John-Helge Heimdal

Continuous Laryngoscopy Exercise Test: A Method for Visualizing Laryngeal Dysfunction during Exercise

Objectives/Hypothesis: To assess the diagnostic feasibility and patient acceptance of a new developed diagnostic test for exercise induced upper airway flow limitation.

Exercise induced dyspnea in the young. Larynx as the bottleneck of the airways.

BACKGROUND Exercise induced asthma may symptomatically be difficult to differentiate from exercise related obstruction in the upper airways, sometimes leading to diagnostic confusion and inappropriate treatment. Larynx accounts for a significant fraction of total airway resistance, but its role as a limiting factor for airflow during exercise has been hampered by lack of diagnostic tools. We aimed to study laryngeal function in exercising humans by transnasal laryngoscopy. METHODS Continuous video recording of the larynx was performed in parallel with continuous film recording of the upper part of the body and recording of breath sounds in subjects running to respiratory distress or exhaustion on a treadmill. RESULTS A successful examination was obtained in 20 asymptomatic volunteers and 151 (91%) of 166 young patients with a history of inspiratory distress or stridor during exercise. At rest, six patients had abnormal laryngeal findings. During exercise, a moderate or severe adduction of laryngeal structures was observed in parallel with increasing inspiratory distress in 113 (75%) patients. In 109 of these, adduction started within supraglottic structures, followed by adduction of the vocal cords in 88. In four patients, laryngeal adduction started in the vocal cords, involving supraglottic structures secondarily in three. CONCLUSION Larynx can safely be studied throughout a maximum intensity exercise treadmill test. A characteristic laryngeal response pattern to exercise was visualised in a large proportion of patients with suspected upper airway obstruction. Laryngoscopy during ongoing symptoms is recommended for proper assessment of these patients.

Mood, anxiety and sense of humor in head and neck cancer patients in relation to disease stage, prognosis and quality of life

Conclusions At diagnosis, control patients had the lowest depression levels and anxiety scores, followed by those with limited HNSCC disease and these with extended HNSCC disease.Anxiety and depression levels at diagnosis predicted prognosis via an association with extent of disease. Sense of humor, but not anxiety score or depression level, predicted lower QoL and depression levels at follow-up. Objective To study the association between anxiety score, depression level and sense of humor at diagnosis in head and neck squamous cell carcinoma (HNSCC) patients versus TNM stage, prognosis and depression level/quality of life (QOL) 6 years following diagnosis. A control group of patients with benign HN disease was also included. Material and methods Male patients with newly diagnosed HNSCC (n=78) or benign HN (n=61) disease completed the following questionnaires: the Beck Depression Inventory, the Spielberger Trait Anxiety Inventory (state) and the Svebak humor questionnaire. Patients with cachexia or those aged >80 years were excluded. In the HNSCC patients, TNM stage, prognosis and QOL/depression level (n=27) were determined following successful therapy. Results HNSCC patients reported higher anxiety scores and lower depression levels than control patients, although there was overlap between the groups. N stage was associated with high anxiety scores and depression levels, whereas T stage was only associated with depression levels. Both anxiety scores and depression levels at diagnosis predicted prognosis through an association with TNM stage. Sense of humor, but not depression levels or anxiety scores, at diagnosis predicted QoL and depression level at follow-up.

ERS/ELS/ACCP 2013 international consensus conference nomenclature on inducible laryngeal obstructions

Individuals reporting episodes of breathing problems caused by re-occurring variable airflow obstructions in the larynx have been described in an increasing number of publications, with more than 40 different terms being used without consensus on definitions. This lack of an international consensus on nomenclature is a serious obstacle for the development of the area, as knowledge from different centres cannot be matched, pooled or readily utilised by others. Thus, an international Task Force has been created, led by the European Respiratory Society/European Laryngological Society/American College of Chest Physicians. This review describes the methods used to reach an international consensus on the subject and the resulting nomenclature, the 2013 international consensus conference nomenclature. The condition leading to episodes of feeling like you cannot breathe now has a name: inducible laryngeal obstructions http://ow.ly/OMaNl

Left Vocal Cord Paralysis After Extreme Preterm Birth, a New Clinical Scenario in Adults

OBJECTIVE: The goal was to study the incidence and long-term consequences of left vocal cord paralysis (LVCP) after neonatal surgical treatment of patent ductus arteriosus (PDA) in a population-based cohort of adults who were born at gestational ages of ≤28 weeks or with birth weights of ≤1000 g in western Norway. METHODS: Subjects with a history of neonatal PDA surgery were examined with transnasal flexible laryngoscopy, and those with LVCP were examined with continuous laryngoscopy during maximal treadmill exercise (continuous laryngoscopy exercise testing). All subjects underwent lung function testing, ergospirometry, and pulmonary high-resolution computed tomography. Symptoms were recorded with a questionnaire. RESULTS: Forty-four (86%) of 51 eligible preterm infants participated in the study, 13 (26%) had a history of PDA surgery and 7 (54%) had LVCP, with the laryngeal appearances varying slightly. As a group, subjects with LVCP had significant airway obstruction, no decreases in aerobic capacity, and no obvious evidence of longstanding aspiration on high-resolution computed tomography scans. The continuous laryngoscopy exercise tests revealed increasing respiratory symptoms in parallel with increasing anteromedial collapse of the left aryepiglottic folds as the exercise load increased. Hoarseness and voice-related symptoms were the most typical complaints. Symptoms were attributed erroneously to other diseases for at least 2 subjects. CONCLUSIONS: LVCP is not uncommon in young adults exposed to PDA surgery as preterm infants. The condition may be overlooked easily, and symptoms may be confused with those of other diseases. Laryngoscopy should be offered on the basis of liberal indications after PDA ligation.

Peripheral Blood Mononuclear Cell (PBMC) Responsiveness in Patients with Head and Neck Cancer in Relation to Tumour Stage and Prognosis

We have previously shown an increased T lymphocyte and monocyte responsiveness in peripheral blood mononuclear cells (PBMC) from patients with head and neck squamous cell carcinoma (HNSCC) compared with PBMC from control patients. This study reports T lymphocyte function of PBMC of 81 patients with HNSCC dependent on disease stage and prognosis. Males with HNSCC under 80 years of age without cachexia, with no auto-immune disease or previous cancer and on no immuno-active medication were included at the time of diagnosis of disease. The follow-up was for at least 18 months. When cells from patients with early vs late stage disease according to the T, N or T + N stage of HNSCC were compared, decreased in vitro mitogen-stimulated and spontaneous T cell proliferation was seen with increasing tumour stage. When patients were studied according to disease-specific survival, a decreased T lymphocyte mitogen-stimulated proliferation was observed to be associated with a poorer prognosis. No changes in prognosis were noticed related to decreased gamma-IFN, IL-2 or IL-4 level of the supernatants of the T lymphocyte-stimulated PBMC in vitro cultures. With stratification for disease stage, we determined that PBMC in vitro T lymphocyte-stimulated proliferation predicted outcome for the HNSCC patients. The results were similar for both laryngeal and oral cavity/pharyngeal cancers. The present investigation provides evidence to support the idea that the relationship between HNSCC and the immune system of the host may provide clinically useful information about prognosis.

Co-culture of Head and Neck Squamous Cell Carcinoma Spheroids with Autologous Monocytes Predicts Prognosis

Co‐culture of monocytes with autologous fragment (F) spheroids originating from malignant (M) tumour or benign (B) control mucosa of head and neck squamous cell carcinoma (HNSCC) yields interleukin (IL)‐6 and monocyte chemo‐attractant protein (MCP)‐1 secretion. This study investigates the association between this cytokine co‐culture response and prognosis. Analysis of IL‐6 and MCP‐1 content of supernatants from monocytes in vitro co‐culture with autologous MF‐ or BF‐spheroids was investigated in a cohort of HNSCC patients (n = 65) diagnosed between 1998 and 2005, all of whom were treated with curative intent by primary surgery. The IL‐6 response was expressed as a fraction of the lipopolysaccharid response of the same batch of monocytes. Recurrence, survival and causes of death were then established following the second part of 2005. MCP‐1 levels did not predict prognosis. We found that increased levels of IL‐6 from autologous monocytes in co‐culture with MF‐spheroids predicted recurrence with a hazard ratio (HR) of 1.5 [confidence interval (CI): 1.01–2.60; P = 0.05] and co‐culture with BF‐spheroids and monocytes predicted recurrence (HR = 4.17; CI: 1.54–11.29; P = 0.005). The same results where obtained in addition with TNM stage of the patients. Simultaneous analysis of BF‐ and MF‐spheroid co‐culture IL‐6 responses as well as adjustment for age and TNM stage of the patients allowed prediction of total survival (HR = 3.1; CI: 1.11–8.56; P = 0.03) based on BF co‐culture levels. IL‐6 secreted upon in vitro co‐culture with monocytes and BF‐spheroids predicts recurrence and prognosis, whereas co‐culture with monocytes and MF‐spheroids predicts recurrence.

Personality traits in head and neck squamous cell carcinoma patients in relation to the disease state, disease extent and prognosis

Objective --We aimed to study whether personality scores, as measured using the Eysenck Personality Inventory (EPI), are associated with the risk and prognosis of head and neck squamous cell carcinoma (HNSCC). Material and methods --A total of 78 male patients with newly diagnosed HNSCC and 61 male patients with benign HN disease completed the EPI, which assesses the following: neuroticism, extraversion and lie score. The TNM stage, prognosis, diagnostic delay, level of education and smoking and alcohol consumption histories of the patients were also recorded. Patients with cachexia and those aged > 80 years were excluded. Results --The cancer patients had higher neuroticism scores (10.7 - 0.5 vs 8.3 - 0.6; p < 0.01) than the control patients. This association was shown to be secondary to the fact that neuroticism is associated with increased alcohol consumption. The personality trait scores were not associated with the length of diagnostic delay. It was also suggested that a low lie score predicted disease-specific death in the HNSCC patients ( p = 0.02). Total survival also seemed to be predictable ( p < 0.05). Conclusion --Neuroticism is probably associated with a risk of HNSCC as a result of increased alcohol consumption. If the prognostic results can be replicated, a potentially important association between this personality trait and the prognosis of HNSCC is suggested.

Stimulated monocyte IL-6 secretion predicts survival of patients with head and neck squamous cell carcinoma

BackgroundThis study was performed in order to determine whether monocyte in vitro function is associated with presence, stage and prognosis of head and neck squamous cell carcinoma (HNSCC) disease.MethodsProspective study describing outcome, after at least five years observation, of patients treated for HNSCC disease in relation to their monocyte function. Sixty-five patients with newly diagnosed HNSCC and eighteen control patients were studied. Monocyte responsiveness was assessed by measuring levels of monocyte in vitro interleukin (IL)-6 and monocyte chemotactic peptide (MCP)-1 secretion after 24 hours of endotoxin stimulation in cultures supplied either with 20% autologous serum (AS) or serum free medium (SFM). Survival, and if relevant, cause of death, was determined at least 5 years following primary diagnosis.ResultsAll patients, as a group, had higher in vitro monocyte responsiveness in terms of IL-6 (AS) (t = 2.03; p < 0.05) and MCP-1 (SFM) (t = 2.49; p < 0.05) compared to controls. Increased in vitro monocyte IL-6 endotoxin responsiveness under the SFM condition was associated with decreased survival rate (Hazard ratio (HR) = 2.27; Confidence interval (CI) = 1.05–4.88; p < 0.05). The predictive value of monocyte responsiveness, as measured by IL-6, was also retained when adjusted for age, gender and disease stage of patients (HR = 2.67; CI = 1.03–6.92; p < 0.05). With respect to MCP-1, low endotoxin-stimulated responsiveness (AS), analysed by Kaplan-Meier method, predicted decreased survival (χ = 4.0; p < 0.05).ConclusionIn HNSCC patients, changed monocyte in vitro response to endotoxin, as measured by increased IL-6 (SFM) and decreased MCP-1 (AS) responsiveness, are negative prognostic factors.

Cross-cultural adaption and translation of the voice handicap index into Norwegian.

Aims: To examine the psychometric properties of a Norwegian translation of the Voice Handicap Index (VHI) and test its ability to discriminate between patients and controls. Abbreviated versions of VHI were also studied. Method: Following standard translation, 126 healthy subjects and 126 patients with laryngeal disease answered the Norwegian translation of the VHI-30 [hereafter, VHI-30(N)]. Results: The VHI(N) showed a high Cronbach α. Control/patient scores were as follows: Emotional (E): 0.88/0.90; Functional (F): 0.77/0.91; Physical (P): 0.86/0.83, and total: 0.93/0.94. One three-level question where the subjects rated the level of voice disease correlated well with the VHI(N) scores. The 90th (95th) percentile of the control score was 18 (33), whereas the mean ± SEM patient score was 52.3 ± 2.04 of a maximum of 120 points. Differences between patient and control groups were significant for all questions on the VHI(N). Receiver operating characteristic analyses demonstrate that the F, P, E and total VHI scores discriminated very well between patients and controls. This was also the case when the abbreviated scales were analyzed as published by Nawka et al. [Folia Phoniatr Logop 2009;61:37–48] and Rosen et al. [Laryngoscope 2004;114:1549–1556]. Conclusion: This Norwegian version of the VHI questionnaire seems to be psychometrically sound.