Canadian journal of otolaryngology最新文献

Every science has limits to its operation, including medical science concerning malignancy. Beyond a certain stage of a disease, palliation is the only recourse. The word "palliation" amounts to an acceptance of defeat by a clinician while trying to salvage his cancer patients. It means that the patient should breathe and eat without much pain till death takes pity on him. Palliative surgery in laryngeal cancer amounts to doing tracheostomies and gastrostomies and administering painkillers. Most of my cases belong to this category. I extended the accepted parameters of surgical excisions for primary lesion and metastatic nodes. These excisions include laryngectomy with cervical esophagectomy, total laryngectomy, total cervical esophagetomy, total glossectomy, and total mandibulectomy. The extended radical neck dissections include carotid artery, vagus nerve, and sympathetic trunk on one side. Removal of these so-called vital structures was not only compatible with life but proved curative in 20 per cent of these cases.

The anterior commissure may be a line or an area with the same vertical extension as the vocal cords anteriorly. If it is an area it may laterally be bounded by the "maculae flavae". The subglottic region includes the under surface of the vocal cords corresponding to the mucosa covering the conus elasticus and the mucosa inferiorly to the lower border of the cricoid cartilage. Serial sectioning has proved that the weak spot of the laryngeal framework is the anterior midline as far as early tumor invasion of cartilage and extension of tumor outside the larynx through the cricothyroid membrane is concerned. Despite many unfavorable anatomico-pathological points at this site, radiotherapy gives at least as good results as those reported with conservative (voice conservation) surgery. Primary subglottic carcinomas are rare. In a series of 110 serially sectioned laryngectomy specimens only four were classified as subglottic. These tumors possess specific characteristics: an extensive circumferential growth, cartilage invasion, and spread outside the larynx through the cricothyroid membrane, to trachea or to the hypopharynx. Twenty-four tumors were classified as glottic-subglottic. Three of these invaded the thyroid cartilage and seven spread outside the larynx through the cricothyroid membrane. Vocal cord fixation occurred in all four subglottic and in six of the glottic-subglottic tumors. The thyroarytenoid muscle was most freqeuntly invaded. Thyroid gland invasion did not occur in any of the subglottic tumors. A metastatic focus of tumor was observed in one lobe of the thyroid in the glottic-subglottic group. Two neck dissections were performed in the subglottic group and one of these contained a metastatic carcinoma. Eleven neck dissections were performed in the glottic-subglottic group and three contained metastatic tumor.

Emphasis is placed on the need to encourage original research in our training programs. This implies an obligation to help trainees inexperienced in research to bridge the gap between theory and practice. Four examples of patterns of research at a postgraduate institute are presented. All are in areas in some way relevant to carcinoma of the larynx: a) the effect of experimental hypothermia on transplanted tumors in rats; b) isotope detection of deep vein thrombosis following head and neck surgery; c) stomal calibre after laryngectomy related to airflow, esophageal voice and cineradiographic appearances; d) a case-controlled study of the etiologic role of asbestos in laryngeal cancer. These studies are still in progress but some preliminary observations can be reported.

Of 13 anterior commissure cancers treated by radiation therapy and reported in 1970, eight had residual or recurrent cancer at the primary site and required total laryngectomy. All but one of the 13 had been treated prior to 1958 by Orthovoltage radiation. A total of 19 patients with anterior commissure lesions were treated at the Yale-New Haven Hospital using a 2MEV Van de Graaf generator between mid 1958 when this supervoltage source first became available and December 1971. None was lost to follow-up and thus all are available for evaluation after more than two years. Results in this group have been compared with 20 glottic carcinomas with involvement of the anterior commissure treated surgically during the same period of time. Thirteen of the resulting 20 surgical specimens have been studied by serial section.