Nalin J. Patel

Concurrent laryngeal abnormalities in patients with paradoxical vocal fold dysfunction.

OBJECTIVE: Our goal was to investigate the presence of laryngeal abnormalities is patients with paradoxical vocal fold dysfunction (PVFD). STUDY DESIGN AND SETTING: A retrospective chart review was performed of patients referred for evaluation of paradoxical vocal fold dysfunction between July 2002 and December 2002. The patients completed questionnaires at the time of the office visit. Data collected from the medical record included age, gender, duration of symptoms before evaluation, asthma, gastroesophageal reflux symptoms, and laryngoscopic findings. Exercise stress test was performed when suitable. The diagnosis of PVFD was made based on patient history and laryngoscopy. RESULTS: Thirty patients were identified. There was a 27:3 (90%) female predominance, and mean age of presentation at was 28 years (range, 12 to 67 years). The median time from the onset of respiratory symptoms to diagnosis was 4.5 years (range, 0.5 to 30 years). Of the 30 patients, 17 (56%) had asthma, 16 had laryngeal findings suggestive of gastroesophageal reflex disease, 4 (12%) had laryngoscopic findings of chronic laryngitis, and 10 (33%) had additional findings, including laryngomalacia, vocal fold motion impairment, sulcus vocalis, nodules, and subglottic stenosis, mostly in the exercise-induced group. CONCLUSIONS: Concomitant laryngeal abnormalities are present in a many patients with PVFD, particularly in those with exercise-induced symptoms. Laryngoscopy is important in the management of these patients. (Otolaryngol Head Neck Surg 2004; 130:686-9.)

Treatment of recurrent respiratory papillomatosis in children with the microdebrider

The mainstay of treatment of children with recurrent respiratory papillomatosis has been CO2 laser laryngoscopy. Powered microdebriders allow precise removal of laryngeal lesions without thermal damage. The microdebrider may reduce costs by reducing operative time and limiting the need for expensive laser-related equipment. To compare the use of the microdebrider with that of the CO2 laser in children undergoing surgery for recurrent respiratory papillomatosis, we retrospectively reviewed the charts of 18 patients from 2 institutions covering a treatment period between December 1998 and October 2001. These patients were initially treated with the CO2 laser, but were switched to microdebrider resection during the review period. We recorded the number of procedures, the technique(s) of resection used, and the operative time for each procedure. We identified 18 patients, 11 male and 7 female, ages 18 months to 14 years. A total of 127 procedures were performed with the CO2 laser, and a total of 50 procedures were performed with the microdebrider. The mean number of procedures per patient was 10 (range, 2 to 17 procedures). The mean surgical time per procedure using the CO2 laser was 59.2 minutes (range, 8 to 130 minutes). The mean time per procedure with the microdebrider was 32 4 minutes (range, 12 to 47 minutes). This reduction in operative time was clinically and statistically significant (p = .0001, unpaired Students t-test). We concluded that microdebrider resection of laryngeal papilloma in children allowed more rapid surgery with potentially reduced treatment costs. Other advantages of this technique include precise excision without thermal injury. Our report details useful refinements of technique with the microdebrider.

Laryngeal electromyography for adult unilateral vocal fold immobility: A survey of the American Broncho-Esophagological Association

Objectives: Diagnostic and management strategies for adult unilateral vocal fold immobility (UVFI) vary among otolaryngologists. The aim of this study was to determine the current attitudes and practices regarding laryngeal electromyography (LEMG) for the management of adult UVFI within a cohort of subspecialty laryngologists. Methods: A 19-item instrument focused on diagnosis and management of adult UVFI was mailed to active members (n = 249) of the American Broncho-Esophagological Association (ABEA). The subset of questions related to LEMG is reviewed in this report. Statistical analysis using a χ2 test was performed. Results: The survey response rate was 34% (n = 84), with 8 surveys returned incomplete because of pediatric-limited practices. Of the respondents, 75% (n = 57) rely on LEMG for evaluation of UVFI, whereas 25% (n = 19) do not use LEMG. Of those who use LEMG, 54% place their own electrodes and 44% interpret the LEMG results themselves. Monopolar electrodes are used by 57% (n = 25), bipolar electrodes by 27% (n = 12), and hooked-wire electrodes by 17% (n = 7). Muscles evaluated by LEMG include the thyroarytenoid (100%), cricothyroid (94%), posterior cricoarytenoid (70%), lateral cricoarytenoid (43%), cricopharyngeus (27%), and interarytenoid (17%). The LEMG is performed in an unblinded fashion by most respondents (85%), and many (66%) feel a more accurate result is obtained when clinical information is known. There was no statistically significant difference in use of LEMG, placement of electrodes, and interpretation of LEMG according to percentage of laryngology practice. Conclusions: The survey results demonstrate congruence among ABEA members in the utility of LEMG in the management of adult UVFI. Some variability was noted in the methods by which LEMG is performed and interpreted.

Does successful segmental tracheal resection require releasing maneuvers

OBJECTIVES: Tracheal resection is a well-established option for the management of airway stenosis. Releasing maneuvers have been described to reduce anastomotic tension. The aim of this study is to report on a series of tracheal resections performed without the use of these maneuvers. STUDY DESIGN: Retrospective chart review. SETTING: Tertiary hospital. METHODS: All patients undergoing tracheal resection by the first author over a 6-year period were reviewed. RESULTS: Patients (n = 17; 7 men and 10 women, ages 23-76) were managed with tracheal resection and anastomosis without stenting or postoperative tracheotomy. 16/17 (94%) patients had successful treatment of their stenosis. 1/17 (6%) failed and 1/17 (6%) required dilation. There was no postoperative swallowing dysfunction. CONCLUSIONS: Segmental tracheal resection without releasing maneuvers was successful in 16/17 (94%) patients. SIGNIFICANCE: Though extrapolation from this series may be limited, future practitioners may consider forgoing additional releasing maneuvers for tracheal resection in many cases.

Oral lesions in young children

Oral lesions in very young children usually have a benign presentation, and only rarely contribute to significant aerodigestive symptomatology. Management begins with early recognition of the pathology and appropriate diagnosis. Hemangiomas, lymphangiomas, and teratomas may present with airway compromise or feeding difficulties, necessitating early intervention.

Cidofovir modulated gene expression in recurrent respiratory papillomatosis.

OBJECTIVE Recurrent respiratory papillomatosis (RRP) is a benign aerodigestive tract neoplasm. Cidofovir, an antiviral drug, has demonstrated efficacy in slowing and/or reducing RRP recurrence. This investigation examined the differential gene expression of RPP before and after cidofovir use in vivo. METHODS Papillomas were harvested from two patients pre- and post-cidofovir treatment. RNA was extracted from the tissues and separate Serial Analysis of Gene Expression (SAGE) libraries created. Overall gene expression as well as relative gene expression in the four libraries was compared. RESULTS Over 19,000 tags were found in each of the libraries, with over 6000 unique transcripts identified in the pre-treatment and over 6000 identified in the post-cidofovir libraries of both patient 1 and 2. Following cidofovir treatment, the greatest up-regulation was in gene families associated with cell proliferation, metabolism, transport and response to biotic stimuli. Post-treatment up-regulation was seen in numerous specific genes, such as Interferon Regulatory Factor 7 (P=0.000014), which has been associated with virus-host interactions, passive viral induction of host immune response, and response to DNA damage stimulus. Down-regulation was demonstrated in gene families associated with transcription, regulation of nucleic acid metabolism, and signal transduction. DISCUSSION Creation of RRP SAGE libraries demonstrates a broad list of genes expressed in RRP, as well as significant differences in gene expression after exposure to cidofovir, potentially allowing for a more thorough understanding of important genetic pathways in RRP treatment. In addition, over 1400 unique transcripts were identified, which will facilitate new gene discovery in RRP research.

Medialization thyroplasty window creation using an ultrasonic surgical aspirator.

Objectives/Hypothesis: The aim of the study was to investigate the use of an ultrasonic surgical aspirator for creation of the laryngeal cartilage window during medialization thyroplasty.

Immune Stimulation for the Treatment of Papilloma

Objectives: There is no curative therapy for recurrent respiratory papillomatosis. Unmethylated dinucleotides of cytosine and guanine (CpG) are potent immune stimulants that have shown efficacy against tumors as monotherapy, as vaccine adjuvants, and in combination with chemotherapies. We examined the therapeutic effect of CpG oligodeoxynucleotides in the treatment of papillomavirus in a cottontail rabbit model (CRPV). Methods: Twenty rabbits were infected with CRPV; 10 were treated with 11 weekly CpG inoculations while treatment control rabbits received intralesional saline solution. Eight rabbits (4 treatment, 4 control) were rechallenged with CRPV 17 weeks after the initial viral challenge and monitored for new papilloma development. Results: Papillomas developed in all 20 rabbits (100%) within 4 weeks of infection. The diagnosis was confirmed histologically. There was no difference in the average tumor burden between the treatment and control groups after 11 weeks of CpG treatments or after 9 additional weeks of observation. There was no difference between the groups in papilloma size at the site of the injections, nor was there eradication of papillomas at remote sites in either group. No new papillomas developed in any of the 8 animals that were rechallenged. Conclusions: We have reproduced an effective mammalian papilloma model for preclinical immunotherapeutic testing. Despite the potency of CpG in triggering host immunity, CpG oligodeoxynucleotide did not show a therapeutic effect against the large papilloma burdens tested in this study. The lack of effect suggests that either enhanced papilloma antigen presentation or targeting of immune-evasive mechanisms used by the papillomas is needed to treat bulky disease with an immunotherapeutic strategy.

Management of pediatric dysphagia and cricopharyngeal dysfunction using botulinum toxin

Objectives: To report the management of cricopharyngeal achalasia and cricopharyngeal discoordination using botulinum toxin in children. As this treatment strategy in children has not been previously reported, appropriate diagnostic methods and indications for management are discussed. Methods: Retrospective chart review of patients who underwent cricopharyngeal botulinum toxin injection for dysphagia between January 2002 and October 2003 at a tertial care children’s hospital was performed. All patients underwent a preoperative esophageal monometry and a preoperative and postoperative video-swallow study. Results: Four children were identified during the study period. Age range was 2 years to 9 years. Etiology of the cricopharyngeal disorder was achalasia in 2 patients and discoordinated relaxation of the cricopharyngeus associated with a vagal or recurrent laryngeal nerve injury in the other 2 patients. The patients with achalasia had significantly elevated pressures across the cricopharyngeus on esophageal manometry testing. The other 2 patients did not have elevated pressures but did show a restricted flow across the cricopharyngeus. Follow-up swallow studies noted improved transit across the cricopharyngeus in all the patients. No complications were noted in these patients. Conclusions: Cricopharyngeal dysfunction with associated dysphagia in children is uncommon. The potential for developmental changes and neural recovery after injury in children make noninvasive therapeutic measures particularly attractive in this patient population. Botulinum toxin injection can be used as an alternative to a cricopharyngeal myotomy for the management of achalasia in children and can also be used safely in children with discoordinated relaxation of the cricopharyngeus for management of their dysphagia.

Concurrent laryngeal anomalies in patients with paradoxical vocal fold motion

Objectives: Paradoxical vocal fold motion (PVFM) is a condition that exhibits inappropriate adduction of the vocal cords during inspiration, with females comprising the majority of the patients. As awareness has increased, more patients are being referred for evaluation. No study to date has reported additional laryngeal pathologies found concurrent to PVFM. Methods: A retrospective chart review of patients referred for evaluation of “paradoxical vocal fold motion” between July 2002 and December 2002 was performed. Questionnaires were completed by the patients at the time of the office visit. Data collected from the medical record included age, sex, duration of symptoms prior to evaluation, asthma, gastroesophageal reflux symptoms, and laryngoscopic findings. Exercise stress testing was performed when suitable. The diagnosis of PVFM was made based on history and laryngoscopy. Results: 32 patients were identified. There was a 29:3 (90.6%) female predominance. Mean age of presentation was at 28 years (12-67 years). The median time from the onset of respiratory symptoms to diagnosis was 4.5 years (range, 0.5 to 30 years). 17/32 (53%) had asthma. 12/32 had laryngeal findings suggestive of GERD. 4/32 (12%) had laryngoscopic findings of chronic laryngitis. 10/32 (31%) had additional findings including laryngomalacia, vocal fold motion impairment, sulcus vocalis, nodules, subglottic stenosis, and Reinke’s edema. Conclusions: PVFM is still under-recognized, as demonstrated by a median duration of symptoms prior to diagnosis of 4.5 years. Additional laryngeal pathologies may be seen in 1/3 of patients. As in previously published studies, there was a female predominance and relative prevalence of asthma.