Karl Kiesler

Effect of Pantoprazole on the Course of Reflux-Associated Laryngitis: a Placebo-Controlled Double-Blind Crossover Study

Background: The optimal management of patients with reflux-associated laryngitis is unclear. We performed a placebo-controlled crossover trial in patients with proven reflux disease and associated laryngitis to determine the effect of pantoprazole and to gain information on the natural course of the disease. Methods: Sixty-two consecutive non-smoking patients with hoarseness and proven laryngitis were examined. Scores with respect to the larynx and for subjective complaints were determined and 24-h pH-metry to assess acid reflux in the lower oesophagus and pharynx was performed. Patients with pathologic reflux were given the chance to enter a double-blinded randomized crossover trial with pantoprazole 40 mg b.i.d. and placebo for a duration of 3 months each, separated by a 2-week washout period. Results: Twenty-four of 62 patients showed pathological reflux; 21 patients were included in the study and 14 concluded all parts of the study. Both pantoprazole and placebo resulted in a marked improvement in laryngitis scores (decrease of 8.0 ± 1.4 versus 5.6 ± 2.6; no significant difference between the 2 treatments) and symptoms after the first 3 months (decrease of oesophageal symptom score of 2.2 ± 1.4 versus 5.4 ± 2.8; decrease of laryngeal scores of 8.3 ± 3.6 versus 10.3 ± 3.9; also no significant difference between the 2 treatments). A second pH-metry 2 weeks thereafter proved the persistence of reflux in most of these patients. Switching to pantoprazole led to a further improvement of scores. In the group switched to placebo there was recurrence only in a minority of patients. Conclusions: The self-limited nature of reflux-associated laryngitis in non-smokers is largely underestimated. Laryngitis improves despite the persistence of reflux. Pantoprazole may be helpful especially in relieving acute symptoms, but the advantage of long-term treatment over placebo has been greatly overestimated.

Sex hormones and the elderly male voice.

The objective was to describe influences of sex hormones on the male voice in an elderly cohort. Sixty-three elderly males were recruited to undergo assessment of voice parameters, stroboscopy, voice-related questionnaires, a blood draw, and an ultrasound examination of the laryngeal skeleton. The group was divided into men with normal hormonal status and men with lowered levels of sex hormones, called hypogonades. Depending on the level of androgens, voice parameters did not differ. In subjects with decreased levels of estrogens, a significant increase in mean fundamental frequency, as well as changes of highest and lowest frequency plus a shift of the frequency range could be detected. We could detect significant changes of voice parameters depending on status of estrogens in elderly males. Androgens appear to have no impact on the elderly male voice. To our knowledge, this is the first prospective study that correlates sex hormones with voice parameters in elderly men.

Short-Term Therapeutic Trial of Proton Pump Inhibitors in Suspected Extraesophageal Reflux

Pharyngoesophageal gastric acid reflux is thought to initiate chronic posterior laryngitis. The gold standard for measuring gastric reflux is dual-channel 24-hour pH monitoring. This is a time-consuming, inconvenient, expensive method that is not available in all areas. New therapeutic regimes that make use of proton pump inhibitors (PPIs) have proven to be therapeutically efficient for control of acid reflux. Twenty-four consecutive patients with chronic voice disorders and signs of posterior laryngitis were selected for therapy. Twenty-four hour pH monitoring was performed independently before the therapy. The trial therapy consisted of all patients receiving pantoprazole, 40 mg once daily for 6 weeks. Immediately following the therapy a statistically significant (p < 0.05) improvement was observed in all patients. This improvement was analyzed retrospectively by comparison with the results of 24-hour pH monitoring. In 71% of the patients the 24-hour pH-monitoring gave a positive result showing a high number of patients with extraesophageal reflux in our study group. Patients with positive results of pH-monitoring responded in a statistically significant manner (p < 0.05) to the pantoprazole therapy, whereas those patients without detected reflux did not. A 3-month follow-up of the patients with a positive result of the pH-monitoring confirmed the improvement. No patients reported adverse effects. A 6-week treatment with pantoprazole can be clinically justified. It helps to save time and reduce costs, allows for selection of reflux-negative patients for alternative therapy, and may prevent inadequate treatment of patients with false-negative pH monitoring. Twenty-four hour pH monitoring is still recommended for patients unresponsive to this trial therapy.

Subjective Breathing Impairment in Unilateral Vocal Fold Paralysis

Introduction: Dysphonia is considered a major symptom of unilateral vocal fold paralysis (UVFP). Besides this, many patients complain of further symptoms such as dysphagia and dyspnea, which might not be expected to such an extent. The aim of this survey was to elucidate these symptoms in a cohort of patients with UVFP. Subjects and Methods: Sixty-three patients (22 men, 41 women) suffering from UVFP were interviewed. Therefore we developed a questionnaire dealing with each of the three symptom categories: voice production, swallowing and breathing. Results: All of the surveyed patients reported voice impairment, almost 60% complained of swallowing problems after the onset of paralysis. Seventy-five percent reported a subjectively impaired breathing sensation, not just phonatory dyspnea but during everyday physical activity as well. Discussion: Our study revealed a certain discrepancy between objectively assessed laryngoscopic findings and subjective symptoms. A majority of patients suffered from an impairment in each of the three laryngeal functions (dysphonia, dysphagia and dyspnea). The latter two differ from the classic approach to this condition but must be considered as well in clinical diagnostics and therapy.

Vitamin D status is associated with disease-free survival and overall survival time in patients with squamous cell carcinoma of the upper aerodigestive tract

Considerable clinical and experimental data suggest that vitamin D plays a role in pathogenesis and progression of cancer; nevertheless clinical data for head and neck squamous cell carcinoma (HNSCC) are not available. The aim of our study was to associate tumor and clinical characteristics with status of vitamin D [25-hydroxyvitamin D (25(OH)D)]. 88 patients with newly diagnosed squamous cell carcinoma of the head and neck were included in the study. A blood draw was taken at the time of diagnosis. The observation period lasted from 2006 until 2010. Results: When compared to a cohort from an epidemiological study, serum levels of 25(OH)D were significantly reduced in patients with HNSCC. We furthermore found disease-free survival, as well as overall survival times to be significantly associated with 25(OH)D levels. In conclusion, results from our study suggest an influence of vitamin D status on cancer incidence, as well as on mortality of HNSCC.

Hyperplastic epithelial lesions of the vocal folds: combined use of exfoliative cytology and laryngostroboscopy in differential diagnosis

The mainstay of successful tumor therapy is early detection of neoplastic tissue. Although exfoliative cytology has proven to be a reliable tool, its importance is still underestimated. Laryngostroboscopy is the most important tool for functional investigation in laryngological and phoniatric diagnosis. Stroboscopic evaluation allows early detection of infiltrative processes of the vocal folds. Aim of our study was to demonstrate that combination of both, exfoliative cytology and stroboscopy, provides a highly sensitive and easy to perform method in differential diagnosis of epithelial hyperplastic lesions of the vocal folds. In 130 patients with varying degrees of vocal fold keratosis up to glottic cancer, preoperative layngostroboscopy was performed. Stroboscopy was classified pathological in case of reduced or abolished amplitude of vocal fold vibration and/or reduced or abolished mucosal wave propagation. Under general anaesthesia histology with corresponding cytological specimens were obtained. The latter were classified in three groups reaching from normal (I), dysplastic (II), up to malignant (III) cytology. Invasive carcinoma was diagnosed in 32 cases by histology, corresponding malignant cytology was found in 21 specimens (sensitivity: 74%). By certain combination of cytology with pathological stroboscopy, a sensitivity of more than 97% can be achieved. Combination of cytology and stroboscopy allows detection of glottic cancer with a sensitivity of 97%, in contrast to 74% as found by cytology alone. This combination can be used as preliminary or sorting procedure and gives the opportunity of early detection, as well as for follow-up examinations. For repeated biopsies can cause scars with consecutive voice impairment, this procedure is very smooth but nevertheless reliable method.

Curved rigid laryngoscope: missing link between direct suspension laryngoscopy and indirect techniques?

Microlaryngoscopy is the standard procedure for endolaryngeal surgery. The advantages are a steady operating field, bimanual handling and stereoscopic view in high-resolution magnification. The major drawback is that the oropharyngeal structures have to be brought into an unnatural position by the straight rigid laryngoscope with considerable forces occurring. These forces can lead to tissue injuries or even make a microlaryngoscopic operation impossible. To overcome these disadvantages, a few case studies using curved rigid laryngoscopes are published. However, there is still a lack of information to what extent curved rigid laryngoscopes could actually improve the endolaryngeal exposure with less forces occurring. It was the aim of this study to gain basic data on the forces that are needed for endolaryngeal exposure with a prototype of a curved rigid laryngoscope and to compare the occurring forces with straight laryngoscopes. In 30 consecutive patients scheduled for routine microlaryngoscopic procedures the curved laryngoscope was inserted and occurring forces were measured by a tension spring balance in four different head positions. A standard straight laryngoscope was inserted afterwards and measurements were taken again. Our results showed that the occurring forces could be reduced significantly in each head position when compared with a standard straight laryngoscope. Similarly, the anterior commissure could be exposed in a significantly higher percentage with the curved laryngoscope. In conclusion, we could show that even with a moderate-curved rigid laryngoscope a significant reduction of the forces to the oro-pharyngeal tissues can be obtained and that endolaryngeal exposure is possible in virtually all patients. Bimanual precise operations should be possible in the common way like in standard microlaryngoscopy with the only difference of not using a microscope, but operating via a monitor. We do not think that traditional microlaryngoscopy with straight instruments can or should be replaced by curved laryngoscopes, but these techniques could bridge the gap to indirect techniques in particular in specialised institutions dealing frequently with difficult patients and situations.

Laryngeal manifestation of gout: a case report of a subglottic gout tophus

A subglottic tophaceous deposition of urate crystals is a rare finding. We report on a case of a male Caucasian who had a moderate dysphonia without any further laryngeal symptoms. The laryngoscopy revealed a hemispheric lesion on the left subglottic region. An excision biopsy was performed, and the histopathological examination of the dissected specimen showed a tophus. Diagnostic and therapeutic strategies are discussed.

Incidence and clinical relevance of herniation of the mylohyoid muscle with penetration of the sublingual gland

Swelling of the submandibular region may cause problems in daily clinical diagnosis and requires further exploration. Ultrasonic examination provides a simple, non-invasive and radiation-free method. The goal of our study was to show the high incidence of herniation of the mylohyoid muscle with penetration of the sublingual glands, in some cases clinically imposing as permanent swelling. Penetration was classified into four grades (Grade 0–III). In course of routine examinations of the neck by ultrasound, the anterior part of the mylohyoid muscle was observed in 124 consecutive patients from our outpatient’s clinic, presenting with unclear swelling of the neck, mostly due to lymph nodes. In resting position and during swallowing the degree of penetration of the sublingual gland through the mylohyoid muscle was staged. Almost 60% of patients showed an affection of the mylohyoid muscle at either site of varying degrees. In 40% only a thinning of the muscle could be noticed (grade I), whereas in 21 patients (17%) a significant herniation of the gland during swallowing could be observed (grade II). In two patients (2%) a constant breach of the mylohyoid muscle with permanent herniation of the gland imposing as swelling could be seen (grade III). Occasional or permanent penetration of the sublingual gland through the mylohyoid muscle is not a rare finding and can be found in almost every fifth individual using ultrasound. This may impose clinically as permanent swelling and may be of value in the differential diagnosis of swelling in the submandibular region.

The unsolved chapter of vocal fold scars and how tissue engineering could help us solve the problem

Vocal fold scarring is a relatively small field in scar research with prerequisites found nowhere else. The deterioration of the delicate tri-layered micro-structure of the epithelium of the vocal folds leads to impaired vibration characteristics resulting in a permanent hoarse and breathy voice. Tissue engineering approaches could help to restore the pre-injury status. Despite a considerable progress in this field during the last years, routine clinical applications are not available so far. One reason might be that vocal fold fibroblasts, as the responsible cell type for fibrogenesis, have very particular properties that are only poorly characterized. Moreover, in vivo trials are costly and time consuming and a representative in vitro model does not exist so far. These particular circumstances lead to innovative in vitro strategies and concepts such as macro-molecular crowding that can also be applied in adjacent fields.