Staging System (CLRSS), based in the initial
TNM stage and the extent of the recurrence. In order to improve this
prognostic prediction, we propose a modification of the CLRSS,
named CLRSS-2. This modification consists in including patients
with initial stage I laryngeal tumour with a regional recurrence in
stage III, instead of stage I. The aim of our study was to compare the
prognostic capacity of the rTNM, CLRSS, and CLRSS-2.
Material and methods: The data used from our Hospital, 1985 to
2001, 1,623 patients with laryngeal carcinoma. Of them, 288 patients
with recurrent laryngeal carcinoma were used for this study: 174 had
only a local recurrence, 40 only a regional recurrence, 36 only distant
metastases, and finally 49 a combination of local and/or regional and/
or distant recurrences. When the study was closed 205 patients (69%)
were dead, 82% of the deaths (168 patients) were consequence of the
recurrence. Five-year adjusted actuarial survival was 39%. Analysis
compared the three staging schemes using measures of hazard consistency, hazard discrimination, and balance. The primary outcome
measure was 5-year actuarial adjusted survival after recurrence.
Actuarial survival was estimated according to KaplanMeiers
method.
Results: rTNM, CLRSS and CLRSS-2, achieved a monotonic prognostic gradient with increasing stage, all produced statistically significant differences in survival rates between stages. Analysing
hazard consistency, hazard discrimination and balance, the rTNM
classification achieved better scores than the CLRSS for all the criteria analysed, but the CLRSS-2, improved noteworthy the rTNM
system. This CLRSS-2 obtained the best scores in all three criteria
used to evaluate objectively the goodness of the classification systems. Conclusions: The CLRSS-2 system, a modification of the
CLRSS, was the best method to classify patients with a recurrent
laryngeal carcinoma, doing better than the rTNM method and
improving the original CLRSS method.
Alaryngeal voice produced by a double-membrane voice-producing
element: preliminary clinical results
J.W. Tack1, H.A.M. Marres2, C.A. Meeuwis3, R. Hagen4, E.B. van
der Houwen1, G. Rakhorst1, H.F. Mahieu5, G.J. Verkerke1
1
Department of BioMedical Engineering, University Medical Center
Groningen, University of Groningen, A. Deusinglaan 1, 9713 AV
Groningen, Netherlands, 2Department of Otorhinolaryngology,
Head and Neck Surgery, Radboud University Nijmegen Medical
Centre, Nijmegen, Netherlands, 3Department of ENT, Daniel Den
319
Hoed Clinic, Erasmus Medical Center Rotterdam, Rotterdam,
Netherlands, 4 Department of ENT, Universitatsklinikum Wurzburg,
Wurzburg, Germany, 5Department of ENT, VU medical center,
Amsterdam, Netherlands
Introduction: Not all patients are able to produce a shunt valve assisted tracheo-esophageal (TE) voice of sufficient quality to replace
the voice after laryngectomy. The usually low pitch of the voice
causes a problem for females in particular. A sound generator based
on a double-membrane design that fits into a regular TE shunt valve
may improve alaryngeal voice quality.
Material and methods: Prototypes of the double-membrane voiceproducing element (VPE) are evaluated in 24 female laryngectomized patients in a randomized crossover trial. Results are compared
to the patients regular TE voice. The evaluation includes acoustical
and aerodynamical registrations during soft, normal, and loud phonation, the maximal phonation time, the patients primary judgment,
and a perceptual voice analysis by an expert listener of read-aloud
prose and spontaneous speech.
Preliminary results: The VPE increased the pitch of the voice, and
also provided sufficient intonation. Currently, the new voice source
appears beneficial especially for patients with a severely hypotonic
PE segment, as their intelligibility and sound pressure level improved. Compared to the regular TE shunt speech the airflow rate
was lower, while similar driving lung pressures were required. Mucus
from the lungs did not interfere with the functioning of the VPE for
the duration of the tests (ca. 1 h).
Conclusions: The VPE can easily be positioned, functions properly
under influence of mucus from the lungs, and significantly improves
voice quality for female patients that have a weak or aphonic TE
voice.
Alcohol, smoking and human papillomavirus in laryngeal carcinoma:

a Nordic prospective multicenter study
Walter J. Koskinen1, 2, Kjell Brndbo3, Hanna Mellin Dahlstrand4,
Tapio Luostarinen5, Timo Hakulinen5, Ilmo Leivo1, 2, Anco Molijn6,
Wim G. Quint6, Tov Rysland3, Eva Munck-Wikland4, Antti A.
Makitie1, Ilmari Pyykko7, Joakim Dillner8, Antti Vaheri2, LeenaMaija Aaltonen1
1
Helsinki University Central Hospital, Helsinki University, Helsinki,
Finland, 2Haartman Institute, Helsinki University, Helsinki, Finland,
3
Rikshospitalet, Oslo, Norway, 4Karolinska University Hospital,
Stockholm, Sweden, 5Finnish Cancer Registry, Helsinki, Finland,
6
Delft Diagnostic Laboratory, The Netherlands, 6Tampere University Hospital, Tampere, Finland, 7Malmo University Hospital, Malmo, Sweden
Study design: This prospective Nordic multicenter study evaluated
factors influencing development of and survival after laryngeal
squamous cell carcinoma (LSCC).
Patients and methods: Fresh-frozen laryngeal cancer biopsies from
108 LSCC patients in Finland, Norway, and Sweden were investigated. Patients whose biopsy samples contained at least 20% tumour
tissue (N = 69) entered the study. Human papillomavirus (HPV)
DNA was determined with GP5+/6+, MY09/11 nested PCR and
SPF10 PCR hybridization assay. Patients were examined by an ENT
specialist and a questionnaire concerning risk factors was filled in.
The median follow-up was 3.7 years.
Results: Three patients (4.4%) harboured HPV DNA in their carcinoma sample. Heavy alcohol drinking was associated with an increased risk of death, shorter survival, advanced-stage disease, and
younger age at diagnosis. However, tumour stage at diagnosis was
not a significant factor for survival in the whole study population. In
these LSCC patients, chronic laryngitis, gastro-esophageal reflux, and
orogenital sex contacts were rare. Poor oral hygiene was not associated with survival, although it correlated with heavy drinking.
Conclusion: The low prevalence of HPV-DNA suggests that HPV in
LSCC is less important than in oropharyngeal carcinomas. A history
of heavy drinking led to major mortality risk in LSCC cases and it
also promoted early carcinogenesis.
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320
Longstanding recurrent laryngeal papillomatosisimpact on voice

quality
Preliminary results of a therapeutic recombinant vaccine to treat

recurrent respiratory papillomatosis
Leena-Maija Aaltonen1, Laura Lehto2,3, Heikki Rihkanen4

1
Helsinki University Central Hospital, Helsinki, Finland, 2Phoniatric
Department, Helsinki University Central Hospital, Helsinki, Finland,
3
Laboratory of Acoustics and Audio Signal Processing, Helsinki
University of Technology, Helsinki, Finland 4Department of Otorhionolaryngology, Head and Neck Surgery, Jorvi Hospital, Espoo,
Finland
Beltran Olga and Rosales Ricardo

Otorhinolaryngology Department, Instituto Nacional de Ciencias
Medicas y Nutricion Salvador Zubiran, Mexico, Department of
Molecular Biology- Virolab Mexico DF
Design: A prospective case-control study was performed to evaluate

the speaking voice quality of patients with longstanding recurrent
respiratory papillomatosis (RRP).
Patients and methods: The patients were 7 males with adult-onset
RRP whose disease had lasted over 5 years and who had been
treated in Helsinki University Central Hospital for RRP minimum of
six times. They were also free of papilloma at the time of ENT
specialists examination. Voice samples were recorded and acoustic
analyses as well as perceptual listening test were performed. Each
patient had a control who was age- and gender matched and whose
smoking habits were similar.
Results and conclusion: Our data show that perceptual test defines
pathological voice quality more precisely than acoustical voice
analysis. Patients with longstanding laryngeal papillomatosis and
several laryngeal procedures had higher fundamental frequency than
their controls, but the rest of the acoustical parameters were not
deviant from normal voice. Perceptual analysis rated 30 to 50% of
the patients as quite or very disordered in overall quality, roughness,
breathiness or manner of voice production. Although the functional
results are not always optimal surgery is still the cobble-stone in
treatment of RRP.
Adult recurrent respiratory papillomatosis (ARRP): new therapeutic

approach with sequential use of Peg-interferon alpha 2a and
granulocyte monocyte colony stimulating factor (GM-CSF)
Ramirez Tannia, Rodriguez Miguel, Martinez Luz, Montano Efrain,
Vazquez Gonzalo, Valenzuela Gabriel, Guerrero Jesus
Department of ORL/Immunology/Pathology, Hospital de Especialidades Centro Medico Nacional de Occidente (CMNO HE) Instituto
Mexicano del Seguro Social (IMSS), Mexico
Abstract: Reported are 10 patients with ARRP diagnosed by immuno-histo-chemical examinations. Analysis of the clinical parameters: Number of previous surgeries, tracheotomy (diseases
severity), glottal stop, quality of voice (related to quality of life),
macroscopic description of vocal cords and obtain specimen to
determine by immunohystochemical techniques the number and
activation of dendritic cells with polyclonal S-100, monoclonal
CD1a, CD68 and DR. Dendritic cells play a key role in innate and
acquired immune response against foreign invaders as bacteria,
fungi, parasite and virus. HPV has a universal distribution and only
affects just a few people, this means that this people have some
kind of immune deficiency and we try to state if the problem resides in dendritic cells (according to literature), stimulating them
with sequential subcutaneous application of PegInterferon alpha 2a
(6 months) and GM-CSF (2 months).
Results: Previous surgeries (mean) 13.6. At time of review 4/10 initially had tracheotomy, 3 cases tracheotomy cannula was removed.
After cessation of treatment there were an improvement in the voice
and thus in quality of life. Glottal stop before therapy had a mean of:
56% (0 to 97%) and after: 97%. The laryngoscopies showed slow or
no progression of lesions. The number and activation of dendritic
cells were lower than autopsies controls; unfortunately we cannot
obtain final biopsies in all cases, in the best interest of patients. The
final biopsies showed a small increase in the activation of dendritic
cells.
Conclusions: The clinical results support the combined treatment of
Peg-IFN alpha 2a plus GM-CSF, but it is necessary with further
clinical trials in order to clarify the role of dendritic cells
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Recurrent Respiratory Papillomatosis (RRP) is an uncommon and

challenging disease.
A definitive solution is still elusive, but the search of a vaccine could
be helpful.
Objective: To assess the effectiveness of MVAE2 (Modified Vaccinia
Ankara recombined with the E2 gene of bovine papilloma virus) in
humans. This vaccine is capable of activating macrophages to kill
tumoral cells and lead to apoptosis (previously showed on animal
models).
Methods: A prospective, open-label, single-arm study performed
from November 2003 to May 2006, on 4 females and 2 males, ages 19
to 55 not immunosupressed, all with RRP, histopathological confirmed. Patients averaged a mean inter surgical interval (ISI) of
4.5 months due to symptomatic respiratory distress (not only because
a recurrence of small papillomas). After microsurgical excision, 1 ml
of MVAE2 vaccine [10 (7) virus particles] was injected intralesionally. Treatment was repeated every 2 weeks, for 4 times. This was
followed every month with grading of quality of voice, respiratory
distress and with nasopharyngolaryngoscopic pictures.
Results: In all, ISI was exceeded, even now in two patients, the follow
up is only 6 months and 8 months respectively. One patient with pretreatment ISI of 6 months, required a new surgical excision at month
14. One female patient (aged 43) wich disease started at age 6 with an
ISI of 5 months has now 20 months with better pretreatment voice,
no respiratory distress and recurrence of papillomas at epiglottidis
laryngeal face.
Conclusions: MVAE2 is a promising vaccine insofar as it reduces the
frequency of ISI. We need longer follow up, a bigger sample and after
new surgical excision, to observe the behaviour with a reinforce dose.
Epidemiology of laryngeal cancer in Northern Greece
K. Markou, I. Karasmanis, K. Vlachtsis, A. Nikolaou
Otorhinolaryngology Department, AHEPA University Hospital,
Thessaloniki, Greece
Introduction: Laryngeal cancer represents 12.5% of all human
neoplasms and constitutes 3040% of all head and neck cancer.
Aim: To analyze the epidemiologic data of laryngeal cancer. These
data include gender, age, profession, use of tobacco and alcohol,
family history, location, stage and grade of the tumor.
Materials and Methods: Between 1992 and 2005, 1,638 new cases of
malignant head and neck tumors were diagnosed and treated in our
Department. Among these cases 1,106 (67.5%) were laryngeal tumors, and 98.4% (1,088 cases) of the malignant laryngeal tumors
were squamous cell carcinomas (LSCC). The median age of the
LSCC patients was 62.1 years (range 3190). Only 35 out of 1,088
patients were women (3.2%).
Results: 86.9% of the patients were smokers (945 patients), and half
of them were smoking more than 30 cigarettes per day. 43.2% of the
LSCC patients were consuming alcohol in a daily basis (470 patients), while 167 patients were heavy consumers. More than 60% of
the patients were farmers or labor workers. 36.1% of the LSCC cases
(392 patients) had positive family history of malignancy. Concerning
the tumor location, 60.2% were glottic carcinomas, 32.8% supraglottic, 5.9% transglottic, and 1.1% subglottic. T staging revealed that
1.2% of the cases were carcinomas in situ, 28% T1 tumors, 19% T2,
32 % T3, and 20% T4. The tumor grading showed that 43% of the
cases were G1, 42.1% were G2, and 11.8% were G3, while the rest
3.1% were carcinomas in situ, micro-invasive carcinomas or verrucous carcinomas.
Conclusions: The rate of LSCC among the head and neck cancers is
higher in our cohort of patients comparing with international data.
Recording of the epidemiologic data in specific populations is very
essential in order to design better prevention and treatment strategies.

Pattern of laryngeal malignancy; a single Iran centre experience
Mohamad Javad Ashraf, Negar. Azarpira, Bijan Khademi, Mahmood
Shishegar
Department of Pathology and Otolaryngology, Shiraz University of
Medical Sciences, Iran
Introduction: Carcinoma of the larynx accounted for 1% of human
carcinomas. The development of laryngeal carcinoma is strongly
associated with smoking. Carcinomas of the larynx are traditionally
divided into supraglottic, glottic and subglottic tumours. There are
important clinical and therapeutic reasons for this subdivision.
Glottic carcinomas account for almost 2/3 of all laryngeal neoplasms.
Methodology: This study reports retrospectively laryngeal tumours
seen during the period 20042006. Demographic data of all the laryngeal tumours are retrieved from the case files of the patients. Clinical
presentation of all the cases was recorded. All the histopathology reports were recorded. Total laryngectomy had been the treatment of
choice. The majority of patients, who had squamous cell carcinoma,
were >60 years of age. Males were more afflicted more. Hoarseness or
obvious alteration in voice was the most common presenting complaint. 50 laryngeal cancers were recorded that all of them were
squamous cell carcinoma (SCC) with average tumour size of 1.54 cm
that 60% of them were located in glottic area and remaining in supra or
subglottic area. Among them 32 (64%) well differentiated, 14 (28%)
moderately differentiated carcinoma and 4 (8 %) were recorded.
Thyroid gland involvement was recorded in 4 (8%) cases. Non-tumoral
tissue had carcinoma in-situ in 4 (8%), dysplastic change in 6 (12%) and
squamous metaplasia in 10 (20%) cases.
Conclusion: Over a 2-year period 50 laryngeal tumours were registered in Khalilie Otolaryngology Clinic, well differentiated squamous
cell carcinoma was the most common malignant tumour. In the future, more epidemiological and demographic studies will be performed using the centralized tumour registry.
Laser CO2 in the treatment of laryngeal cancer
E. Czecior, G. Namyslowski, W. Scierski, M. Misiolek, A. Polok,
L. Turecka
Department of Otolaryngology, Silesian Medical University, Zabrze,
Poland
Transoral laser microsurgery is an efficient alternative treatment to
open surgery for T1 and some cases of T2 laryngeal tumours. The
oncological results are similar to open surgery and the functional
results are often better.
The aim of our study was to evaluate 162 patients suffering from T1
and T2 laryngeal cancer. All of them were treated in the Department
of Otolaryngology Silesian Medical University in Zabrze, Poland,
between 1996 and 2002, using laser microsurgery. The oncological
(survival rate, recurrence) as well as phoniatric (voice quality) results
were analyzed.
In the evaluated group of patients local condition of the larynx,
tumour recurrence, duration of hospitalization, tracheotomy necessity and the reasons of death were studied. We studied also voice
quality using GRBAS scale (G: grade, R: roughness, B: breathiness,
A: asthenicity, S: strain).
Survival rate at 3 years observation time was 95%. In 52% of patients
we assessed good phoniatric results using GRBAS scale.
Laser CO2 microsurgery is a successful method for treatment of T1
and some T2 cancers of the larynx. Oncological as well as functional
results after laser microsurgery of the larynx are good.
N0 neck in supraglottic carcinoma treated by bilateral selective neck
dissection
Z. Petrovic, V. Djordjevic, V. Djukic, V. Nesic
Institute of Otorhinolaryngology and Maxillofacial Surgery of the
Clinical Center of Serbia, Belgrade
Aim: The study comprised patients with a supraglottic laryngeal
carcinoma treated in the period 19832000, at our institution. All
patients had primary surgery. They all had clinically and ultrasound
321
negative findings in the neck (N0). Bilateral selective neck dissection
at the level IIIV was performed in all patients. Postoperative
radiotherapy was given to all patients with verified occult metastases.
Results: One hundred and -three patients were studied. Occult cervical node metastases were found in 18% (35/193). Ipsilateral occult
metastases were more common (77%, 27/35), but both bilateral and
contralateral spread was seen (14%, 5/35 and 9%, 3/35, respectively).
Extracapsular spread was found in 8/40 cases (20%).
Conclusion: Only in two patients (1%) did metastases develop subsequently indicating the effectiveness of planned postoperative
radiotherapy.
Quality of life of patients with early glottic cancer: a comparative
non-randomized post-treatment study
Slavicek Ales1, Bahannan Abdulrehman1 , Zabrodsky Michal1,
Lohynska Radka2, Cerny Libor3, Vokral Jan3
1
2
Department of Oncology and Radiotherapy, 3Foniatric clinic, The
First Medical Faculty of the Charles University in Prague, Faculty
Hospital Motol
Aim: Oncological results were considered to be the most important
factor in evaluation of the treatment success of any specific cancer
treatment modality. Recently, the importance of quality of life of
cancer patients has emerged as one of the most significant values for
assessment of patient post-treatment life.
Material and Methods: This study was designed to compare the
quality of life of patients successfully treated for early stages of
glottic cancer. Patients were divided according to the primary treatment into two groups. Post-treatment quality of life was assessed for
both radiotherapy and laser-assisted surgery arm and the results were
compared and statistically analyzed.
Forty-eight patients (11 women and 37 men) with early-staged glottic
carcinoma were enrolled in the study. Eighteen patients were treated
with curative radiotherapy and 30 patients received laser-assisted
endoscopic chordectomy. Quality of life was evaluated retrospectively using EORTC QLQ-C30 (version 2.0) and QLQ-H&N 35
questionnaires.
Mean follow-up was 24 months (189 months) and only patients in
complete remission were assessed. The majority of cases treated with
chordectomy were Tis (carcinoma in situ) lesions whereas in radiotherapy group T1 lesions predominated.
Results: There was no statistical difference between the two groups
for the overall QOL score calculated for both questionnaires separately. The evaluation of the symptom scales of the EORTC QLQC30 showed statistically significant difference in salivation with better
scores in the surgery group. The radiotherapy group also showed
significantly less sexual interest. This could be hypothetically explained by the fact that patients treated with radiotherapy were significantly older than those treated surgically. There were no
significant differences in voice quality between the groups.
This study was supported by IGA MZ CR 8430-3
Chronic aspiration secondary TM
to a Staffieri fistula: successful therapy
with an insertion of a Provox voice prosthesis
M. Bremke1, A.M. Sesterhenn1, G. Lichtenberger2, J.A. Werner1,
B.J. Folz1
1
Department of Otolaryngology, Head and Neck Surgery, Marburg,
UKGM, Germany, 2Department of Otolaryngology, Szent Rokus
Hospital, Budapest, Hungary
Background: The Staffieri technique is a method for surgical voice
restoration after laryngectomy. A fistula between trachea and
esophagus is created to achieve a so-called Neoglottis phonatoria.
The assignment of the neoglottis is to protect the airways during
ingestion and to give the patient a chance to phonate during expiration. The quality of the voice has been reported to be good, but
complications like aspiration, higher frequency of pharyngocutaneous fistulas, salivary fistulas and stenosis of the neoglottis have been
reported.
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322
Patient: A case of a 71-year-old man with aspiration via his Staffieri
fistula is presented. The fistula was created in 1979 after laryngectomy because of a laryngeal carcinoma. He also suffered from a
metastasized gastric carcinoma which was cured by a 2/3 resection of
the stomach in 1970. He is free of recurrence with regard to his
oncologic diseases. Until 2003 the patient had no problems with the
fistula and was able to phonate well. In 2003 the patient had progressive aspiration via the fistula and the Staffieri fistula was therefore reduced in diameter by surgery. In 2005 the patient presented
himself again because of a recurrence of the aspiration. Endoscopy of
the upper aerodigestive tract showed healthy mucosa, contrast
imaging of the esophagus showed a significant aspiration of the
contrast medium into the trachea. Due to these findings a voice
prosthesis was inserted into the fistula. This therapy cured the patient
from aspiration. He is able to phonate well and has no further
complaints.
Conclusion: Aspiration via a Staffieri fistula is described in about
25% of cases and therapy is sometimes difficult. Surgical narrowing
of the diameter of the fistula is inadequate in most cases and many
patients would lose their restored voice if the fistula was closed
permanently. Through the insertion of a voice prosthesis aspiration
could be stopped and voice was immediately restored.
Peristomal geometry and morphology in laryngectomees: a field
study
E.B. van der Houwen1, R.V. Moerman1, B.F.A.M. van der Laan2,
G.J. Verkerke1,3
1
Department of Biomedical Engineering, University Medical Center
Groningen, University of Groningen, A. Deusinglaan 1, 9713AV,
Groningen, vdHouwen@gmail.com, 2Department of Oto-RhinoLaryngology, University Medical Center Groningen, the Netherlands, 3Department of Biomechanical Engineering, University of
Twente, Enschede, the Netherlands
Introduction: Filters and tracheostoma valves attached to the stoma
of TLE (total laryngectomy) patients improve the quality of life.
Most commonly used for attaching these aids are adhesive patches,
called stoma stickers. Using, applying and maintaining these stickers
are perceived to be very cumbersome and disappointing by the patient, to the point of not being used at all. Most stickers attach very
poorly to the skin around the stoma, partly due to the shape of the
stomal area. The aim of this study is to collect (peri-) tracheostomal
geometry data to benefit the development of better tracheostomal
flanges or stickers.
Methods: In a pilot study, peristomal geometry data of 30 TLE patients, under treatment of ENT-specialists of the University Medical
Center Groningen was collected using simple rulers. Patients were
asked to complete a questionnaire about experiences with stickers
and filters. Photos of the stoma under different angles were taken to
supplement the data.
Results: Preliminary results show a smaller variety for stoma width
and height than for the area around the stoma, predominantly of the
stomal depth. In most patients, the peristomal area forms a secondary stoma that could facilitate stickers.
Conclusion: Tracheostomal geometry varies tremendously amongst
patients. Available stickers only work in some cases. Most air leakage
with stickers is caused by a pour fit on the wrinkled skin of these
mostly elderly patients.
Physiological aspects of aging voice
S. Fernandez*, D. Ruba*, F. Vazquez**
*Department of ORL-HNS, University Hospital, School of Medicine, University of Navarra, Pamplona, **Hospital Nuestra Senora
de Belen, La Coruna, Spain
Older patients are frequently seen by otolaryngologists for voice
complaints which include hoarseness, effortfull voicing and voice
fatigue.
Normal physiological and anatomical age-related changes affecting
voice quality. Vocal fold atrophy is apart of the normal aging process,
123

with up to 60% of 60-year-old individuals displaying evidence of
glottal insufficiency. Several studies have suggested that aging may
affect laryngeal adductory function by altering muscle fiber type
composition to a slower-contracting isoform, in a manner similar to
that observed with denervation.
Many questions have no answers nowadays. Is vocal cord paresis
normal for aged? What is presbyphonia? Is dysphonia in the old
patient the same as dysphonia of the old patient?
Material and Methods: We have studied 28 people, 14 men and 14
women aged more than 70 years old for acoustical, aerodynamic and
laryngoscopic characteristics. Our objective was to characterise what
is normal aging voice and abnormal aging voice.
Results: The physical examination reveal frequent glottal incompetence, impaired arytenoid cartilage adduction (60%), vocal fold
bowing (40%), incomplete glottic closure in the region of the membranous vocal fold (55%) and excessive ventricular fold activity
(65%). Functional studies reveal an impaired maximum phonation
time, normal levels of translaryngeal airflow (0.19 l/s men; 0.13 l/s
women), increased intraoral pressure in men (118.57 mmH2O) and
decreased contact index during vocal fold vibration as identified on
electroglottography. Acoustical studies reveal a fundamental frequency increased in men (144 Hz) and deceased in women (229 Hz),
normal maximum phonation time, frequent vocal tremor (60%) and
normal maximum intensity.
Conclusion: It is necessary to evaluate more parameters and a large
population to establish correlations between acoustical, aerodynamic
and anatomical parameters in order to offer better preventive measures, speech therapy or phonosurgical treatment.
A case of a foreign body in the esophagus entrance, which resulted
in a temporary laryngeal paralysis
Al. Valkov, G. Nikolov
Department of ENT Surgery, University Hospital av Pleven,
Bulgaria
A case of a patient, a prisoner, who deliberately swallowed a few
foreign bodies is presented.
The last of the objects remained fixed in the entrance of the esophagus and due to its specific form and sharp edges caused a temporary
laryngeal paralysis. At the time when received in our clinic, the patient had a hoarse voice. He did not report on swallowing any foreign
bodies. When indirect laryngoscopy was performed, paralysis of the
left true vocal cord and saliva retention in the left recessus piriformis
was detected. The radiological examination proved the presence of a
foreign body in the entrance of the eseophagus. A fortnight from its
extraction, the vocal cord paralysis subsided.
Three-dimensional computed tomography of the larynx for evaluation of unilateral vocal fold paralysis
Hiroyuki Hiramatsu, MD, Ryoji Tokashiki, MD, Mamoru Suzuki,
MD
The Department of Otolaryngology, Tokyo Medical University
Design and method of study and analysis: We performed a retrospective study of patients with unilateral vocal fold paralysis who had
undergone three-dimensional computed tomography (3DCT) imaging between March 2003 and May 2006. A total of 50 3DCT studies
were performed for diagnostic evaluation. For 3DCT, 1 mm axial CT
scan images were obtained on a multislice CT scanner. The mimics
version 9.01 (Materialise Japan K.K) was also used to create 3DCT
images through its surface-rendering protocols. The intensity value
for extracting the cartilage shadow was determined based on these
sliced images. We evaluated the spatial relationships of arytenoid and
cricoid cartilage based on the 3DCT data of the unilateral vocal fold
paralysis.
Summary of results: The muscular process of the arytenoid cartilage
was located in the upper part of a cricoarytenoid joint of the paralysed side during rest and phonation, regardless of severity, in comparison with the healthy side. The arytenoid cartilage of the
paralysed side had a passive movement caused by the contact with

mobile side during phonation in many cases. Furthermore, in many
cases (80.2%), a part of the paralysed side was located outside the
cricoarytenoid joint and these cases tended to have a large difference
in a vocal fold level because there is no ligament limiting displacement to the upper part of the arytenoid cartilage. On the other hand,
cases in which the paralysed side was located intraarticularly had a
tendency forward mild paresis (active movement was slightly seen in
3DCT).
Conclusions: Images generated by 3DCT facilitated the definition of
the anatomic relationships between arytenoid and cricoid cartilage in
case of unilateral vocal fold paralysis.
Tracheal reconstruction with composite carbon prosthesis in sheep
W. Scierski1, G. Namyslowski1, M. Misiolek1, E. Czecior1, M. Blazewicz2, S. Blazewicz2, J. Nozynski3, J. Pilch1
1
Department of Otolaryngology, Silesian Medical University,
Zabrze, Poland, 2Department of Biomaterials, University of Mining
and Metallurgy, Krakow, Poland, 3Silesian Centre for Heart
Diseases, Zabrze, Poland
Introduction: Large tracheal stenosis and its reconstruction has been
a difficult and challenging problem over the past years mainly because of prosthesis extrusion and dislocation, local infection, luminal
restenosis and hemorrhage. There is no appropriate synthetic material developed up to date, the use of which would bring positive longterm experimental results in reconstructive surgery of large tracheal
segment.
Study: This study describes an animal experiment using composite
carbon prosthesis in sheep. The prosthesis was made from carbon
fibres and resin as a matrix. The composite samples were prepared in
the form of five integrally bonded laminates differing in their structure, mechanical and biological properties. Carbon fibres in the form
of unwoven fabric and woven fabrics were immersed in liquid resin
solution followed by drying process to remove the solvent. In this
study the segmental defects 3 cm long of the cervical trachea were
created in 15 sheeps.
Analysis and results: In the group of 15 animals we used three different types of prosthesis and reconstruction. Type I prosthesis was
impregnated by terpolimer (polytetrafluoroetylene: 57.6%, polyvinylidene fluoride: 27.3% and polypropylene: 15.1%). Type II was
covered inside by polyurethane layer. Type III of prosthesis composed only of carbon fibres and resin. After 1, 2, 3, 4, 6, 8, 24 and
38 weeks the animals were killed. The degree of stenosis, inflammation and epithelialization of prosthesis were compared.
Conclusion: The composite carbon prosthesis can be used to reconstruct the trachea in this animal model. There is less stenosis,
inflammation and better epithelialization in the type III of implant.
Development of tracheal prostheses of porous titanium: sheep study
323
was not the direct result of death. The prostheses were integrated
into the surrounding tissue, but endoprosthetic colonisation by
pseudostratified ciliated columnar epithelium was low or nil.
Conclusion: The absence of endoprosthetic lining was responsible for
the complications. The biocompatibility of the biomaterial is not in
question, but the surgical procedure will have to be modified by an
endoprosthetic mucous graft before implantation so as to accelerate
cicatrisation.
Rare malignant tumors of the larynx
K. Vlachtsis, K. Markou, I. Karasmanis, A. Nikolaou
Otorhinolaryngology Department, AHEPA University Hospital,
Thessaloniki, Greece
Introduction: The vast majority of the laryngeal tumors are SqCCa
(SCC). The rest of the laryngeal malignant tumors represent a small
percentage that varies between 1 and 5%. These tumors are mainly
sarcomas, neuroendocrine tumors and lymphomas. The aim of the
present study is to investigate and present the cases of the non-SCC
which were diagnosed and treated in our Department during the past
14 years.
Patients and methods: Since 1991, 1,106 new cases of laryngeal
tumors were diagnosed and treated in our department. Among these
cases 1,088 were SCC, while 18 were non-SCC cases (1.62%). Specifically, 5 cases were sarcomas (in 1 patient coexisted rhabdomyosarcoma and SCC), 3 carcinosarcomas, 3 lymphomas (in 1 patient
coexisted non-Hodgkin lymphoma and SCC), 3 cases were neuroendocrine tumors (1 was paraganglioma), while the rest 4 cases were
1 tracheal adenocarcinoma, 1 salivary gland adenocarcinoma, 1 adenosquamous carcinoma, and 1 metastatic renal adenocarcinoma.
The patients with lymphoma were treated with radiotherapy (RT)
and chemotherapy (CT), and the rest of the patients were treated
with surgery and CT and/or RT, depending on the histology and the
stage of the tumor.
Results: The lymphoma cases appeared to have better response to
the treatment comparing with the rest of the patients. Patients with
sarcoma had worse prognosis, while the neoplasms showed diverse
behavior according to the histological type and the stage of the tumor.
Conclusions: The malignant tumors of the larynx apart from the SCC
are rare and in our cohort of patients represent 1.62%. These tumors
are mainly sarcomas, lymphomas and neuroendocrine tumors. In
every case of laryngeal tumor there must be a histological confirmation of the neoplasia before any treatment commences, despite
the macroscopic appearance of the tumor. The treatment of these
tumors varies according to the histological type and the stage. Sarcomas appear to be more aggressive tumors with poor prognosis.
P. Schultz1, D. Vautier2, A. Charpiot1, P. Lavalle2, C. Debry1

1
Department of Otorhinolaryngology, CHU Hautepierre, Strasbourg, France, 2Department of Research, INSERM 595, Strasbourg,
France
Haemangioma of the larynx and hypopharynx in adults: clinical

presentation and surgical management of three patients
. Remenyi, S. Leitersdorfer, G. Lichtenberger
A. Bihari, A
Szent Rokus Hospital and Institute, Department of ORL-HNS, 1085
Design: Development of a biomaterial to be used for tracheal and

laryngeal reconstruction. This experimentation follows the replacement of trachea in rats with porous titanium implants. The aim of the
study is to test this type of prosthesis on sheep, whose trachea is of
comparable size to that of humans.
Methods: Six ewes were implanted with porous titanium implants
after resection of 5 cm of trachea. The planned period for the
implantation was from 3 to 6 months before the sacrifice of the
animals for histological analysis.
Results: After a simple immediate postoperative course, the
implantations developed complications of tracheal patency, responsible for four deaths (tracheal obstruction by mucous plug n = 2,
inferior necrosis of trachea n = 1, pneumopathy n = 1). The two
remaining sheep presented no complications. The mechanical performance of the prostheses was good. The histological results showed
an inflammatory stenosis of the tracheo-prosthetic junctions, which
Objectives: Laryngeal and hypopharyngeal haemangioma in adults is

a rare condition. It is more often in males. The causative factors are
not known adequately. It can be asymptomatic, or may cause
hoarsness,coughing and dysphagia. Before the laser era it was a
challenge, to manage this condition. Nowadays laser surgery is the
most common procedure, to treat these patients.
Patients and methods: We present three cases of laryngeal and
hypopharyngeal haemangioma in adult patients.Their age ranged
from 38 to 53 years. There were two female and one male patient.
They all had some complaint. These were: hoarsness, dysphagia, and
coughing. The location of the lesions were in one case on the aryregion and on the false vocal cord, and in the other two cases at the
postcricoid region. After check-up all patients were treated surgically, using CO2 laser endoscopically. In two patients after removing
of the haemangioma, the coagulation of bleeding area was sufficient.
In one patient, who had a larger lesion at the postcricoid region, the
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324
coagulation was not sufficient to controll haemorrhage. There we had
to adapt the mucosal edges around the wound bed and suture them
using the ligature-suture technique and instrument by Lichtenberger.
Results: There were no complications. Histology proved to be in all
three cases cavernuos type haemangioma. All patients have remained free of recurrence, and have no complaint.
Conclusion: These cases show, that most laryngeal haemangiomas
(under a reasonable size) can be safely managed by endoscopic laser
surgery. In larger lesions the bleeding may cause difficulties. The
ligature-suture technique by Lichtenberger helps us to overcome this
problem.
Transoral laser management of hypopharygeal low-grade malignant

peripheral nerve sheet tumor (MPNST)
Zsolt Kaszas, Peter Pogany, Gyorgy Lichtenberger
Department of ORL-HNS, Szent Rokus Hospital and Institute, 1085
Budapest, Gyulai P.u. .2, Hungary
Introduction: The study reports a case of a patient with an extremely
large hypopharyngeal low-grade malignant peripheral nerve sheet
tumor (MPNST), causing severe dyspnoe and swallowing inability.
Case history: The oval tumor filled the whole hypopharynx and the
entrance of the larynx. As the patient suffered from serious, life
threatening dyspnoe, tracheostomy became mandatory. The tumor
recurred twice on slightly different localization in a 19-year period.
The tumor appearance site varied from left aryepiglottical fold to left
arytenoid region. We removed the tumor with laser. After removal of
the tumor there was a constant diffuse bleeding. While the bleeding
couldnt be controlled by coagulation, we used the transoral ligaturesuture technique performed by Lichtenberger. It was not easy to
provide an exact histological diagnosis of this rare tumor. On the first
two occasions the diagnosis was lipoma. Finally the exact histological
diagnosis proved to be MPNST. From our point of view the MPNST
corresponds much more with the patients clinical symptoms and case
history than lipoma. After the transoral operation that we performed,
the patient could be decanulated. The patient has a 1-year symptom
free follow up since the last surgery.
Conclusion: We would like to recommend to follow the patients
suffering from rare diseases like MPNST regularly, at least in every
2 months, and in case of recurrence to perform immediate transoral
laser surgery preserving the delicate parts of larynx.
Primitive neuroectodermal tumour of the larynx

R.M. Muller1, M. Suttorp2, T. Herrmann3, R. Fischer4, Gabriele
Hahn5
1
Klinik und Poliklinik fur HNO-Heilkunde, 2Klinik und Poliklinik
fur Kinder- und Jugendmedizin, 3Klinik und Poliklinik fur Strahlentherapie und Radioonkologie
4
Institut fur Pathologie, 5Klinik und Poliklinik fur Radiologische
Diagnostik
des Universitatsklinikums der Technischen Universitat Dresden
Objectives: Since primitive neuroectodermal tumours (PNET) of the
larynx occur seldom they cause diagnostic and therapeutic problems
when they arise.
Methods: The case of an 18-year-old young man with a supraglottic
PNET is reported.
Summary of results: A tracheotomy had to be performed primarily as
an emergency measure because of dyspnea. The PNET, which was
diagnosed secondarily, was treated successfully by chemotherapy and
radiation following the EuroE.W.I.N.G. 99record.
The latest histological findings were free of tumour.
Discussion: Is a laryngectomy reasonable in case of a PNET of the
larynx, especially in an 18-year-old patient? The decision in favour of
a radio-chemotherapy was made in our interdisciplinary tumour
board because of the success of this therapy documented in international studies.
Conclusions: Unusual locations of tumours always require interdisciplinary co-operation.
123

Inflammatory myofibroblastic tumor of the larynx: report of two
cases associated with head and neck cancer
A. Minni, M. Barbaro, D. Bernardeschi, G. Rispoli, R. Filipo
Neurology and Otolaringology Department, University of Rome
La Sapienza, Rome, Italy
Background: Inflammatory myofibroblastic tumour (IMT), is an
unusual, benign solid mass that mimics a neoplastic process, characterized microscopically by the proliferation of a spindle cell component
against a heavy inflammatory infiltrate of mixed composition but
usually with a predominance of mature lymphocyte and plasma cells.
Various pathogenetic factors have been proposed (reactive, traumatic,
infectious, autoimmune, and neoplastic) but the etiology of most IMTs
remains unknown. The presence of human herpesvirus-8 and Epstein
Barr virus, have been reported. Although the lung is the best known
and most common site, inflammatory myofibroblastic tumour occurs in
several extrapulmonary locations; in head and neck, the areas most
commonly involved are the orbit and paranasal sinuses, but IMT has
been also described in the larynx, pterygomaxilar space, tonsils, middle
ear, periodontal tissues, tongue, node, parotid gland and trachea.
Method:
Case 1: Male 75 years, with 3 months hoarseness, presenting a lesion
involving the right vocal fold, with no impaired mobility. A biopsy
showed IMT, a neck CT scan showed a low enhancement lesion of
right vocal cord. A partial frontal laryngectomy was performed. No
relapse at 1 year. Four months after surgery a nasopharynx cancer
was detected.
Case 2: Female 81 years with 1 year hoarseness, presenting polipoid
like tumour of anterior portion of right vocal cord. A biopsy revealed
larynx cancer associated with IMT; a neck CT scan was negative. An
ELS type III laser CO2 cordectomy was performed. No relapse at
4 months.
Conclusion: In patients with a malignant-like laryngeal mass an
inflammatory myofibroblastic tumour should be considered. Nevertheless IMT is a benign lesion, it is mandatory to check for other
cancer. The association with nasopharynx cancer could testify the
role of EpsteinBarr virus in IMT aetiology.
Non-invasive swallowing monitor
Jeremy Eggleton1, Majid Hashemi2 and Adrian Fourcin1
1
Laryngograph Ltd., UK 2Whittington Hospital, NHS, UK
FEES provides useful information down to the nasopharynx but a
practical daily problem in the clinical management of disorders of
deglutition arises from the lack of means for the non-invasive monitoring of post-pharyngeal bolus passage activity. Both X-ray based
videofluorography and a range of different invasive sensor arrays
provide solutions to this problem but their intrinsic nature precludes
their systematic repeated use.
The electro-laryngograph is a familiar non-invasive method for the
observation and measurement of aspects of vocal fold vibration,
which is based upon changes in the electrical conductance of tissues
of the larynx. The present swallowing monitor uses the same principles but with radically re-developed operational parameters.
Initial measurements show good sensitivity in general to the swallow
process. Clinical work continues to associate features of the monitors
response to particular physiological events of the swallow.
Examples are presented and discussed of its application and practical
use.
Manuel P Garcia, The bicentennial and the Laryngoscope
S. Fernandez*, D. Ruba* and F. Vazquez**
*Department of ORL-HNS, University Hospital, School of Medicine, University of Navarra, Pamplona, Spain, **Hospital Nuestra
Senora de Belen, La Coruna, Spain
Who is Manuel P Garca? Was the same person that Manuel
Rodriguez Sitches? Where and when he was born? In Madrid, In
Zafra? Was he a Physician, a singer, a teacher? Did he discovered the
laryngeal mirror?

Last year, 2005, we celebrated the 200th year of his birthday and this
year, 2006, we commemorate the 100th year of his death.
Usually Manuel Patricio Garcia is well known by Otorhinolaryngologists but in the specialised literature, books, papers, etc. We can
find many errors about him, about his nationality, about the city
where he was born, the date of the laryngoscopes discovery, the date
of his birthday, his personality. It is no well known the real history
about his true surname.
We present in this work the most important biographical aspects, his
works, and a complete diagram of his family. We review the history
of Laryngoscope; the failed attempts, the episode of the invention
of the laryngeal mirror, the consolidation phase and the modernisation or expansion of this technique in the last decades of the XIX
century. We present Manuel Garcia as the first voice scientist, the
first vocologist, his influence on laryngology and on the art of singing,
his most famous students and the legacy of this great man nowadays.
Laryngeal amyloidosis in patients with apolipoprotein AI L174S and
L178P
A.J.C. Hazenberg1, F.G. Dikkers2, P.N. Hawkins3, J. Bijzet1,
D. Rowczenio3, M.D. Posthumus1, J.E. van der Wal4, B.P.C.
Hazenberg1
1
Department of Rheumatology and Clinical Immunology, University
Medical Center Groningen, The Netherlands, 2Department of Otorhinolaryngology, University Medical Center Groningen, The Netherlands, 4Department of Pathology, University Medical Center
Groningen, The Netherlands, 3National Amyloidosis Centre, Royal
Free Hospital, Royal Free and University College Medical School,
London, UK
Purpose: Hoarseness associated with laryngeal amyloid deposits is
one of the characteristic clinical presentations of localized AL amyloidosis. We report two patients with laryngeal amyloid who atypically were found to have associated systemic amyloid deposits on
further investigation. No plasma cell dyscrasia was identified. DNA
analysis identified mutations in the apoAI gene respectively encoding
the variants Leu174Ser, previously associated with systemic amyloidosis, and Leu178Pro which has previously been associated with
accelerated atherosclerosis. Objective was to study the clinical and
pathological characteristics of two patients with laryngeal amyloidosis in whom these apoAI mutations were detected.
Methods: The larynx was examined by videolaryngostroboscopy. The
voice was analyzed with the GRBAS-system, phonation times and
phonetography. Laryngeal biopsies were stained with HE, Congo red,
and analyzed immunohistochemically. Organ function was assessed
and tissue involvement by amyloid further determined by rectal biopsy,
abdominal fat tissue aspirate, and 123I-SAP scintigraphy.
Results: The laryngeal localization of amyloid was remarkably similar in the two patients, occurring as small, irregular floppy proliferations affecting the borders of both vocal cords. The picture
contrasted with the firm bulky proliferations typically seen in localized laryngeal AL amyloidosis.
Conclusions: The various findings in these patients, including the
simple macroscopic appearances, suggest that their laryngeal amyloid
deposits may be the first manifestation of hereditary systemic ApoAI
amyloidosis. Comprehensive investigation including apoAI genotyping should be considered in patients who present with apparently
localized laryngeal amyloidosis.
MHC class I expression in human laryngeal and tonsillar epithelium
C.G.L. Hobbs1,3, L.E.N. Rees1, R.S. Heyderman2, M.A. Birchall3 and
M. Bailey1
1
Department of Clinical Veterinary Science, 2Department of Cellular
& Molecular Medicine, 3Clinical Sciences at South Bristol, University of Bristol, Bristol, UK
Background: Understanding the immunological structure of the upper aerodigestive tract is important for analysing the interaction
325
between incident challenges, such as human papillomavirus infection,
and disease, particularly head and neck cancer. We have previously
shown that laryngeal and tonsillar epithelium express major histocompatibility complex (MHC) class II locus products, but that
expression of human leucocyte antigen (HLA)-DQ is reduced compared to HLA-DR. This may confer a decreased repertoire of presented T-cell epitopes generated by the processing of exogenous
peptides in upper airway mucosa.
Objective: To determine whether the peptide repertoire presented by
MHC class I loci varies in squamous epithelium of the larynx and
tonsil.
Design: A multi-centre, hospital-based, cross-sectional biopsy study.
Methods: Laryngeal and tonsil biopsies were taken from 19 patients
undergoing routine tonsillectomy (M:F 6:13, 1664 years). Quantitative immunofluorescence microscopy was performed using
antibodies to MHC class I a-chain (pan-locus specific, HLA-A,
HLA-B+C) and 2-microglobulin.
Results: MHC a-chain and 2-microglobulin showed lower expression in laryngeal and tonsillar epithelium than in either lamina propria (larynx 68% vs. 85%, P < 0.005; tonsil 73% vs. 89%,
P < 0.0001). Within the epithelium itself, intensity of a-chain
expression decreased from the basal to apical layers. In paired
squamous epithelia from the two sites, a-chain expression was significantly higher in the tonsil compared to the larynx (79% vs. 62%,
P < 0.05).
Conclusions: We suggest that these findings reflect functional stratification of this epithelia, with the superficial layer, most exposed to
incident challenges, less equipped to present antigens to conventional
T-cells. This may affect immunosurveillance directed at viral and
tumour-related epitopes in the upper airway.
Idiopathic subglottic stenosis: progesterone as possible etiologic

factor
A. Ruess, S. Blum, C. Sittel
Department of HNO, Heidelberg, Germany
Idiopathic subglottic stenosis is predominant in women of younger
and middle age. Differential diagnoses are various systemic diseases
as well as esophagolaryngeal reflux. However, there are contradicting
reports in the literature on the influence of female sexual hormones.
We present two female patients with an idiopathic subglottic stenosis.
Therapy consisted of cricotracheal resection with thyreotracheal
anastomosis. A
1.52-year-old female with progressive stridor on inspiration. Rigid
microlaryngobrochoscopy (MLB) revealed an 8090% stenosis due
to lateral shelving of the subglottic region. Intraoperatively a marked
thickening of the submucous tissue on the cricoid plate was resected.
However, pathologic examination could not reveal specific characteristics. Airway reconstruction was successfully performed using a
cricotracheal resection (CTR).
A 2.24-year-old female with progressive hoarseness and dyspnoe.
Multiple surgical attempts had been performed elsewhere without
success. MLB revealed a subglottic re-stenosis of 90%. Again, fibrotic and thickened submucous tissue on the cricoid plate was
resected. Pathological examination revealed a laryngeal fibromatosis with immunohistochemical expression of progesterone receptors. Airway reconstruction was performed using CTR, minor
re-stenosis was managed using endoscopic dilatation with topical
application of corticosteroids and Mitomycin C. 6 months prior to
her first symptoms the patient had been started on oral contraception.
The pathophysiology of so-called idiopathic subglottic stenoses remains unclear until today. It has been suspected that female sexual
hormones may play an etiologic role in a subset of these patients. Our
findings support this hypothesis and underline the importance to pay
attention to this potential gynaecological aspect of the disease. CTR
is a reliable technique of airway restoration in idiopathic subglottic
stenosis.
123
326
Combined nerve transfer and neurotrophin therapy for reinnervation
of the larynx
Paul J. Kingham*#, Pamela Murison#, Alan Jones#, Giorgio Terenghi*, Martin A. Birchall#
#
Laryngeal Research Group, University of Bristol, UK, *Blond
McIndoe Research Laboratories, University of Manchester, UK
Direct repair of the recurrent laryngeal nerve (RLN) results in
synkinesis and compromised function of the larynx. We have
therefore developed a pig model to investigate whether anastomosis of the phrenic nerve with the abductor branch of the RLN
leads to accurate reinnervation of abductor muscles. The application of neurotrophins (NT) to the site of repair may enhance nerve
regeneration. Therefore, in this study we have examined the effect
of nerve repair with poly-b-hydroxybutyrate (PHB) wrap-around
conduits impregnated with NT-3 (500 ng/ml). Pan-neurofilament
(NF) immunohistochemistry indicated there was progressive and
organised nerve regeneration through the conduit 24 months following repair. Immunoblot analysis of the distal segment revealed
significantly elevated levels of NF in the NT-3 treated animals
2 months following surgery, suggesting a beneficial effect for nerve
regeneration. Nerve injury resulted in altered expression of myosin
heavy chain (MyHC) protein in the laryngeal muscles and a
reduction in muscle fibre diameter, consistent with denervation
atrophy. There was a significant shift from a fast to slow phenotype
in both abductor and adductor muscles. Four months following
PHB repair, there was a progressive normalisation of muscle fibre
diameter (assessed using computerised image analysis software)
and MyHC types in the abductor muscles but not the adductor
muscles, suggesting that PHB alone could promote accurate
reinnervation. NT-3 treatment did not significantly enhance these
effects. In conclusion, the early positive effects of NT-3 on nerve
regeneration are not sustained and translated into more effective
muscle reinnervation. We are currently examining the effect of
other growth factors and developing methods to promote their long
lasting delivery.
Lifestyle factors influence the immunological architecture

of the human larynx
Louisa Rees1, Philip Jones2, Omar Ayoub2, Sinnappa Gunasekaran3,
Krishnan Rajkumar4, Karin Haverson2, Mick Bailey1, Martin
Birchall1
1
University of Bristol, Bristol, UK 2University of Liverpool, Liverpool, UK 3St James Hospital Leeds, Leeds, UK 4Derriford Hospital
Plymouth, UK
Background: The larynx has a rich immunological component, but
little is currently known about the effects of smoking on the immunological function of the larynx.
Methods: Pinch biopsies of laryngeal tissue were taken from 65
hospital control patients who also completed a lifestyle questionnaire. Frozen tissue sections were processed for 2- and 3-color
immunofluorescence, using mouse anti-human monoclonals to leucocyte antigens. Percentage areas of positive staining in epithelium
and lamina propria were calculated using quantitative immunofluorescence. Patients were stratified according to gender and smoking
status, and statistical analysis performed using ANCOVA.
Results: In a model including smoking status and age (as a continuous variable), current cigarette smokers had increased numbers of
CD4+ T cells in the epithelium (P = 0.0134), and lamina propria
(P = 0.0128), compared to non-smokers. Larynx epithelium expressed MHC class II locus products differentially, but these were
not associated with smoking.
Conclusions: These data indicate that T cell populations in the larynx
may be influenced by smoking. We postulate that smoking induces a
change in the normal immunological function of the larynx, which
may contribute to the aetiology of cancer.
123

The management of the traumatic rupture of the trachea
and recurrent laryngeal nerve by anastomosis and laterofixation
kos Remenyi MD, Gyorgy Lichtenberger MD
A
Szent Rokus Hospital & Institute, Department of ORL-HNS,
Budapest, 1085, Gyulai P. u. 2., Hungary
Introduction: The authors describe the case of a patient whose trachea has been separated off from the larynx after self-hanging.
Case history: The patient underwent urgent tracheotomy and transmitted to the department of the authors. In the course of admission it
has been seen that a gap of continuity of several centimetres was
present between the cricoid cartilage and the broken-off trachea. In
this area the vaulting of the trachea was conspicuous. Based on
indirect examination, the vocal cords were in paramedian position.
After excision of the wound edges the continuity of the larynx and
trachea was restored by end-to-end anastomosis. After healing of the
wound, some months later partial arytenoidectomy and submucosal
cordectomy was performed with laser, preserving and lateralizing the
medial mucous part of the vocal cord according to Lichtenberger.
Then the patient was decannulated.
Result: Five years have passed since the performed operations and
the closing of the tracheostoma. The breathing of the patient is satisfactory, the voice is slightly weaker than normal, but can be well
accepted for every day conversation.
Conclusion: This case represents, that also combined laryngotracheal
injuries could be managed with satisfactory result performing adequate techniques in appropriate time.
External trauma to the larynx secondary to strangulation
in attempted suicide
S. Wiegand, B.J. Folz, J.A. Werner
Department of Otolaryngology, Head and Neck Surgery, Marburg,
UKGM, Germany
Backround: In contrast to internal trauma of the larynx caused by
endolaryngeal procedures external laryngeal traumas are relatively
rare. The most common symptoms of blunt larynx trauma are
dyspnoea, dysphagia, dysphonia, stridor, shortness of breath and
anterior neck pain. The proper initial treatment of laryngeal trauma
will determine the final airway and voice.
Patient: We report the case of a 38-year-old man who presented to
the emergency room of our ENT-department after strangulation
with a cord in suicidal intention. Although the patient had suffered
considerable trauma to the neck during the attempted suicide, he
was able to breathe and was not stridorous at rest. Immediate
endoscopic laryngeal examination showed a disruption of the supraglottis. The initial CT of the larynx revealed fractures of the
thyroid cartilage and a cervical subcutaneous emphysema. The
supraglottic structures were reconstructed and reattached by an
external approach and a temporary tracheotomy was performed to
secure the airway. Due to the intense wish of the patient the tracheostomy was closed 1 month later. A further month later the
patient complained about dyspnoea and a combined inspiratory
and exspiratory stridor. CT scan and endoscopy were performed to
evaluate the location of obstruction. The imaging studies revealed
a severe subglottic stenosis with a minimal transverse diameter of
the tracheal lumen of 6.4 mm. For this reason the patient was
tracheotomised again in the area of the stenosis and we plan to
perform a segmental tracheal resection.
Conclusion: The presented case shows that the damage of the larynx
is difficult to evaluate during the first days after trauma. The longterm prognosis is more easily determined when the primary wounds
are healed. A common problem of the posttraumatic period is the
development of granulation tissue which can lead to fibrosis and
subsequent stenosis as demonstrated in this case. In conclusion, although external laryngeal traumas are rare, their initial management
has a tremendous impact on the immediate probability of survival of
the patient. Secondary pathologies like laryngeal dysfunction or

stenoses occur with delay. Thus definite assessment and treatment
planning should not be decided on the basis of initial findings.
Impact of allergy on prevalence of subglottic laryngitis in children
Beata Zielnik-Jurkiewicz1, Dariusz Jurkiewicz2
ENT Childrens Hospital1 , ENT Military Institute of the Health
Services2, Warsaw, Poland
327
hospitalization for subglottic laryngitis was observed. These children
needed in addition statistically significant (P < 0.05) less of concomitant treatment. The treatment with Broncho-Vaxom shows the
high effectiveness in prevention of recurrences of subglottic laryngitis.
Optimising training for junior doctors in otolaryngology in the
United Kingdom
J. Wasson, N. Jacobsen, D. Bowdler, C. Hopkins
Department of Otolaryngology, University Hospital Lewisham,
London, UK
Aim: The aim of this study was to verify the etiological factors that
influence the occurrence of clinical symptoms of subglottic laryngitis
among children.
Methods: The study comprised 115 children with subglottic laryngitis.
Allergic skin tests, determination of concentration of total serum IgE
and allergen specific serum IgE, NBT test, total rosette E test, IgA,
IgM, IgG immunoglobulin serum level were included into the specific
examination. The patients were divided into two groups. One group
consisted of patients with atopic diathesis who suffered from subglottic laryngitis (61 children, average age: 4 years 10 months). The
second group was composed of patients without atopic diseases who
were affected with subg1ottic laryngitis (54 children, average age:
5 years 11 months). The control group consisted of 28 children
(average age: 6 years 9 months), with no symptoms of hypersensitivity to food allergens prevailed among these patients who had atopy
and were younger than 3 years old, whereas hypersensitivity to
inhalant a1lergens dominated among patients older than 3 years. It
was proved that there was a positive correlation among patients with
atopy suffering from subglottic laryngitis between the disease
occurrence rate and: male sex (correlation index +0.075), allergic
diseases in their families (correlation index +0.093), their or their
family members smoking (correlation index +0.037), and the place of
their permanent residence (correlation index +0.215). Among these
patients, a negative correlation was found between subglottic laryngitis occurrence rate and age (correlation index 0.133).
Results: The results suggest that allergic factors can influence the
presence of clinical symptoms among patients suffering from subglottic laryngitis. The fact that patients suffering from subglottic
laryngitis who have atopy outnumber the others makes allergological
diagnostics indispensable. The application of these diagnostics make
it possible to apply proper treatment.
Introduction: Implementation of the European Working Time

Directive (EWTD) and the Modernising Medical Careers (MMC)
initiative will mean junior surgeons must be trained in fewer hours,
over a shorter period. For this reason junior surgeon training
opportunities must be optimised. We undertook a departmental audit
to identify where opportunities to train senior house officers (SHOs)
in theatre were lost, such that appropriate timetable changes could be
made to optimise exposure to suitable cases.
Standard: SHOs collectively should attend 50% of all theatre sessions
and cases performed in the department.
Methods: A 2-week, prospective audit was undertaken. Attendance
at theatre lists, and level of participation of SHOs was recorded.
Reasons for non-attendance or participation were also documented.
Results were compared against the standard, timetable changes were
made and a second prospective two-week audit was undertaken.
Rota changes included designating the on call SHO to cover preadmissions and allocating one SHO only to cover emergency clinic.
Supernumery SHOs were allocated to available theatre sessions,
accommodating for absences, changes to lists, and the suitability of
cases. SHO rotas were devised on a weekly basis.
Results: During the first audit cycle, only 30% of theatre sessions
were attended and 27% of cases participated in. However, implementation of the new rota yielded a 46% theatre attendance and
48% case participation.
Conclusion: Simple timetable changes allowed an increase in the
opportunities for training junior surgeons, almost achieving the
standard set.
Usefulness of immunostimulating treatment in prevention

of subglottic laryngitis in children
The effect of interactions between bacterial species in the human

larynx on epithelial barrier function
Beata Zielnik-Jurkiewicz1, Dariusz Jurkiewicz2

ENT Department Childrens Hospital, Warsaw, Poland,
2
ENT Department, Military Institute of the Health Services,
Warsaw, Poland
S. Gillett, L. Rees, T. Cogan, A. Dodson, M. Birchall, M. Bailey

Bristol University/Royal United Hospital Bath, Bristol, UK
Subglottic laryngitis is a multifactorial disease, which etiology is not

yet explained. Dyspnoea during the attack of subglottic laryngitis is
life-threatening condition. The main problems of subglottic laryngitis
focused on looking for etiological factors and prevention of recurrent
attacks of dyspnoea. The aim of the study was to evaluate the efficacy
of immustimulating treatment in prevention of subglottic laryngitis in
children.
The study comprised 30 children (14 girls and 16 boys with mean age
9.8 years) with diagnosed subglottic laryngitis in last year. Children
were treated with Broncho-Vaxom 10 consecutive days per month
for 3 months. The treatment was provided four times in spring and in
autumn during last 2 years. The control group comprised of 20
children (8 girls and 12 boys with mean age 9.5 years) with diagnosed
subglottic laryngitis which did not receive treatment with BronchoVaxom. The observation of treatment consisted of children/parents
observation and otolaryngological examination. The clinical evaluation of treatment consisted of frequency of attacks of dyspnoea, its
intensivity, hospitalization and applied concomitant treatment. The
results are compared in both groups. Time of observation was
2 years. Children treated with Broncho-Vaxom showed statistically
significant (P < 0.01) decrease in frequency of occurrence as well as
shortening of duration of attacks of dyspnoea. In children treated
with Broncho-Vaxom statistically significant (P < 0.05) decrease in
Background: A functioning larynx is vital for the health of the

respiratory tract. Laryngeal epithelial cells adhere via a variety of
cellular methods, including tight cell junctions. Breakdown of tight
cell junction in other organs, has been implicated in inflammatory
bowel disease, carcinogenesis and tumour invasion.
Method: A pig model was used as this structurally and immunologically resembles the human larynx. The pig is currently being used as
a laryngeal transplant model.
Swabs and biopsies from laryngeal mucosa were analysed. Bacterial
species were isolated by culture and DNA based cloning techniques.
Species were characterised using 16s ribosomal DNA fragments and
the BLAST neuclotide-neuclotide search engine. Action of commensal bacterial species on the tight cell junction was assessed using
immunofluorescence staining in a caco 2 monolayer.
Results: 32 isolates were examined by culture techniques from supra
and subglottis and 24 by DNA cloning methods from supraglottis. 2
species were confined to supra glottis and 5 to subglottis. 6 species
were common to both. Both non-pathogenic pathogenic species were
identified.
DNA cloning identified a further 6 species not identified from culture; including fastidious species.
Immunofluorescence studies, did not identify tight cell junction
breakdown with single non-pathogenic species, but breakdown in
tight cell junctions was observed after inoculation with multiple nonpathogenic species.
123
328
Conclusions: We have developed a robust model that highlights
variability of bacterial species in the laryngeal subsites. Cloning
techniques are superior in identifying bacterial species including
fastidious species. Synergistic action of non-pathogenic species causes
tight cell junction breakdown in an epithelial monolayer.
123

This work has potential implications in laryngeal disease and we are
currently extending this work into humans.

Abstracts of The 6th Congress of The European Laryngological Society

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Abstracts of The 6th Congress of The European Laryngological Society

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Eur Arch Otorhinolaryngol (2007) 264:295328