Murray Morrison

Is Chronic Gastroesophageal Reflux a Causative Factor in Glottic Carcinoma

Several forms of laryngeal dysfunction and pathology can be attributed to the effects of chronic gastric reflux through direct acid irritation, from a reflex alteration in voluntary muscle tone or referred sensation. It is widely accepted that contact ulcers and granulomata over the arytenoid are associated with gastric reflux, but there have not been well-documented cases of glottic carcinoma that are reflux-related. This article presents six cases of glottic carcinoma, all with T1 lesions of the anterior two-thirds of the vocal cord. All of these patients are lifetime nonsmokers, and all had no other ailments other than moderately severe chronic gastroesophageal reflux. Clinical details from the study of these patients gives strong indication that the reflux may have been a factor in the development of the disease. In addition, review of 21 lifetime nonsmokers with glottic carcinoma presenting over a 10-year period at the Cancer Control Agency of British Columbia revealed that 48% had probably experienced reflux, compared to 16% in a group that had stopped smoking 10 or more years earlier. While this small number of cases cannot be said to prove the etiologic relationship between reflux and glottic carcinoma, it is important for the otolaryngologic community to be aware of the possible clinical relationship.

Extrinsic Laryngeal Muscular Tension in Patients with Voice Disorders

The objective of this study was to establish a standard clinical evaluation tool for assessment by palpation of extrinsic laryngeal muscular tension (ELMT) and investigate the relationship between ELMT and different voice disorder diagnosis categories, particularly muscle misuse dysphonia (MMD), and the presence or absence of gastroesophageal reflux (GER). A palpation technique and tension grading system for four separate muscle groups (suprahyoid, thyrohyoid, cricothyroid, and pharyngolaryngeal) were established. 465 patients, 65% female and 35% male, were assessed sequentially and ELMT results were analyzed in relation to diagnosis and reflux status. A strong relationship was found between thyrohyoid muscle tension and both GER and MMD (p < or = 0.01). Thyrohyoid muscle tension is the only group that demonstrated a significant relationship with MMD. No significant difference in the ELMT scores was found between GER and non-GER patients, although a possible causal relationship was found between MMD type 3 and reflux. It is postulated that palpation of extrinsic laryngeal muscles can yield important information about internal laryngeal postures and diagnosis of muscle misuse voice disorders, particularly MMD type 3 (anteroposterior supraglottic compression). Integration of this technique into routine laryngeal examination can be a significant aid to diagnostic accuracy.

The Management of Voice Disorders

1 Evaluation of the voice disordered patient.- 2 Classification of muscle misuse voice disorders.- 3 Medical aspects of voice disorders.- 4 Approaches to voice therapy.- 5 Psychological management of the voice disordered patient.- 6 Psychological and neurological interactions in dysphonia.- 7 Pediatric voice disorders: special considerations.- 8 Voice disorders in the elderly.- 9 The singing teacher in the voice clinic.- 10 Anatomy and physiology of voice production.- 11 Basics of singing pedagogy.- Appendix A Antireflux instructions.- Appendix B Vocal rehabilitation exercises.- B.1 Vocal hygiene: how to get the best mileage from your voice.- B.2 Gravity and relaxation.- B.3 Dynamic alignment: optimizing posture for movement.- B.4 Specific relaxation: liberating the speech articulators.- B.4.1 Face.- B.4.2 Jaw.- B.4.3 Tongue.- B.4.4 Lips.- B.4.5 Throat.- B.5 Coordinated voice onset.- B.6 Feeding the resonators and mmmaking the mmmost of resonance.- B.7 Extending your dynamic pitch range.- B.7.1 Bubbling and frilling.- B.7.2 Vocal siren.

Use of radiotherapy for control of sialorrhea in patients with amyotrophic lateral sclerosis.

Many patients with amyotrophic lateral sclerosis (ALS) develop progressive difficulty with swallowing secretions, and drooling becomes a significant problem. The production of saliva can be reduced with radiation of the submandibular and sublingual salivary gland tissue. This method has been used successfully in Europe and had limited use at Vancouver Hospital. This study was undertaken to determine the lowest effective dose of radiation necessary to control salivary production. Over a 3-year period, patients with ALS who developed significant problems with drooling were identified and treated with a predetermined dose of radiation. The first group received a single dose of 8 Gy in one fraction and the second received a total of 12.5 Gy in two fractions. They were followed over the next 6 months and were evaluated for effectiveness and side effects. Their saliva was measured pre- and postradiation treatment, and they were also asked to evaluate the change subjectively, using a questionnaire. The preliminary findings suggest that 8 Gy of radiation was effective in controlling drooling, and increasing the dose did not improve initial control. Long-term control was difficult to evaluate as the patients entered in the study were very ill and their life expectancy was very short. Radiation at this low dose resulted in very few side effects. Low-dose radiation can safely help control secretions in selected patients with ALS.

Injection Laryngoplasty With Hyaluronic Acid for Unilateral Vocal Cord Paralysis. Randomized Controlled Trial Comparing Two Different Particle Sizes

The objective was to determine if particle size affects durability of medialization in patients undergoing injection laryngoplasty (IL) with hyaluronic acid (HA) for unilateral vocal cord paralysis (UVCP). We hypothesized that large particle-size HA (LPHA) persists longer after injection to produce a more durable vocal result. The study design used was a prospective randomized controlled single-blind trial. Patients underwent IL with Restylane (small particle-size HA, SPHA) or Perlane (LPHA) (Q-Med AB, Uppsala, Sweden). Injections were performed transcutaneously in the outpatient clinic. The Voice Handicap Index (VHI) at 6 months postinjection was the primary outcome measure. Secondary outcomes included videostroboscopic findings, and objective acoustic and aerodynamic measures. Seventeen patients (eight SPHA, nine LPHA) were available for follow-up at 6 months. Normalized VHI scores at 6 months after IL were significantly lower in the LPHA group compared to the SPHA group when not adjusted for age and sex (P=0.027). After adjustment, the difference was not significant (P=0.053) but the LPHA group trended toward lower normalized VHI scores. The findings support the hypothesis that the larger particle-size of LPHA makes this material more durable than SPHA for IL. This material may be considered for temporary medialization in patients with UVCP in whom medium-term improvement of at least 6 months is desirable. The transcutaneous route can be used safely in the office setting in non-anticoagulated patients.

Voice disorders in the elderly

A review of the literature clearly shows that connective tissue degeneration in the larynx, particularly of elastic and collagen fibers, is more prevalent in males than in females. Reinkes edema or polypoidal degeneration of vocal cords may or may not be more common in females. Whether or not the above statements are true, tissue atrophy causes a problem in males because the voice becomes higher pitched, weak or reedy, less masculine, whereas polypoidal change in the older female larynx results in a lower pitch, husky voice that would be acceptable in a male but makes the female voice more male-like and undesirable. Functional misuses of laryngeal muscles come into play when patients try to compensate for these changes. The etiology of dysphonia in the elderly gets even more confusing when psychological factors such as loneliness and depression add their effects to laryngeal muscle misuse. Laryngeal cancer is still probably the most common cause of hoarseness in older persons. Unfortunately the biopsy to rule out cancer in a person who is hoarse from degenerative or functional causes will often greatly worsen the dysphonia and render voice therapy less effective.

Treatment of laryngeal contact ulcers and granulomas: a 12-year retrospective analysis.

Multiple etiological factors including gastroesophageal reflux, hyperfunctional voice use, and endotracheal intubation have been implicated in the development of posterior laryngeal ulcers and granulomas. The optimal approach to treatment of these lesions remains controversial. The mainstay of treatment at Vancouver General Hospital has been aggressive medical management of gastroesophageal reflux, with complimentary voice therapy offered to patients suspected of having significant hyperfunctional phonation. The authors reserve Botulinum toxin injection or surgical excision for patients who fail initial therapy. They conducted a retrospective analysis of their voice clinic records from 1985-1997 to examine the efficacy of this approach. They identified 76 patients with the diagnosis of contact ulcer or granuloma. Fifty-two patients had follow-up data available for review. Ninety-four percent of patients were treated nonsurgically: 35 patients were treated solely by dietary and medical therapy to control gastroesophageal reflux, 10 patients were treated by a combination of medical gastroesophageal reflux control and voice therapy, 3 patients had Botox injections, 2 patients had surgical excision of granuloma, 1 patient had a Kenalog injection, and 1 patient underwent laparoscopic fundoplication. Overall, 77% of patients had complete resolution, whereas 11% had partial resolution and another 11% had no significant improvement. The data supports control of gastroesophageal reflux as a central component in treatment of posterior laryngeal ulcers and granulomas.

Interdisciplinary Approach to Functional Voice Disorders: The Psychiatrisf's Role

A review is given of the experience obtained over 6 years of having a psychiatric consultant available as part of the staff of the Voice Clinic, to which more than a thousand patients have been referred. The presenting features in a case that should alert the otolaryngologist to the need for psychiatric consultation and possible treatment are noted. Suggestions are made as to how to prepare the patient for the referral to a psychiatrist with the appropriate Interests and willingness to collaborate closely with the otolaryngologist and the speech pathologist.

The Reliability of the Reflux Finding Score Among General Otolaryngologists

BACKGROUND The reflux finding score (RFS) is a validated clinical severity scale for findings of laryngopharyngeal reflux (LPR) on fiberoptic laryngoscopy. To our knowledge, there have been no studies to determine whether severity of patient symptoms influence the RFS; in addition, the reliability of the RFS has not been tested for general otolaryngologists. OBJECTIVES The objectives of this study were (1) to determine whether the RFS for LPR is influenced by symptoms of reflux and (2) to determine the inter-rater reliability for general otolaryngologists in diagnosing LPR using the RFS. METHODS Ten general otolaryngologists were selected to participate. Participants were asked to complete an Internet survey consisting of flexible endoscopic videos of larynges with varying physical findings of reflux and grade the severity of reflux using the RFS. The videos were randomly shown with and without accompanying patient symptoms. RESULTS Our data suggest that patient symptoms influence the RFS. Inter-rater reliability for general otolaryngologists using the RFS is fair. CONCLUSIONS Among general otolaryngologists in our study, the reliability and objectivity of the RFS in diagnosing reflux cannot be demonstrated.

Management of Unilateral Vocal Cord Paralysis by Injection Medialization with Teflon Paste Quantitative Results

This paper prospectively analyzes eight patients who were selected for injection medialization of a unilateral vocal cord paralysis by a transcutaneous technique. Preoperative and postoperative videolaryngoscopic recordings of the position of the paralyzed cord were made with a scoring system correlated to the laryngeal airflow measurements. Quantitative acoustic recordings of the patients voice were also taken and compared with the patients own subjective analysis of his or her voice. Results indicate that Teflon injection by the transcutaneous method gives a statistically and clinically improved voice in the short term.