Journal of Otology & RhinologyISSN: 2324-8785

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Research Article, J Otol Rhinol Vol: 2 Issue: 3

Radiofrequency Coblation for Treatment of Vocal Cords Leukoplakia

Qingfeng Zhang*, Lin Ma, Xinran Zhang, Nannan Zhang, Delong Liu, Cuiping She and Hui Wang*
Department of Otolaryngology, Dalian municipal central hospital, 826 Xinan Road, Dalian, 116033, China
Corresponding authors : Qingfeng Zhang
Department of Otolaryngology, Dalian Municipal Central Hospital, 826 Xinan Road, Dalian 116033, China
Tel: 86-411-84412001
E-mail: [email protected]
Hui Wang
Department of Otolaryngology, Dalian Municipal Central Hospital, 826 Xinan Road, Dalian 116033, China
Tel: 86-411-84412001
E-mail: [email protected]
Received: April 07, 2013 Accepted: April 24, 2013 Published: May 10, 2013
Citation: Zhang Q, Ma L, Zhang X, Zhang N, Liu D, et al. (2013) Radiofrequency Coblation for Treatment of Vocal Cords Leukoplakia. J Otol Rhinol 2:3. doi:10.4172/2324-8785.1000121

Abstract

Radiofrequency Coblation for Treatment of Vocal Cords Leukoplakia

Background: The aim of the present study was to evaluate the use of radiofrequency coblation surgery as a practical alternative to conventional surgery of vocal cords leukoplakia.

Methods: Ninety-five patients affected by vocal cords leukoplakia were enrolled. Vocal cords leucoplakia was initially diagnosed by laryngoscopy and successively confirmed by radiofrequency coblation excision for histologic assessment. All the patients were subjected to voice assessment and the Jitter, Shimmer, F0, MPT and DSI values were used as sensitive indicators for voice assessment of patients with vocal cords leucoplakia.

Results: The mean leukoplakia resection time was 23.14 ± 5.36 minutes. 83 (87.37%) patients were “clinically” healed as 78.95% (75/95) the histological results shows chronic mucosal inflammation or squamous epithelial hyperplasia without dysplasia, as well as 8 (8.42%) patients with mild dysplasia. Conclusions: Radiofrequency coblation is a useful surgical technique, as effective as, or even superior to, other surgical techniques when dealing with patients suffering from vocal cords leukoplakia with potentially fewer adverse effects and subsequent improved quality of life for patients.

Keywords: Radiofrequency coblation; Vocal cords leukoplakia; Laryngeal dysplasia

Keywords

Radiofrequency coblation; Vocal cords leukoplakia; Laryngeal dysplasia

Introduction

Leukoplakia, a clinical descriptor indicating the presence of keratin on the epithelial surface in the oral cavity or in the larynx that cannot be scraped off, can be a premalignant precursor of squamous cell carcinoma. Histologically, it is characterized by increasing grades of epithelial dysplasia, which has a statistically higher likelihood of malignant transformation than normal mucosa. The annual incidences of vocal cords keratosis in the United States are 10.2 and 2.1 lesions per 100,000 in male and female persons respectively [1]. The risk of malignant evolution of a leukoplakia is extremely variable, ranging from 4 to 20% and as high as 40%, which is directly related to the degree of histologic abnormality [2,3]. The presence of dysplasia appears to be the most important prognostic factor in considering the risk of conversion to malignancy.
The most appropriate treatments of vocal cords leukoplakia and criteria for evaluation of the results are still a highly controversial issue. Treatment strategies vary, ranging from simple follow-up to surgical excision. Mainstays of treatment include laryngectomy, laser excision [1], microflap excision [4] photodynamic therapy [5] and to a lesser extent vocal cords stripping. Recent applications of lasers, such as the pulsed-dye laser (PDL), the carbon dioxide (CO2) laser, and the thulium: yttrium-aluminum-garnet (Tm: YAG) laser [6,7], to treat leukoplakia of the larynx are popular. However, lasers may in some cases incur adjacent tissue damage and vocal cords scarring [8]. Others chose to apply retinyl palmitate [9] or folic acid [10] for the first time in leukoplakia of the larynx, especially in elderly patients who were considered as high-risk patients for general anesthesia.
The present study was designed to explore the use of radiofrequency coblation surgery as a practical alternative to conventional surgery. And the operation time, preoperative and postoperative voice assessment and clinical characteristics of vocal cords leukoplakia patients were demonstrated.

Materials and Methods

Clinical data of 95 cases with vocal cords leukoplakia were analyzed. The patients affected by vocal colds leukoplakia, as evidenced by patient’s history, typical subjective symptom reports, and biopsy, were enrolled in our Ear, Nose, and Throat Department of Dalian Municipal Central Hospital in the years 2006-2011 Leukoplakia was clinically defined as a white patch or plaque that could neither be rubbed off nor diagnosed as any specific disease [11]. Leukoplakia was diagnosed histologically following the criteria proposed in the World Health Organization’s Blue Book [12]. A comprehensive statistics were obtained from all the participants regarding medical history, characteristics of hoarseness, histology, associated with potential diseases, operating time, follow-up, etc.
All the patients and thirty volunteers (15 males and 15 females) as control were subjected to voice assessment by Divas software and the values of Jitter, Shimmer, and fundamental frequency (F0), maximum phonatory time (MPT) and Dysphonia Severity Index (DSI) were calculated before and one year after the surgery. Radiofrequency coblation was performed on all patients at the department of otolaryngology in Dalian Municipal Central Hospital by the same surgeon, using a radiofrequency device (Coblator II, Arthrocare, Sunnyvale California USA). All patients were treated under general anesthesia with vocal cords exposure with the use of endoscopic selfretaining laryngoscope. Evac-7070 Coblator II probe with suction and saline irrigation were used for resections, and the console was set for 3 (coblation) and 3 (coagulation). After the procedures, hemotoxylin and eosin staining was performed on the lesion issues, and the patients were advised to keep silent for at least two weeks. All the patients were monitored every 8 weeks until one year by the examination of laryngostroboscopy (XION, German).
In this study, assessment of the “clinically” healed included there is no clinically perceptible difference in the appearance under the observation of laryngostroboscopy as well as associated hoarseness. Follow-up care for one year included communication by phone in the case of recurrence of symptoms, re-examination of laryngostroboscopy and voice assessment.

Statistical Analyses

Data were analyzed using ANOVA with SPSS for Windows (ver.16.0), followed by post hoc tests, as appropriate. Results were considered statistically significant when p<0.05. All data are presented as means ± standard deviation (SD).

Results

All the patients were monitored every 8 weeks until one year by the examination of laryngostroboscopy. Seven patients refused to re-examination of laryngostroboscopy and lost to follow-up, others remained disease free with good vocal quality without hoarseness. The white patch or plaque disappeared in the whitish surface area and a return of pink and red epithelium until 6 months after the coblation surgery. An example of recovery of vocal cords leukoplasia is shown in Figure 1 (A) (preoperative) and Figure 1 (B) (postoperative). Removing the plaque took a mean time of 23.14 ± 5.36 minutes using coblator. In all patients, the postoperative course was normal without scarring or complications. 91 (95.79%) patients were male and 4 (4.21%) were female, with mean ages of 63.47 and 61.25 years, respectively. The clinical characteristics of participants are shown in Table 1. There were 65 (68.42%) smokers and 54 (56.84%) drinkers. 18 (18.95%) of the lesions were located in bilateral vocal cords, while 77 (81.05%) of the lesions were unilateral. The results of pathological examination were systematic classified for precancerous lesions of the larynx [5] and showed that chronic mucosal inflammation in 46 cases (48.42%), squamous epithelial hyperplasia in 36 cases (48%), mild dysplasia in 8 cases (8.42%), moderate dysplasia in 3 cases (3.16%), severe dysplasia in 2 cases (2.11%). Median duration of symptoms was 6.35 ± 3.14 months. All the patients were bothered by continuous or intermitted hoarseness. 83 (87.37%) patients were “clinically” healed as 78.95% (75/95) the histological results shows chronic mucosal inflammation or squamous epithelial hyperplasia without dysplasia, as well as 8 (8.42%) patients with mild dysplasia, while five had local recurrences six months after the surgery. Second surgery was carried out in the five patients with local recurrence, whose histological type was moderate or severe dysplasia.
Figure 1: An example of recovery of vocal cords leukoplasia is shown in A (preoperative) and B (postoperative). The white patch or plaque in the right vocal cord disappeared in the whitish surface area and a return of pink and red epithelium after the coblation surgery. And the pathological result is squamous epithelial hyperplasia with mild dysplasia.
Table 1: Clinical characteristics of Vocal Cord Leucoplakia.
Voice assessment results
One year later, the Jitter and Shimmer values measured after the coblation surgery were obviously lower than those before the procedure. A one-way ANOVA was performed against the factor of time to show a significant effect (F=104.337, p<0.001). Post-hoc evaluation was performed using paired t-tests to verify the significance (p<0.05). And there was no statistically significant difference compared with the control group; there was no statistically significant difference in F0 value between preoperative and postoperative. Their MPT and DSI value was higher than those of preoperative, also, post-hoc evaluation was performed using paired t-tests after coblation surgery to show the significance (p<0.05). And there was no statistically significant difference compared with the control group (Figure 2).
Figure 2: Voice assessment results of vocal cords leukoplakia before and after the surgery.

Discussion

The present study showed radiofrequency coblation is a useful surgical technique when dealing with patients suffering from vocal cord leukoplakia with potentially fewer adverse effects and subsequent improved quality of life for patients.
Following the first coblation tonsillectomy in the late 1990s [13], radiofrequency coblation has increasingly been used throughout otolaryngology practice. It has been shown to provide impressive benefits in tonsillectomy technique [14], adenoidectomy technique [15], coblation channeling tongue [16], reducing obstructive lesions in the tongue base, more broadly, in the application to early glottic carcinoma [11], turbinate reduction [12], and so on. It was found good control of disease, with minimal scarring, bloodless, less pain and excellent wound healing. Coblation achieves low-temperature molecular disintegration, with minimal necrosis of surrounding tissue. This process begins when electrodes at the tip of the coblation probe emit radiofrequency energy within the target tissue. This energy is transmitted through a conductive medium of normal saline, resulting in creating a field of electrically active sodium ions that are able to break down intercellular bonds, resulting in tissue ‘melting’ at a temperature of approximately 70°C [17]. Despite the low temperatures generated by coblation, small blood vessels are still sealed during the process, minimizing haemorrhage and morbidity.
Worldwide, several management modalities are used to vocal cords leukoplasia, both medical and surgical [4,9], including CO2 laser ablation, vocal cord stripping, radiotherapy or retinyl palmitate, etc. We opted for a radiofrequency protocol, the main technology available besides laser. Coblation offers many advantages over CO2 laser excision with thermal trauma to the surrounding soft tissue, superficial lamina propria scarring that make it a suitable technique for the treatment of vocal cords leukoplakia. The electrode arrangement and flexible wand configuration enable precise leukoplakia removal with minimal damage to neighbouring tissues and the technique is easy to learn and extremely efficient. As the probe is able to ablate and coagulate, no instrument change is required. Additionally, we find removing the white plaque with coblation does take a shorter time to perform than with CO2 laser as reported previously [18-20], usually averaged 15-30 minutes in this study. Although surgery duration is not a primary consideration we feel it does merit documentation. Besides, laser surgery requires a greater number of personnel to ensure effectiveness and safety, thereby increasing procedural costs and inconvenient [8].
Recurrence is without doubt the most significant worry of the patients with vocal cords leukoplakia. It is well known that recurrence can follow the incomplete removal of altered cells within the lesion or as a consequence of an altered re-colonization by cells of the apparently “normal” adjacent epithelium. Relapse rate varies from the histological evaluation; it seems that all patients with severe dysplasia or carcinoma in situ did relapse more readily than patients with mild or moderate dysplasia. In our study, five cases (5.26%) had local recurrences, whose histological type was moderate (3 cases), severe dysplasia (2 cases). It is similar to the results of CO2 laser excision as reported previously [21]. The patients with histological epithelial dysplasia should be pay great attention because of their higher canceration rate, and enlarged operation ranges appropriately with the patient consent could effectually prevent recurrence or canceration during the early lesions.
After the surgery, the evolution of hoarseness was monitored on comprehensive evaluation including acoustic analysis and laryngovideostroboscopy. Acoustic analysis is the most easily applicable method for assessment of voice disorders [22]. Various studies have reported that this method could help distinguish between organic and functional dysphonia [23] and laryngovideostroboscopy, considered to represent the gold standard in diagnosing of voice disorders was used as the reference during the comparative analysis. In our study, the Jitter and Shimmer values measured after the coblation surgery were obviously lower than those before the procedure. And there was no statistically significant difference compared with the control group. It indicates the recovery of vocal cords lesion. There was no statistically significant difference in F0 value between pre and postoperative. Their MPT and DSI values improved significantly after the surgery. Hoarseness still existed in the five recurrence cases, but partial relieved compared with preoperative.

Conclusion

In conclusion, this is the first reported prospective study to show that clinical healing of leukoplakia treated by radiofrequency coblation. It appeared to be safe, effective and be considered as a treatment option for vocal cords leukoplakia removal.
We believe that Radiofrequency coblation is likely to continue to be an important emerging part of otolaryngology.

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