David M. Alessi

Vocal fold scarring: current concepts and management.

Scarring of the vocal folds can occur as the result of blunt laryngeal trauma or, more commonly, as the result of surgical, iatrogenic injury after excision or removal of vocal fold lesions. The scarring results in replacement of healthy tissue by fibrous tissue and can irrevocably alter vocal fold function and lead to a decreased or absent vocal fold mucosal wave. The assessment and treatment of persistent dysphonia in patients with vocal fold scarring presents both diagnostic and therapeutic challenges to the voice treatment team. The common causes of vocal fold scarring are described, and prevention of vocal fold injury during removal of vocal fold lesions is stressed. The anatomic and histologic basis for the subsequent alterations in voice production and contemporary modalities for clinical and objective assessment will be discussed. Treatment options will be reviewed, including nonsurgical treatment and voice therapy, collagen injection, fat augmentation, endoscopic laryngoplasty, and Silastic medialization.

Granular cell tumors of the head and neck

Granular cell tumors have a predilection to occur in the head and neck. Thirty granular cell tumors have been diagnosed during the past 26 years at UCLA; 13 of which presented in the head and neck. Of these 13 cases, 10 were correctly diagnosed on the primary pathological specimen, which included one fine‐needle aspirate and three frozen sections. Four cases required diagnostic confirmation with electron microscopy or histochemistry. The tongue accounted for more than one third of the cases. Three lesions exhibited locally aggressive behavior, but none of the tumors metastasized. Initial treatment was wide local excision in all but one case; recurrence was noted in two cases. Fine‐needle aspiration can be used to provide preoperative diagnosis of granular cell tumors. Wide local excision with histologically confirmed clear margins provides definitive treatment.

Aspiration and Nasogastric Intubation

Routine use of nasogastric tubes in major surgery is associated with unwarranted risks of aspiration through at least three mechanisms: (1) hypersalivation—allowing pooling of secretions in the hypopharynx, (2) a depressed cough reflex, which is often associated with nasogastric intubation, and (3) various laryngeal and pharyngeal abnormalities that are frequently caused by nasogastric tubes, leading to an inability to handle secretions and protect the airway. Using indirect cinelaryngoscopy, we can accurately document these mechanisms; three representative cases are presented here. Aspiration associated with nasogastric intubation is a newly described but potentially serious complication. Routine use of nasogastric intubation should be abandoned, except when the clinical situation warrants it.

Bedside Videolaryngoscopic Assessment of Intubation Trauma

Telescopic laryngoscopic examination was performed at the bedside after extubation in 29 consecutive surgical intensive care unit patients who required endotracheal intubation for more than 16 hours. The examinations were documented with a portable video recording system. The majority of patients exhibited evidence of acute endolaryngeal trauma. Vocal fold ulceration and vocal fold motion abnormalities were the most common lesions. Patients with abnormal larynges were followed up after discharge from the intensive care unit. Most of the identified injuries resolved without intervention. However, silent aspiration was identified frequently in patients with vocal fold paresis and was thought to be a significant factor in postoperative pulmonary complications. Early identification of significant laryngeal trauma and/or vocal fold paresis in critically ill patients is important for both postoperative pulmonary care and voice rehabilitation. This pilot study demonstrated that documentation of the laryngeal examination is feasible in critically ill patients in an intensive care unit setting.

The Actor and Singer as Patients of the Laryngologist

Educational objectives: To assist the singer and actor in a vocal emergency and to pattern surgical indications to the special problems of entertainers.

171 Otolaryngologic Manifestations of Ectodermal Dysplasia

tus arteriosus (PDA) using either clips (53% of infants), suture ligatures (41%), or both (6%) from 1991 through 1994 at the University of Iowa Hospitals and Clinics. Compared with infants without VFP, infants with VFP were smaller at birth (0.9 kg vs 2.3 kg, p <0.001), more premature (26.3 weeks vs 33.8 weeks gestational age, p <0.001), and smaller (1.1 kg vs 3.4 kg, p <0.001) and younger (31.9 days vs 88.4 days, p <0.001) at the time of surgery. Weight gain from birth to surgery was significant only in infants without postoperative VFP (p <0.05). Although the overall incidence of VFP in all infants undergoing ligation of PDA was 8.8%, five of the six cases (83%) of postoperative VFP occurred in premature infants weighing less than 1 kg at birth. Among only the premature neonates, the incidence of VFP after ligation of PDA was 22.7%. VFP was universally associated with the use of surgical clips; however, because clips were used in 90% of all premature neonates, it is not possible to establish whether suture ligature is safer. This study demonstrates that the major single risk factor for VFP following ligation of PDA is prematurity.