Premalignant epithelium and microinvasive cancer of the vocal fold: The evolution of phonomicrosurgical management

Laryngoscope - Tập 105 Số S1 - Trang 1-44 - 1995
Steven M. Zeitels1
1Department of Otology and Laryngology, Harvard Medical School, Boston, Mass

Tóm tắt

AbstractPhonomicrosurgical treatment of premalignant vocal fold epithelium and microinvasive cancer combines principles of surgical oncology with advanced laryngoscopic microsurgical‐techniques. This treatment is guided by mucosal‐wave theory of voice production and strives not only to cure the disease but also to achieve optimal vocal function.Surgical techniques developed during the past two centuries have improved methods for vocal fold visualization, tissue retrieval, and tissue evaluation. Examination of the evolution of these surgical techniques reveals the incomplete convergence of laryngoscopic surgical theory with both the concept of premalignancy and the anatomical‐physiological principles of voice production. This historical review, which helps to explain the lack of consensus about current treatment options, led to a series of four investigations. They were conducted with the aim of developing a laryngoscopic (phonomicrosurgical) management approach for improving the treatment of premalignant and microinvasive vocal fold epithelium.In the first of four investigations, 42 patients (each of whom had a significant smoking history) underwent microlaryngoscopic biopsy of 52 vocal fold lesions. These lesions, which were suspicious for atypia or malignancy and were confined to the musculomembranous vocal fold, were mapped according to surface involvement and depth of penetration. Review of the maps revealed that 27 of the 52 lesions involved only the superior/ventricular surface. For these patients, the entire layered vocal fold structure could potentially be preserved on the medial/vocalizing surface. Twenty‐five of the 52 lesions involved both the superior/ventricular surface and the medial/vocalizing surface. No lesion involved only the medial surface.These data suggest that (in smokers) geographic localization of keratotic and erythroplastic lesions on the superior/ventricular surface of the musculomembranous vocal fold are likely to contain atypia. This characteristic facilitates the appropriate selection of patients for biopsy and may spare individuals, who have lesions resulting from hyperfunctional dysphonia and/or gastroesophageal reflux, from unnecessary biopsy. These two disorders typically result in pathology on the medial and/or posterior glottal surfaces.In order to determine whether a directed biopsy or an excisional biopsy approach is preferable for obtaining an accurate diagnosis, all specimens underwent whole‐mount sectioning for three‐dimensional histopathological analysis. Keratosis was noted: without atypia in 14; with atypia in 27; and with carcinoma in 11. The severity of the atypia usually varied throughout each specimen. The surface appearance of the lesion was not a reliable prognosticator of the severity of dysplasia either between patients or in different areas of the same lesion; therefore, excisional biopsy and whole‐mount, multiple‐section histopathological analysis were necessary for obtaining an accurate diagnosis.In the second study, submucosal vocal fold dye infusions were performed to identify where the glottal mucosa was supported by the superficial lamina propria (SLP). The histological sections of these vocal folds demonstrated that the caudal limitation of the SLP was in close proximity to the epithelial surface change from ciliated to nonciliated epithelium (inferior arcuate line). It is generally thought that the inferior arcuate line denotes the proximal subcordal vibratory epithelium. The infusions also demonstrated that dye‐induced hydrostatic distension of the SLP would provide more room for surgical dissection in the SLP and would reduce instrumental trauma to the layered vocal‐fold microstructure. These features assisted in the design of a procedure that, by simulating Reinke's edema, would help to preserve the vocal fold's layered anatomy.The third investigation employed the anatomical SLP‐infusion studies in a clinical trial. A submucosal infusion of saline and epinephrine in conjunction with microflap excisional biopsy was performed on 43 vocal folds. Complete excisional biopsy was accomplished in all. The infusion produced hydrostatic distension of the SLP and the overlying epithelium. This improved the visualization of the lesion's perimeter and resulted in precise placement of incisions around the lesion. The increased depth of the SLP and the hydrodissection of the epithelium from the vocal ligament facilitated both the development of a precise microflap and the maximal preservation of the vocal fold's layered microstructure. The infusion effectively demonstrated invasion through the SLP into the vocal ligament by causing distension of the epithelium and of the SLP not involved with cancer, while leaving a relative depression where the SLP was replaced by cancer.In the fourth study, a pilot group of 17 patients was assessed to determine which postoperative objective vocal‐measurement criteria would be valuable, and to begin to establish expected postsurgical outcome data. The results generally suggested that as the epithelial resection extended from the superior surface to include the medial surface as well, the measures used began to reflect deteriorating vocal function. Specifically, the acoustic data revealed that the most likely aberrations postoperatively were increased jitter (cycle‐to‐cycle irregularity of pitch) and reduced maximal ranges for both loudness (intensity) and pitch (frequency). These changes appeared to be related to higher levels of stiffness and/or tension in the vocal mechanism. With these changes, there was often an increase in subglottic aerodynamic support (pressure), which could be a compensatory adjustment or the manifestation of persistent (presurgical) hyperfunctional behaviors. While patients did not describe discomfort in conjunction with voice production, the stroboscopic evaluations visually confirmed the presence of increased stiffness/restriction in the glottal valve. The most common abnormal sequela seen with stroboscopy was a decrease in the magnitude of the mucosal wave on the superior/ventricular vocal‐fold surface. If a medial/vocalizing surface resection was done, the amplitude of vocal fold vibration (excursion) was also likely to be diminished. The perceptual vocal assessment parameters were typically normal or revealed mild dysphonia.Phonomicrosurgical treatment of premalignant and microinvasive vocal fold epithelium integrates principles of surgical oncology with those of voice production. The use of submucosal infusion with microflap excisional biopsya.provides a tissue specimen suitable for multiple‐section histopathological analysis;b.establishes an unequivocal diagnosis;c.treats the lesion;d.reserves all cancer treatment options;e.is simple, repeatable, and cost‐effective;f.preserves the layered vocal‐fold anatomy, andg.avoids the medial aspect of the vocal fold (vocalizing surface) as much as is oncologically possible for optimal postoperative voice. The pilot voice evaluations that were done suggest that while patients treated by this approach did not typically achieve “normal” vocal function (according to measures of underlying physiology), most did manage to produce voices that were, acoustically and perceptually, within normal limits during conversational‐level speech.

Từ khóa


Tài liệu tham khảo

Wright J., 1914, A History of Laryngology and Rhinology., 333

Bozzini P., 1807, Der Lichtleiter oder Beschreibung einer einfachen Voriehtung, und ihrer Anwendung zur erleucht ung inherer Hohlen, und Zwischenraume des lebenden animaschen Korpers.

Tour C. D. L.Cited by Fournie.:Physiologie de la voix. Journal I'Institut p.350 1825.

Senn. Cited by Mackenzie.:The Use of the Laryngoscope in Diseases of the Throat. Jour. de Progres p.11 1829.

Babington B.G., 1829, London Medical Gazette, 3, 555

Selligue. Cited by Mackenzie.:The Use of the Laryngoscope in Diseases of the Throat. p.17 1832.

Liston R., 1837, Practical Surgery.

Baumes, 1836, Compte Rendu des Travaux de la Societe de Medecine de Lyons., 19, 18

Avery Cited by Mackenzie.:The Use of the Laryngoscope in Diseases of the Throat. p.25 1844.

Garcia M., 1855, Observations on the Human Voice, Proceedings of the Royal Society of London, 7, 397

Wright J., 1914, A History of Laryngology and Rhinology, 207

Turck L., 1858, On the Laryngeal Mirror and Its Mode of Employment, With Engravings on Wood, Zeitschrift der Gesellschaft der Aerzte ze Wein, 26, 401

Czermak J., 1858, Uber den Kehlkopfspiegel, Wiener Med. Wocjenschrift, 8, 196

Czermak J.N., 1861, On the Laryngoscope and Its Employment in Physiology and Medicine, New Sydenham Society, 11, 1

Turck L., 1860, Atlas zur Klinik der Kehlkopfkrankheiten.

Stoerk C., 1858, On the Value of the Laryngopharyngeal Mirror, Zeitschrift der Gesellschaft der Aerzte zu Wein, 51, 797

Mackenzie M., 1871, Growths in the Larynx.

Stoerk C., 1859, On the Laryngoscope, Zeitschrift der Gesellschaft der Aerzte ze Wein, 46, 721

Mackenzie M., 1865, The Use of the Laryngoscope in Diseases of the Throat with an Appendix on Rhinoscopy.

Mackenzie M., 1880, Diseases of the Pharynx, Larynx, and Trachea., 158

Boas E., 1950, The First Use of the Laryngoscope in the United States, Journal of the History of Medicine, 5, 452

Elsberg L., 1879, President's Address: Laryngology in America, Transactions of the American Laryngological Association, 1, 30

Krackowizer E.:Church on the Laryngoscope. New York Academy of Medicine 162 1861.

Elsberg L., 1864, Laryngoscopal Medication or the Local Treatment of the Diseases of the Throat, Larynx, and Neighboring Organs, Under Sight.

Elsberg L., 1866, Laryngoscopal Surgery Illustrated in the Treatment of Morbid Growths Within the Larynx.

Solis‐Cohen J.:Removal of a Fibrous Polyp From the Inferior Surface of the Right Vocal Fold With the Aid of the Laryngoscope. American Journal of Medical Science 404–407 1867.

Elsberg L., 1880, President's Address: Laryngological Instruction, Transactions of the American Laryngological Association, 2, 4

Solis‐Cohen J., 1872, Diseases of the Throat: A Guide to the Diagnosis and Treatment.

Solis‐Cohen J., 1881, President's Address, Transactions of the American Laryngological Association, 3, 2

Wright J., 1914, A History of Laryngology and Rhinology, 214

Green H., 1852, On the Surgical Treatment of Polypi of the Larynx, and Oedema of the Glottis., 56

Kirstein A., 1895, Autoskopie des Larynx und der Trachea (Laryngoscopia directa, Euthyskopie, Besichtigung ohne Spiegel), Archiv fur Laryngologie und Rhinologie, 3, 156

Green H., 1854, On the Subject of the Priority in the Medication of the Larynx and Trachea, American Medical Monthly, 1, 241

Green H., 1856, Report on the Use and Effect of Applications of Nitrate Silver to the Throat, Either in Local or General Disease, Transactions of the American Medical Association, 9, 493

Brunings W., 1912, Direct Laryngoscopy, Bronchoscopy, and Esophagoscopy, 93

Clerf L.H., 1956, Manuel Garcia's Contribution to Laryngology, Bulletin of the New York Academy of Medicine, 32, 603

Donaldson F., 1890, The Laryngology of Trousseau and Horace Green, Transactions of the American Laryngological Association, 12, 10

Lewin G., 1861, Allgemeine Medicinische Central‐Zeitung., 30, 654

Sands H.B.:Case of Cancer of the Larynx Successfully Removed by Laryngotomy; With an Analysis of 50 Cases of Tumors of the Larynx Treated by Operation. New York Medical Journal 110–126 1865.

Mackenzie M., 1888, The Fatal Illness of Frederick the Noble.

10.1288/00005537-198410000-00009

Delavan D.B., 1900, A Consideration of the Statistics of the Operations for the Relief of Malignant Disease of the Larynx, Transactions of the American Laryngological Association, 22, 66

Delavan D.B.:A History of Thyrotomy and Laryngectomy. Transactions of a Commemorative Meeting in the Honour of Dr. John Edmund Mackenty Held by the Section of Otolaryngology: The New York Academy of Medicine 1932.

10.1056/NEJM198411083111923

Solis‐Cohen J.Cited by Wright :A History of Laryngology and Rhinology. p.330 1881.

Browne L., 1878, The Throat and Its Diseases.

Semon F.: In Reference to Transition of Benign Laryngeal Tumors to Malignant Lesions Post Laryngeal Surgery: bezuglich des Ueberganges gutartiger Kehlkopfgeschwulste i bosartige nach intralaryngealen Operatienen.Internationales Centralblatt fur Laryngologie Rhinologie Jahrgang IV No. 7:245–246 1888.

Semon F., 1889, Internationales Centralblatt fur Laryngologie, 271

Butlin H.T., 1883, Malignant Disease (Sarcoma and Carcinoma) of the Larynx.

Fraenkel B., 1900, The Anatomo Pathologic Diagnosis of Cancer of the Larynx, Ann Otol Rhinol Laryngol, 9, 276

Chiari O., 1898, Contributions to the Diagnosis and Treatment of Laryngeal Cancer, Ann Otol Rhinol Laryngol, 7, 572

Solis‐Cohen J., 1900, The Surgical Treatment of Laryngeal Cancer, Transactions of the American Laryngological Association, 22, 75

Mackenzie J., 1900, A Plea For Early Naked‐Eye Diagnosis and Removal of the Entire Organ, With the Neighboring Area of Possible Lymphatic Infection in Cancer of the Larynx, Transactions of the American Laryngological Association, 22, 56

10.1177/000348940601500102

Delevan D.B., 1904, Recent Advances in the Treatment of Malignant Disease of the Larynx, Transactions of the American Laryngological Association, 26, 150

Moore I., 1921, Intrinsic Cancer of the Larynx and the Operation of Laryngofissure., 13

Mackenty J., 1922, Laryngectomy for Cancer, With Remarks on Seventy Operated Cases, Transactions of the American Laryngological Association, 44, 205

10.1288/00005537-190408000-00003

Jackson C., 1915, Peroral Endoscopy and Laryngeal Surgery., 107

Jackson C., 1939, Cancer of the Larynx., 231

Jackson C., 1939, Cancer of the Larynx., 237

Fraenkel B., 1886, First Healing of a Laryngeal Cancer Taken Out Through the Natural Passages, Archiv fur Klinische Chirurgie, 12, 283

Arslan A., 1901, Emorragia Laringes, Archive Italiano, 11, 390

10.1288/00005537-190705000-00007

Sendziac J., 1907, Treatment of Cancer of the Larynx, New York Medical Journal, 86, 1042

Finder, 1910, Comments from; The diagnosis and treatment of carcinoma of the larynx, J Laryngol Otol, 25, 602

Thompson S.C., 1914, Intrinsic Cancer of the Larynx‐Complete Excision Apparently Effected by the Endo‐laryngeal Operation, Transactions of the American Laryngological Association, 36, 34

Freudenthal W., 1906, Bernhard Fraenkel—What He Has Done for Rhino‐Laryngology, Ann Otol Rhinol Laryngol, 15, 606

10.1177/000348941502400301

Lynch R.C., 1916, A Resume of My Years Work With Suspension Laryngoscopy, Transactions of the American Laryngological Association, 38, 158

Lynch R.C., 1920, Intrinsic Carcinoma of the Larynx, With a Second Report of the Cases Operated on by Suspension and Dissection, Transactions of the American Laryngological Association, 40, 119

New G.B., 1941, Suspension Laryngoscopy in the Treatment of Malignant Disease of the Hypopharynx and Larynx, Mayo Clin Proc, 16, 411

LeJeune F.E., 1946, Intralaryngeal Operation for Cancer of the Vocal Cord, Ann Otol Rhinol Laryngol, 55, 531

Lillie J.C., 1973, Transoral Surgery of Early Cordal Carcinoma, Transactions of the American Academy of Ophthalmology & Otolaryngology, 77, 92

10.1288/00005537-197212000-00009

10.1177/000348947208100606

10.1288/00005537-197508000-00003

10.1002/lary.1978.88.9.1399

10.1288/00005537-198404000-00012

10.1177/000348948509400607

10.1177/019459988609500502

10.1177/000348949009900108

Kirstein A., 1897, Autoscopy of the Larynx and Trachea (Direct Examination Without Mirror).

10.1016/S0892-1997(05)80350-9

Jackson C., 1915, Peroral Endoscopy and Laryngeal Surgery., 77

Boyce J.W., 1907, Tracheobronchoscopy, Esophagoscopy and Gastroscopy., 145

10.1017/S1755146300015985

Jackson C., 1939, Cancer of the Larynx., 52

Killian G., 1912, Die Schwebelaryngoscopie, Archiv fur Laryngologie und Rhinologie, 26, 277

10.1017/S1755146300014104

Killian G., 1915, Peroral Endoscopy and Laryngeal Surgery., 133

Killian G., 1920, Die Schwebelaryngoscopie und ihre praktische.

Brunings W., 1912, Direct Laryngoscopy, Bronchoscopy, and Esophagoscopy., 110

Jackson C., 1939, Cancer of the Larynx.

Jackson C., 1937, The Larynx and Its Diseases.

LeJeune F.E., 1945, Diseases of the Nose, Throat and Ear., 178

10.1177/000348946006900421

Roberts S.E., 1948, Direct Laryngoscopy—A Simplified Technique With Screw Driven Fulcrum Lift, Laryngoscope, 57, 245

10.1288/00005537-195202000-00008

10.1001/archotol.1951.03750010108010

10.1001/archotol.1952.00710010496015

10.1288/00005537-195408000-00007

Netter F. H., 1987, The Ciba Collection of Medical Illustrations: Musculoskeletal System., 216

10.1288/00005537-195804000-00008

10.1001/archotol.1971.00770070252013

10.1177/000348947808700419

Jackson C., 1907, Tracheo‐Bronchoscopy, Esophagoscopy and Gastroscopy., 15

Killian G., 1910, Demonstration of an Endoscopic Spatula, Journal of Laryngology and Rhinology, 25, 549

10.1288/00005537-192312000-00008

10.1001/archotol.1925.00560010179005

10.1007/BF02134838

10.1001/archotol.1970.00770040266019

Jako G.J., 1980, Otolaryngology., 2410

Kleinsasser O.:Die Laryngomicroscope (Lupenlaryngoskopie) und ihre Bedeutung fur die Erkennung der Vorerkrankungen und Fruhformen des Stimmlipencarcinomas. Arch fur Ohren Nasen und Kehlkopfheilkunde 724–727 1962.

Kleinsasser O.:Weitere technische Entwicklung und erste Ergebnisse der endolaryngealen Mikrochirurgie. Z Laryng Rhinol 711–727 1965.

Kleinsasser O., 1978, Microlaryngoscopy and Endolaryngeal Microsurgery., 3

10.1001/archotol.1970.00770040482003

10.1288/00005537-197010000-00003

10.1177/000348948909801013

Castro J., 1989, Tobacco Road's Dirty Ashtrays, Time, 17, 52

MacMahon B., 1986, National Cancer Institute. Health Implications of Smokeless Tobacco Use, Public Health Rep, 101, 349

Jackson C., 1915, Peroral Endoscopy and Laryngeal Surgery., 637

10.1177/000348942002900102

Jackson C., 1922, Cancer of the Larynx: Is It Preceded by a Recognizable Precancerous Condition, Transactions of the American Laryngological Association, 44, 182

Jackson C., 1930, Discussion on Precancerous Conditions of the Larynx, Proc R Soc Med, 24, 301

10.1001/jama.1932.02740720024007

10.1001/jama.1946.02870490001001

10.1001/archotol.1942.03760050127013

10.1288/00005537-193410000-00006

10.1001/archotol.1945.00680040498007

Putney F. O' J., 1953, The Clinical Significance of Keratosis of the Larynx as a Premalignant Lesion, Arch Otolaryngol, 62, 348

Bishop J.:Experimental Researches Into the Physiology of the Human Voice. The London & Edinburgh Philosophical Magazine & Journal of Science 1836.

Fournie E., 1866, Physiologie de la voix et de la parole.

Durant G., 1870, Hygiene of the Voice: Its Physiology and Anatomy., 22

Fournie E., 1880, Proceedings of the International Congress of Laryngology, Arch Laryngol, 99, 378

Hirano M., 1975, Phonosurgery: Basic and Clinical Investigations, Otologia (Fukuoka), 21, 239

Hirano M., 1981, Structure of the Vocal Fold in Normal and Diseased States: Anatomical and Physical Studies, 11

Hirano M., 1991, Phonosurgery., 25

10.1007/978-4-431-68358-2

Oertel M., 1895, Das laryngo‐stroboskop und die Laryngo‐Stoboskpische Untersuchung, Archiv fur Laryngologie und Rhinologie, 3, 1

10.1177/000348946107000319

Alberti P.W., 1978, The Diagnostic Role of Laryngeal Stroboscopy, Otolaryngol Clin North Am, 11, 3457, 10.1016/S0030-6665(20)32544-5

10.1001/archotol.1934.03790060057007

10.1001/archotol.1932.00630040806003

10.1001/archotol.1958.00730020005001

10.1001/archotol.1959.00730030448011

10.1001/archotol.1960.03770010020003

Morrison M.D., 1984, A Clinical Voice Laboratory, Videotape and Stroboscopic Instrumentation, Otolaryngol Head Neck Surg, 92, 487, 10.1177/019459988409200421

Hajek M., 1891, Anatomische Untersuchungen uber das Larynxodem, Archiv fur Klininsche Chirurgie, 42, 46

10.1007/BF02317550

10.1177/000348945606500409

Pressman J.J., 1960, Anatomic Studies Related to the Dissemination of Cancer of the Larynx, Transactions of the American Academy of Ophthalmology & Otolaryngology, 64, 628

Zeitels S.M.:Microflap Excisional Biopsy for Atypia and Microinvasive Glottic Cancer. In: Operative Techniques in Otolaryngology—Head & Neck Surgery (Phonosurgery Edition) 218–222 1993.

10.1288/00005537-198205000-00011

10.1111/j.1365-2273.1987.tb00161.x

10.1002/1097-0142(195309)6:5<963::AID-CNCR2820060515>3.0.CO;2-Q

Batsakis J.G., 1982, Tumors of the Head and Neck. Clinical and Pathological Considerations., 121

10.1001/archotol.1970.00770040745004

10.1001/archotol.1952.00710020140003

Myers E.N. Wagner R.L.andJohnson J.T.:Microlaryngoscopic Surgery for T1 Glottic Lesions: A Cost‐effective Option. Presented at the American Laryngological Association 1993.

Ryan R.F., 1955, The Pathological Effects of Smoking on the Larynx, Arch Pathol, 60, 472

10.1177/000348943904800118

10.1002/1097-0142(197001)25:1<92::AID-CNCR2820250114>3.0.CO;2-E

10.1001/jama.1962.03050440011003

Kytta J., 1962, Endoscopic Aspects of Bronchogenic Carcinoma, Ann Chir Gynaecol Fenn, 51, 361

10.1177/000348947308200602

10.1017/S1755146300019508

10.1017/S0022215100061120

10.1001/archotol.1959.00730040295001

McGravran M.H., 1960, Isolated Laryngeal Keratosis. Its Relation to Carcinoma of the Larynx Based Upon a Clinicopathologic Study of 87 Consecutive Cases With Long‐term Follow‐up, Laryngoscope, 70, 932, 10.1288/00005537-196007000-00005

10.1017/S0022215100085388

10.1017/S0022215100087296

10.1002/hed.2890010503

10.1111/j.1365-2273.1982.tb01557.x

Goodman M.L., 1984, Keratosis (Leukoplakia) of the Larynx, Otolaryngol Clin North Am, 17, 179, 10.1016/S0030-6665(20)32006-5

10.1017/S0022215100076702

Velasco J.R., 1987, Premalignant Lesions of the Larynx; Pathological Prognostic Factors, J Otolaryngol, 16, 367

10.3109/00016488909127492

10.1002/hed.2880130604

Bauer W.C., 1976, Workshops From the Centennial Conference on Laryngeal Cancer., 122

Friedman I., 1976, Workshops From the Centennial Conference on Laryngeal Cancer., 122

DeSanto L.W., 1976, Workshops From the Centennial Conference on Laryngeal Cancer., 146

Miller A.H., 1976, Workshops From the Centennial Conference on Laryngeal Cancer., 109

Putney F. J. O', 1953, The Clinical Significance of Keratosis of the Larynx as a Premalignant Lesion., 62, 348

Som M.L., 1976, Workshops From the Centennial Conference on Laryngeal Cancer., 145

10.1016/0002-9610(83)90243-X

10.1177/000348947108000412

10.1177/000348946807700309

Moore C., 1971, Cigarette Smoking and Cancer of the Mouth, Pharynx and Larynx, JAMA, 218, 553, 10.1001/jama.1971.03190170031005

Bouquot J.E., 1991, Laryngeal Keratosis—It's Relation to Carcinoma in the Rochester, Minnesota Population, 1935–1984, Cancer Detect Prev, 15, 83

Weymuller E.A.:A Surgical Protocol Designed to Improve Outcome Data in Head and Neck Cancer Trials. Presented at the American Laryngological Association 1993.

10.1007/BF00405505

10.1288/00005537-195404000-00003

10.1016/S0196-0709(86)80020-5

10.1017/S0022215100061144

Greven K.M. Randall M.E. McGuirt W.F. et al.:Assessment of Prognostic Factors for Voice Quality in Patients Treated Definitively for Early Glottic Carcinoma. Presented at the Third International Conference on Head and Neck Cancer 1992.

Padovan I.F., 1976, Workshops From the Centennial Conference on Laryngeal Cancer.

Hyams V.H., 1976, Workshops From the Centennial Conference on Laryngeal Cancer., 134

Strong M.S., 1976, Workshops From the Centennial Conference on Laryngeal Cancer., 154

Strong M.S., 1976, Workshops From the Centennial Conference on Laryngeal Cancer., 165

Vaughan C.W., 1980, Treatment of T1 and In Situ Carcinoma: The Transoral Approach, Otolaryngol Clin North Am, 13, 509, 10.1016/S0030-6665(20)32350-1

10.1288/00005537-197109000-00011

Miller A.H., 1976, Workshops From the Centennial Conference on Laryngeal Cancer., 161

10.1288/00005537-199306000-00015

10.1177/000348948509400303

10.1177/019459989110500322

10.1288/00005537-198406000-00001

Kashima H.K., 1991, Vestibulectomy in Early Vocal Fold Carcinoma, Transactions of the American Broncho‐Esophagological Association, 71, 28

10.1177/019459989310800605

10.1016/S0892-1997(89)80127-4

Baken R., 1987, Clinical Measurement of Speech and Voice., 95

Holmberg E.B. Hillman R.E. Perkell J.S. et al.:Relationships Between Intraspeaker Variation in Aerodynamic Measures of Voice Production and Variation in SPL Across Repeated Recordings. J Speech Hear Res (In press.)

10.1121/1.396829

10.1044/jshr.3202.373

10.1016/S0892-1997(05)80082-7

Tucker G.F.: In:Human Larynx Coronal Section Atlas. pp.7–20 1971.

10.1177/019459988809800205

10.1001/archotol.1991.01870210087017

10.1177/000348949210100207

Ludlow C.L., 1987, Laryngeal Function in Phonation and Respiration., 492

Thông tin
Thông tin xuất bản

Laryngoscope

Tập 105 Số S1

1-44

Thông tin tác giả