HEAD AND NECK

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The functions of the larynx have to do with the speech, the protection of the lungs against aspiration, the circulation of air to and from the lungs and the cough for the cleaning of the lungs from secretions.  Hence, it is logical that our patient comes to us exhibiting symptoms related to these functions.

So, our patient may be complaining about hoarse voice, difficulty in ingestion and aspiration, dyspnea or noisy breathing, inability to cough effectively etc.  Sometimes, of course, the pathology of the larynx may be discovered by accident, during a detailed examination for other symptoms.  Always, the taking of the history comes first.  The time the symptoms appear, their connection with other reasons, like virus infections, injuries or operations, the patient’s occupation, personal habits like smoking or drinking, possible breathing of toxic substances, but also any health problems, connected especially with the gastrointestinal system, may be related to or consist predisposition factors for the patient’s problem.

The clinical examination is particularly important and is sufficient, in the majority of the cases, in providing us with a diagnosis.  The endoscopy of the larynx is, of course, the basic examination, but this does not mean that the general check up should be omitted.  The feeling of the neck for bulges, the study of the mobility of the rear wall of the pharynx, as well as other signs, may prove rather important for the diagnosis.  Of course, from the clinical examination, the doctor has to study also some parameters which may interfere in a contemplated operation.  The opening of the mouth, the state of the denture, especially the one of the maxilla, the length of the neck and the mobility of the cervical spine, are data which must be studied and which the anesthetist should also take into consideration.

The endoscopy of the larynx is a simple, easy and usually well tolerated by the patient examination.  Via endoscopy we can identify the mobility of the vocal cords and possible alterations of the mucosa of the larynx.  In this way we will diagnose unilateral or bilateral paralyses of the vocal cords, spastic dysphonia, cysts, polyps or nodules of the vocal cords, and other lesions of the mucosa, some of them being indicative of malignancy.  The endoscopy of the larynx, possible to be recorded in optic means, gives us the possibility to explain to the patient the problem and, also, to include it in his/her history, for reference in a future re-examination.

A more advanced, compared to simple endoscopy, examination is the stroboscopy.   With stroboscopy, we can also examine the mobility of the mucosa of the vocal cords.  In this way, we can clarify further some benign alterations of the mucosa of the vocal cords which were found in the simple endoscopy.  But mainly, in alterations of the mucosa of the vocal cords with characteristics indicative of malignancy, we may identify possible spreading due to an invasion of the deeper layers of the vocal cords.

For the majority of the benign diseases of the larynx, the diagnostic examination is already complete.  In special cases, additional tests will be necessary, for example an imaging exam.  Now is the time to discuss the problem with our patient and to suggest existing solutions.  This discussion is usually easy and it rarely becomes unpleasant for the patient.  In many benign diseases, the doctor will suggest a conservative or pharmaceutical treatment, for example, antacids or speech therapy.  However, even in cases for which surgery is suggested, this procedure is easy and without any particular complications for the patient.  It may prove more difficult, when we have to ask the patient to quit certain habits of his/hers, like smoking.

As we said, surgery for the benign diseases of the larynx is relatively easy.  We feel that two issues need our special attention.  The first is about the concept of phonosurgery.  Whether our patient is a professional singer or not, the polyp will have to be removed in the same way.  And this will be done according to the rules of phonosurgery.  Phonosurgery is not only a different technique, it is a development of the traditional one.  Its basic rule is to maintain as much of the normal mucosa as possible and it must be applied on all patients.

The second issue has to do with the use of the laser.  The laser has some properties which we can take advantage of for certain benign diseases of the larynx.  These properties are the low percentage in the creation of symphyses and granulomatous tissue, the precision in moving through a narrow field of vision and the possibility of dissection through the tumor without running the danger of spreading.  The absolute indications of the laser include the bilateral paralysis of the vocal cords, symphyses and membranes of congenital or acquired origin, granulomas, dyskeratotic lesions, papillomas, and some forms of stenoses of the larynx and the trachea.  It is, however, in the malignant diseases of the larynx where the application of laser is really revolutionary, relieving many patients from the need to undergo laryngectomy or, at least, delaying this amputating operation for some years.  It is in those diseases we should insist on using the laser.