Melin Tan

Injection Laryngoplasty with Micronized Dermis: A 10-Year Experience with 381 Injections in 344 Patients

Micronized Dermis (MD) has been used for injection laryngoplasty for correction of glottic insufficiency since 2000. There is controversy whether the material is temporary or permanent. This is a retrospective review of 381 injections in 344 patients. From this review, we hope to better define the role of MD in injection laryngoplasty.

Allograft (Alloderm) and Autograft (Temporalis Fascia) Implantation for Glottic Insufficiency: A Novel Approach

OBJECTIVE Traditionally, glottic insufficiency because of scar, atrophy, and sulcus has been treated by injection or medialization laryngoplasty. These procedures do not reestablish the vertical height of the vocal fold margin. We propose soft tissue augmentation laryngoplasty with allograft (sheet Alloderm; LifeCell Corporation, Branchburg, NJ) or autograft (temporalis fascia) via a minithyrotomy or a transoral approach. STUDY DESIGN A retrospective case series analysis of 21 patients treated by sheet Alloderm or temporalis fascia for correction of glottic insufficiency. METHODS Twenty-one patients with glottic insufficiency secondary to scar, atrophy, or sulcus were treated. Ten failed prior techniques. Seventeen had minithyrotomy by a small fenestration in the thyroid cartilage. Exploration of scar or lamina propria through the fenestration allowed for the creation of a pocket for Alloderm implantation within the intermediate layer of the lamina propria. Four patients underwent a transoral approach by cordotomy with either Alloderm or temporalis fascia implantation, which also allowed for exploration of scar but required repair using sutures. These implantation approaches allowed for both restoration of the layered structure and augmentation of the middle third of the musculomembranous vocal fold. Preoperative and postoperative videostroboscopic examinations were reviewed with review of clinical outcome. RESULTS With a median follow-up time of 12 months, patients demonstrated excellent long-term vocal fold augmentation and minimal absorption of the implant in 19 out of 21 patients. There is improved pliability of the vocal fold with good oscillation in scar patients. CONCLUSION Minithyrotomy with soft tissue augmentation is a novel approach for soft tissue augmentation of glottic insufficiency. It has the advantage of augmentation of the medial edge of the vocal fold with a soft tissue implant that has long-term viability. Its role should be explored further in patients with atrophy and scar.

Risk factors associated with severe and recurrent angioedema: An epidemic linked to ACE-inhibitors

To evaluate the etiology and risk factors for severe manifestation and recurrent episodes of angioedema; to evaluate efficacy of short‐term and long‐term management strategies for angioedema among a high‐risk population.

Western Blot Confirmation of the H+/K+-ATPase Proton Pump in the Human Larynx and Submandibular Gland

Objective. The authors have previously demonstrated the H+/K+-ATPase (proton pump) in human larynx and lung glands via immunohistochemistry (IHC). The present hypothesis is that the proton pump is expressed in other seromucinous glands of the digestive tract that can be confirmed by IHC and Western blot analysis. Study Design. Prospective controlled tissue analysis study. Setting. Academic medical institution. Methods. Ten anonymous fresh-frozen donor specimens were obtained, comprising 3 submandibular glands, 4 larynges, and 3 normal stomach specimens for control. Submandibular gland sections were immunostained with 2 monoclonal antibodies selectively reactive with α or β subunits of the H+/K+-ATPase. Western blot analysis was performed on all specimens. Results. Consistent IHC staining was observed in the submandibular gland specimens for both α and β subunits. Western blot analysis revealed very strong expression for the stomach at 100 kDa, corresponding to the α protein, and weak but notable banding for all larynx and submandibular gland specimens. Similar findings were noted for the 60- to 80-kDa glycosylated β subunit protein, as well as the 52-kDa β subunit precursor for all specimens. Conclusion. The H+/K+-ATPase (proton) pump is present in the human larynx and submandibular gland although in much lower concentrations than in the stomach. Proton pump involvement in human aerodigestive seromucinous glands may have a role in protecting mucosa from acid environments (local or systemic), explain heightened laryngeal sensitivity in those patients with laryngopharyngeal reflux, and be a site of action for proton pump inhibitor pharmacotherapy.

Application of Natural Orifice Transluminal Endoscopic Surgery (NOTES) Instrumentation to the Endolarynx

Objectives: RealHand instruments are high-dexterity instruments that have been designed for natural orifice transluminal endoscopic surgery applications. They provide dexterity by offering a full range of motion to endoscopic instruments. We hypothesize that RealHand instruments will resolve some of the limitations encountered in traditional endolaryngeal surgery. They have the potential to do so in the following ways: 1) they negate the limitation of mobility of traditional laryngoscopy instrumentation, which is rigid and fixed; 2) they maintain the ability of direct visualization through a telescope while precluding the need for an operating microscope; 3) they provide the dexterity to perform tasks that are otherwise not possible with traditional instrumentation; and 4) they provide flexibility that can be advantageous in difficult foreign body retrieval from distal airways. Methods: To test this hypothesis, we developed and optimized a cadaveric lamb larynx model for endolaryngeal microsurgery. To evaluate the feasibility of the RealHand instruments in their application to laryngeal surgery, we had 2 otolaryngology senior residents and 2 laryngology fellows-in-training perform 5 different endoscopic tasks: 1) foreign body removal; 2) arytenoidectomy; 3) microflap elevation; 4) cricopharyngeal myotomy; and 5) endoknot suture tying. Results: Experience with RealHand instruments demonstrated that although they are limited in application to phonosurgery, they have the potential for more facile tissue manipulation in the supraglottic and hypopharyngeal structures. Endoscopic suturing ability is enhanced. Conclusions: RealHand high-dexterity instrumentation allows for full range-of-motion instrumentation and, with modification, has potential for wider application in endoscopic laryngeal surgery.

Clinical grading of Reinke's edema

Reinkes edema (RE) is a pathologically benign structural change of the vocal folds with a wide spectrum of clinical severity. We aim to propose and validate a clinical grading system based on size of the lesion to facilitate effective universal communication of disease severity.

Pressure and Flow Comparisons Across Vocal Pathologies

OBJECTIVE The aim of this study was to aid in the distinction among hyperadductive dysphonias by evaluating peak glottal pressure, release burst, and mid and final airflow values across repeated /pa/ syllable trains. METHODS Sixty subjects were assessed for aerodynamic patterns during onset-offset for the /papapapapa/ task in modal voice. Subject groups included adductory spasmodic dysphonia (AdSD), benign vocal fold lesion, primary muscle tension dysphonia (MTD-1), secondary muscle tension dysphonia with an identifiable primary benign vocal fold lesion (MTD-2), vocal fold paresis or paralysis, and normal controls. RESULTS Increased peak pressure (PP) was found for AdSD and MTD-2 subjects compared with controls. Release burst and mid airflow were not significantly different among groups. Final airflow was significantly higher for AdSD compared with the other groups. Final airflow was significantly lower for MTD-1. CONCLUSIONS Significant differences in aerodynamics are seen in subjects with AdSD compared to MTD. AdSD was characterized by higher PP and higher final airflow. MTD-1 was characterized by lower final airflow, whereas MTD-2 was characterized by higher PP. Aerodynamic evaluation may aid in differential diagnosis for those patients in whom distinction among hyperadductive disorders is challenging.

Does Reinke’s Edema Grade Determine Premalignant Potential?

Objective: Reinke’s edema (RE) is a benign disease of the vocal folds with a wide spectrum of clinical severity. We aim to evaluate the clinical impact of RE grade and determine if RE grade correlates with severity of dysplasia and tobacco exposure. Methods: Patients with isolated RE who underwent surgical excision between December 2010 and December 2014 were retrospectively reviewed. The RE grade was determined from archived laryngeal videostroboscopy exams. Pathologic severity of dysplasia, categorized by squamous intraepithelial neoplasia (SIN) classification, and tobacco history were extracted from medical records. Results: Of 95 lesions, 3 (3.16%) were RE grade 1, 33 (34.74%) were RE grade 2, 24 (25.26%) were RE grade 3, and 35 (36.84%) were RE grade 4. Fifty-nine lesions (62.11%) had no dysplasia (SIN0), 19 (20.00%) had mild dysplasia (SIN1), 15 (15.79%) had moderate dysplasia (SIN 2), and 2 (2.11%) had severe dysplasia (SIN3). The 2 patients with severe dysplasia had grade 4 lesions. No statistical correlation was identified between RE grade and the severity of dysplasia. Furthermore, no statistical correlation was seen between tobacco exposure and the severity of dysplasia or the RE grade. Conclusions: Size of RE lesion does not reflect premalignancy. The majority of RE lesions, regardless of size, have little to no premalignant potential. Severe dysplasia/carcinoma in situ may be more likely seen in grade 4 lesions; however, the paucity of severe dysplasia published in RE data and in this cohort preclude any formal inference. Further study of grade 4 lesions is warranted.

Case‐control study evaluating competing risk factors for angioedema in a high‐risk population

Black race is a risk factor for angioedema. The primary aim was to examine the relationship between race–ethnicity and risk factors for angioedema.

Clinical laryngology : the essentials

Clinical Laryngology addresses the practical issues faced by residents and seasoned practitioners in managing patients with diseases of the larynx. It is a concise manual covering common, everyday procedures that residents must master and provides all the up-to-date information needed by otolaryngologists caring for patients with laryngeal pathology. Key Features: * Contains chapters on dysphagia, aspiration, tracheotomy, and cough* Includes more than 100 high-quality illustrations and clinical photographs that clarify the information in the text* Written and edited by renowned experts in the field of laryngology This clinical resource is the go-to book that residents, fellows, and practicing otolaryngologists will consult when they are in need of practical guidance on managing cases of laryngeal pathology in the course of their practice. Thieme eOtolaryngology is the premier online resource for otolaryngology-head and neck surgery. For a free trial, go to: thieme.com/eototrial