Gary Y. Shaw

Laryngeal manifestations of gastroesophageal reflux before and after treatment with omeprazole

Background. Laryngeal manifestations of gastroesophageal reflux disease are thought to be prevalent in our society. In general, diagnosis has been primarily based on symptoms. Historically, additional testing has included laryngoscopy, barium swallow, manometry, and single and double probe pH monitoring. Methods. We assessed 96 patients who had symptoms suggestive of reflux laryngitis. We administered surveys grading their symptoms. All patients had standardized videolaryngostroboscopic evaluation and computerized acoustic analysis. Patients then received a uniform regimen of dietary restrictions and omeprazole (a proton pump inhibitor) for 12 weeks, after which they were retested. Results. Using the new laryngoscopic grading system, we found that this regimen produced statistically significant improvement in all symptoms except granulomas. In patients with the pretherapy complaint of hoarseness, acoustic measurements of jitter, shimmer, habitual frequency, and frequency range all showed significant improvement. Conclusions. We conclude that in patients with symptomatic reflux laryngitis, standardized videolaryngoscopy and, if the patient is hoarse, acoustic analysis are useful techniques to aid diagnosis and monitor therapy. Antireflux therapy with omeprazole is effective, and improvement can be objectively shown with the techniques described.

Botulinum toxin treatment for cricopharyngeal dysfunction.

Hypertonicity and spasticity of the cricopharyngeal muscle (CPM) often result in dysphagia characterized by difficulty passing a bolus through the upper esophageal sphincter. Past treatments for this problem have included mechanical dilation and endoscopic and transcervical cricopharyngeal myotomy. More recently, botulinum toxin injections into the CPM have been successful, but only in isolated case studies and small series. This study reports pre- and post-botulinum toxin A injection results for 12 subjects, including patient ratings of symptom severity, changes noted during modified barium swallow studies, and, in some cases, manometry of the upper esophageal sphincter. Results indicate that botulinum toxin A treatment provided significant improvement in swallowing as indicated by patient symptom ratings and investigator ratings of function from modified barium swallow studies. Greater improvement was seen in those with more isolated CPM or Xth nerve dysfunction rather than those with more global dysphagia abnormalities.

Transcutaneous Neuromuscular Electrical Stimulation (VitalStim) Curative Therapy for Severe Dysphagia: Myth or Reality?

Objectives: VitalStim therapy was approved by the US Food and Drug Administration in 2001 for the treatment of dysphagia through the application of neuromuscular electrical stimulation to cervical swallowing muscles. This approval was based upon submission of data on more than 800 patients who received this therapy collected by the principal developer and patent-holder of the device. The therapy is marketed as successful in restoring long-term swallowing function in 97.5% of dysphagic patients past the point of requiring a feeding tube and as significantly better than existing therapies. More than 2,500 speech-language pathologists have taken the certification course, and thousands of devices have been sold. To date, however, aside from the developers own studies, there are no peer-reviewed publications supporting these claims. We sought to evaluate the effectiveness of VitalStim therapy in a heterogeneous group of dysphagic patients. Methods: We performed a retrospective analysis of 18 patients who received this therapy at an urban tertiary referral center. All patients underwent pretherapy evaluation by speech-language pathologists, including modified barium swallow and/or functional endoscopic evaluation of swallowing and clinical evaluation of swallowing that included assessment of laryngeal elevation, diet tolerance, and swallowing delay, and were then assigned an overall dysphagia severity score. After therapy, all patients underwent the same assessments. Twelve of the 18 also underwent a functional swallowing telephone survey months (range, 1 to 21 months) after their therapy to assess whether the improvement was worthwhile and sustained. Results: Eleven of the 18 patients (61%) demonstrated some improvement in their swallowing. Six of the 18 patients (33%) were improved enough to no longer require a feeding tube. However, of the 5 patients categorized as having “severe dysphagia” before therapy, only 2 showed any improvement, and these patients still required a feeding tube for adequate nutrition. Telephone surveys did confirm that those who improved with their therapy seemed to maintain their progress and that most patients were satisfied with their therapy. Conclusions: VitalStim therapy seems to help those with mild to moderate dysphagia. However, the patients with the most severe dysphagia in our study did not gain independence from their feeding tubes. The authors conclude that VitalStim therapy clearly has a place in the management of dysphagia, but that the most severely afflicted are unlikely to gain dramatic improvement.

Subjective, laryngoscopic, and acoustic measurements of laryngeal reflux before and after treatment with omeprazole

Laryngeal manifestation of gastroesophageal reflux is felt to be prevalent in our society. In general, diagnosis has been based primarily on symptoms. Historically, additional testing included laryngoscopy, barium swallow, manometry, and more recently, single- and double-probe pH monitoring. We evaluated 68 patients who were symptomatically suggestive of having reflux laryngitis. We administered surveys grading their symptoms. All patients underwent standardized videolaryngostroboscopic evaluation and computerized acoustic analysis. Patients then underwent a uniform therapy of dietary restrictions and omeprazole, a hydrogen ion inhibitor, for 12 weeks. Patients were then retested. This regimen demonstrated an 85% success of relieving symptoms. Utilizing the new laryngoscopic grading system, improvement was found to be statistically significant in improvement of all findings except granulomas. In patients with the pretherapy complaint of hoarseness, acoustic measures of jitter, shimmer, habitual frequency, and frequency range all showed significant improvement. The authors conclude that in patients with symptomatic reflux laryngitis, standardized videolaryngoscopy and, if hoarse, acoustic analysis are useful exam techniques to aide diagnosis and monitor therapy. Anti-reflux therapy with omeprazole is effective and improvement can be objectively demonstrated with the techniques described.

Laryngeal manifestations of gastroesophageal reflux disease: endoscopic appearance and management

The association between gastroesophageat reflux (GER) and laryngeal disorders in adults has been recoguized since the late 1960s. 1, 2 The true extent of laryngeal complications is unknown. However, with an estimated 7% of adults experiencing heartburn daily and 30% experiencing symptoms monthly, 3 the potential number of patients with GER-related laryngeal disorders is considerable. Laryngeal symptoms that have been attributed to GER include hoarseness, repetitive throat clearing, a sensation of fullness in the back of the throat, and chronic cough. 4 Structural abnormalities detected by laryngoscopy associated with GER include posterior or reflux laryngitis (vocal cord edema and erythema along with interarytenoid epithelial hypertrophy), and vocal cord ulcers and granulomas.5, 6 The rare patient may develop vocal cord scarring and laryngeal or subglottic stenosis as a result of GER, usually in association with prolonged endotracheal intubation. 7, s Finally, it has been postulated on the basis of minimal data that chronic reflux of gastric material on the posterior glottis contributes to the development of laryngeal carcinoma.9, 10 During upper gastrointestinal endoscopy, inspection of the larynx can be accomplished prior to esophageal intubation or on withdrawal of the endoscope. Although largely underutilized, evaluation for laryn

Predictors of laryngeal complications in patients implanted with the Cyberonics vagal nerve stimulator.

Objectives: Since its approval by the US Food and Drug Administration in 1997 for management of medically refractory seizures, more than 35,000 patients have been implanted with the Cyberonics vagal nerve stimulator. Preliminary reports described transient vocal changes in the majority of subjects, which were thought to be short-term. However, these reports were for the most part based upon perceptual evaluations by the subjects themselves. Later reports described possibly more permanent recurrent laryngeal nerve injury and recommended measuring the nerve diameter to use the safest spiral cuff electrode. To date, no study has systematically evaluated vocal fold mobility in subjects before and after implantation. The objectives of this study were to determine the true incidence of both short- and long-term recurrent laryngeal nerve injuries and determine whether there are any potential indicators to predict in which patients long-term nerve deficits may develop. Methods: Thirteen subjects underwent preimplantation laryngeal electromyography, videolaryngoscopy, measurement of the maximum phonation time, Voice Handicap Index determination, and Consensus Auditory-Perceptual Evaluation of Voice. Two weeks after implantation, all subjects underwent videolaryngoscopy. Three months after implantation and activation of the device, all subjects were reevaluated. Results: Six of the 13 subjects had significant vocal fold mobility abnormalities at 2 weeks. Significant electromyographic abnormalities were detected before implantation in 5 subjects. All 5 of these subjects, at 3 months after implantation, had prolonged left vocal fold paresis. Conclusions: The authors conclude that perioperative vocal fold paresis occurs in approximately 50% of subjects. Further, laryngeal electromyography performed before implantation of the vagal nerve stimulator is a statistically significant predictor (p > .05) of which patients may be at risk for extended vocal fold abnormalities. Possible explanations for this phenomenon are offered. Surgical modifications to limit vagal nerve injury are offered.

Diagnosis and treatment of unilateral cricothyroid muscle paralysis with a modified Isshiki type 4 thyroplasty.

Cricothyroid adduction increases tension to the vocal folds, thus increasing fundamental frequency and upper pitch range. We treated 10 patients with cricothyroid muscle dysfunction using this technique. Preoperative electromyographic, acoustic, and perceptual analysis was performed. Intraoperatively the effect of increasing tension on the fundamental, falsetto, and basal frequencies was measured by using a strain gauge to the adducting suture at several tensions and a cervical microphone connected to a pitch meter. Postoperative acoustic and perceptual analysis was then performed up to 18 months later. Analysis of pitch vs. tension curves indicates a near-linear relationship until very high tensions are applied. Statistically significant improvement was achieved in both acoustic and perceptual analysis, although some deterioration was noted between early and late results. Cricothyroid adduction is indicated for a large range of vocal fold tension problems.

Posterior Cricoarytenoid Myoplasty with Medialization Thyroplasty in the Management of Refractory Abductor Spasmodic Dysphonia

Of the approximately 100,000 Americans with primary (idiopathic) laryngeal dystonia, 10% to 15% are thought to have the abductor form. Botulinum A toxin injected into the posterior cricoarytenoid muscle and/or cricothyroid muscle has been employed as the “gold standard” for therapeutic management; however, successful results are significantly less frequent than with injections for the adductor form. This report describes a new phonosurgical procedure, posterior cricoarytenoid myoplasty with medialization thyroplasty, designed for these refractory patients. Posterior cricoarytenoid myoplasty with medialization thyroplasty has been performed on 3 patients with abductor laryngeal dystonia. All patients had failed at least 5 previous botulinum A injections to the posterior cricoarytenoid and cricothyroid muscles. All patients underwent preoperative and 3 postoperative (2 weeks, 3 months, and 1 year) phonatory analyses. Analysis consisted of recording an aloud reading of a standard passage while a blinded trained speech pathologist counted prolonged voiceless consonants. The patients also completed a satisfaction survey at 1 year. The results demonstrated significant, long-lasting, uniform reduction in breathy breaks in all subjects. The participants all judged their symptoms as greatly improved. Bilateral procedures may be necessary, but should be staged to prevent possible airway compromise. When applied appropriately, posterior cricoarytenoid myoplasty with medialization thyroplasty is a viable tool in the management of refractory abductor laryngeal dystonia.

Electroglottographic and acoustic changes following type I thyroplasty or autologous fat injection

This study identified the electroglottographic (EGG) and acoustic measures that were most predictive of change in the glottic gap size of patients undergoing type I thyroplasty or autologous fat injection. Simultaneous EGG and acoustic recordings were made before and after autologous fat injection in 23 patients and type I thyroplasty in 45 patients. Relative measures of glottic gap size were obtained before and after operation from videostroboscopic images. Regression and correlation analysis was used to determine the strength of associations between the EGG or acoustic measures and glottic gap changes. A significant regression equation for both patient groups was constructed. The strongest predictors of glottic gap size change were changes in the EGG open quotient, signal-to-noise ratio, and mean fundamental frequency. Glottography provided a clinically useful means of evaluating glottic gap changes in patients undergoing vocal fold medialization procedures. Preoperative-postoperative differences in signal-to-noise ratio and mean fundamental frequency also were correlated to glottic gap size changes, but to a lesser degree.

Secondary tracheoesophageal puncture using a KTP laser.

INTRODUCTION The technique for tracheoesophageal puncture (TEP) in patients who have had laryngectomy is widely accepted as a reliable method to restore speech. Since its introduction in 1980, the technique of Singer and Blom has been generally adopted as the technique of choice in the establishment of a secondary TEP. Despite its worldwide acceptance, a number of technical difficulties exist. Hong et al. noted that passage of a standard esophagoscope is often difficult, especially in the scarred neck after irradiation. Other authors have had difficulty performing the puncture itself. Silver et al. noted a 15% complication rate associated with this procedure. Complications include false passage into the mediastinum, esophageal perforation, and pharyngeal tears. The most difficult step is generally believed to be performing the puncture itself through a variably thick common wall where the tracheal mucosa is relatively tightly attached and the esophageal mucosa is relatively loose, making an externally approached fistula somewhat difficult. This report describes a technique for tracheoesophageal (TE) fistula creation using an internal approach with a KTP laser. Preliminary outcome data using this new technique are presented.