|
| |
 |
| EDITORIAL |
|
| Year : 2011 | Volume
: 1
| Issue : 2 | Page : 45-46 |
|
Emerging trends in laryngology
Vasant Oswal
Emeritus Consultant Otolaryngologist H&N Surgeon, James Cook University Hospital; Vice President and Chairman, Education Committee, British Medical Laser Association;Secretary General, European Laser Association, United Kingdom
| Date of Web Publication | 19-Sep-2011 |
Correspondence Address:
Vasant Oswal
Far Shirby, Upleatham, Redcar, Cleveland, TS11 8AG
United Kingdom
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/2230-9748.85060
How to cite this article:
Oswal V. Emerging trends in laryngology. J Laryngol Voice 2011;1:45-6 |
Larynx and pharynx surgeries and treatment reports date back to Egyptian, Hindu, and Greek physicians. In India, medical documents Sushruta Samhita, from 300 B.C. and Charaka Samhita, from the year 100 B.C., had chapters describing drugs and treatments for voice disorders, suggesting some anatomical knowledge of the throat and larynx as the origin of our voice. [1]
In the subcontinent of South East Asia where this journal will be most read, the clinical and the surgical practices of ENT surgeons cover general ENT. However, in some major cities, the trend is emerging toward subspecialization. Past 30 odd years saw much progress in laryngology as a subspecialty, largely due to technological advances in diagnosis and surgical techniques. Long gone are the days where a cursory mirror examination was sufficiently informative of the health of the vocal cords. Optical fibers, first developed by Hopkins in 1954, made inroads for laryngeal examinations in the 1970s, and rigid or flexible endoscopy is now an integral part of a diagnostic set-up. Videoendoscopy not only provides an enlarged image, but also helps in monitoring the surgical outcome. Video recording helps in archiving for inter-observer comparison and retrospective studies.
Voice disorder clinics are evolving as a subspecialty in laryngology due to better understanding of pathophysiology. Vocal cord analysis assessed by examining the structure and the function of the vocal folds with stroboscopy, distal chip endoscope, and high-definition imaging has provided further sophistication leading to precision in diagnosis of disease and dysfunction. [2] In the field of research, recording of vocal cord vibrations, around 100-160 per second without strobe light is possible with the new high-speed camera. Further analysis of the images with video kymography helps in analyzing the extent of as well as dimensions of the pathological lesion.
Hand in hand, in the operating theatre, binocular vision provided by the operating microscope resulted in precision surgery. Microsurgical instrumentation gave a further boost to the removal of disease more accurately. The introduction of CO 2 laser in the 1980s saw a quantum leap in surgery on the laryngeal structures. For the first time, the operating site was totally bloodless due to the concomitant sealing of blood vessels. Free beams, delivered coaxially, provided an unobstructed view of the target. Jet ventilation techniques for anesthesia obviated the need for endotracheal intubation. Lack of postoperative edema ensured recovery without tracheostomy even after extensive excisions of the disease. The patients were much more comfortable and could resume their work within a short span of time.
Today, most of the benign laryngeal pathology is managed transorally. Refinement in the laser technology has provided finesse so that the spread of the destructive energy within the tissue is limited to 100 ΅m. Surgery on the free edge of the vocal fold with such shallow spread of thermal energy results in the preservation of the vocal ligament, with a high degree of quality voice preservation and restoration. By using phonosurgical techniques, the emphasis is shifting toward the preservation of the normal tissue, rather than the removal of the diseased tissue. Voice restoration surgery thus aims at preserving that all important vibratory layer, and the removal of disease may thus be considered as a by-product of voice restoration surgery!
In malignancy, the primary aim has always been oncological "sterility." Any preservation of the useful voice is considered a bonus. However, here also, the concept of functional preservation is beginning to take priority, seemingly violating oncological principles. Glottic carcinoma is unique in tendency to metastatize late. A glottic tumor thus can be removed in layers by cutting through the tumor without any concern of causing metastatic spread. By submitting the specimens thus removed to a frozen section, the surgery is limited to a layer which is reported as "clear" of carcinoma. It is thus possible to precisely identify the junction of the pathological and normal tissue, allowing maximum preservation of the latter. This so called ultra-thin technique is increasingly being practiced toward achieving maximum functional preservation. Even if subsequent examination shows further cancer, it can be similarly removed, in the knowledge that lack of "en block" removal will not influence the ultimate surgical and functional outcome due to the lack of metastatic spread. Proponents of the piecemeal removal of tumor have extended their concept to the advanced transoral removal of even T3 and T4 tumors, followed by a course of radiotherapy.
In the quest of obtaining prolonged remissions from the debilitating disease of recurrent respiratory papillomatosis (RRP), a novel concept of using angiolytic lasers is being actively investigated by Steve Zeitels'group from Harward Medical School in Boston, USA. The pulsed-dye laser (PDL) emitting at 585 nm and the pulsed-KTP laser emitting at 532 nm are specifically and selectively absorbed by hemoglobin. [3] The deprivation of blood supply results in the regression of RRP lesions and at the same time, preserve the microstructure of superficial lamina propria (SLP) and the epithelium from thermal damage thus maintaining the pliability of the vocal folds with an obvious benefit of better voice quality. The concept of attacking the microvasculature to affect involution is taken a step further by inhibiting neovascularization for new lesions with topical injection of anti-angiogenic drug bevacizumab periodically in the postoperative outpatient follow-ups. [4] Again, an excellent high-definition imaging provided by distal chip flexible endoscopes has shifted these procedures from the operating theatre to the office-based set-up, under effective topical anesthesia. [5] This shift is not only cost effective, but also convenient to the patient since there is no general anaesthetic recovery period. Patients can leave the facility as soon as the gag reflex is restored.
The final frontier of this current great era of technological excellence is perhaps some success in laryngeal transplants reported from a few centers. Robotic surgery is another avenue that may come the laryngeal way in fullness of time. Photodymanic therapy (PDT), widely accepted for skin and oral cavity lesions, as the fourth modality (the first three being surgery, radiotherapy, and chemotherapy) may also find its way to the intractable laryngeal malignant lesions. [6],[7] Intraoperative photodiagnosis to detect residual cancer, not discernible with white light, is another promising development. [8]
To my mind, over a span of 50 years of my professional ENT life, three advances stand proud of anything else. The first one was the introduction of an operating microscope which showed us what there was beyond the unaided vision or the loupe of the 1950s. The second was the introduction of endoscopes which allowed us to diagnose laryngeal pathology with a vastly enhanced degree of accuracy, and, finally, the laser technology - a true paradigm shift in the armamentarium for the benefit of the patients and the surgeons alike.
Recently established Laryngology and Voice Association based in India, it's official publication, the Journal of Laryngology and Voice, and sprouting training courses are testimonials that our younger professionals are set to witness some exciting developments, as I have in the past five decades.
 References | |  |
| 1. | Nogueira JF Jr, Hermann DR, Américo Rdos R, Barauna Filho IS, Stamm AE, Pignatari SS. A brief history of otorhinolaryngolgy: Otology, laryngology and rhinology. Braz J Otorhinolaryngol 2007;73:693-703. 
|
| 2. | Heman-Ackah YD. Diagnostic tools in laryngology. Curr Opin Otolaryngol Head Neck Surg 2004;12:549-52.
[PUBMED] [FULLTEXT] |
| 3. | Zeitels SM, Akst L, Burns JA, Hillman RE, Broadhurst MS, Anderson RR. Office based 532nm pulsed-KTP laser treatment of glottal papillomatosis and dysplasia. Ann Otol Rhinol Laryngol 2006;115:679-85.
|
| 4. | Zeitels SM, Lopez-Guerra G, Burns JA, Lutch M, Friedman AM, Hillman RE. Microlaryngoscopic and office-based injection of bevacizumab (Avastin) to enhance 532-nm pulsed KTP laser treatment of glottal papillomatosis. Ann Otol Rhinol Laryngol Suppl 2009;201:1-13.
[PUBMED] |
| 5. | Zeitels SM, Burns JA. Office-based laryngeal laser surgery with local anaesthesia. Curr Opin Otolaryngol Head Neck Surg 2007;15:141-7.
[PUBMED] [FULLTEXT] |
| 6. | Hopper C. Photodynamic therapy: A clinical reality in the treatment of cancer. Lancet Oncol 2000;1:212-9.
[PUBMED] |
| 7. | Jerjes W, Upile T, Betz CS, El Maaytah M, Abbas S, Wright A, et al. The application of photodynamic therapy in the head and neck. Dent Update 2007;34:478-80, 483-4, 486.
[PUBMED] |
| 8. | Jerjes W, Upile T, Conn B, Hamdoon Z, Betz CS, McKenzie G, et al. In vitro examination of suspicious oral lesions using optical coherence tomography. Br J Oral Maxillofac Surg 2010;48:18-25.
[PUBMED] [FULLTEXT] |
| Authors | | |
|
