HSC Section 6 Nov2016 Green Book

Journal of Voice, Vol. 28, No. 2, 2014

TABLE 5. Patients With Recurrent Disease, Progression of the Disease, and Developed Invasive Carcinoma After 12 Months of Follow-Up Recurrence (%) Progression of the Disease (%) Malignant Transformation (%) Mild dysplasia 12/53 (22.6) 4/53 (7.5) 0/53 (0) Moderate dysplasia 9/26 (34.6) 3/26 (11.5) 1/26 (3.8) Severe dysplasia 7/33 (21.2) 3/33 (9.1) 3/33 (9.1) All patients 28/112 (25) 10/112 (8.9) 4/112 (3.6)

ferent degrees of laryngeal dysplasia). Among the 15 cases with absence of mucosal wave in the stroboscopic exploration, 60% of the cases had severe dysplasia with squamous cell carci- noma. The authors concluded that the stroboscopic results were related to the pathologic results. Atypical mucosal waves, as viewed through stroboscopy, should travel one-half of the width of the superior surface of the vocal fold during modal phonation. A reduced mucosal wave and decreased amplitude during modal phonation sig- nifies stiffness, which may result from a lesion, edema, or scar. The vocal fold epithelium normally shows five to 10 cell layers and a thickness of 100–200 m m. Arens et al 14 determined that vocal fold mucosa shows progressive thickening from nor- mal epithelium (147 m m) over the different epithelial dysplasia grades (grade I epithelial dysplasia, 258 m m; grade II epithelial dysplasia, 301 m m; and CIS, 445 m m) up to early invasive car- cinoma (974 m m). This result can explain the increasing num- ber of patients with decreased mucosal wave in the three dysplasia groups. Colden et al 15 also conducted a study to deter- mine whether stroboscopy is a reliable method for differentiat- ing invasive glottic carcinoma from intraepithelial atypia and determining the depth of cancer invasion. The authors exam- ined 62 keratotic lesions (45 intraepithelial and 17 carcinomas). The reduced amplitude of vocal fold vibration and/or mucosal wave propagation associated with keratosis did not reliably predict the presence of cancer or the depth of cancer invasion. Reductions in the amplitude of vocal fold vibration and in mu- cosal wave magnitude were noticed in intraepithelial atypia, de- spite the fact that there was no invasion into the superficial lamina propria. The authors concluded that the reduced epithe- lial flexibility could be caused by voluminous keratosis without dysplasia and that abnormalities of the superficial lamina prop- ria could be provoked by inflammation or fibrovascular scar- ring; for this reason, the absence of mucosal wave was not synonymous with malignancy. The existence of atypical vocal fold vibration patterns was also reported in normophonic speakers. 16 Nonvibrating seg- ments were associated with the existence of malignant infiltra- tion of the vocal fold epithelium and basal membrane. In our patients, nonvibrating segments were present in 15.1% of the patients with mild hyperplasia, 38.5% of the patients with mod- erate hyperplasia, and 54.5% of the patients with severe hyper- plasia. Shaw and Deliyski 17 determined the presence of atypical magnitude and symmetry of the mucosal waves in the vocal fold vibration of normophonic speakers. In their study, mucosal wave absence was noted in at least 21% of vocal fold vibration

significant in patients with moderate dysplasia, but factors, such as cordectomy type, abnormal amplitude of the vocal fold vi- brations, and the existence of nonvibrating segment, placed the patients at greater risk of recurrent disease. In patients with severe dysplasia type of cordectomy, insufficient glottic occlusion and abnormal amplitude of the vocal fold vibrations carried higher risk of recurrent disease than others, but this re- sult was not statistically significant. In this group, logistic re- gression could not be performed for phase symmetry because all patients had asymmetric vibrations of the vocal fold vibra- tions. For all patients, regardless of the degree of dysplasia, ab- normal amplitude of vocal fold vibrations ( P ¼ 0.01) was a significant factor connected with recurrence. Considering the other factors, the type of cordectomy and the existence of vibratory segment placed the patients at greater risk of recur- rence, but this result was not statistically significant. Regarding the disease progression, none of the considered factors proved to be statistically significant. Some factors placed the patients at greater risk of progression ( Table 8 ). The existence of nonvibrating segment carried higher risk of progression in group with mild and moderate dysplasia and in all patients regardless of the degree of dysplasia. In a group of patients with severe dysplasia, logistic regression could not be performed for the phase symmetry because all patients had asymmetric vibrations of the vocal fold vibrations. DISCUSSION In our study, there is male predominance in laryngeal dysplasia (87.5% males). The average age of our patients was 55.63 years, and most patients were in their sixth and seventh decades of life. There were 105 (93.7%) smokers. These facts aligned with other studies, with slight variations; therefore, we can gen- erally expect this demography. 2,9–11 Malignant transformation occurred in 3.6% of the patients after 12 months of follow-up. Most patients were from the group with severe dysplasia. Ricci et al 2 observed a recurrence rate of 14.1% for all dysplasia patients. Dispenza et al observed a recurrence rate of 13.2% for patients with LIN1 and 29% for patients with LIN2 after a 1-year follow-up. 9 Malignant transformation in those studies ranged from 6.48% 2 to 16%. 9,10,12 Weller et al observed a progression rate (according to severity) of 21% with severe dysplasia compared with 14% for mild and moderate dysplasia, which differed from our results. Gamboa et al 13 conducted a study on stroboscopic assess- ment of chronic laryngitis in 27 patients (eight of whom had dif-

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