Ozlem E. Tulunay-Ugur

Functional Outcomes of Chemoradiation in Patients with Head and Neck Cancer

Objective Concurrent chemoradiotherapy (CCRT) has become the treatment of choice for oropharyngeal and hypopharyngolaryngeal cancers in many centers. Although it has increased the rates of organ preservation, there has also been an increase in treatment-related complications. We aimed to evaluate the functional outcomes of CCRT in head and neck cancer. Study Design Case series with chart review. Setting Tertiary cancer center. Subjects and Methods A retrospective study of patients treated with CCRT at the University of Arkansas for Medical Sciences was performed. Demographic data and treatment outcomes were extracted, specifically feeding tube and tracheotomy dependence and number of esophageal dilatations. Results Of the 243 patients treated with concurrent chemoradiotherapy (5-flourouracil + cysplatin and radiotherapy), 152 patients received a feeding tube. The median percutaneous gastrostomy tube (PEG) use was 9 months (range, 1-96 months). More than 70% of the patients who had a PEG more than 6 months had a T3 or T4 tumor. Thirty-seven patients underwent esophageal dilatations, (median, 1; range, 1-7). The median use of a tracheotomy was 7 months, and 77% of these patients were treated for hypopharyngolaryngeal cancer. Conclusions Despite major improvement in locoregional control rates, CCRT has a significant negative impact on the functional outcomes of head and neck cancer patients, with a high number of patients remaining PEG and tracheotomy dependent.

Cricopharyngeal dysfunction: A systematic review comparing outcomes of dilatation, botulinum toxin injection, and myotomy

Cricopharyngeal dysfunction may lead to severe dysphagia and aspiration. The objective of this systematic review was to evaluate the existing studies on the effectiveness of myotomy, dilatation, and botulinum toxin (BoT) injection in the management of cricopharyngeal dysphagia.

Telepractice Versus In-Person Delivery of Voice Therapy for Primary Muscle Tension Dysphonia

PURPOSE The purpose of this study was to investigate the utility of telepractice for delivering flow phonation exercises to persons with primary muscle tension dysphonia (MTD). METHOD Fourteen participants with a diagnosis of primary MTD participated, 7 on site and 7 at remote locations. Each participant received 12 treatment sessions across 6 weeks. Treatment consisted of flow phonation voice therapy exercises. Auditory-perceptual, acoustic, aerodynamic, and quality-of-life measures were taken before and after treatment. RESULTS Perceptual and quality-of-life measures were significantly better posttreatment and were statistically equivalent across groups. Acoustic and aerodynamic measures improved in both groups, but changes did not reach statistical significance. Results for the 2 service delivery groups were comparable, with no significant differences observed for perceptual and quality-of-life measures. CONCLUSIONS Although the American Speech-Language-Hearing Association supports the use of telepractice for speech-language pathology services, evidence for the use of telepractice for providing behavioral treatment to patients with MTD has been lacking. The results of this study indicate that flow phonation exercises can be successfully used for patients with MTD using telepractice.

Characteristics of dysphagia in older patients evaluated at a tertiary center

To determine laryngoscopic and videofluoroscopic swallowing study (VFSS) findings in geriatric patients with dysphagia; to evaluate management.

Treatment of laryngeal hyperfunction with flow phonation: A pilot study

Context: While clinical successes and descriptions have been reported in a few texts, no data exist to define the utility of flow phonation to improve voice quality in patients with laryngeal hyperfunction. Aims: To provide pilot data regarding the utility of three exercises (gargling, cup bubble blowing, and stretch-and-flow) to improve phonatory airflow during voicing in patients with laryngeal hyperfunction. Settings and Design: Outpatient Voice and Swallowing Center in a University Medical Center. Materials and Methods: Participants received five treatment sessions and were evaluated prior to treatment and after each session using a Phonatory Aerodynamic System to measure airflow during voicing tasks. Noise-to-harmonic ratio and perceptual voice measures were also obtained, as was self-perception of voice handicap. Statistical Analysis Used: Repeated All increased airflow and decreased laryngeal airway resistance over five sessions. Measures Analysis of Variance. Results: Six participants completed the protocol. All participants decreased self-perception of voice handicap and improved on noise-to-harmonic ratio and perceptual ratings of vocal quality. Conclusions: Data derived on a small sample of patients in an exploratory investigation suggest further research into the use of these three exercises to improve airflow with voicing and improve vocal quality in patients with laryngeal hyperfunction is warranted.

SonoKnife: Feasibility of a line-focused ultrasound device for thermal ablation therapy

PURPOSE To evaluate the feasibility of line-focused ultrasound for thermal ablation of superficially located tumors. METHODS A SonoKnife is a cylindrical-section ultrasound transducer designed to radiate from its concave surface. This geometry generates a line-focus or acoustic edge. The motivation for this approach was the noninvasive thermal ablation of advanced head and neck tumors and positive neck nodes in reasonable treatment times. Line-focusing may offer advantages over the common point-focusing of spherically curved radiators such as faster coverage of a target volume by scanning of the acoustic edge. In this paper, The authors report studies using numerical models and phantom and ex vivo experiments using a SonoKnife prototype. RESULTS Acoustic edges were generated by cylindrical-section single-element ultrasound transducers numerically, and by the prototype experimentally. Numerically, simulations were performed to characterize the acoustic edge for basic design parameters: transducer dimensions, line-focus depth, frequency, and coupling thickness. The dimensions of the acoustic edge as a function of these parameters were determined. In addition, a step-scanning simulation produced a large thermal lesion in a reasonable treatment time. Experimentally, pressure distributions measured in degassed water agreed well with acoustic simulations, and sonication experiments in gel phantoms and ex vivo porcine liver samples produced lesions similar to those predicted with acoustic and thermal models. CONCLUSIONS Results support the feasibility of noninvasive thermal ablation with a SonoKnife.

Transoral robotic supracricoid partial laryngectomy with cartilaginous framework preservation

To report the technical feasibility of performing transoral robotic supracricoid partial laryngectomy with preservation of the thyroid cartilage. This is a case report from a tertiary-care academic institution. A patient with recurrent T2 glottic squamous cell carcinoma of the larynx underwent supracricoid partial laryngectomy with negative margins and preservation of the laryngeal framework using transoral robotic surgery, where an adequate exposure to the endolarynx was obtained by using a Feyh-Kastenbauer retractor. The patient was successfully decannulated in postoperative week 4, and his gastrostomy tube was removed in postoperative week 6. Transoral robotic surgery may be feasible in select glottic/subglottic laryngeal lesions, if adequate exposure is obtained.

Venous Anastomosis with Microvascular Coupler in Head and Neck Reconstruction: Experience in 200 Consecutive Procedures

Objectives: There is a scarcity of data on outcomes when GEM microvascular coupler is used for head and neck reconstruction. We sought to review our experience in a large, contemporary series. Methods: Retrospective chart review of 201 consecutive flaps performed in 193 patients between September 2009 and January 2013 in a tertiary academic setting. Results: The cohort consisted of 125 males with a mean age of 64 years (range 3-83). A double free flap was performed in 8 cases. The most common defect locations were mandible (n = 62, 30.8%); oral cavity (n = 27, 13.4%), and cutaneous (n = 24, 11.9%). Flaps included anterolateral thigh (n = 85, 42.3%); fibula (n = 53, 26.4%); radial forearm (n = 37,18.4%); scapula, latissimus, and rectus (n=5, 2.5% respectively); iliac crest and vastus (n = 4, 2% respectively); and other (n = 3, 1.5%). A double venous anastomosis was performed in 26 flaps. The entire range of couplers (1-4mm) was used, but the 2.5mm was the most commonly used (n = 83, 36.6%) followed by the 2.0mm (n = 47, 20.7%). Facial (n = 134, 59%), External jugular (n = 32, 14.1%), and superficial temporal (n = 22; 9.7%) were the most common recipient vessels. Seven cases underwent microvascular revision yielding arterial thrombosis in 1 case, pedicle torsion in 1 case, and venous thrombosis in 5 cases. The flap was successfully salvaged in 3 cases. A delayed failure in another patient yielded an overall flap success rate of 97.5%. None of the tested variables reached statistical significance for venous thrombosis or flap survival. Conclusions: The microvascular coupler is a reliable alternative for venous anastomosis in head and neck flaps. Given the low failure rate, a multi-institutional study could help elucidate outcome predictors in this setting.

Voice and Swallowing Outcomes of Unilateral Vocal Fold Paralysis: Comparing Younger Adult and Geriatric Patients:

Objective To compare voice and swallowing outcomes after treatment in younger adult (<65 years) and geriatric (≥65 years) patients with unilateral vocal fold paralysis (UVFP). Study Design Case series with chart review. Setting Tertiary care center. Subjects and Methods The cases of patients presenting to a tertiary voice clinic with UVFP between June 2005 and February 2015 were reviewed. Clinical characteristics and outcomes in a geriatric subset were compared with those in younger adult group. Results A total of 206 patients met our inclusion criteria (n = 110, <65 years; n = 96, ≥65 years). Etiology was most commonly iatrogenic (59.2%), and computed tomography led to diagnosis for 62.3% of patients for whom it was obtained. The Voice Handicap Index improved on average by 31.3 points after treatment (P < .001), with equal improvement between the patient subsets (P = .71). Swallowing, as objectively assessed by the National Outcomes Measurement System for modified barium swallow, showed a statistically significant improvement in the patient population as a whole (–0.9, P = .02) but was not significantly different within the subgroups (younger, P = .07; geriatric, P = .25). Conclusion Geriatric patients have similar voice and swallowing outcomes as younger adults and should be treated equally aggressive.

Effects of supramaximal balloon dilatation pressures on adult cricoid and tracheal cartilage: A cadaveric study: Balloon Dilatation of the Larynx and Trachea

Cricoid fracture is a serious concern for balloon dilatation in airway stenosis. Furthermore, there are no studies examining tracheal rupture in balloon dilatation of stenotic segments. The aim of this study was to evaluate the effect of supramaximal pressures of balloons on the cricoid and tracheal rings.