Ahmed M. S. Soliman

Dysphagia, hoarseness, and unilateral true vocal fold motion impairment following anterior cervical diskectomy and fusion.

The charts of 100 patients who underwent anterior cervical diskectomy with fusion performed at our institution between January 1996 and February 1999 were reviewed. The incidences of hoarseness, dysphagia, and unilateral true vocal fold motion impairment were calculated. Univariate logistic regression was used to estimate the relationship of several patient and technical factors to the rates of occurrence of hoarseness and dysphagia. Patient age was found to be a significant predictor of postoperative dysphagia (p < .006), with an odds ratio of 1.113 (95% confidence limits, 1.04, 1.21) per year of age. Other factors studied were not found to be significant predictors. The overall incidence of these complications from the world literature was also calculated. The overall incidences of dysphagia, hoarseness, and unilateral true vocal fold motion impairment in the literature were calculated as 12.3%, 4.9%, and 1.4%, respectively. We conclude that dysphagia, hoarseness, and unilateral vocal fold motion impairment continue to remain significant complications of anterior cervical diskectomy with fusion. Older patients may be at higher risk for dysphagia.

Pharmacological dissection of the human gastro oesophageal segment into three sphincteric components

Quantifications of gastro‐oesophageal anatomy in cadavers have led some to identify the lower oesophageal sphincter (LOS) with the anatomical gastric sling‐clasp fibres at the oesophago‐cardiac junction (OCJ). However, in vivo studies have led others to argue for two overlapping components proximally displaced from the OCJ: an extrinsic crural sphincter of skeletal muscle and an intrinsic physiological sphincter of circular smooth‐muscle fibres within the abdominal oesophagus. Our aims were to separate and quantify in vivo the skeletal and smooth muscle sphincteric components pharmacologically and clarify the description of the LOS. In two protocols an endoluminal ultrasound‐manometry assembly was drawn through the human gastro‐oesophageal segment to correlate sphincteric pressure with the anatomic crus. In protocol I, fifteen normal subjects maintained the costal diaphragm at inferior/superior positions by full inspiration/expiration (FI/FE) during pull‐throughs. These were repeated after administering atropine to suppress the cholinergic smooth‐muscle sphincter. The cholinergic component was reconstructed by subtracting the atropine‐resistant pressures from the full pressures, referenced to the anatomic crus. To evaluate the extent to which the cholinergic contribution approximated the full smooth‐muscle sphincter, in protocol II seven patients undergoing general anaesthesia for non‐oesophageal pathology were administered cisatracurium to paralyse the crus. The smooth‐muscle sphincter pressures were measured after lung inflation to approximate FI. The cholinergic smooth‐muscle pressure profile in protocol I (FI) matched closely the post‐cisatracurium smooth‐muscle pressure profile in protocol II, and the atropine‐resistant pressure profiles correlated spatially with the crural sling during diaphragmatic displacement. Thus, the atropine‐resistant and cholinergic pressure contributions in protocol I approximated the skeletal and smooth muscle sphincteric components. The smooth‐muscle pressures had well‐defined upper and lower peaks. The upper peak overlapped and displaced rigidly with the crural sling, while the distal peak separated from the crus/upper‐peak by 1.1 cm between FI and FE. These results suggest the existence of separate upper and lower intrinsic smooth‐muscle components. The ‘upper LOS’ overlaps and displaces with the crural sling consistent with a physiological LOS. The distal smooth‐muscle pressure peak defines a ‘lower LOS’ that likely reflects the gastric sling/clasp muscle fibres at the OCJ. The distinct physiology of these three components may underlie aspects of normal sphincteric function, and complexity of sphincter dysfunction.

Endoscopic Botulinum Toxin Injection for Cricopharyngeal Dysphagia

Twelve patients underwent 17 endoscopic injections of botulinum toxin type A in the cricopharyngeus muscle for the treatment of dysphagia and cricopharyngeal spasm over a 3-year period. The patients charts were reviewed. Preoperative and postoperative symptoms, examination, and swallowing studies were reviewed. Eleven of the 12 patients had improvement in their symptoms, which lasted for a mean of 3.8 months. Two patients elected cricopharyngeal myotomy for permanent correction of their dysphagia. There was 1 case of postoperative neck cellulitis in an immunocompromised patient undergoing simultaneous excision of a thyroglossal duct cyst. We conclude that endoscopic injection of botulinum toxin is a relatively safe and viable technique for the treatment of dysphagia associated with cricopharyngeal spasm. It requires simple tools readily available to otolaryngologists. Larger, prospective controlled studies are necessary to establish its effectiveness and role in the management of this condition.

Risk Factors for Adult Laryngotracheal Stenosis: A Review of 74 Cases

Objectives: We sought to identify risk factors for and review our experience in the management of adult acquired laryngotracheal stenosis (LTS) at an academic urban medical center. Methods: A retrospective review of all patients given a diagnosis of acquired LTS between 1997 and 2005 was performed. Seventy-four patients with LTS were identified. Demographic information, medical and surgical history, surgical procedures performed, and outcomes were collected. A control group of 106 patients admitted over the same time period with respiratory distress but without LTS was identified. The data collected for both groups were analyzed by Fishers exact test and logistic regression analysis. Results: Demographically, the control group was not significantly different from the LTS group. Patients who had a previous tracheostomy were 10.99 times more likely to develop LTS than control patients (95% confidence interval [CI], 4.68 to 25.80). Patients irradiated for carcinomas of the oropharynx and larynx were 5.95 times more likely to develop LTS than control patients (95% CI, 1.87 to 18.91). Those previously intubated for more than 48 hours were 3.91 times more likely to develop LTS than control patients (95% CI, 1.91 to 8.02). Finally, patients who were intubated for any non-airway surgery were found to be 2.07 times more likely to develop LTS (95% CI, 1.09 to 3.93). Conclusions: Prolonged intubation, tracheostomy, previous non-airway surgery, and irradiation for oropharyngeal and laryngeal tumors are risk factors for LTS. Multiple surgical procedures are often required for treatment. Mitomycin C did not significantly improve decannulation rates.

Chronic rhizopus invasive fungal rhinosinusitis in an immunocompetent host

Hypothesis: Rhizopus species may cause chronic invasive fungal rhinosinusitis in an immunocompetent host.

Changing trends in angioedema

Angioedema can be a life-threatening event presenting to otolaryngologists, emergency medicine physicians, and other physicians. Recent reports suggest an increasing role of angiotensin-converting enzyme inhibitors (ACEIs) in the causation of angioedema. Sixty-four cases occurring between 1994 and 1998 were identified and examined retrospectively. Fifty-eight percent of patients presenting with angioedema were using ACEIs. Ninety-four percent of patients overall, and 92% of patients with ACEI-associated angioedema, were African-American. Tongue, lip, facial, and supraglottic edema were most common. Treatment included intubation in 13% and intensive care unit monitoring in 20%. Nearly all patients were treated with corticosteroids and antihistamines. There were no deaths. Angioedema associated with ACEI use appears to be much more common than previously reported. African-American patients may be at higher risk for angioedema with ACEI use. Successful management was achieved with Observation, expectant airway management, corticosteroids, and discontinuation of ACEIs. Patients without airway obstruction or pharyngeal or laryngeal edema who improved with treatment and observation were successfully treated as outpatients.

Angiotensin Converting Enzyme Inhibitor-Related Angioedema: Onset, Presentation, and Management

Objective: This study aimed to determine the duration of use, presentation, and management of angiotensin converting enzyme (ACE) inhibitor-related angioedema patients at an urban academic medical center. Methods: Retrospective chart review. Results: Eighty-eight patients who presented with ACE inhibitor-related angioedema between January 1, 2012, and December 31, 2012, were identified. They presented anywhere from 1 day to 20 years after starting an ACE inhibitor. About half the patients (50.7%) presented after taking an ACE inhibitor for at least 1 year. Fifty-five patients were female (62.5%). Twenty-eight patients (31.8%) had an airway intervention with 27 intubated and 1 requiring cricothyroidotomy. Six patients were intubated after more than 1 flexible laryngoscopy. The percentage of patients with involvement of the face, lips, tongue, floor of mouth, soft palate/uvula, and larynx were 12.5%, 60.2%, 39.7%, 6.8%, 17.0%, and 29.5%, respectively. Sixty-eight percent of patients with laryngeal edema were intubated. The majority of patients were treated with a corticosteroid and H1 and H2 receptor antagonists. Conclusion: Angioedema can occur at any time after starting ACE inhibitor use, with nearly half occurring after 1 year of use. Laryngeal involvement occurred in a minority of patients, but most of these patients were felt to require airway protection.

Ectopic growth hormone-secreting pituitary adenoma in the sphenoid sinus.

Fig I. Unenhanced axial computed tomogram through sphenoid sinus shows large, expansile mass within sphenoid, eroding sella turcica. unsuccessful trial of medical therapy, a computed tomography scan of the paranasal sinuses was performed; it demonstrated a large, expansile mass of the sphenoid sinus (Fig 1). Magnetic resonance imaging revealed a large, inhomogeneous, nonenhancing mass, distinct from a normal pituitary gland, and involvement of the cavernous sinus (Fig 2). Laboratory evaluation revealed a normal serum growth hormone level. Transnasal endoscopic sphenoidotomy demonstrated a soft, rubbery mass within the sphenoid sinus; a biopsy was performed. Hematoxylin and eosin staining revealed large, ovoid cells with eosinophilic granular cytoplasm and round to ovoid nuclei (Fig 3). The results of immunohistochemical staining for growth hormone were positive and are demonstrated in Fig 4. The tumor was also positive for thyroid-stimulating hormone. Electron microscopy revealed abundant neurosecretory granules.

Evaluation of the Upper Esophageal Sphincter (UES) Using Simultaneous High-Resolution Endoluminal Sonography (HRES) and Manometry

The aim of this study was to characterize the motion, morphology, and pressure of the upper esophageal sphincter (UES). The UES and its surrounding structures were evaluated in seven normal subjects and four human cadavers, using simultaneous high-resolution endoluminal sonography and manometry. The UES musculature on ultrasound is a C-shaped structure with an angle of 107 ± 19°. The mean peak resting UES pressure was 74 mm Hg, with a total cross-sectional area (CSA) of 0.87 ± 0.33 cm2. During swallowing, the UES moved in an orad direction. Localizing the UES sonographically, the peak UES pressure in the cadavers was 19.7 ± 10.0 mm Hg. The UES has a greater muscular CSA and resting pressure than the upper esophageal body. In the cadaver studies, the UES was imaged in conjunction with a significant increase in pressure, indicating that the pressure is due to passive mechanical conformational changes.

Thyroglossal Duct Cyst with Intralaryngeal Extension

Objectives: Thyroglossal duct cysts with intralaryngeal extension are rare. We present only the 10th reported case in the literature. Methods: The clinical presentation, diagnosis, and treatment of the patient are reviewed and summarized. The uniqueness of the case, as well as the diagnostic and treatment pitfalls of this subgroup of patients, is presented. Results: Our patient, at 76 years of age, is the only woman and the oldest person reported to have had a thyroglossal duct cyst with intralaryngeal extension. Conclusions: Intralaryngeal extension should be considered when there is hoarseness, dysphagia, or dyspnea associated with a thyroglossal duct cyst. Office laryngoscopy and computed tomography make the diagnosis. Care must be taken with airway management and intraoperative dissection for good outcomes.