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ORIGINAL ARTICLE
Year : 2014  |  Volume : 51  |  Issue : 6  |  Page : 33-36
 

Outcome analysis of benign vocal cord tumors treated by laryngeal endoscopy under low temperature-controlled radiofrequency


Department of Otolaryngology Head and Neck Surgery, Clinical School of Medical College, Jinling Hospital, Nanjing University, Nanjing, Jiangsu 210002, China

Date of Web Publication24-Feb-2015

Correspondence Address:
Prof. W Chen
Department of Otolaryngology Head and Neck Surgery, Clinical School of Medical College, Jinling Hospital, Nanjing University, Nanjing, Jiangsu 210002
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-509X.151994

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 » Abstract 

Objective: This study aimed to evaluate the outcome of benign vocal cord tumors treated using a laryngeal endoscopy under low temperature-controlled radiofrequency and to elucidate the application of a dynamic laryngoendoscopy in the operation. Materials and Methods: 85 patients with benign vocal cord tumors were treated by laryngeal endoscopy under low temperature-controlled radiofrequency from September 2011 to October 2013. A XION electronic dynamic laryngoendoscopy (Germany) was used to observe curative effects 3 months after operation. Wave images were recorded with larynx-wave recording software to analyze tumor characteristics. Results: Among the 85 patients, 81 showed smooth surface of operation wounds without any residue. The mucosal wave was also basically normal. Sound was generally recovered after 1-3 months. Three cases presented improved pronunciation function after the operation, whereas 1 patient with residual tumor at the front of vocal chords underwent another operation after 6 months. Conclusion: Low temperature-controlled radiofrequency exhibited many advantages, including minimal trauma, minimal bleeding, high safety, and few complications. Moreover, treatment of benign vocal cord tumors with a laryngeal endoscopy presented satisfactory outcomes. Therefore, this technology has broad application prospects.


Keywords: Benign vocal cord tumor, low temperature-controlled radiofrequency, minimal invasive treatment


How to cite this article:
Wang Z Y, Xu L, Wu K M, Zhang Y, Chen W. Outcome analysis of benign vocal cord tumors treated by laryngeal endoscopy under low temperature-controlled radiofrequency. Indian J Cancer 2014;51, Suppl S2:33-6

How to cite this URL:
Wang Z Y, Xu L, Wu K M, Zhang Y, Chen W. Outcome analysis of benign vocal cord tumors treated by laryngeal endoscopy under low temperature-controlled radiofrequency. Indian J Cancer [serial online] 2014 [cited 2021 Nov 30];51, Suppl S2:33-6. Available from: https://www.indianjcancer.com/text.asp?2014/51/6/33/151994

Z Y WangFNx01, L XuFNx01
FNx01Zhiyi Wang and Li Xu contribute equally to this work.



 » Introduction Top


Daily life in a modern and social environment is characterized by frequent contacts and lifestyle adjustments, consequently increasing the incidence rate of benign vocal cord tumors, such as leukoplakia of the vocal cords. [1] With the continuous development of minimally invasive techniques for laryngeal surgeries, clinicians focused on investigating how to perform a complete a surgery with minimal wound and maximal intact function. Low temperature-controlled radiofrequency is the most commonly used new technology that provides accurate curative effect. This technique has been widely used in obstructive sleep apnea-hypopnea, as well as in tongue and throat operation. [2],[3] In this study, a high curative effect was obtained among 85 patients with benign vocal cord tumors treated under low temperature-controlled radiofrequency in our hospital from September 2011 to October 2013. The results are reported in this paper.


 » Materials and Methods Top


Clinical data

Eighty-five patients with benign vocal cord tumor consisted of 34 male and 51 female aged between 18 and 72 years with an average of 36.4 years. All patients showed different degrees of hoarseness. The course of the disease was 3 months to 2 years. 41 cases presented unilateral lesions, and 44 cases demonstrated bilateral lesions. All tumors showed a wide base or diffuse swelling, and >1/3 of the patients had vocal cord tumors [Figure 1]. Benign vocal cord tumor is difficult to completely resect using a conventional indirect laryngoendoscopy or an electronic laryngoendoscopy. Electronic laryngoendoscopy examination was performed on all patients before surgery and 1 week or 3 months after the operation to assess the location and size of lesions and vocal activity by using the obtained photographic images. Postoperative pathology showed benign vocal cord tumors on all cases.
Figure 1: Preoperative laryngoendoscopy and larynx - wave recording showed benign tumors in the right vocal cord. The mucosal wave differed in both sides

Click here to view


Inspection of equipment and operation

Operative instruments included a direct-coupled interface-laryngeal endoscopic system (Storz; includes a special supportive laryngoendoscopy, laryngeal endoscopy, camera, video recording system, and surveillance system). Micro-laryngeal instruments (laryngoendoscopy blades, micro-laryngeal scissors, laryngeal forceps etc.,) were also used. The operative equipment for low temperature-controlled plasma included a main engine, power supply, cable, foot switch, and disposable EVac70 plasma blade head with grade 5 power setting. This equipment was produced by ArthroCare System (America). All equipment including a dynamic laryngoscope system (XION, German), video recording equipment, computer system with image grasping, and analyzer for the recorded wave-graph video strobo kymograph (VSK) were inspected.

Operation procedure

Routine examinations were performed on patients to ensure no operation contra indication before surgery. All operations were performed under general anesthesia through intubation with a fine-diameter balloon (6.5 mm for male and 6.0 mm for female). After anesthesia, the operation field was fully exposed by using a laryngoendoscopy. A clear imaging was obtained by adjusting the focus site under the laryngeal endoscopy. All operations were conducted under a monitor or open sight. Low temperature-controlled plasma radiofrequency (ArthroCare System, American) and other auxiliary operation system were applied through treatment. During the operation, output power was scheduled to fifth grade. A disposable EVAC70 plasma blade head was also connected to 0.9% sodium chloride solution, and the switch was started. A foot pedal controller was used to control the blade head, and the vocal cord was traced with laryngeal forceps to expose the tumor base. The base was then cut and ablated through the junction of the muscles tissues of the normal vocal cord and tumor substrates. The blade head was operated from the top to bottom until the basal attachment was completely cut off.

After the operation, all patients were treated with intravenous infusion of 10 mg of dexamethasone for 1 day to prevent vocal fold mucosa edema and atomized inhalation with 1 mg of budesonide souled in 2 mL of normal saline solution. Daily dose was administered for 10 min/time twice, thus reducing the local inflammatory edema reaction and preventing adhesion of the vocal cord. Sound production was strictly forbidden for 1 week to repair the operation wound.

Standard of the curative effect

Cure


subjective feeling revealed satisfied voice quality. The vocal cord exhibited smooth surface and normal color. Larynx-wave recording revealed a symmetrical bilateral vocal cord movement with consistent periodicity and completely closed vocal cord. The mucosal wave was also normal.

Improved

subjective feeling of improved voice quality. The vocal fold edges presented a generally smooth surface with slight congestion. Larynx-wave recording revealed general symmetrical bilateral vocal cord movement with diverse periodicity and generally closed vocal cord. The mucosal wave was almost normal with deference.

Invalid

subjective feeling showed no evident improvement of voice quality. The vocal fold presented no improvement and contained congestion and edema. The larynx-wave recording revealed general asymmetrical bilateral vocal cord movement with transparent diverse periodicity and vocal cord dysraphism. The mucosal wave was weak and with remarkable deference.


 » Results Top


All patients were followed up for 3-24 months. 81 patients were cured (95.29%), 3 patients presented improved condition (3.53%), and 1 patient showed an invalid treatment (1.18%). The images from the XION electronic dynamic laryngoscope (Germany) were examined using the larynx-wave recording software. The characteristics of the 81 cured cases were analyzed 3 months after surgery [Figure 2]. All patients showed smooth surgery wound of the vocal cord without residue. The mucosal wave was basically normal, and voice was recovered within 1-3 months. Among the three improved cases, two cases showed visible defects in the central part of the vocal cord 1 week after the operation. This finding could be attributed to the extensive radiofrequency ablation range. However, the ablation was evidently repaired, and the pronunciation function distinctly improved after 3 months. The remaining 1 patient showed similar results in general but with unsatisfactory sound quality. The invalid case revealed problems, including residual tumor at the front of the vocal cords and poor glottal closure 3 months after operation. However, these conditions were cured by performing a second surgery after 6 months. All patients presented no complications of vocal cord adhesion, throat injury, tongue body sensory disturbance, and so on.
Figure 2: Laryngoendoscopy and larynx - wave post - surgery images of benign tumor on the right side of the vocal cords after 3 months, with consistent bilateral mucosal waves

Click here to view



 » Discussion Top


Benign vocal cord tumor has been the most common disease in clinics; this type of tumor is frequently caused by incorrect and excessive vocalization or bad habits. Benign vocal cord tumors can be treated using various methods. A high incidence of tumor residual or extensive operative wound tends to occur in traditional treatment using a vocal cord clamp operation under local anesthesia with an indirect laryngoendoscopy. [4],[5] This technique reveals unsatisfactory surgery outcome because of damages sustained in the vocal ligament or vocal cord muscles. An operation under local anesthesia with an electronic laryngoendoscopy and a fiber laryngoendoscopy has gained considerable clinical applications because of its features such as convenient operation and low cost. [6] However, this procedure is difficult to perform on patients with dispersed wide-base tumors or diffuse lesions. In this case, complete resection is difficult to perform and patient cooperation is highly required but cannot be easily obtained particularly on patients with vocal cord-exposed difficulties and unsatisfied epidermal anesthesia. Our hospital has introduced the use of laryngeal endoscopic operation system from Storz Company (Germany) combined with a micro-instrument and a radiofrequency equipment for operation of benign vocal cord tumors under general anesthesia. This procedure can maximally preserve the structure and function of the vocal cords and maintain the integrity of its normal epithelium, and thus beneficial to improve postoperative voice.

Laryngeal endoscopy is a new operation technique performed by directly placing an endoscopy onto the lesion surface with a specific supporting laryngoendoscopy. [7] This technique can provide an open-operation view and is conducive to assistants because images are shown on the video system. In the set-up of the combined supporting laryngoendoscopy and endoscopy, the mirror is closer to the operative field, and the operation visual field is clearer with highlighting. Hence, the image is magnified and clear. The extent of resection is also accurate, and the surgery would not be influenced by the depth of field of the microendoscopy because of microscopic magnification. Radio frequency and all types of micro-instruments can be used according to the needs of surgeons; such instruments can provide an extremely favorable condition for precise excision of laryngeal lesions.

The basic rationale of low temperature-controlled plasma radiofrequency is ablation at low temperature. In this process, electrolytes are converted into low temperature-controlled plasma by using a plasma radio frequency electric field. The charged particles formed on the electrodes gain sufficient kinetic energy to break molecular bonds, thus disintegrating the cells into single element molecules and low-molecular weight gases (O 2 , H 2 , and CO 2) in molecular units. Consequently, the tissues undergo coagulation, necrosis, shedding or direct, precise excision. By using the low temperature-controlled plasma radiofrequency, operators can change the path according to the shape of the blade head; hence, the visual dead angles at the front of the vocal cord, particularly in former united, laryngeal ventricle, and upper and lower border of the vocal cords, are eliminated, resulting in thorough operation. [8],[9] Moreover, the peripheral vascular nerve injury is minimal; thus, the lesion can be removed without causing irreversible damages to the surrounding tissues. This procedure is beneficial for ablating while cutting wide range of benign vocal cord tumors and Reinke's edema. In addition, "thermal equipment," including lasers and microwaves tend to ablate and cut at a high temperature of 300°C, causing heat damages and carbonization in the lamina or deep tissues of the vocal cord. [10] A foggy vision during operation may also lead to severe tissue edema, adhesion, and extended recovery. By contrast, low temperature-controlled plasma radiofrequency provides advantages, including less damage, less bleeding, high accuracy rate, and fast healing. [11]

Until date, low temperature-controlled plasma radiofrequency treatment has been widely used in nasal surgery, [12] snoring surgery, and tonsil resection [13] but rarely used for benign vocal cord tumors. Our study showed that the surgery wound surface of all patients was smooth without residue. Voice recovered after 1-3 months without serious complications caused by low temperature-controlled radiofrequency. Only one case showed poor voice improvement. Overall, low temperature-controlled plasma radiofrequency is an effective treatment of benign vocal cord tumor with characteristics of minimal invasion, high safety, and less complications. However, the following points should be considered during operation. All blade head should be connected to 0.9% sodium chloride solution and continuously flushed during the operation to minimize thermal damage to surrounding tissues and reduce the pain of patients. The same blade head should be used in complete cutting and hemostasis procedures. Intraoperative hemorrhage should be immediately stopped by adjusting the pedal. [14]

A general dynamic laryngoendoscopy is widely applied in clinics. However, outcome analysis mainly depends on subjective judgments. Lack of quantitative indicators makes it difficult to perform case comparison and further analysis. [15] Our hospital has introduced laryngeal endoscopy with a function of recording wave images. The continuous dynamic laryngoendoscopy images were digitally recorded with the wave scanning software, and the image information of each framed image was stored in the same site on a computer. Hence, a VSK image was extracted from top to bottom row by row and the characteristics of vocal cord movement were analyzed to obtain a diagnosis of the vocal cord lesion. [16] Synthesis of VSK image provides microscopic observation of the vocal cord vibration characteristics in a specific site on the basis of a relatively objective analysis on dynamic laryngoendoscopy images. This procedure present three advantages relative to dynamic laryngoendoscopy: (1) Analysis based on the database without interference of emergency situations; (2) larynx wave image displays laryngeal vibration mode in a single image, resulting in a feasible assessment compared with the long complicated data of dynamic laryngoendoscopy video; (3) larynx wave image can provide unique vocal cord vibration information that cannot be provided by a dynamic laryngoendoscopy. [17],[18] Minimal invasive surgical technique requires minimal damages to normal tissues and structure. As the main vocal organs, the vocal cord exhibits a unique ultrastructure. The unique layered function corresponds to the meticulous motor function, thus producing minimal damage in the inherent mucosa with minimal effect on pronunciation. [19],[20] The vocal fold lesions can be safely and accurately removed through laryngeal endoscopy under low temperature-controlled plasma radiofrequency. This procedure causes minimal trauma and maximum vocal cord structure protection. Patient phonation function is also restored. This procedure generally reflects a minimally invasion technology with a better outcome and sound protection. [21],[22],[23],[24],[25]

 
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    Figures

  [Figure 1], [Figure 2]

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