Kenneth W. Altman

Cough and paradoxical vocal fold motion

OBJECTIVES: The differential diagnosis and treatment of patients with chronic cough, paradoxical vocal fold motion, and disordered breathing can be a challenge to most practicing otolaryngologists. Tracheobronchial (ie, asthma, bronchitis, and tracheal stenosis), laryngeal (ie, vocal fold paralysis and neoplasms), and rhinologic (ie, allergies and rhinosinusitis) etiologies are commonly diagnosed and treated effectively. However, occasionally one is faced with patients who are refractory to medical treatment and have no obvious rhinologic, laryngeal or pulmonary cause. STUDY DESIGN AND SETTING: We conducted a review of the literature. METHODS: We present a thorough review of the current medical literature exploring the complex neurologic mechanisms involved in the production of cough and the relationship between gastroesophageal reflux disease, vagal neurapathy, and paradoxical vocal fold motion. RESULTS: The diagnosis and successful treatment of chronic cough can be complex. It requires a thorough understanding of the neurologic mechanisms behind cough excitation and suppression. Successful treatment strategies include aggressive management of the patients reactive airway disease, gastroesophageal reflux disease, and, in select cases, paradoxical vocal fold motion. This may involve a well-coordinated effort among pulmonologists, otolaryngologists, gastroenterologists, and speech pathologists. CONCLUSION: Gastroesophageal reflux disease, vagal neuropathy, and paradoxical vocal fold motion are additional causes of chronic cough and disordered breathing that need to be considered, in the absence of obvious laryngotracheal and/or rhinologic pathology. A high index of suspicion is essential in making the diagnosis and formulating an effective multidisciplinary treatment plan for these patients.

Changing Impact of Gastroesophageal Reflux in Medical and Otolaryngology Practice

Objectives/Hypothesis: A major trend in gastroesophageal reflux disease (GERD) is an observed increased prevalence of the problem, with an associated burden on health care resources. There are relatively few objective reports of increasing prevalence of this disease, and there are no epidemiologic reports that discuss changing practice strategies in managing the disease. The clinical problem is of critical importance to practicing otolaryngologists, who manage the impact of GERD on diseases affecting the ear, nose, and throat. The hypothesis of this thesis is that 1) GERD is an increasing problem affecting outpatient office visits over time, and 2) the disease is increasingly managed with prescription pharmacotherapy.

Common Movement Disorders Affecting the Larynx: A Report from the Neurolaryngology Committee of the AAO-HNS

Laryngeal physiology depends on dynamic neuromuscular forces acting on a basic framework of cartilage and specialized soft tissues, that is, the vocal folds. A working understanding of this organ in health and disease requires knowledge of specific neurological processes that may affect voice, swallowing, and airway regulation. Neuromuscular impairment continues to be a dominant topic in the study of laryngeal disorders. This subcommittee presentation reviews important aspects of the neurolaryngeal history and physical examination. After this foundation, 4 common movement disorders affecting the larynx are covered in separate subsections. These are stroke, Parkinsons disease, laryngeal tremor, and spasmodic dysphonia. State-of-the-art reviews reflecting our understanding of these clinical issues are presented in this summary.

Urgent Surgical Airway Intervention: A 3 Year County Hospital Experience

Objectives: To review the indications, complications, and outcomes of patients undergoing urgent surgical airway intervention.

Identification of Thyroid Hormone Receptors in the Human Larynx

Purpose: Thyroid hormone is essential for normal development, growth, and function of the majority of tissues. Among the many clinical signs associated with hypothyroidism, alterations in the voice may occur even in cases of mild thyroid failure, suggesting that the larynx is a target tissue for thyroid hormone. The objective of our study is to further understand the effects of thyroid hormone on the larynx by first identifying the presence and locations of its receptors. Methods: Two human cadaveric larynges (one male and one female) were harvested, formalin‐fixed, and paraffin‐embedded. Sections were immunostained with antibodies reactive with the two identified thyroid hormone receptors, TR‐α and TR‐β. The slides were examined under light microscopy. Results: Both male and female specimens revealed consistent patterns of staining for thyroid hormone receptors. The staining pattern for TR‐α included the fibrous connective tissue of the lamina propria, the cartilage, and the glandular elements. The staining pattern for TR‐β included the fibrous connective tissue of the lamina propria only. No receptors were identified in the respiratory mucosa or muscle. Conclusions: Thyroid hormone receptors are present in both the male and the female human larynx. These findings imply a role for thyroid hormone within the human larynx, through both TR‐α and TR‐β.

Myotonic dystrophy type 1 (DM1) presenting with laryngeal stridor and vocal fold paresis

Myotonic dystrophy type 1 (DM1) is the most common inherited muscle disorder and may present in numerous ways due to characteristic multisystem involvement. We report a 47‐year‐old man who presented with an 8‐year history of slowly progressive dyspnea and episodic stridor. The laryngeal paresis was documented with videostroboscopy and laryngeal electromyography, and treated with tracheostomy and antimyotonia agents.

Chronic lymphocytic leukemia manifesting in the paranasal sinuses

Chronic lymphocytic leukemia (CLL) is the most frequent leukemia of adults in Western countries. A neoplastic clonal expansion of B cells, CLL is an indolent disease most prevalent in older patients; 90% of patients are 50 years old. CLL is commonly associated with enlargement of the spleen and lymph nodes but uncommonly associated with expression in the head and neck, as seen in leukemia cutis (a leukemic infiltration of the skin). Expression of CLL in the paranasal sinuses is very rare, with only 2 cases reported.4,5 This report describes the case of a man with CLL and chronic sinusitis who was found to have a leukemic infiltrate in the nasal mucosa.

Laryngeal inflammatory response to smoke and vape in a murine model

PURPOSEnTo build a murine model for tobacco smoke and electronic cigarette vapor exposure to characterize the inflammatory and immune responses in the larynx.nnnMATERIALS AND METHODSnIn this pilot study, twenty-four wild-type C57BL/6 mice were divided into four groups: smoke, vapor with nicotine, vapor without nicotine, and air only. Following daily exposure for 4u202fmonths, larynges were dissected and processed with cytokine detection arrays. Each laryngeal cytokine level between the four different groups was analyzed statistically by using statistical analysis software (SAS) to calculate the analysis of variance (ANOVA).nnnRESULTSnIL-4 was the only cytokine found to achieve statistically significant different levels in this study, with elevated levels of IL-4 in the tobacco smoke and vapor with nicotine groups compared to the levels found in the vapor without nicotine and air only groups (pu202f=u202f0.0418). While statistically non-significant, prominent findings revealed up-regulation of TGF-β2 and TGF-β3 in the smoke group, but near-normal levels of TGF-β2 and TGF-β3 and suppression of IL-10 in the vapor groups (pu202f>u202f0.05).nnnCONCLUSIONnThe potential utility of the murine model is established for studying the inflammatory and immune effects of tobacco smoke and vapor on the mammalian larynx. IL-4 levels in mice larynges were significantly elevated in the tobacco smoke and vapor with nicotine groups.