Ozan Bagis Ozgursoy

Current diagnosis and treatment of laryngocele in adults

Objective To evaluate the treatment outcome of a series of laryngoceles and to comment on the current diagnosis and management of laryngoceles. Study Design and Setting A retrospective review of charts, radiological and histopathological notes, videolaryngostroboscopic records, and acoustic voice analyses of patients with laryngocele treated over a 10-year period was undertaken. Results Seven patients had internal laryngoceles; one had external; another one had combined laryngocele. Patients with internal laryngocele underwent endoscopic CO2 laser resection, while those with external or combined laryngocele were treated via external approach. Quality of voice was improved and no recurrences were encountered during the follow-up. No evidence of laryngeal cancer was found on the histological examinations. Conclusion Endoscopic CO2 laser resection of internal laryngocele provides a reliable and cost-effective method that minimizes hospitalization and the need for tracheotomy. We believe that advances in the applications of laser in microlaryngosurgery will alter the traditional management of all type of laryngoceles.

Fat graft myringoplasty: a cost-effective but underused procedure

OBJECTIVES The objective of this study was to evaluate the success of fat graft myringoplasty and to discuss the utilities and advantages of a fat graft in primary versus revision myringoplasties. METHODS Eighteen patients who had not had previous otological surgery, and twelve patients whose tympanic membrane perforations have persisted despite myringoplasty with temporalis fascia were included in this prospective clinical trial. All patients were treated by fat graft myringoplasty and followed up for one year. RESULTS Successful closure of the perforation was obtained in 82.4 per cent of the ears at the final follow up. The success rate in the group of patients who had not had previous otological surgery was higher than those of revision cases. CONCLUSIONS Adipose tissue provides the basic requirements for grafting of the tympanic membrane, with its own favourable characteristics. Fat graft myringoplasty is a cost-effective alternative in small perforations of the tympanic membrane, including revision cases.

Manofluorographic and functional outcomes after endoscopic laser cricopharyngeal myotomy for cricopharyngeal bar

Objective: To investigate the manofluorographic and functional outcomes after endoscopic laser cricopharyngeal myotomy (ELCPM) for cricopharyngeal (CP) bar. Study Design: Case series with chart review. Setting: Academic medical center. Subjects and Methods: Review of patients undergoing ELCPM between 2001 and 2007 was undertaken to determine the demographic, clinical, and manofluorographic findings before and six months after surgery. Two groups were established according to pharyngeal driving pressures: normal pressure group (> 55 mm Hg) and low pressure group (< 55 mm Hg). Results: Fourteen patients underwent ELCPM for CP bar without a concomitant head and neck or Zenkers procedure. There were no major surgical complications. All 14 patients improved at least one stage on the Functional Outcome Swallowing Scale (FOSS) after surgery. There was a statistically significant decrease in the FOSS stages after surgery. Videofluoroscopy demonstrated a significant postoperative increase in the mean cross-sectional CP opening (CP-area) from 32.75 to 123.52 mm2. Manofluorographic pressure recordings showed a significant postoperative decrease in the intrabolus pressure gradient across the cricopharyngeal region (IB-Gra) from 25.44 to 13.22 mm Hg. Despite significant overall results, the change in the IB-Gra showed no difference between the patient groups. Conclusion: Subjective (FOSS) and objective manofluorographic (CP-area, IB-Gra) improvement in CP bar patients occurred after ELCPM. We suggest IB-Gra as a reliable objective indicator for patients who might benefit from ELCPM and as an appropriate parameter for follow-up after surgery. However, continued research on a larger patient population is required to enhance our understanding of CP bar and predictors of outcome after treatment of CP bar dysphagia.

Anterior cervical osteophyte dysphagia: Manofluorographic and functional outcomes after surgery

Our aim was to investigate the clinical and manofluorographic findings of patients with anterior cervical osteophyte (ACO) dysphagia before and after surgery.

Laryngeal reconstruction by platysma myofascial flap after vertical partial laryngectomy

Many methods of glottic reconstruction have been described for patients undergoing vertical partial laryngectomy to reestablish the glottic integrity.

One-year follow-up results of combined use of CO2 laser and cold instrumentation for Reinke's edema surgery in professional voice users.

The purpose of this study was to present our experience with combined use of CO2 laser and cold instrumentation for Reinke’s edema surgery and to evaluate 1-year follow-up results of the technique in a series of professional voice users. Fifteen patients with Reinke’s edema who underwent microlaryngoscopic surgery were included. Videolaryngostroboscopy, perceptual and acoustic voice analyses were performed before and after surgery. During the 1-year follow-up, no recurrence of Reinke’s edema was encountered. Significant postoperative improvement was obtained in the quality of voice, in terms of GRBAS scores, Fo, jitter, shimmer and NHR. No evidence of laryngeal cancer was found on the histological examinations. Combined use of CO2 laser and cold instrumentation provides a reliable and safe method for Reinke’s edema surgery, and cessation of smoking, voice rest and control of the laryngopharyngeal reflux contribute to the success of surgery. We consider that the removal of redundant mucosa of the vocal fold reduces the risk of the recurrence of Reinke’s edema and provides better quality of voice. However, it does not imply that our method is superior to others’, but this procedure constitutes an effective treatment of choice for Reinke’s edema patients, including professional voice users.

Hidden unilateral agenesis of the frontal sinus: human cadaver study of a potential surgical pitfall

PURPOSE The aim of the study was to attract attention to the surgical significance of unilateral agenesis of the frontal sinus hidden by the overlapping expansion of the contralateral sinus toward the agenetic side. MATERIALS AND METHODS Retrospective review of endoscopic transnasal sinus dissections of 55 human cadavers (42, formalin fixated; 13, fresh frozen) was done in a tertiary care academic medical center. Surgical and radiologic findings were noted. RESULTS Absence of right frontal sinus ostium in the presence of a connection between the right and left frontal sinuses was demonstrated in 2 (3.6%) cadavers. An absent and an incomplete septum between the frontal sinuses were also noted in these cadavers. No accompanying abnormality of other sinuses was found, and no evidence of previous sinus surgery was noted in these 2 cadavers. CONCLUSIONS If one of the frontal sinus ostia cannot be found during sinus surgery, although this sinus and its recess can be seen on the thick-sliced coronal computed tomographic (CT) scans, keep in mind that it may be (3.6%) an agenetic frontal sinus hidden by the extensive pneumatization of the contralateral sinus that is crossing the midline. It may not be possible to foresee this variant preoperatively by endoscopic examinations or thick-sliced CT scans. If there is suspicion, thin-sliced CT scans with reconstruction will be ideal to confirm the agenesis of the frontal sinus and to avoid complications. In the presence of such variant of frontal sinus, 1-sided successful frontal sinusotomy is adequate because this sinus or cell will already be drained through the treated frontal recess.

Safety of Audiology Direct Access for Medicare Patients Complaining of Impaired Hearing

BACKGROUND Allowing Medicare beneficiaries to self-refer to audiologists for evaluation of hearing loss has been advocated as a cost-effective service delivery model. Resistance to audiology direct access is based, in part, on the concern that audiologists might miss significant otologic conditions. PURPOSE To evaluate the relative safety of audiology direct access by comparing the treatment plans of audiologists and otolaryngologists in a large group of Medicare-eligible patients seeking hearing evaluation. RESEARCH DESIGN Retrospective chart review study comparing assessment and treatment plans developed by audiologists and otolaryngologists. STUDY SAMPLE 1550 records comprising all Medicare eligible patients referred to the Audiology Section of the Mayo Clinic Florida in 2007 with a primary complaint of hearing impairment. DATA COLLECTION AND ANALYSIS Assessment and treatment plans were compiled from the electronic medical record and placed in a secured database. Records of patients seen jointly by audiology and otolaryngology practitioners (Group 1: 352 cases) were reviewed by four blinded reviewers, two otolaryngologists and two audiologists, who judged whether the audiologist treatment plan, if followed, would have missed conditions identified and addressed in the otolaryngologists treatment plan. Records of patients seen by audiology but not otolaryngology (Group 2: 1198 cases) were evaluated by a neurotologist who judged whether the patient should have seen an otolaryngologist based on the audiologists documentation and test results. Additionally, the audiologist and reviewing neurotologist judgments about hearing asymmetry were compared to two mathematical measures of hearing asymmetry (Charing Cross and AAO-HNS [American Academy of Otolaryngology-Head and Neck Surgery] calculations). RESULTS In the analysis of Group 1 records, the jury of four judges found no audiology discrepant treatment plans in over 95% of cases. In no case where a judge identified a discrepancy in treatment plans did the audiologist plan risk missing conditions associated with significant mortality or morbidity that were subsequently identified by the otolaryngologist. In the analysis of Group 2 records, the neurotologist judged that audiology services alone were all that was required in 78% of cases. An additional 9% of cases were referred for subsequent medical evaluation. The majority of remaining patients had hearing asymmetries. Some were evaluated by otolaryngology for hearing asymmetry in the past with no interval changes, and others were consistent with noise exposure history. In 0.33% of cases, unexplained hearing asymmetry was potentially missed by the audiologist. Audiologists and the neurotologist demonstrated comparable accuracy in identifying Charing Cross and AAO-HNS pure-tone asymmetries. CONCLUSIONS Of study patients evaluated for hearing problems in the one-year period of this study, the majority (95%) ultimately required audiological services, and in most of these cases, audiological services were the only hearing health-care services that were needed. Audiologist treatment plans did not differ substantially from otolaryngologist plans for the same condition; there was no convincing evidence that audiologists missed significant symptoms of otologic disease; and there was strong evidence that audiologists referred to otolaryngology when appropriate. These findings are consistent with the premise that audiology direct access would not pose a safety risk to Medicare beneficiaries complaining of hearing impairment.

Functional and Manofluorographic Outcomes After Transoral Endoscopic Pharyngoesophageal Diverticulostomy

OBJECTIVES To investigate functional and manofluorographic findings of patients with pharyngoesophageal diverticulum before and after transoral endoscopic pharyngoesophageal diverticulostomy (TEPD) and to comment on outcomes relative to predictors of successful treatment and pathogenesis of pharyngoesophageal diverticulum. DESIGN Retrospective medical record review. SETTING Academic center. PATIENTS Thirty patients underwent TEPD between July 1, 1997, and June 30, 2007, and met the study inclusion criteria. According to the depth of their pharyngoesophageal diverticulum, patients were categorized as having small (<20 mm) or large (>or=20 mm) diverticula. INTERVENTION Manofluorography before and 6 months after TEPD. MAIN OUTCOME MEASURES Functional and manofluorographic findings before and 6 months after surgery. RESULTS Functional Outcome Swallowing Scale stage was significantly decreased in patients after surgery. Videofluoroscopy demonstrated normal swallowing coordination and a significant decrease in pouch depth after surgery (from 29.62 to 4.78 mm). Manometry confirmed normal swallowing coordination and showed significant mean postoperative pressure reductions in the following: cricopharyngeal (CP) resting pressure (from 16.23 to 9.26 mm Hg), CP midbolus pressure (from 32.86 to 19.26 mm Hg), intrabolus pressure gradient across the CP region (from 22.48 to 10.16 mm Hg), and CP peak clearing pressure (from 41.98 to 26.99 mm Hg). The mean preoperative intrabolus pressure gradient across the CP region and the mean postoperative CP nadir were significantly greater in patients having large diverticula. CONCLUSIONS Statistically significant decreases in functional and objective measures occurred after TEPD. High CP midbolus pressure and high intrabolus pressure gradient across the CP region are reliable objective indicators of patients who might benefit from TEPD and are appropriate variables for follow-up after surgery. There was no manofluorographic evidence of abnormal swallowing coordination in this small series. Our study supports the hypothesis that anatomical hypopharyngeal wall weakness has a major role in the pathogenesis of pharyngoesophageal diverticulum.

Unique variation of digastric muscle: a confusing landmark for head and neck surgeons

An anatomical variation of the left digastric muscle was found during the functional neck dissection of a patient with laryngeal carcinoma. This variant of the digastric muscle had three bellies including an accessory posterior belly. The anterior and posterior bellies had normal origin and course and were linked to each other by an intermediate tendon, whereas the accessory posterior belly took its origin from the mastoid notch of the temporal bone, together with the original posterior belly, sloped inferiorly and anteriorly, and inserted to the lateral border of the strap muscles by an evident tendon. This unique variation has not been reported in the literature. Presentation of this variation will guide surgical procedures, as well as anatomical dissections and medical imaging of the neck.