Kevin K. Bach

Prevalence of esophagitis in patients with pH-documented laryngopharyngeal reflux.

Objective To report the prevalence of esophagitis in patients with pH‐documented laryngopharyngeal reflux.

The role of transnasal esophagoscopy in head and neck oncology.

Objectives/Hypothesis To review the current role of transnasal esophagoscopy (TNE) in all aspects of head and neck cancer patient treatment.

In-office tracheoesophageal puncture using transnasal esophagoscopy

INTRODUCTION Vocal rehabilitation following a total laryngectomy employing a prosthesis placed within a surgically created tracheoesophageal fistula has become a well accepted and widely practiced technique since its first description by Singer and Blom in 1980. The tracheoesophageal puncture (TEP) may be performed primarily (i.e., at the time of laryngectomy) or secondarily, following maturation of the tracheostoma. Many surgeons elect to perform TEP as a secondary procedure in an effort to optimize placement of the puncture and to avert complications that may be associated with its primary placement. Initial descriptions of secondary TEP focused on techniques employing rigid esophagoscopes during general anesthesia. –7 Although efficacious in the majority of patients, these rigid techniques have several drawbacks. Often, passing the rigid endoscope is difficult, particularly in the irradiated patient, because of limited passive neck extension, cervical spondylosis, cervical osteophytes, stenosis of the neopharynx at the resection site, prominent superior incisors, or a low stoma in a long neck. Altered hypopharyngeal anatomy following more complex reconstructive techniques may also present problems for rigid endoscopy. The use of general anesthesia in patients with significant cardiopulmonary disease, which is often coexistent in patients with laryngeal cancer, may also be associated with significant morbidity. Placement of the TEP with the patient under a general anesthetic precludes the immediate placement of the voice prosthesis itself and therefore prohibits immediate voicing at the conclusion of the procedure. More recent reports have described the use of a standard gastroenterological flexible fiberoptic endoscope (passed through the oral cavity) for direct visualization of the esophagus during creation of the TEP. –13 This technique offers several advantages, the most important being improved visualization of the operative site within esophageal lumen during TEP. It also averts many of the difficulties and potential complications associated with the use of the rigid endoscope. Its ability to be performed in the outpatient surgical setting using only intravenous sedation confers another significant advantage. As an alternative, several authors have described a range of techniques employing specific instruments designed to assist in performing the TEP. Although these variations are touted as simplifying the procedure, none can provide direct visualization of the esophageal lumen during the creation of the puncture and its initial instrumentation. This is a significant detriment because unrecognized injuries of the posterior esophageal wall may lead to the creation of a false passage, infectious complications, and subsequent stenosis formation. Ultimately, suboptimal voice rehabilitation may occur. In addition to the safety concerns brought about by nonendoscopic TEP techniques, there is the associated disadvantage of failing to recognize a recurrent or second primary malignancy within the neopharynx or esophagus. In 2001, in a series reported by Desyatnikova et al., a technique employing only local anesthesia in the clinic setting was described for the placement of TEP. However, although the flexible nasopharyngoscope was employed for visualizing the hypopharynx, direct visualization of the esophageal lumen during the procedure was not obtained. Recent advances in fiberoptic endoscopy have become available that allow in-office transnasal esophagoscopy requiring only topical anesthetic, without sedaFrom the Center for Voice Disorders of Wake Forest University, Winston-Salem, North Carolina, U.S.A. Editor’s Note: This Manuscript was accepted for publication June 13, 2002. Send Correspondence to Gregory N. Postma, MD, Center for Voice Disorders of Wake Forest University, Department of Otolaryngology, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157-1034, U.S.A. E-mail: gpostma@wfubmc.edu

The evaluation of esophageal function using transnasal esophagoscopy

of the vocal folds with CaHA between 06/01/02 and 12/31/02 were prospectively evaluated. Data concerning indications, technique, functional outcome, and complications were collected. In addition, the larynx donated from a woman who underwent vocal fold augmentation with CaHA and subsequently died from terminal cancer was histologically examined. Results: A total of 35 vocal folds in 20 individuals were injected with CaHA. The mean age of the cohort was 62. Fifty-five percent were male. The indications for augmentation were unilateral vocal fold paralysis (7/20), unilateral vocal fold paresis (5/20), presbylarynx (3/20), bilateral vocal fold paresis (2/20), sulcus vocalis (2/20), and abductor spasmodic dysphonia (1/20). There were no adverse reactions. All individuals reported improvement on a self-administered disease-specific outcome measure (P 0.05). The pathology from the donated larynx 3 months after injection revealed intact CaHA spherules in good position with a minimal, monocellular inflammatory reaction to the gel carrier and no evidence of implant rejection. Conclusions: Initial experience with vocal fold augmentation using CaHA is promising. Long-term safety and efficacy need to be established.