Haruna Yabe

Endoscopic investigation and evaluation of anxiety for the management of globus sensation

OBJECTIVE To verify whether the severity of globus sensation would be affected by the results of investigations on possible underlying serious pathology in the head, neck and esophagus. METHODS Thirty-six patients with globus sensation were enrolled in this study. All the patients suffered relatively persistent globus sensation which remained after conventional laryngoscopy at their family doctors. These patients were investigated for possible underlying oropharyngeal and esophageal lesions using fiberoptic endoscopy. The severity of globus was evaluated by the visual analog scales (VAS), and the degree of anxiety was evaluated by the state section of State Trait Anxiety Inventory (STAI-s). The questionnaires were administered at their first visits, and 9.6±3.2 months after endoscopy. The follow-up data obtained from 22 patients were incorporated in the further evaluations. Multiple regression analysis was used to evaluate the relationship between the improvement of VAS scores and that of STAI-s scores. Afterwards, Pearson product-moment correlation coefficient was measured. The recorded images of fiberoptic endoscopy were retrospectively verified by an expert of upper gastrointestinal endoscopy. RESULTS No malignancies were observed in the endoscopic examination. Despite no treatment administered during the follow-up period, significant improvement of VAS scores was observed from the initial scores (40±21) to follow-up scores (27±27, p=0.014) in the patients examined in this study. The multiple linear regression analysis proved that the improvement of STAI-s scores was the only factor significantly affected the improvement of VAS scores (p=0.029) among the dependent valuables. The retrospective evaluation of the recorded images revealed comorbid esophagitis in 10 out of the 22 patients. When patients were stratified with the presence of comorbid esophagitis, significant improvement of VAS scores was observed only in the group without comorbid esophagitis at their follow up (17±20, p=0.026) compared with their initial scores (36±17). The multiple linear regression analysis proved that the improvement of VAS scores was significantly affected by the improvement of STAI-s scores (p=0.047) in this group. Moreover, significant positive relationship between the improvement of VAS scores and that of STAI-s scores was observed only in the group without comorbid esophagitis (r=0.61, p=0.047). CONCLUSION Proper investigation to prove no underlying serious pathology may lead to the improvement of globus sensation in the patients without comorbid esophagitis through the reduction of their anxiety even when their symptoms are relatively persistent. Our results also indicated that some treatments against esophagitis may be helpful for the improvement of globus sensation in the patients with this comorbid disease.

Comparative multidimensional assessment of laryngeal function and quality of life after radiotherapy and laser surgery for early glottic cancer

This study was designed to comparatively assess laryngeal function and quality of life (QOL) of patients after laser surgery (LS) or radiotherapy (RT) for early glottic cancer.

Harmonious Team Approach for Safe Airway Management -The Keio University Experience-

Surgical Tracheostomy (ST) has been a standard procedure for surgical airway management for a long time. Recently, Percutaneous Dilatational Tracheostomy (PDT) is getting more and more popular in the US and Europe in this field. In Japan, PDT is becoming well-known following the trend in other countries mainly due to its relatively easy procedure even for non-surgeons to secure the airway. However, part of the multidisciplinary participants in preparing/ performing tracheostomy and postoperative care do not have opportunities to understand the (contra) indications of PDT, or to precisely learn the technical difference between ST and PDT. Furthermore, instruction for use is hard to be strictly followed in diverse situations to potentially induce multiple accidents. In our institution, PDT was adopted under the collaboration between anesthesiologists and otolaryngologists in January 2008. However, at that time, responsibilities and roles of every participant engaged in the tracheostomy were not clarified, while multiple responsible decisions were necessary for harmonious procedure, e.g. necessity of tracheostomy for the candidate, timing to perform the procedure, selection of proper surgical procedure, and the place where the tracheostomy should be performed. Considering such a muddled situation, we organized a committee consisted of surgeons, anesthesiologists, nurses and administrative organizers to comprehend the recent complicated situations surrounding tracheostomy. The final purpose of organizing the committee was to build a unique intramural rule to prepare and perform elective tracheostomy safely and harmoniously. In this communication, multiple issues to produce the present confused situation for harmonious elective tracheostomy are summarized. We show our current intramural protocol for elective tracheostomy, delivered in July 2010, which clarifies the sequential role and responsibility of every multidisciplinary participant at each indispensable decision for safe procedure. Furthermore, current practice of tracheostomy in our institution, especially in the intensive care unit, was assessed.

Phonosurgical resection using submucosal infusion technique for precancerous laryngeal leukoplakia.

This study was designed to assess the feasibility of the submucosal infusion technique combined with microflap dissection as a radical therapeutic and diagnostic option for precancerous laryngeal leukoplakia.

Multidimensional vocal assessment after laser treatment for recurrent respiratory papillomatosis.

Recurrent respiratory papillomatosis (RRP) is a benign epithelial tumor that exhibits a high frequency of recurrence. This study assesses the vocal function after laser treatment for RRP, particularly in relation to the frequency of surgery.

A rare case of bilateral vagus nerve schwanomatosis

Schwanomatosis is the third most common form of neurofibromatosis. Schwanomatosis affecting the vagus nerve is particularly rare. In this report, we describe an extremely rare case bilateral vagus nerve schwanomatosis in a 45-year-old male patient. The patient initially presented with bilateral neck tumors and hoarseness arising after thoracic surgery. We performed left neck surgery in order to diagnose and resect the remaining tumors followed by laryngeal framework surgery to improve vocal cord closure and symptoms of hoarseness. Voice recovery was successfully achieved after surgery. An appropriate diagnosis and surgical tumor resection followed by phonosurgery improved patient quality of life in this rare case.

Clinical Review of Globus Patients with a Focus on GERD Cases: ―胃食道逆流が関連した症例を中心に―

Globus sensation is a common symptom seen daily in ear-nose-throat (ENT) clinics. Globus is affected by multiple factors, and of these, gastroesophageal reflux disease (GERD), has been recognized as a relatively more manageable cause of globus than the other causes. However, we still commonly encounter globus patients with unclear backgrounds who require multiple diagnostic and therapeutic modalities. To provide an appropriate treatment approach and create favorable situations for these patients, we developed and applied an intramural algorithm to manage globus considering GERD, laryngeal allergy, and psychological problems as major factors of this pathology. 　Twenty-six patients with globus sensation who visited our voice clinic from June 2012 to March 2015 were enrolled in this study. All these patients had undergone general ENT examinations, including naso-pharyngo-laryngeal endoscopies and cervicothoracic computed tomographic scans. Upper gastrointestinal endoscopy revealed 2 cancers. Further study classified 23 patients into the GERD group and 1 patient into the allergy group. Proton pump inhibitor (PPI) therapy was successful in 11 patients of the GERD group (response rate, 47.2%). Improvement in subjective symptoms of globus were measured by the scores of questionnaires, including the F scale and Reflux Symptom Index. Significant improvement in these scores were observed 1 month after PPI prescription in the PPI-responder group in this study. Further assessment of medical history as well as the scores of questionnaires to measure the severity levels of depression (Self-rating Depression Scale) and anxiety (State-Trait Anxiety Inventory-Form JYZ, STAI) proved that relatively longer lasting symptoms (≥4 months) or relatively higher anxiety scores (STAI≥50 points) were predictive of PPI resistance. Our study results suggested that the pathology of globus is affected by multiple factors and that a multidisciplinary team approach is required for better management of this disease.

Postoperative Glottal Function and Voice-Related QOL after Type1 and Type2 Cordectomy against Laryngeal Leukoplakia

Objectives: Recent progress in phonomicrosurgical technique and equipment enabled one to precisely differentiate the subepithelial (type1) and subligamental (type2) cordectomy concept as needed. The purpose of this study was to compare postoperative glottal function and voice-related quality of life (QOL) between these 2 surgical concepts against laryngeal leukoplakia. Methods: From January 2007 to August 2013, 42 consecutive laryngeal leukoplakia patients had excisional biopsies using type1 procedures. Of these, cancer patients (n = 10) had additional type2 laser surgeries. Furthermore, some severe dysplasia/carcinoma in situ patients (n = 11) preferred additional type2 surgery aiming at relatively safe surgical margins. Sequential pre- and postoperative measurements of Grade, Roughness, Breathiness, Asthenia, Strain (GRBAS) scale and evaluations of laryngeal videostroboscopic images were performed. Acoustic measurements and voice-related QOLs (VHI and V-RQOL) were examined at the patients’ last visits. All data were compared between type1 and type2 groups. Results: Vocal quality was well-preserved in type1 group after surgery. Although immediate postoperative deterioration of GRBAS score was observed in type2 group, vocal recovery was obtained in 6 months to present no significant difference compared with type1 group. Impaired glottal closure and pliability were observed in both groups after surgery. While videostroboscopic findings of type1 group recovered to normal in 3 months, impaired glottal findings remained for 1 year in half of the type2 patients. Moreover, voice-related QOLs were significantly better in type1 group. Conclusions: Our study proved that advanced phonomicrosurgical technique and equipment could offer a well-preserved vocal quality even in the type2 group. However, subjective voice-related QOLs were better in the type1 group with superior videostroboscopic findings.

Unique Clinical Findings in Laryngeal Leukoplakia to Predict Serious Histopathology in Low-Risk Nonsmokers

Objectives: Although most of the laryngeal leukoplakias are temporal inflammatory lesions in non-smokers, some patients represent serious histopathologies to require careful management. The purpose of this study was to clarify unique clinical features of the patients who require cautious care in this low-risk group. Methods: One hundred fifty-four consecutive patients referred to our institution with laryngeal leukoplakia from June 2006 to May 2013. Of these, 24 patients without smoking history were incorporated in this study. Retrospective chart reviews and the re-evaluations of video-taped laryngeal images were performed. Sequential change of vocal quality (Grade, Roughness, Breathiness, Asthenia, Strain scale) was assessed in each patient. Timings to show improvements of laryngeal images were studied in the patients with spontaneous disappearances of leukoplakias (n = 12). Furthermore, excisional biopsies were performed on 12 patients and their histopathologies and vocal/stroboscopic characteristics were compared with each other. Results: Spontaneous disappearances of the lesions were observed 4.6 months after referral to our hospital on average, and these patients presented vocal quality of G1 or G0 at their first visits. Additionally, gradual recoveries in their glottal closure and/or pliability of diseased vocal folds were observed in this group. Furthermore, patients with histopathology of severe dysplasia/cancer presented with either (1) no improvement in their G2 voice for 1 month, (2) incomplete glottal closure coupled with abnormal pliability of diseased vocal folds for 1 month, or (3) abnormal pliability of diseased vocal folds for 4 months. Conclusions: Our analyses identified several specific findings to predict serious pathology in laryngeal leukoplakia patients without smoking history.

3D Measurement of Paralyzed Larynx in Japanese Using Cone Beam CT

Objectives: Precise measurement of human organs with an error by less than one millimeter was realized by cone beam computed tomography (CBCT) imaging technology. The purpose of this study was to measure the shape/size of paralyzed larynges in Japanese patients with multiple parameters using CBCT. Methods: Eighty-nine Japanese patients who referred to our institution with unilateral vocal fold paralysis from April 2007 to November 2011 were incorporated in this case series study. There were 54 males and 35 females, and the mean age was 59.9 years. Laryngeal CBCT images were taken in 2 conditions: 1) patients sitting relaxed (R image), and 2) patients applying pressure at their diaphragm (P image). Lengths of bilateral vocal folds, bilateral horizontal glottal angles, and sizes of gaps from a median plane of each larynx were measured in R images. Vertical gaps of bilateral vocal folds were measured in P images. Results: Mean lengths of non-diseased vocal folds (males, 18.5 mm; females, 12.9 mm) were significantly longer compared with diseased side (males, 17.7 mm; females, 12.4 mm) in both males ( P =0.011) and females (P = 0.001). Glottal angles were significantly wider in no diseased side (16.1°) compared with diseased side (9.4°, P = 0.0011). Vertical gaps were normalized with the lengths of non-diseased vocal folds with mean value of 0.057. Conclusions: Our study showed the first correct measurement of paralyzed larynx in live Japanese patients. These data will contribute to the improvement of diagnosis and surgical procedures for the patients with laryngeal paralysis in the future.