CO_(2)激光声带部分切除治疗声带白斑599例的长期疗效分析

Analysis of long-term efficacy of CO_(2) laser partial excision of vocal folds for 599 cases in the treatment of vocal cord leukoplakia

目的分析CO_(2)激光声带部分切除治疗声带白斑的长期疗效。方法回顾性分析2000年1月至2023年12月首都医科大学附属北京同仁医院咽喉科在全身麻醉下行CO_(2)激光声带部分切除手术的599例声带白斑患者[男566例,女33例,年龄17~84岁(中位年龄55岁)]的临床特征、病理级别、手术方式、术后嗓音功能变化、复发及恶变情况,分析远期疗效及影响因素。599例患者术后随访6~249个月(中位随访时间48个月)。采用SPSS 20.0软件进行统计学分析。结果599例患者中,病理级别为单纯鳞状上皮细胞增生264例(44.08%)、轻度异型增生96例(16.03%)、中度异型增生74例(12.35%)、重度异型增生43例(7.18%)、原位癌35例(5.84%)、原位癌伴微浸润87例(14.52%)。Kaplan-Meier生存曲线显示,患者3年总体复发率12.91%,5年总体复发率16.00%。非浸润癌的512例患者中,3.91%(20例)复发后出现病理级别升高,2.34%(12例)出现癌变。当病变累及前连合、大面积病灶、黏膜波明显减低/消失、有新生血管/可疑新生血管、异型增生/原位癌/原位癌伴微浸润的患者复发风险更高(F值分别为:44.76,21.54,11.55,8.78,23.20,P值均<0.05),同时复发患者的反流症状指数评分较未复发患者高。病变呈外生性生长和术后未戒烟为病理分级升高风险增加的独立危险因素,风险分别为非外生性生长及术后戒烟患者的8.675和11.380倍。术后6个月,Ⅰ型声带切除术的患者基频较术前显著升高(t=-3.38,P<0.01),其余嗓音声学指标无显著差异;接受Ⅲ型声带切除的患者,多项嗓音声学参数与术前相比差异有统计学意义(P<0.05)。84例患者术后出现声带粘连,13例患者接受了声带粘连松解手术。结论病变累及前连合、大面积病灶、病理为异型增生/原位癌/原位癌伴微浸润、声带黏膜波明显减低/消失以及窄带成像(narrow band imaging,NBI)内镜下可见新生血管提示患者存在更高的复发风险,而外生性病变与术后未戒烟患者复发病理分级升高的风险显著提高。术后嗓音质量的恢复与手术方法的选择相关。

ObjectiveTo analyze long-term prognosis and influencing factors of recurrence in vocal fold leukoplakia treated by endoscopic cordectomy with CO_(2) laser.MethodsA retrospective review was conducted on 599 patients with vocal fold leukoplakia[566 males and 33 females,aged 17-84 years(median age 55 years)],undergoing endoscopic cordectomy by CO_(2) laser under general anesthesia at the Department of Otorhinolaryngology Head and Neck Surgery of Beijing Tongren Hospital,Capital Medical University,from January 2000 to December 2023.The study analyzed the clinical features,pathological grade,surgical methods,postoperative voice function,recurrence,malignant changes and analyzed the long-term efficacy and and its influencing factors.The patients were followed up for a duration of 6-249 months postoperatively,with a median follow-up time of 48 months.SPSS 20.0 software was used for statistical analysis.ResultsAmong the 599 patients,the histopathological grades included simple squamous cell hyperplasia in(n=264,44.08%),mild dysplasia(n=96,16.03%),moderate dysplasia(n=74,12.35%),severe dysplasia(n=43,7.81%),carcinoma in situ(n=35,5.84%),and carcinoma in situ with microinvasion(n=87,14.52%).The 3-year and 5-year overall recurrence rates were 12.91%and 16.00%,respectively.In patients with precancerous lesion,3.91%of recurrences presented with an upgraded pathologic grade and 2.34%evolved into carcinoma.The risk of recurrence was higher in lesions involving the anterior commissure,larger lesions,significant reduction/absence of mucosal waves,neovascularization/suspected neovascularization,and pathology of dysplasia/carcinoma in situ/carcinoma in situ with microinvasion(F=44.76,21.54,11.55,8.78,23.20,respectively,P<0.05).Additionally,patients with recurrent disease exhibited higher reflux symptom index scores compared to those without recurrence.Exophytic lesion characteristics and the inability to cease smoking postoperatively were identified as independent risk factors for recurrence with an upgraded pathological grade,with odds ratios of 8.675 and 11.380 times greater than those with non-exophytic lesions and successful smoking cessation,respectively.At the 6-months postoperative assessment,patients who underwent subepithelial cordectomy(typeⅠ)demonstrated a statistically significant increase in fundamental frequency(t=-3.38,P<0.05),and while other voice acoustic parameters were not significantly different.Conversely,those who underwent transmuscular cordectomy(TypeⅢ)exhibited significant alterations in multiple voice acoustic parameters when compared to preoperative values(P<0.05).Furthermore,postoperative vocal fold adhesions developed in 84 patients with 13 of these individuals requiring surgical intervention for adhesion release.ConclusionsLesions involving the anterior commissure,larger lesions,pathology of dysplasia/carcinoma in situ/carcinoma in situ with microinfiltration,significant reduction/absence of vocal fold mucosal waves,and neovascularization visible under NBI are indicative of an increased risk of recurrence,whereas exophytic lesions and the inability to cease smoking postoperatively significantly increase the risk of recurrence with elevated pathologic grade.Recovery of postoperative voice quality is procedure-dependent,underscoring the importance of surgical approach selection in the management of vocal fold leukoplakia.