Klaus Wassermann

Cordectomy versus Arytenoidectomy in the Management of Bilateral Vocal Cord Paralysis

Our objective was to assess the effectiveness of transoral laser cordectomy and laser arytenoidectomy and to compare the results with a view to respiratory and phonatory function and deglutition. Twenty-eight patients with bilateral vocal cord paralysis were included in a prospective study. Eighteen patients had cordectomy, and 10, arytenoidectomy. Lung function tests and voice analysis were performed preoperatively and postoperatively. Subclinical aspiration was determined by endoscopic evaluation of the larynx during deglutition. The results were compared to determine the relative effectiveness of both surgical methods. How volume spirograms documented equally improved flow rates in both groups. The final voice evaluation revealed that maximum phonation time, peak sound pressure levels, and frequency range were reduced in all 28 patients, but the phonatory results varied considerably in each group. Subclinical aspiration was noticed in 5 of 10 patients after arytenoidectomy, but in none of 18 patients after cordectomy. Four of 6 previously tracheostomized patients were decannulated within 2 weeks after surgery, while the other 22 patients had no perioperative tracheostomies. We conclude that transoral laser cordectomy and arytenoidectomy are equally effective and reliable in the management of the restricted airway. Phonatory outcome is not predictable with either surgical procedure. Cordectomy is easier and faster to perform, and subclinical aspiration is not encountered with this procedure.

Impairment of exercise capacity in various groups of HIV-infected patients

It is known that pulmonary function is impaired during the course of HIV infection even in early stages. In order to estimate the resulting reduction of exercise capacity, different groups of HIV patients were investigated. Group 1 consisted of 20 patients without a history of respiratory disease and without actual lung disease, group 2 of 18 patients with a former episode of Pneumocystis carinii pneumonia (PCP) without actual lung disease, and group III of 37 patients with different broncho-pulmonary complications including PCP. 20 normal subjects served as controls. Spirometry, diffusing capacity (DLCO) and exercise tests including arterial blood gas analysis (BGA) were performed in patients and controls. Compared to the controls group 1 patients revealed a decreased DLCO (TCO: 83 +/- 15 vs. 67 +/- 15% pred.norm.) while spirometric data were normal. VO2 and O2 pulse at the anaerobic threshold (17.7 +/- 5.1 vs. 14.3 +/- 2.6 ml/kg.min and 10.8 +/- 4.0 vs. 8.6 +/- 1.9 ml/beat, respectively) and maximum exercise (33.9 +/- 9.7 vs. 22.1 +/- 3.4 ml/kg.min and 15.0 +/- 5.0 vs. 11.3 +/- 2.5, respectively) were decreased, whereas AaDO2, VD/VT, and the HR/VO2 slope were normal. The reserves of heart rate and ventilation were high. Except for a reduced maximum work rate in group 1, no significant difference was found between groups 1 and 2. Group 3 patients differed most from groups 1 and 2 with respect to spirometry, DLCO and AaDO2, rather than VO2.(ABSTRACT TRUNCATED AT 250 WORDS)

Measuring in Situ Central Airway Resistance in Patients With Laryngotracheal Stenosis

Objectives: To evaluate a newly developed bronchoscopic technique for the assessment of intratracheal pressures.

Suspension Laryngoscopy for Endotracheal Stenting

Objectives/Hypothesis Airway stents have recently been used to establish and maintain patent airways in patients with malignant central airway obstruction, but insertion modalities remain controversial to date. The study seeks to determine the role of suspension laryngoscopy in interdisciplinary airway stenting.

Concurrent Glottic and Tracheal Stenoses: Restoration of Airway Continuity in End-Stage Malignant Disease

Six patients known to have inoperable esophageal carcinoma presented with stridor due to both malignant tracheal stenosis (with additional respiratory-digestive tract fistula in 2 patients) and bilateral vocal cord paralysis. Patency was restored by endotracheal stenting plus unilateral cordotomy. Four patients had immediate relief. Two patients required enlargement of the vocal cord incision. One of them declined reoperation and underwent tracheostomy. The stent function was uneventful, with no dislodgment or mucus impaction. The fistula seal was complete, with no aspiration through the newly shaped glottic orifice. The peak expiratory flow increased from 24.4% ± 9.7% of predicted normal before the procedure to 40.5% ± 13.7% after the procedure. Restoration of airway continuity in serial laryngotracheal stenoses by a combined approach is a feasible technique in end-stage cancer patients. It effectively relieves respiratory distress and ensures voice preservation. In addition, it may avoid the risks of tracheotomy.

Chronic Eosinophilic Pneumonia with Atypical Radiographic Presentation

Chronic eosinophilic pneumonia (CEP) is a rare disease characterized by a progressive symptomatic deterioration of more than 1 month, pulmonary infiltrates with eosinophils, and a dramatic response to corticosteroid treatment. We describe a patient with CEP who presented with right upper lung infiltrates with evidence of cavitation.

Malignant laryngotracheal obstruction: a way to treat serial stenoses of the upper airways

BACKGROUND Six patients known to have inoperable esophageal carcinoma presented with stridor due to both malignant tracheal stenosis (n = 6) and bilateral vocal cord paralysis. Two patients also had respiratory-digestive fistula. METHODS Patency was restored by endotracheal stenting plus unilateral cordectomy. Four patients had immediate relief. Two patients required enlargement of the cord incision. One of them declined reoperation and underwent tracheotomy. RESULTS Stent function was uneventful. There was no dislodgement or mucous impaction. Fistula seal was complete. There was no aspiration through the new-shaped glottic orifice. Peak expiratory flow increased from 24.4% +/- 9.7% predicted normal before to 40.5% +/- 13.7% after the procedure, whereas the dyspnea score decreased from 74.2 +/- 12.7 to 24.2 +/- 14.0. CONCLUSIONS Restoration of airway continuity in serial laryngotracheal stenoses using a combined approach is a feasible technique in end-stage cancer patients. It effectively relieves respiratory distress and ensures voice preservation. In addition, it may avoid the risks of tracheotomy.

Suspension laryngoscopy for endotracheal stenting

OBJECTIVES/HYPOTHESIS Airway stents have recently been used to establish and maintain patent airways in patients with malignant central airway obstruction, but insertion modalities remain controversial to date. The study seeks to determine the role of suspension laryngoscopy in interdisciplinary airway stenting. STUDY DESIGN Retrospective, single-institution analysis of a case series treated by a multidisciplinary airway team. METHODS Ninety-three consecutive patients with malignant obstruction of the trachea and/or tracheobronchial bifurcation underwent endotracheal stenting through a suspension laryngoscopy approach for the relief of impending respiratory distress. Feasibility, mortality, survival, and complications were analyzed as main outcome measures. RESULTS Stenting through a suspension laryngoscopy approach was feasible 91 of 93 patients (97.8%). Fifteen patients needed repeated stenting, and in all, 121 stents were implanted during the observation period. This approach allowed for the repeated insertion of rigid bronchoscopes of graded sizes to establish an airway and for precise stent positioning. Optical instruments and stent introducer systems could easily be used while adequate ventilation was continuously maintained. Silicone stents of maximal size were inserted without injury of the vocal cords during intubation. Median survival for all patients was 8 months. No intraoperative airway complications were observed, and no patient died secondary to stenting. CONCLUSIONS Suspension laryngoscopy and jet ventilation provide an ideal setting for the precise placement of tracheal and bifurcation airway stents. Laryngologists should actively participate in interdisciplinary airway stenting programs.

Cardiopulmonary Exercise Testing in the Diagnosis of HIV-Infected Patients

Pulmonary complications are a major cause of morbidity and mortality in patients with acquired immunodeficiency syndrome (AIDS). Full-blown pneumocystis carinii pneumonia (PCP) with fever, cough, dyspnea, interstitial infiltrates in the x-ray, and low oxygen tension in the arterial blood gas analysis is easy to diagnose. In contrast, early diagnosis of PCP is difficult, because x-ray of the chest and arterial oxygen tension are often normal and respiratory symptoms are unspecific. Early treatment of pulmonary complications improves prognosis of the HIV-infected patients, therefore functional screening tests for early recognition are needed. Exercise blood gas analysis (Ex.-BGA) has been proven to be a highly sensitive marker of approaching interstitial pneumonia [1]. Cardiopulmonary exercise testing (CPX) measures pulmonary gas exchange and is a modern computerized version of spiroergometry, used to test cardiopulmonary limitations to exercise. Little is known about CPX in the diagnosis of HIV-associated pulmonary complications. It was therefore the aim of our study to investigate the diagnostic value of CPX for early diagnosis of pulmonary complications in HIV-infected patients.