Robert W. Bastian

Vocal fold scarring: current concepts and management.

Scarring of the vocal folds can occur as the result of blunt laryngeal trauma or, more commonly, as the result of surgical, iatrogenic injury after excision or removal of vocal fold lesions. The scarring results in replacement of healthy tissue by fibrous tissue and can irrevocably alter vocal fold function and lead to a decreased or absent vocal fold mucosal wave. The assessment and treatment of persistent dysphonia in patients with vocal fold scarring presents both diagnostic and therapeutic challenges to the voice treatment team. The common causes of vocal fold scarring are described, and prevention of vocal fold injury during removal of vocal fold lesions is stressed. The anatomic and histologic basis for the subsequent alterations in voice production and contemporary modalities for clinical and objective assessment will be discussed. Treatment options will be reviewed, including nonsurgical treatment and voice therapy, collagen injection, fat augmentation, endoscopic laryngoplasty, and Silastic medialization.

Epidermoid cysts, sulci, and mucosal bridges of the true vocal cord: A report of 157 cases

Presented is a summary of our experience with 157 patients having a diagnosis of epidermoid cyst, glottic sulcus, or mucosal bridge of the true vocal cord. Each patient in this group was diagnosed and treated jointly by a phoniatrist and microlaryngoscopist and then evaluated for results of surgical and phoniatric therapy.

Sensory Neuropathic Cough: A Common and Treatable Cause of Chronic Cough:

OBJECTIVE: To describe our experience with chronic sensory neuropathic cough and its response to amitriptyline in a first group of patients. STUDY DESIGN AND SETTING: A prospective cohort of patients is described in detail. Each was referred to an academic laryngological practice after extensive prior negative workup for cough and failure to respond to various treatments. Each of these patients was treated with amitriptyline and asked to report the effect on the cough at fixed intervals by means of telephone interviews. RESULTS: A first cohort of 12 consecutive patients with a chronic, nonproductive cough that lasted between 2 months and 20 years, with no (formerly) discernible cause is described. Purely clinical criteria of inclusion and exclusion are proposed. All patients had at least 40% reduction of self-reported symptoms, with most describing between 75% to 100% short-term relief. CONCLUSION: Sensory neuropathic cough can be diagnosed clinically in patients with chronic idiopathic cough. A trial of amitriptyline 10 mg or of other antineuralgia type medications may be helpful. Longer term and controlled trials are warranted to validate this entity and prove efficacy of neurologic medication in chronic sensory neuropathic cough. EBM rating: C-4

Role of sensation in swallowing function.

Objectives: Sensation in the oral cavity and laryngopharynx has long been believed to be crucial for normal swallowing. One illustration of this belief has been intense interest in reconstruction after cancer resection using sensate tissue transfer as a means of improving swallowing function. A contrarian view is that mucosal sensation, by itself, is, in fact, relatively unimportant to swallowing function.

Clinical evaluation of vocal fold paralysis.

Vocal fold paralysis is regarded as a sign of other pathologic findings until investigation has proven that there is no lesion to explain the paralysis. We have outlined a cost-effective and time- and labor-efficient method for the clinical evaluation of vocal fold paralysis, including a focused history; vocal capability assessment to find deficits in the function of palate,pharynx, and larynx: and, finally, an intense examination under topical anesthesia to demonstrate these deficits. In essence, it is the endoscopic version of a radiographic study from the skull base through the aortic arch. This method is streamlined as compared with prior protocols for evaluation of vocal fold paralysis, because it directs the necessary further workup according to the likely site of the lesion as indicated by the extended physical examination and can be conducted entirely in the physicians office. Radiographic workup should include CT of the skull base through the upper mediastinum if solely a recurrent nerve paralysis is present; it should include MRI of the skull base if high vagal signs and symptoms are present. If MRI is negative, CT may also be needed for complete evaluation. Neurologic signs that are not all ipsilateral require MRI of the brain and consultation with a neurologist. Esophageal obstruction combined with vocal fold paralysis mandates evaluation via esophagoscopy or an esophagram.

Postintubation phonatory insufficiency: an elusive diagnosis.

OBJECTIVE To describe postintubation phonatory insufficiency, a routinely overlooked complication of prolonged intubation. This entity results from an erosive injury with permanent divots of the medial surfaces of the arytenoid cartilages and/or scarring of the anterior cricoarytenoid joint capsule so that during phonation there is incomplete adduction and a glottic gap remains. SETTING Tertiary care center. STUDY DESIGN/RESULTS We present a retrospective review of the findings of 138 patients evaluated for chronic intubation injuries in our voice laboratory using a diagnostic model composed of pertinent history, elicited vocal capabilities and limitations, and an intense fiberoptic laryngeal examination directed at revealing the suspected injuries. CONCLUSION/SIGNIFICANCE In many patients, the diagnosis of postintubation phonatory insufficiency was made years after the intubation injury occurred and after numerous nondiagnostic examinations elsewhere. Mechanisms of intubation injury are reviewed, and prevention and treatment of the condition are discussed.

Laryngeal image biofeedback

The proper treatment of many voice disorder patients includes modification of voice production. Laryngeal image biofeedback (LIB), a new technique to help selected patients modify vocal fold posture and thereby vocal production is described. The effectiveness of this technique as a learning tool is assessed in 20 subjects.

A Comparison of Methods of Botulinum Toxin Injection for Abductory Spasmodic Dysphonia

Treatment of abductory spasmodic dysphonia with botulinum toxin injection into the posterior cricoarytenoid muscles often results in only partial symptom relief. In contrast, excellent results can be achieved after thyroarytenoid injection for the adductory type of spasmodic dysphonia. One reason for disappointing results may be inaccurate placement of the botulinum toxin into the posterior cricoarytenoid muscles. We describe a new approach to posterior cricoarytenoid injection used in 18 patients for treatment of abductory spasmodic dysphonia. Of the 30 patients treated for abductory spasmodic dysphonia at Loyola University-Chicago, 6 underwent both a retrocricoid approach and the newer transcricoid method, thus allowing patient and clinician comparison of techniques. We and all six of our patients preferred the transcricoid approach because of less discomfort, equivalent or better voice results, and fewer side effects.

Suction drain management of salivary fistulas

Salivary fistulas remain an unpleasant complication of upper aerodigestive tract surgery. To avoid a disastrous outcome such as carotid rupture, clinicians “medialize” (i.e., incise the skin flap in the anterior aspect of the neck and insert a Penrose drain) to divert fistula fluid from the carotid sheath and then perform laborious wound care. Meanwhile, patients endure the unpleasant odor, discomfort due to the wound dressing, occasional secondary surgical procedures, a lengthened hospital stay, and increased financial costs.

The use of neuralgia medications to treat sensory neuropathic cough: our experience in a retrospective cohort of thirty-two patients

Objective. This study sought to: (1) quantify response rate and efficacy of amitriptyline, desipramine, and gabapentin in treating sensory neuropathic cough; and (2) describe an efficient treatment protocol. Study Design. This study is a retrospective case series. Methods. Persons diagnosed with sensory neuropathic cough during a one-year period were potential study candidates. To bolster the diagnosis credibility, only persons who had been treated elsewhere for gastroesophageal reflux disease, asthma, and allergy with no reduction of cough were included. Upon diagnosis of sensory neuropathic cough, each person was treated with either amitriptyline, desipramine, or gabapentin, titrating the dose upward to desired benefit or the dose limit. If the benefit was insufficient, another of the medications was used next, using a similar dose escalation strategy. Data points included patient demographics, initial and final medication, final dose, and degree of improvement. Results. 32 patients met the diagnostic and inclusion criteria and had a complete data set. 94% (30 of 32) of the patients responded to at least one of the medications. The 32 patients undertook a total of 45 single-medication trials. Patients reported symptom relief during 78% (14 of 18) of amitriptyline trials, 73% (11 of 15) of desipramine trials, and 83% (10 of 12) of gabapentin trials. At final dosage, symptom reduction averaged 77% on amitriptyline, 73% on desipramine, and 69% on gabapentin. Conclusion. Amitriptyline, desipramine, and gabapentin appear to vary in their effectiveness for individual cases of sensory neuropathic cough; across a whole cohort, symptom relief was similar in frequency and degree on any of the three medications. More evidence is needed to demonstrate more convincingly the effectiveness of these medications, but this data set suggests that each of these three medications deserves consideration in the codified treatment protocol presented here.