Other sites 251 Larynx

Laryngeal chondronecrosis is a rare complication of radiotherapy: less than 1 % with conventional daily fractions126,223-225.

The most common presenting symptom is hoarseness225; the others accompanying symptoms are pain, dysphagia, odynophagia, dyspnea, induration of neck skin and subcutaneous tissues, fistula formation,

223,225

fetor223,225. As for osteoradionecrosis, a tumor recurrence must be excluded.

Hypofractionation, total radiation dose, large treatment fields and involvement of cartilage by tumor are risk factors225'226. In 1979, Chandler226 proposed a grading system, with a proposition of treatment for each grade. Grades I and II are expected, whereas grades III and IV are complications. The conventional treatment of chondronecrosis includes analgesics, steam, corticosteroids, antibiotics, temporary or permanent tracheostomy, and even laryngectomy. In early stage reactions (grades I and II), humidification and anti reflux regimen are usually effective. Grade III requires the addition of oral steroids, and appropriate antibiotics223,226. Chandler226 reported 13 cases of grade III, treated with humidification and antibiotics, with clinical resolution in all of them. In non responsive grades III and grades IV, the treatment is surgical. If airway obstruction is present, a temporary or permanent tracheostomy is performed. A total laryngectomy is warranted for a necrotic and nonfunctional larynx.

Several investigators have studied the interest of HBO as an adjunct to the treatment. Hart227 used HBO for five patients; all had cutaneous fistulae. Improvement was present in four of them. Ferguson228 in eight patients with Chandler grade III and IV (4 grade IV) chondronecrosis found an improvement in seven of them; two patients with grade IV required temporary tracheostomy; one of the four required laryngectomy. Feldmeir229 in nine patients (eight Chandler grade IV, one Chandler grade III) obtained the following results: the three patients with tracheostomies were able to be decannulated. All nine patients maintained their voice, and seven without hoarseness. None required laryngectomy. In 1998, London230 published the results of an retrospective study. Five patients have been treated with 15 to 25 HBO sessions at 2.5 ata for 90 minutes; additional dives were given depending on clinical response. All the patients had advanced disease (Chandler grade III or IV) and were tracheostomy dependent; two were decannulated, and none required laryngectomy. Narozny231 reported major improvement in all six patients. In the largest study published, Filntisis232 presented 18 patients (two grade III, sixteen grade IV) treated with HBO. They received a mean number of 41 sessions (2 ata, 2 hours, twice a day, 6 days a week). Thirteen patients (72 %) had a major improvement; all of them maintained their voice. Five underwent total laryngectomy.

All these studies suggest that HBO has a beneficial effect in the management of laryngeal necrosis, whereas they are all retrospective studies and the global number of patients is small.

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