John M. Schweinfurth

Risk factors and demographics in patients with spasmodic dysphonia.

Objectives Spasmodic dysphonia has been characterized as a functional, psychogenic, or movement disorder with no known etiology or cure. In the present study, risk factors associated with other movement disorders were evaluated in patients with spasmodic dysphonia.

Factors Associated with Long-Term Complications after Repair of Mandibular Fractures

Educational Objective: At the conclusion of this paper, the participants should be able to identify, compare, and discuss the natural history of complications of mandible fractures and repair.

Age of Child, More than HPV Type, Is Associated with Clinical Course in Recurrent Respiratory Papillomatosis

Background RRP is a devastating disease in which papillomas in the airway cause hoarseness and breathing difficulty. The disease is caused by human papillomavirus (HPV) 6 or 11 and is very variable. Patients undergo multiple surgeries to maintain a patent airway and in order to communicate vocally. Several small studies have been published in which most have noted that HPV 11 is associated with a more aggressive course. Methodology/Principal Findings Papilloma biopsies were taken from patients undergoing surgical treatment of RRP and were subjected to HPV typing. 118 patients with juvenile-onset RRP with at least 1 year of clinical data and infected with a single HPV type were analyzed. HPV 11 was encountered in 40% of the patients. By our definition, most of the patients in the sample (81%) had run an aggressive course. The odds of a patient with HPV 11 running an aggressive course were 3.9 times higher than that of patients with HPV 6 (Fishers exact p = 0.017). However, clinical course was more closely associated with age of the patient (at diagnosis and at the time of the current surgery) than with HPV type. Patients with HPV 11 were diagnosed at a younger age (2.4y) than were those with HPV 6 (3.4y) (p = 0.014). Both by multiple linear regression and by multiple logistic regression HPV type was only weakly associated with metrics of disease course when simultaneously accounting for age. Conclusions/Significance Abstract The course of RRP is variable and a quarter of the variability can be accounted for by the age of the patient. HPV 11 is more closely associated with a younger age at diagnosis than it is associated with an aggressive clinical course. These data suggest that there are factors other than HPV type and age of the patient that determine disease course.

High level expression of human epithelial β-defensins (hBD-1, 2 and 3) in papillomavirus induced lesions

BackgroundEpithelial defensins including human β-defensins (hBDs) and α-defensins (HDs) are antimicrobial peptides that play important roles in the mucosal defense system. However, the role of defensins in papillomavirus induced epithelial lesions is unknown.ResultsPapilloma tissues were prospectively collected from 15 patients with recurrent respiratory papillomatosis (RRP) and analyzed for defensins and chemokine IL-8 expression by quantitative, reverse-transcriptase polymerase chain reaction (RT-PCR) assays. HBD-1, -2 and -3 mRNAs were detectable in papilloma samples from all RRP patients and the levels were higher than in normal oral mucosal tissues from healthy individuals. Immunohistochemical analysis showed that both hBD-1 and 2 were localized in the upper epithelial layers of papilloma tissues. Expression of hBD-2 and hBD-3 appeared to be correlated as indicated by scatter plot analysis (r = 0.837, p < 0.01) suggesting that they were co-inducible in papillomavirus induced lesions. Unlike hBDs, only low levels of HD5 and HD6 were detectable in papillomas and in oral mucosa.ConclusionHuman β-defensins are upregulated in respiratory papillomas. This novel finding suggests that hBDs might contribute to innate and adaptive immune responses targeted against papillomavirus-induced epithelial lesions.

Arytenoid dislocation: An analysis of the contemporary literature.

To discuss the incidence, diagnosis, laryngeal findings, and management of arytenoid dislocation as a separate entity from vocal fold paralysis.

Presence of human papillomavirus DNA in tonsillectomy specimens

Objectives: The objectives of this prospective case–control study were to study the prevalence of human papillomavirus (HPV) in tonsillectomy specimens from pediatric patients without recurrent respiratory papillomatosis (RRP), and to study methods of HPV detection.

Single-Stage, Stentless Endoscopic Repair of Anterior Glottic Webs

INTRODUCTION The majority of laryngeal scars occur at the level of the glottis. Even limited scarring of the anterior commissure can severely impair voice production, whereas more extensive scarring can restrict respiration. The management of laryngeal scarring is made difficult by the tendency of fibrosis to recur locally. Treatment is further complicated by limited access. The solution to these problems has traditionally been exposure through a laryngofissure and placement of a stent or keel. This procedure has significant downsides in that it requires prolonged intubation or tracheotomy and a second procedure to remove the stent. Single-staged repair has been described without the use of a stent; however, this requires a laryngofissure and mechanical ventilatory support for 5 to 7 days. In addition, once divided by laryngofissure, the anterior commissure can be difficult to reapproximate into its original premorbid state. The primary problem in the approach to laryngeal scars is the handling of raw surfaces created by the division of the web. When unopposed, these surfaces have a strong tendency to create further fibrosis and webbing. The technique described in the present report provides a means of destroying the web without the creation of uncovered mucosal surfaces.

Image Guidance–Assisted Repair of Bilateral Choanal Atresia

INTRODUCTION Image guidance systems have been employed in endoscopic sinus surgery because of the precision and added safety when working near the orbit and skull base. Proponents of image-guided surgery recommend its use when surgical landmarks may be obscured. Similarly, endonasal anatomy in the face of congenital abnormalities, such as CHARGE or Down’s syndrome, can be significantly altered to make the endoscopic approach more challenging. The purposes of the present study were to employ an image-guided system in the endoscopic repair of bilateral bony choanal atresia and to demonstrate its advantages in the face of altered skull base anatomy. The surgical approach for choanal atresia may be transpalatal, transnasal, or transeptal. The transpalatal approach carries the advantages of excellent visualization of the atretic plate, creation of a mucosa-lined cavity, and reduced duration of stenting. Disadvantages include the risk of maldevelopment of the dental arch, crossbite deformity, and palatal fistula. The transnasal approach has been popularized with the increasingly common use of endoscopic instrumentation and lasers. This approach has the advantage of decreased operative time and morbidity. Despite the advantages of the transnasal approach, a recent survey of the American Society of Pediatric Otolaryngology members revealed that it was only slightly more commonly employed than the transpalatal approach. To prevent restenosis, many authors have recommended removal of the vomer and medial pterygoid. Enlargement of the newly formed choana is restricted by the known and perceived limits of the dissection: the skull base, midbrain, spine, carotid arteries, and palate. Proponents of the transpalatal or transseptal approaches cite the potential for damage to the sphenoid, eustachian tubes, brainstem, and spinal cord. Clearly, surgical goals of a widely patent choanal opening and prevention of complications secondary to violation of local structures are at odds. Therefore, the potential advantage of image-guided surgery in this application would be to allow the surgeon to maximize choanal patency while minimizing risk to adjacent structures.

Management of recurrent laryngeal sensory neuropathic symptoms.

Objectives We identify management strategies for the treatment of upper respiratory tract symptoms stemming from dysfunction of the recurrent laryngeal nerve. Methods We present a retrospective case series of patients who had symptoms of sensory neuropathy, including persistent dysphonia, laryngospasm, and chronic cough. The patients were followed for symptomatic improvement after initiation of treatment with a neuromodulator. Treatment outcome was defined by improvement or resolution of symptoms on a self-reported outcome scale. Results Of 12 patients identified, 75% exhibited evidence of motor neuropathy on laryngoscopy and 83% had symptoms related to chronic cough treated with neuromodulator therapy over a mean follow-up of 20.4 months. The median dose of amitriptyline hydrochloride was 25 mg daily, and that of gabapentin was 300 mg 3 times daily. The mean time from the initiation of therapy to a complete response was 2 months. Conclusions Patients with suspected neuropathy of the recurrent laryngeal nerve frequently respond to neuromodulator therapy. The addition of reflux precautions and acid suppression therapy is helpful in cases of chronic and recurrent laryngospasm. Patients with evidence of motor neuropathy appear to have better outcomes with neuromodulator therapy.

Jugular foramen syndrome as a complication of metastatic melanoma

INTRODUCTION The jugular foramen (Vernet) syndrome with neuropathy of cranial nerves IX-XI is more commonly due to metastatic lesions than primary neoplasms. Hypoglossal nerve involvement is referred to as the Collet Sicard variant of the jugular foramen syndrome. MATERIALS AND METHODS We report an elderly man who presents with dysphagia, dysarthria, hoarseness, and a 12-pound weight loss. Examination demonstrated paralysis of the right vagus and hypoglossal nerve. Communication and collaboration with the radiologist resulted in identification of the lesion. Computed tomographic (CT) guided needle aspiration confirmed metastatic melanoma. DISCUSSION The onset of cranial neuropathy may allow the site of lesion to be predicted based on knowledge of the cranial base and neural anatomy. Diagnostic evaluation is tailored to evaluate the area in question. Active, multidisciplinary collaboration is essential for success.